The epidemiology of invasive fungal disease (IFD) due to filamentous fungi other than Aspergillus may be changing. We analysed clinical, microbiological and outcome data in Australian patients to determine the predisposing factors and identify determinants of mortality. Proven and probable non-Aspergillus mould infections (defined according to modified European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria) from 2004 to 2012 were evaluated in a multicentre study. Variables associated with infection and mortality were determined. Of 162 episodes of non-Aspergillus IFD, 145 (89.5%) were proven infections and 17 (10.5%) were probable infections. The pathogens included 29 fungal species/species complexes; mucormycetes (45.7%) and Scedosporium species (33.3%) were most common. The commonest comorbidities were haematological malignancies (HMs) (46.3%) diabetes mellitus (23.5%), and chronic pulmonary disease (16%); antecedent trauma was present in 21% of cases. Twenty-five (15.4%) patients had no immunocompromised status or comorbidity, and were more likely to have acquired infection following major trauma (p <0.01); 61 (37.7%) of cases affected patients without HMs or transplantation. Antifungal therapy was administered to 93.2% of patients (median 68 days, interquartile range 19-275), and adjunctive surgery was performed in 58.6%. The all-cause 90-day mortality was 44.4%; HMs and intensive-care admission were the strongest predictors of death (both p <0.001). Survival varied by fungal group, with the risk of death being significantly lower in patients with dematiaceous mould infections than in patients with other non-Aspergillus mould infections. Non-Aspergillus IFD affected diverse patient groups, including non-immunocompromised hosts and those outside traditional risk groups; therefore, definitions of IFD in these patients are required. Given the high mortality, increased recognition of infections and accurate identification of the causative agent are required.

Mucormycosis is the second most common cause of invasive mould infection and causes disease in diverse hosts, including those who are immuno-competent. We conducted a multicentre retrospective study of proven and probable cases of mucormycosis diagnosed between 2004-2012 to determine the epidemiology and outcome determinants in Australia. Seventy-four cases were identified (63 proven, 11 probable). The majority (54.1%) were caused by Rhizopus spp. Patients who sustained trauma were more likely to have non-Rhizopus infections relative to patients without trauma (OR 9.0, p 0.001, 95% CI 2.1-42.8). Haematological malignancy (48.6%), chemotherapy (42.9%), corticosteroids (52.7%), diabetes mellitus (27%) and trauma (22.9%) were the most common co-morbidities or risk factors. Rheumatological/autoimmune disorders occurred in nine (12.1%) instances. Eight (10.8%) cases had no underlying co-morbidity and were more likely to have associated trauma (7/8; 87.5% versus 10/66; 15.2%; p <0.001). Disseminated infection was common (39.2%). Apophysomyces spp. and Saksenaea spp. caused infection in immuno-competent hosts, most frequently associated with trauma and affected sites other than lung and sinuses. The 180-day mortality was 56.7%. The strongest predictors of mortality were rheumatological/autoimmune disorder (OR = 24.0, p 0.038 95% CI 1.2-481.4), haematological malignancy (OR = 7.7, p 0.001, 95% CI 2.3-25.2) and admission to intensive care unit (OR = 4.2, p 0.02, 95% CI 1.3-13.8). Most deaths occurred within one month. Thereafter we observed divergence in survival between the haematological and non-haematological populations (p 0.006). The mortality of mucormycosis remains particularly high in the immuno-compromised host. Underlying rheumatological/autoimmune disorders are a previously under-appreciated risk for infection and poor outcome.

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Most antibiotic use in Australia arises from prescriptions in the community. The risk of antibiotic-related adverse events, including resistance, increases with longer treatment courses. When antibiotics are indicated for treatment, short courses are as effective as standard ones for most common infections. Therapeutic Guidelines: Antibiotic is a key reference for antimicrobial prescribing in Australia. General practitioners play a key role in reducing antibiotic use. Antibiotic. 8 While other resources are commonly used, such as the Australian Medicines Handbook and MIMS, it is Therapeutic Guidelines that offers comprehensive information on the clinical indications for antibiotic prescription and advice on antibiotic choice, dose and duration. It is also the guideline currently endorsed by the Australian Commission on Safety and Quality in Health Care as the preferred reference for prescribing in the absence of local guidelines. Antimicrobials are not always needed Antibiotics are not necessary for most acute respiratory infections including acute rhinosinusitis, acute sore throat and acute otitis media. This is not just because so many of these infections are viral, but because even when the infection is bacterial, the benefits of antibiotic therapy for most patients are modest and outweighed by the harm from adverse effects. 9-12 Australian and local guidelines provide recommendations on when antimicrobial therapy should be used for these conditions. 8,13

Lodderomyces elongisporus has been recently identified in the literature as an infrequent human bloodstream isolate, commonly mistaken for a non-albicans Candida. A case of Lodderomyces endocarditis in an intravenous drug user is described. To our knowledge, this report highlights the first documented case of Lodderomyces as a cause of endocarditis and summarizes the susceptibility patterns in the reported literature. All isolates reported so far have fluconazole MICs of ¡0.25 mg ml "1 . Case reportA 30-year-old male carpenter presented febrile to a hospital emergency department with associated recurrent swelling of his left forefoot. He had experienced a week of night sweats and rigors and no history of foot trauma. He had sought medical treatment in primary care for his foot symptoms in the preceding weeks prior to the commencement of the night sweats. The presumptive diagnosis had been a soft tissue injury and was treated symptomatically with no improvement.His past medical history included depression and claustrophobia. He was known to have a pre-existing cardiac murmur that had never been investigated. He was an intravenous heroin user, cigarette smoker and social drinker. He injected primarily via his left cubital fossa and occasionally the venous networks on the dorsal surfaces of his hands. He last admitted to intravenous drug use 8 weeks prior to presentation. His medications included oral quetiapine and he had no allergies.Vital signs on admission were as follows: temperature 38.4 u C, pulse rate regular at 102 beats min 21 , blood pressure of 102/ 74 and respiratory rate of 18 respirations min 21 . Examination revealed an ejection systolic murmur and oedema localized to the left ankle region associated with full range of movement. There were no peripheral stigmata of endocarditis, neurological abnormalities or cardiac failure.Three sets of blood cultures in addition to standard bloods were taken from two different sites (BacT/ALERT; bioMérieux). The aerobic bottles of all sets flagged positive after approximately 40 h (range 37.6-43.8 h). Yeast was seen on microscopy. Preliminary identification was that of a non-albicans Candida after growth on Sabouraud Dextrose Agar, a negative germ tube test and subsequent isolation of blue/green colonies on CHROMagar Candida media (BD Diagnostics). The isolate was referred to a reference laboratory for definitive identification. A further two sets of blood cultures taken 2 days later also flagged positive prior to the commencement of antifungal agents. He was empirically commenced on caspofungin whilst awaiting further investigations and results. Blood cultures taken 48 h after therapy was commenced had no growth.A transoesophageal echo was performed and demonstrated a bicuspid aortic valve with mild stenosis and aortic regurgitation. Bulky lesions up to 1 cm were attached to both leaflet margins. An MRI of his brain revealed right frontal and left parietal hyperintense lesions on the T2 weighted images consistent with presumed embolic lesions. A bone scan was con...

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Background The high burden of infectious disease and associated antimicrobial use likely contribute to the emergence of antimicrobial resistance in remote Australian Aboriginal communities. We aimed to develop and apply context-specific tools to audit antimicrobial use in the remote primary healthcare setting. Methods We adapted the General Practice version of the National Antimicrobial Prescribing Survey (GP NAPS) tool to audit antimicrobial use over 2–3 weeks in 15 remote primary healthcare clinics across the Kimberley region of Western Australia (03/2018–06/2018), Top End of the Northern Territory (08/2017–09/2017) and far north Queensland (05/2018–06/2018). At each clinic we reviewed consecutive clinic presentations until 30 presentations where antimicrobials had been used were included in the audit. Data recorded included the antimicrobials used, indications and treating health professional. We assessed the appropriateness of antimicrobial use and functionality of the tool. Results We audited the use of 668 antimicrobials. Skin and soft tissue infections were the dominant treatment indications (WA: 35%; NT: 29%; QLD: 40%). Compared with other settings in Australia, narrow spectrum antimicrobials like benzathine benzylpenicillin were commonly given and the appropriateness of use was high (WA: 91%; NT: 82%; QLD: 65%). While the audit was informative, non-integration with practice software made the process manually intensive. Conclusions Patterns of antimicrobial use in remote primary care are different from other settings in Australia. The adapted GP NAPS tool functioned well in this pilot study and has the potential for integration into clinical care. Regular stewardship audits would be facilitated by improved data extraction systems.

Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.