Mixed fungaemia: an 18-year report from a tertiary-care university hospital and a systematic review.
BACKGROUND
While fungaemia caused by two or more different species of yeasts (mixed fungaemia, MF) is infrequent, it might be underestimated.


AIMS
This study aimed to determine the incidence of MF, clinical characteristics of the patients, and antifungal susceptibility profiles of the isolates with a systematic review of the literature.


SOURCES
Data sources were PubMed and Scopus.


STUDY ELIGIBILITY CRITERIA
Studies reporting ten or more mixed fungaemia episodes.


CONTENT
Study included MF episodes in adults between January 2000 and August 2018 in Hacettepe University Hospitals, Turkey. The isolation, identification and antifungal susceptibility testing (AFST) of the isolates were by standard mycological methods. Patient data were obtained retrospectively. Literature search was performed using relevant keywords according to PRISMA systematic review guidelines. A total of 32 patients with 33 MF episodes were identified. Among all fungaemia episodes, MF incidence was 3.7% (33/883). All patients had one or more underlying disorders among which solid-organ cancer (50.0%, 16/32) was the most common. Overall mortality was 51.5% (17/33). The most preferred antifungal agents for initial treatment were fluconazole (48.5%, 16/33) and echinocandins (39.4%, 13/33). Fluconazole susceptible-dose-dependent (S-DD) or -resistant Candida species were detected in 15 episodes, and an isolate of C. parapsilosis was classified as S-DD by AFST. All Candida isolates were susceptible to echinocandins. Non-candida yeasts with intrinsic resistance/reduced susceptibility to both echinocandins and fluconazole were detected in two episodes. Systematic review of the literature revealed 24 studies that reported more than ten MF episodes. Methodology was variable. Improvement of detection rates was reported when chromogenic agars were used. Most studies underlined detection of isolates with reduced susceptibility.


IMPLICATIONS
Although rare, the MF rate is affected by the detection methods, which have improved in recent years. Fluconazole and echinocandins were used for initial treatment in accordance with the current guideline recommendations; however, isolates non-susceptible to both were detected. Detection of a mixed infection offers an opportunity for optimum treatment.
['Gülmez|D|D|', 'Alp|S|S|', 'Gursoy|G|G|', 'Ayaz|C M|CM|', 'Dogan|O|O|', 'Arikan-Akdagli|S|S|', 'Akova|M|M|']
D000328:Adult D000368:Aged D000369:Aged, 80 and over D000935:Antifungal Agents D060085:Coinfection D025141:Drug Resistance, Fungal D005260:Female D016469:Fungemia D006785:Hospitals, University D006801:Humans D015994:Incidence D008297:Male D008875:Middle Aged D012189:Retrospective Studies D062606:Tertiary Care Centers D016896:Treatment Outcome D014421:Turkey D015003:Yeasts
Mixed fungaemia Antifungal treatment Candida albicans Candida glabrata Candida parapsilosis Mixed candidaemia Non-Candida fungaemia Non-albicans candidaemia