Therapeutic and prophylactic use of antifungals is rising continuously. However, inadequate awareness of diagnostic and treatment guidelines and limited laboratory modalities lead to inappropriate use. This study assessed the impact of an institutional antifungal stewardship program on antifungal use practices and patient outcomes. In the pre-intervention phase, data was collected regarding antifungal therapy among patients with invasive fungal infections. Appropriateness of antifungal prescription was assessed. In the intervention phase, simple algorithms for diagnosis and management of fungal infections were prepared from international guidelines and incorporated into a booklet for distribution. Monthly training sessions were conducted. New serological and molecular tests and therapeutic drug monitoring were introduced. In the post-intervention phase, an antifungal stewardship team was constituted for clinical advisory on demand and ongoing training. Data regarding antifungal therapy was collected and compared with pre-intervention data. Untreated patients decreased from 25% to 18.9% post-intervention (P = .28). Appropriate antifungal use increased from 72.6% to 77.9% (P = .4) among patients with a single fungal infection, and from 57.1% to 88.5% (P = .04) for at least one infection among those with dual fungal infections. 49 incidents of inappropriate use in various categories were seen among 75 patients receiving antifungals pre-intervention, decreasing to 42 incidents among 94 patients post-intervention (P = .06), particularly evident among patients with dual infections (P = .002). Mortality increased from 51% to 75.86% post-intervention (P = .0001). Overall, the small improvement noticed in antifungal usage pattern can still be considered significant, given the limited study period.

IntroductionInvasive mould infections (IMIs) are a leading cause of death in patients with compromised immune systems. Proven invasive mould infection requires detection of a fungus by histopathological analysis of a biopsied specimen, sterile culture, or fungal DNA amplification by PCR in tissue. However, the clinical performance of a PCR assay on blood samples taken from patients suspected of invasive mould disease has not been fully evaluated, particularly for the differential diagnosis of invasive aspergillosis (IA) and invasive Mucormycosis (IM).ObjectivesTo assess the diagnostic utility of our previously validated in-house real-time PCR in blood samples for diagnosis of invasive aspergillosis and mucormycosis in patients with suspected invasive mould infection.MethodsAll patients with suspected invasive mould infection were prospectively enrolled from May 2021 to July 2021. Conventional fungal diagnosis was performed using tissue and respiratory samples. In-house PCR was performed on blood samples and its diagnostic performance evaluated.ResultsA total of 158 cases of suspected invasive mould infection were enrolled in the study. The sensitivity and specificity of in-house PCR performed on blood samples was found to be 92.5% and 81.4% respectively for diagnosis of probable IA, and 65% and 84.62% respectively for diagnosis of proven and probable IM. It was also able to detect 3 out of 5 cases of possible IM where no other microbiological evidence of IM was obtained.ConclusionsThis assay could be helpful in minimally invasive diagnosis of IMIs for patients in whom invasive sampling is not feasible, especially as a preliminary or screening test. It can help in early diagnosis, anticipating conventional laboratory confirmation by days or weeks. Possible correlation between fungal load and mortality can help in initiating aggressive treatment for patients with high initial fungal load.

Unusual fungi, encountered infrequently in practice, present a significant diagnostic challenge, leading to potential delays in diagnosis and treatment. This study aims to describe a number of cases, where infections were caused by rare yeast pathogens. Organisms isolated included rare Candida species, Geotrichum, Lodderomyces and Trichosporon species. The mean duration of the outcome of the patients from microbiological diagnosis was 20 days. A total of 3 patients succumbed to their illness. This study aims to shed light on the varied clinical presentation and outcome of infections caused by rare yeast pathogens.

Rhino-orbital-cerebral mucormycosis (ROCM) is linked to uncontrolled diabetes, diabetic ketoacidosis, iron overload, corticosteroid therapy, and neutropenia. This study evaluated a commercial real-time PCR system's effectiveness in detecting Mucorales from nasal swabs in 50 high-risk patients. Nasal swab PCR showed 30% positivity, compared to 8% with KOH microscopy. Despite its improved sensitivity, nasal swab PCR has limitations, highlighting the importance of established sampling methods in mucormycosis diagnosis. Participants were predominantly male (64%), with diabetes (78%) and amphotericin B use (96%). Prior COVID-19 was 42%, with 30% positive for Mucorales by PCR, compared to 8% with KOH microscopy.

Objective The antifungal audit aimed to evaluate antifungal usage in a tertiary care center. It focused on patient profiles, the appropriateness of antifungal use, associated adverse drug reactions, reasons for suboptimal usage, and the economic burden caused by prolonged non-optimal antifungal use. Methodology Conducted at All India Institute of Medical Sciences, New Delhi, India from January 2019 to December 2020, the study evaluated systemic antifungal use in 100 hospitalized adults with invasive fungal infections. Data collected included patient characteristics, evidence of disease, antifungal agents used, drug ADRs, appropriateness, and economic impact. Antifungal use was assessed using a predefined score (score <10 considered non-optimal), and ideal therapy duration was calculated based on treatment guidelines (IDSA & ECIL). Results Optimal antifungal use was observed in 66.0 % of cases. Common reasons for non-optimal use included alternate drug selection (18 %), inappropriate dosage (12 %), lack of adjustment after microbiological results (14 %), and incorrect therapy duration (16 %). Targeted antifungal therapy was observed in 39 out of 100 patients, while pre-emptive antifungal therapy was used in 32 out of 100 patients. Voriconazole (35.1 %), caspofungin (23.1 %), and liposomal amphotericin B (20.1 %) were commonly prescribed. Liposomal amphotericin B had the highest adverse reaction rate (81.4 %). The total cost of antifungal therapy for 100 patients was ₹67,06,840 (approximately 80,350 $), with non-optimal prolonged therapy leading to an additional economic burden of ₹1,149,191 (approximately 13,841 $). Overall, 748 (39.7 %) day of therapy were non-optimal, contributing to 17.1 % of the total cost of antifungal therapy. Conclusion We observed non-optimal use of antifungal agents in 34 % of the study participants. The study results show that the antifungal audit enhances stewardship by pinpointing causes of non-optimal use, ensuring adherence to prescribing standards, optimizing clinical outcomes, and minimizing drug-related toxicities in tertiary care centres.

Introduction. Invasive mucormycosis (IM) is a potentially fatal infection caused by fungi of the order Mucorales. Histopathology, culture, and radiology are the mainstays of diagnosis, but they are not sufficiently sensitive, resulting in delayed diagnosis and intervention. Recent studies have shown that PCR-based techniques can be a promising way to diagnose IM. Hypothesis/Gap Statement. Early diagnosis of fungal infections using molecular diagnostic techniques can improve patient outcomes, especially in invasive mucormycosis. Aim. The aim of this study was to evaluate the utility of our in-house mould-specific real time PCR assay (qPCR) in comparison with the commercially available real time PCR (MucorGenius PCR), for the early diagnosis of mucormycosis in tissue samples from patients with suspicion of invasive mucormycosis (IM). This in-house assay can detect and distinguish three clinically relevant mould species, e.g. Aspergillus spp., Mucorales and Fusarium spp. in a single reaction with only one pair of primers, without the need for sequencing. Methodology. We enrolled 313 tissue samples from 193 patients with suspected IM in this prospective study. All cases were classified using EORTC/MSGERC guidelines. All samples were tested using traditional methods, in-house qPCR, and MucorGenius PCR. Results. Using direct microscopy as a gold standard, the overall sensitivity and specificity of in-house qPCR for detection of IM was 92.46% and 80% respectively, while that of the MucorGenius PCR was 66.67% and 90% respectively. However, co-infection of IM and IA adversely affected the performance of MucorGenius PCR in detection of IM. The in-house PCR detected Aspergillus spp. in 14 cases and Fusarium spp. in 4 cases which showed clinical and radiological features of fungal sinusitis. The in-house qPCR also performed better in detecting possible cases of IM. This aids early diagnosis and appropriate treatment to improve patient outcomes. Conclusion. Because the in-house PCR is not only sensitive and specific, but also entirely based on SYBR Green for detection of targets, it is less expensive than probe-based assays and can be used on a regular basis for the diagnosis of IM in resource-constrained settings. It can be used to distinguish between mucormycosis and fungal sinusitis caused by Aspergillus and Fusarium in high-risk patients, as well as to accurately detect Mucorales in fungal co-infection cases.

Abstract Background Fungi are ubiquitous in the environment, and for patients with risk factors, they can present as pathogens. Unusual fungi often pose a diagnostic challenge and when encountered in practice, albeit infrequently, can delay diagnosis and treatment. Methods Over a period of three years (2018-2020), such cases were followed up till death or discharge and all details were noted down. All patients were diagnosed to have invasive fungal disease according to the EORTC/MSG criteria. Species identification was performed using MALDI-TOF MS and antifungal susceptibility testing (AFST) was done using standard CLSI guidelines. Results A total of 14 cases of rare yeasts were noted out of a total of 155 infections due to yeasts. Among these 5 presented with fungemia and 9 with invasive fungal infections (IFI). Of the IFI clinical isolates, there were 2 pus samples and 7 sterile fluids. The majority of these 14 patients were male (11) and belonged to extremes of age (8). The risk factors included CKD (2), prior history of tuberculosis (2), CLD (1), congenital heart disease (2), and type 2 diabetes mellitus (1). Pathogens isolated were Candida guilliermondii (2), Candida pelliculosa (2), Lodderomyces elongisporus (1) from the blood samples, and Trichosporon asahii (6), Candida guilliermondii (1), Candida kefyr (1), and Geotrichum spp. (1) from the other samples. Certain Candida species showed higher MICs to azoles and echinocandins. Trichosporon and Geotrichum showed higher MICs to azoles. Unfortunately, half of the patients (7) received no antifungals. Of those who did, 4 received mono therapy with azoles or Amphotericin B, while other 3 received combination or sequential therapy with azoles, echinocandins and Amphotericin B. Of the 14 patients, 3 patients expired. The etiological agents in these cases were Candida pelliculosa (fungemia) and Trichosporon asahii (IFI, 2 cases). Conclusion This study aims to highlight the clinical presentation of uncommon yeasts, presenting both as bloodstream infections (BSI) and as invasive disease. Improved methods of detection will help us improve our diagnostic accuracy of uncommon pathogens. The clinician should liaise closely with the laboratory, and treatment should be instituted according to the AFST data. Disclosures All Authors: No reported disclosures.

Molecular diagnostic assays can expedite the diagnosis of fungal infections, and subsequently help in early interventions and appropriate management of patients. The aim of this study was to develop a single set of primers for a real-time quantitative polymerase chain reaction (qPCR) assay to detect and identify commonly reported, clinically relevant molds i.e., Aspergillus spp, Mucorales and Fusarium spp., up to genus level by melting curve analysis. This assay was evaluated in whole blood from patients with suspected invasive aspergillosis (IA), and in tissue biopsy, bronchoalveolar lavage (BAL) fluid and other site-specific samples from patients with suspected invasive mucormycosis (IM). The limit of detection (LoD) was determined as 10 copies/μl for all three molds. The mean coefficient of variation (CV) across all sets of intra- and inter-assay data was 0.63% (ranging from 0.42 to 1.56%), showing high reproducibility of the assay. Sensitivity and specificity of the assay were 93.3 and 97.1% respectively for diagnosis of IA, and 99.29 and 83.84% respectively for diagnosis of IM. Fusarium was not detected in any of the clinical samples included and the few laboratory confirmed cases of fusariosis did not meet the inclusion criteria of the study. Hence no ROC curve or cutoff value could be generated for the same. This newly developed qPCR assay therefore appears to be a promising tool in detection of IA and IM.

Abstract Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM Objectives To assess the diagnostic utility of MucorGenius® real-time PCR in tissue samples for the diagnosis of mucormycosis in patients suspected of having invasive mucormycosis (IM) during the second wave of the COVID-19 pandemic. Methods A total of 193 clinically suspected cases of IM presenting at our tertiary care center from May to July 2021 were included and defined as proven, probable, possible, or negative for invasive fungal disease (IFD) according to EORTC/MSGERC guidelines. One sample from each patient (nasal/sinus biopsy, nasal crust, or orbital tissue) was subjected to conventional methods for diagnosis of IM and MucorGenius® real-time PCR (hereafter called ‘the assay’). Results A total of 5 (1.92%), 124 (47.6%), and 44 (16.9%) cases respectively were classified as having proven, probable, and possible IM. The remaining 20 (7.69%) were classified as not having invasive fungal infections and were used as controls to calculate the specificity of the test. The majority of cases were classified as ‘probable’ because specimens received included biopsy from the nasal or sinus cavity. According to radiological findings, sino-nasal involvement was seen in 26/173 (15.02%), sino-orbital involvement in 122/173 (70.5%), and additional intracranial extension in 25/173 (14.4%) of the 173 cases of IM. Among 129 proven and probable cases, direct microscopy of samples showed only aseptate hyphae in 70 cases, and both aseptate and septate hyphae in 36 cases; the assay was positive in 53 and 13 of these cases respectively. In the remaining 23 cases, direct microscopy of samples showed only septate hyphae and the assay was negative. Additionally, the assay was able to detect the presence of Mucorales among 44 possible cases of IM in which direct microscopy of samples showed no fungal elements, but the patients displayed clinical and radiological features of IM and improved with antifungal therapy. The overall sensitivity and specificity of the assay were 63.21% and 90.48% respectively. The sensitivity of the assay in proven and probable cases of IM was 60% and 66.7% respectively, while specificity was 90% for both, using the presence of aseptate hyphae in direct microscopy as a gold standard. Sensitivity and specificity in possible cases were 27.27% and 90% respectively, using the presence of clinical and radiological features of IM and response to antifungal treatment as a reference. When sensitivity and specificity were determined independently in cases of mucormycosis and mixed infection (mucormycosis + aspergillosis), they increased to 75.71% and 90.48% respectively in the former, and both decreased to 38% in the latter. Conclusion The MucorGenius® real-time PCR performs well in detecting IM as a single infection, especially in cases of possible IM which are not detected by conventional methods. However, it is inefficient in detecting co-infections of invasive mucormycosis and aspergillosis, possibly because Aspergillus can suppress the growth of Mucorales. With further studies using the results to guide clinical intervention and measuring the impact on the outcome, it can be a useful tool to make an early diagnosis of mucormycosis in patients with a high index of clinical suspicion.

PURPOSE:This study was planned to determine the trends and susceptibility pattern of invasive pulmonary aspergillosis (IPA) in severely ill chronic obstructive pulmonary disease (COPD) patients admitted in pulmonary ward and ICU of our tertiary care centre.METHODS:Fifty COPD patients suspected of IPA from pulmonary ward and ICU from April 2017 to September 2018 were investigated. Samples were processed by standard methods, culture positive isolates were confirmed by MALDI-TOF MS and antifungal susceptibility testing was performed by microbroth dilution method.RESULTS:Twenty-two critically ill COPD patients were microbiologically positive for IA infection, of which 13 were classified as putative invasive aspergillosis. The most common comorbid illness associated was diabetes. A. flavus and A. fumigatus were the commonest species isolated. The minimum inhibitory concentration of the antifungals was low. Morbidity due to IPA in COPD patients was very high.CONCLUSIONS:Prevalence of IPA in the pulmonary ward and ICU was found to be 9.6%. MALDI-TOF seems to be a promising tool for aiding rapid identification especially for slow growing and non-sporulating fungi. Heightened awareness and suspicion for pulmonary mould infections along with early diagnosis can substantially alter the patient prognosis.

Abstract Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives To present details of a case series of fungal osteomyelitis initially misdiagnosed as disseminated tuberculosis, in pediatric patients with chronic granulomatous disease. Method Informed consent was obtained from the parents of three children (known cases of chronic granulomatous disease) with clinical features suggestive of chronic osteomyelitis. Clinical history was collected by interview and chart review. Samples were sent to the mycology laboratory for direct microscopy and fungal culture. Following a diagnosis of fungal osteomyelitis, antifungal therapy was administered and patients were monitored till discharge. Results First case: The first patient presented with fever, cough and progressive painful swelling over the left lower chest, and a past history of recurrent pneumonia and cervical lymphadenopathy, which were previously empirically treated with anti-tubercular therapy (ATT) and broad-spectrum antibiotics. Imaging revealed a soft tissue abscess with underlying rib osteomyelitis and pulmonary consolidation. Pus samples showed hyaline septate hyphae in direct microscopy and growth of Aspergillus nidulans in culture. The patient was successfully treated with intravenous voriconazole, which was switched to oral formulation on discharge. Second case: The second patient presented with fever and post-auricular swelling with multiple discharging sinuses, and a past history of fever and hilar lymphadenopathy, which were previously empirically treated with ATT and broad-spectrum antibiotics. Imaging revealed osteomyelitis involving mandible, temporal bone and skull base, with underlying sigmoid sinus thrombosis. Pus and tissue samples showed hyaline septate hyphae in direct microscopy and growth of Aspergillus fumigatus in culture. The patient was successfully treated with a combination of intravenous voriconazole and liposomal amphotericin B, and discharged on oral posaconazole. Third case: The third patient presented with progressive painful swelling over the right upper chest, and a past history of pneumonia, hemoptysis, and mediastinal lymphadenopathy, which were previously empirically treated with ATT and broad-spectrum antibiotics. During a previous hospitalization, imaging showed features suggestive of fungal pneumonia; BAL showed hyaline septate hyphae in direct microscopy and growth of Aspergillus fumigatus and Aspergillus flavus in culture, providing a diagnosis of fungal pneumonia which was treated with voriconazole and liposomal amphotericin B. During the present admission, imaging of the chest lesion revealed pus collection with underlying rib osteomyelitis, communicating with a cavity in the middle lobe of the right lung. FNAC from the lesion showed hyaline septate hyphae in direct microscopy but no growth in culture (probably due to previous antifungal therapy). The patient was successfully treated with a combination of intravenous voriconazole and liposomal amphotericin B, and discharged on oral posaconazole. Conclusions Fungal pneumonia and fungal osteomyelitis are often misdiagnosed as tuberculosis or bacterial infections, leading to unnecessary and ineffective ATT or broad-spectrum antibiotics. A high index of suspicion for fungal osteomyelitis is required in pediatric patients with a history of recurrent/chronic soft tissue infections, preceded by febrile episodes and/or pneumonia, especially if a diagnosis of chronic granulomatous disease (CGD) has already been established; if not, this characteristic clinical picture should in fact warrant evaluation for CGD.

BACKGROUND: The Sysmex XN-series hematology analyzers provide newer parameters including high fluorescence lymphocyte cell percentage (HFLC%) which correlates with the presence of atypical lymphocytes in peripheral blood. We aimed to analyze the sensitivity and specificity of HFLC% as a diagnostic tool and its association with serological status in diagnosed dengue patients and thereby establish a cutoff of HFLC% based on serology. Besides, we also wish to correlate HFLC% with thrombocytopenia in these patients. MATERIALS AND METHODS: A total of 1500 serum samples were subjected to serological evaluation for dengue. After excluding hematological malignancies and autoimmune disorders, the same day complete blood count parameters including HFLC% and platelet counts were collected retrospectively for 292 serologically positive dengue cases and 76 seronegative controls. RESULTS: Our result shows that in nonstructural 1 antigen-positive cases, a cutoff of >5.2% HFLC can have a sensitivity of 79.5% and specificity of 98.6%. We found a different cut off of HFLC% >3.2% (sensitivity 83.4%, specificity 98.6%) for the cases with only immunoglobulin M positivity and a cut off of HFLC% >2.6% (sensitivity 86.1%, specificity 96%) in the dual positive cases (immunoglobulin M with nonstructural 1 antigen). Besides, high HFLC% also shows a strong correlation with platelet count with a Spearman correlation coefficient of −0.6. CONCLUSIONS: The result of our study shows that a specific cutoff of HFLC% can not only help us to suspect dengue fever but also predict the risk of thrombocytopenia in already diagnosed dengue patients. The sensitivity and specificity of HFLC% varied with the serological status of the patients which depend on the days of fever on presentation.

Abstract Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives To discuss the occurrence and diagnosis of dematiaceous fungi as a causative organisms of fungal sinusitis in patients at a tertiary care center in North India. Since there is limited data on its prevalence, this study was aimed to know the non-Aspergillus causes of fungal sinusitis focusing on the dematiaceous fungi. Methods A total of 451 nasal biopsy samples, from the department of pulmonary medicine ward and ICU were received over a period of 3 years, from January 2019 to December 2021. The samples were subjected to conventional mycological diagnostic techniques including direct epifluorescence and light microscopy, culture on solid media and visual identification of growth in culture using lactophenol cotton blue mounts. Results Out of 451 samples, no fungi were isolated from 299 samples (66.29%), Aspergillus spp from 63 samples (13.96%), dematiaceous fungi from 10 samples (2.21%), and other fungi from 79 samples (17.5%). Among the dematiaceous fungi isolated, 7 isolates were identified as Alternaria spp. (70%) and 3 isolates were identified as Curvularia species (30%) and described. Conclusion Most reported cases of allergic and invasive sinusitis were attributed to Aspergillus spp. However, in the current study, dematiaceous ‘black’ fungi like Alternaria and Curvularia, were also identified as causes of fungal sinusitis in both immunocompromised and immunocompetent individuals, showing an increasing pathogenic spectrum. Hence a high index of clinical suspicion and appropriate laboratory diagnosis assists in initiating appropriate treatment such as surgical debridement, reducing immunosuppression, and antifungal treatment with newer azoles.

Abstract Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives Cryptococcus spp. is usually opportunistic pathogens affecting immunocompromised individuals causing meningitis primarily. Non-CNS presentations are a rare entity and we hereby present a series of 3 cases in the past 1 year (2021-2022). Methods Case records of the three patients were studied. Detailed history, demographic details, investigations, treatment were noted. Results Patient-1 was a 14-year-old girl who came with complaints of fever, pain, swelling, and restricted movements of the right wrist, elbow, and ankle joints with multiple subcutaneous swellings initially on the thigh followed by elbows, arms, and forearms. The swellings became hemorrhagic bullae bursting to form ulcers. She had a history of being treated 4 times for tuberculous lymphadenopathy. KOH-Calcofluor white mount of biopsy and pus aspirate samples showed circular yeast cells which were confirmed by cryptococcal antigen detection. All the samples had grown Cryptococcus neoformans on culture except blood, BAL, and CSF. She responded to Liposomal amphotericin-B drastically. Retesting of pus swabs from the ulcers after a week of antifungal therapy were negative for C. neoformans. Subcutaneous nodules and joint swellings decreased but she developed reactions to amphotericin B and was changed to fluconazole. She is on regular follow-up with no recurrence. Patient-2 was a 22-year-old male, a known case of Hodgkin Lymphoma stage 4 who underwent Autologous stem cell transplantation (ASCT) and was on immunosuppressants. He presented with fever, dyspnea, and cough which got worsened along with multiple cervical, hilar and abdominal lymphadenopathy. KOH-Calcofluor white mount of biopsy samples demonstrated circular yeast cells which were confirmed by cryptococcal antigen detection test of biopsy and BAL samples. Cryptococcus neoformans was grown on culture from all the samples. He succumbed to ARDS and cardiorespiratory arrest before any treatment could be initiated. Patient-3 was a 38-year-old female, known case of SLE with lupus nephritis, presented with intermittent fever, dyspnea, chest pain, decreased urinary output, and gradual swelling of the body starting from the face and progressing to the whole body. She further developed synpneumonic effusion, multiple erythematous tender papules over the right thigh, and cellulitis of the right lower limb. She was started on voriconazole in view of HRCT findings suggestive of fungal pneumonia. As galactomannan antigen test was negative, voriconazole was stopped. Pleural tap fluid flagged positive in Bactec and C. neoformans grown on subculture. Her condition worsened with septic shock and succumbed to the disease before any treatment could be initiated. Conclusion Subcutaneous, joint, and pulmonary involvement is rare, without a primary focus on the central nervous system. Culture and antigen detection can aid in early detection and hence early initiation of therapy.

Abstract Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives To report a case of Lodderomyces elongisporus fungemia in a late post-operative patient with the ventricular septal defect. Methods Informed consent was obtained from the parents of the child. Clinical history was collected. Routine biochemical tests were conducted. Blood samples were sent to the bacteriology and mycology laboratory for culture. Radiological examination of the head was done to ascertain the cause of neurological manifestations. Results An 11-year-old boy, previously diagnosed as a case of ventricular septal defect (VSD) and severe aortic regurgitation, had undergone VSD closure in December 2010 and aortic valve replacement in January 2011. He was discharged on oral anticoagulants. However, he did not follow up. In August 2018, he presented with fever and right-sided hemiparesis. Hemogram was within normal limits except for decreased hemoglobin. Bacteriological blood culture was sterile, but I.V. antibiotics were administered empirically. However, the patient started to have epileptic attacks and therefore was intubated and antiepileptics were administered. An NCCT of the head revealed a large intraparenchymal bleed. Echocardiography revealed intra-cardiac vegetation measuring 8 × 7 mm and moderate aortic regurgitation. Fungal blood culture inoculated in BACTEC Mycosis IC/F bottle flagged positive after 5 days of incubation. A smear and Gram stain from the same revealed budding yeast cells. Sub-culture was done on Sabouraud dextrose agar and HiCromeTM Candida Differential Agar, and blue-tinged colonies were observed on the latter. The isolate was identified as L. elongisporus when subjected to MALDI-TOF analysis. Identification was confirmed by sequencing the internal transcribed spacer (ITS) region of the ribosomal DNA. Antifungal susceptibility test was performed by broth microdilution as per CLSI guidelines. Antifungal therapy was initiated with liposomal amphotericin B, but he continued to have fever even after 1 week and consequently developed status epilepticus. CT scan of the brain revealed massive intracranial hemorrhage. Parents were advised neurosurgery, but they requested discharge against medical advice. The patient was lost to follow-up. Conclusions Lodderomyces elongisporus is a rare cause of invasive bloodstream infections and should not be ignored as a contaminant when isolated from sterile sites. It is often misidentified as Candida parapsilosis by conventional methods and commercially available systems but can be distinguished from it using chromogenic culture media and MALDI-TOF-MS. The current case report highlights the significance of L. elongisporus as a rare cause of invasive fungal infections, the difficulties faced in the identification of this pathogen, and the importance of newer diagnostic methods in identifying it.

Abstract Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM Objectives To establish a baseline of antifungal usage patterns (indication, duration, toxicity, and cost) and physician's knowledge of management of invasive fungal infections, as a basis for implementation of a multidisciplinary antifungal stewardship (AFS) program at a tertiary care center. Methods Data including clinical history, investigations, and antifungal therapy was collected by chart review and bedside rounds from 100 patients with laboratory-confirmed invasive fungal infections (IFIs). Requirement and adequacy of antifungal therapy were assessed in comparison with IDSA and EORTC/MSG guidelines and scored at discharge/death using the Valerio system. This system assigns points to six parameters: indication, optimal selection of antifungal agent, dosage according to individual characteristics, loading and maintenance dose, therapy adjustment after microbiological results, route of administration, and length of therapy. The maximum score (10) indicates appropriate therapy. Any score of ˂ 10 is classified as inappropriate. Results Out of 100 patients who met the criteria for IFI, 85 patients had a single IFI, 45 (52.9%) of whom received appropriate antifungal therapy, 17 (20%) received other than the recommended antifungal therapy and 23 (27.1%) received no antifungals. A total of 15 patients had dual IFIs, 10 (66.7%) of whom received other than the recommended antifungal therapy for one or both infections, 1 (6.7%) was treated appropriately for one infection but left untreated for the other, 2 (13.4%) patients were untreated for both infections and 2 (13.4%) were appropriately treated for both infections. The most common types of inappropriate antifungal use were inappropriate antifungal for organism (16 incidents), inadequate dosage (11 incidents), inappropriate antifungal for site (6 incidents), inadequate duration (6 incidents), and failure to adjust antifungal therapy based on microbiological test results (6 incidents). Common reasons observed for inappropriate antifungal use were delay in starting antifungal therapy or in ordering appropriate tests for establishing diagnosis, uncertainty in distinguishing fungal pathogens from colonisers, lack of rigorous antifungal charting, unavailability of first-line drug, and attempts to use a single antifungal to cover dual IFIs. Conclusions There are several inadequacies in Valerio scoring system, i.e., no weightage given to timely initiation of treatment, no deductions for delay in starting treatment once reports have been received, or for use of unnecessary antifungals in addition to recommended ones. Antifungals are often chosen by organism only while ignoring site-specific action and penetration of the drug. There is no comprehensive system for recording antifungal use, making it difficult to ascertain cumulative antifungal use over time. Direct association could not be made between inappropriate antifungal use and outcome as most patients had multiple comorbidities apart from fungal infection. Where fungal infection occurs along with TB, fungi are often considered commensals and left untreated. Many immunocompetent patients with IFIs are ‘unclassifiable’, ie, cannot be categorized under existing guidelines. Even for ‘classifiable’ patients, there is considerable subjectivity in antifungal treatment guidelines. There is a need for a standardized algorithm-based treatment at institutional level for these groups of patients.

The epidemiology of invasive fungal infections (IFI) is ever evolving. The aim of the present study was to analyze the clinical, microbiological, susceptibility, and outcome data of IFI in Indian patients to identify determinants of infection and 30-day mortality. Proven and probable/putative IFI (defined according to modified European Organization for Research and Treatment of Cancer/Mycoses Study Group and AspICU criteria) from April 2017 to December 2018 were evaluated in a prospective observational study. All recruited patients were antifungal naïve (n = 3300). There were 253 episodes of IFI (7.6%) with 134 (52.9%) proven and 119 (47%) probable/putative infections. There were four major clusters of infection: invasive candidiasis (IC) (n = 53, 20.9%), cryptococcosis (n = 34, 13.4%), invasive aspergillosis (IA) (n = 103, 40.7%), and mucormycosis (n = 62, 24.5%). The significant risk factors were high particulate efficiency air (HEPA) room admission, ICU admission, prolonged exposure to corticosteroids, diabetes mellitus, chronic liver disease (CLD), acquired immunodeficiency syndrome (AIDS), coronary arterial disease (CAD), trauma, and multiorgan involvement (p < 0.5; odds ratio: >1). The all-cause 30-day mortality was 43.4% (n = 110). It varied by fungal group: 52.8% (28/53) in IC, 58.8% (20/34) in cryptococcosis, 39.8% (41/103) in IA, and 33.9% (21/62) in mucormycosis. HEPA room, ICU admission for IC; HEPA rooms, diabetes mellitus for cryptococcosis; hematological malignancies, chronic kidney disease (CKD), sepsis, galactomannan antigen index value ≥1 for IA and nodules; and ground glass opacities on radiology for mucormycosis were significant predictors of death (odds ratio >1). High minimum inhibitory concentration (MIC) values for azoles were observed in C. albicans, C. parapsilosis, C. glabrata, A. fumigatus, A. flavus, R. arrhizus, R. microsporus, and M. circinelloides. For echinocandin, high MIC values were seen in C. tropicalis, C. guillermondii, C. glabrata, and A. fumigatus. This study highlights the shift in epidemiology and also raises concern of high MICs to azoles among our isolates. It warrants regular surveillance, which can provide the local clinically correlated microbiological data to clinicians and which might aid in guiding patient treatment.

Abstract Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM Objectives Mucormycosis is an aggressive, life-threatening infection caused by fungi in the order Mucorales. There was an explosion of new cases of rhino-sino-orbital mucormycosis following the COVID pandemic in India, and the need for easy and rapid diagnostics was felt. The current diagnosis of mucormycosis relies on mycological cultures, radiology, and histopathology. These methods lack sensitivity and are most definitive later in the course of infection, resulting in the failure of timely intervention. A real-time multiplex PCR platform is commercially available for the detection of Rhizopus spp., Mucor spp. Rhizomucor spp., Lichtheimia spp., and Cunninghamella spp. (PN-700, MucorGenius®, PathoNostics®, Maastricht, The Netherlands) This real-time PCR has been validated to identify these fungal pathogens from bronchoalveolar lavage, tissue, and serum samples. This study aimed to validate this PCR-based system to detect Mucorales from nasal swab samples and evaluate its utility in the detection of Mucorales from nasal cavities of high-risk patients developing signs and symptoms of mucormycosis. Methods A single-center cross-sectional observational study was conducted on 50 hospitalized adult patients with signs and symptoms of mucormycosis. Nasal swabs were taken for PCR analysis once there was a clinical suspicion and were compared with the results of the gold standard. The gold standard for the diagnosis of mucormycosis was the conventional method (KOH mounted microscopy/HPE). Demographic details and risk factors for these patients were recorded, and the RTPCR-based test was run on the nasal swab samples of all these 50 patients. The workflow is depicted graphically in Fig. 1 (Created with BioRender.com). Results The study population mean (SD) age was 50 (16) years and consisted of 32 (64%) males. A total of 39 (78%) patients were known cases of diabetes mellitus, 48 (96%) patients had amphotericin B intake, and 20 (40%) had posaconazole intake. In all, 21 (42%) patients had a past history of COVID-19 infection; 14 patients had received steroids and 10 patients received oxygen support. PCR for Mucorales was positive in 15 (30%) patients while the KOH mount was positive in 4 (8%) patients. Conclusion These results are not encouraging for the use of nasal swabs as the sample for diagnosis of mucormycosis. Though the PCR performed better on the swab samples than KOH preparation and culture techniques, it highlights the importance of using standard sampling methods.