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Biyun L, Yahui H, Yuanfang L, Xifeng G, Dao W. Risk factors for invasive fungal infections after haematopoietic stem cell transplantation: a systematic review and meta-analysis. Clin Microbiol Infect 2024; 30:601-610. [PMID: 38280518 DOI: 10.1016/j.cmi.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Invasive fungal infections (IFIs) are common infectious complications after haematopoietic stem cell transplantation (HSCT), seriously threatening the survival of patients. OBJECTIVES This systematic review aimed to investigate risk factors associated with IFIs following HSCT. METHODS Two authors independently conducted the selection of studies and extraction of data. Risk factors for IFIs, invasive aspergillosis or invasive mould infections and invasive candida infection after HSCT were compiled separately by meta-analysis using RevMan 5.4 and R language 4.1.2. DATA SOURCES Pubmed, EMBASE, Web of Science, and the Cochrane Library until April 2023. STUDY ELIGIBILITY CRITERIA Case-control or cohort studies that assessed risk factors for IFIs among HSCT recipients were included. PARTICIPANTS Patients experiencing HSCT. TEST/S None. REFERENCE STANDARD The IFIs were defined according to the European Organisation for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG) criteria, or a similar definition. ASSESSMENT OF RISK OF BIAS A modified version of the Newcastle-Ottawa Scale was used. METHODS OF DATA SYNTHESIS A random-effects model with the Mantel-Haenszel method was used to pool results from primary studies. RESULTS Out of 1637 studies screened, 51 studies involving 109 155 patients were included, with 45 studies providing adequate data for meta-analysis. Identified risk factors for IFIs included prolonged neutropenia, intensified therapy for graft-versus-host disease (GVHD), previous transplantation, previous proven or probable IFI, acute GVHD ≥ grade II, extensive or severe chronic GVHD, use of anti-thymocyte globulin during transplantation, haploidentical transplantation, high-dose glucocorticoids, Epstein-Barr virus infection, cytomegalovirus infection or reactivation, and lower albumin. Conversely, antifungal prophylaxis emerged as the sole preventive factor. For invasive aspergillosis or invasive mould infections, the top risk factors were extensive or severe chronic GVHD, respiratory viral infection, high-dose glucocorticoids, acute GVHD ≥ grade II, and human leukocyte antigen mismatch. Cord blood transplantation was the sole significant risk factor for invasive candidiasis. However, there was likely a high degree of interdependence among various risk factors. DISCUSSION This meta-analysis provides a thorough review of risk factors for IFIs infection after HSCT. The achieved insights can aid in stratifying patients who are at an elevated risk of IFIs and promoting antifungal preventive strategies.
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Affiliation(s)
- Li Biyun
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Han Yahui
- Department of Pediatric Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Yuanfang
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guo Xifeng
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wang Dao
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Zoowa R, Shah R, Pradhan D, Karmacharya S, Bhandari D. Candida krusei pneumonia in graft-versus-host disease after allogeneic hematopoietic stem cell transplant for paroxysmal nocturnal hemoglobinuria: a case report. Ann Med Surg (Lond) 2023; 85:6168-6172. [PMID: 38098551 PMCID: PMC10718395 DOI: 10.1097/ms9.0000000000001374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/24/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction and importance Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder caused by a somatic mutation of PIGA (phosphatidylinositol glycan anchor biosynthesis, class A) gene that leads to the destruction of blood cells. Allogeneic haematopoietic stem cell transplant (HSCT) is a treatment option for PHN, but it can cause graft-versus-host disease (GVHD). Long-term immunosuppression as a treatment of GVHD increases the risk for invasive fungal infections such as Candida krusei pneumonia. Case presentation We present the case of a 22-year-old male with C. krusei pneumonia in a known case of chronic GVHD following HSCT for PNH undergoing long-term immunosuppressive therapy. The patient presented with progressive shortness of breath, productive cough, palpitations, and difficulty swallowing. On examination, he had skin rashes and oral lesions, along with signs of severe malnutrition. Diagnosis was made on the basis of radiological imaging and fungal culture. Discussion The combination of PNH, GVHD, and HSCT created an immunocompromised state, making the patient susceptible to opportunistic infections, including fungal pneumonia. Early recognition of this condition is challenging due to its non-specific symptoms and potential overlap with other post-transplant complications. Timely diagnosis and appropriate treatment, including antifungal therapy and immunosuppression management, are crucial for optimising patient outcomes. Conclusion This case highlights the importance of early recognition and timely treatment of fungal infections in patients with severe conditions such as GVHD following HSCT for PNH. Timely treatment with appropriate antifungals is necessary for optimal outcomes. Additionally, more research with long-term follow-up and monitoring is necessary to address the necessary knowledge gaps in this field.
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Affiliation(s)
- Ronit Zoowa
- Nepalese Army Institute of Health Sciences, Sanobharyang
| | - Ravi Shah
- Nepalese Army Institute of Health Sciences, Sanobharyang
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O'Keeffe JC, Singh N, Slavin MA. Approach to diagnostic evaluation and prevention of invasive fungal disease in patients prior to allogeneic hematopoietic stem cell transplant. Transpl Infect Dis 2023; 25 Suppl 1:e14197. [PMID: 37988269 DOI: 10.1111/tid.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/15/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
In recent years, advancements in the treatment landscape for hematological malignancies, such as acute myeloid leukemia and acute lymphoblastic leukemia, have significantly improved disease prognosis and overall survival. However, the treatment landscape is changing and the emergence of targeted oral therapies and immune-based treatments has brought forth new challenges in evaluating and preventing invasive fungal diseases (IFDs). IFD disproportionately affects immunocompromised hosts, particularly those undergoing therapy for acute leukemia and allogeneic hematopoietic stem cell transplant. This review aims to provide a comprehensive overview of the pretransplant workup, identification, and prevention of IFD in patients with hematological malignancy. The pretransplant period offers a critical window to assess each patient's risk factors and implement appropriate prophylactic measures. Risk assessment includes evaluation of disease, host, prior treatments, and environmental factors, allowing a dynamic evaluation that considers disease progression and treatment course. Diagnostic screening, involving various biomarkers and radiological modalities, plays a crucial role in early detection of IFD. Antifungal prophylaxis choice is based on available evidence as well as individual risk assessment, potential for drug-drug interactions, toxicity, and patient adherence. Therapeutic drug monitoring ensures effective antifungal stewardship and optimal treatment. Patient education and counselling are vital in minimizing environmental exposures to fungal pathogens and promoting medication adherence. A well-structured and individualized approach, encompassing risk assessment, prophylaxis, surveillance, and patient education, is essential for effectively preventing IFD in hematological malignancies, ultimately leading to improved patient outcomes and overall survival.
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Affiliation(s)
- Jessica C O'Keeffe
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nikhil Singh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Department of Pharmacy, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Monica A Slavin
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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4
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Matsumi S, Kimura SI, Nakamura Y, Kawamura M, Takeshita J, Kawamura S, Yoshino N, Misaki Y, Yoshimura K, Gomyo A, Okada Y, Akahoshi Y, Tamaki M, Kusuda M, Kameda K, Wada H, Tanihara A, Sato M, Nakasone H, Kako S, Kanda Y. Substitution of calcineurin inhibitors with corticosteroids after allogeneic hematopoietic cell transplantation. Int J Hematol 2023; 118:450-461. [PMID: 37480446 DOI: 10.1007/s12185-023-03645-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 07/24/2023]
Abstract
Combination of calcineurin inhibitors (CIs) with short-term methotrexate is a standard prophylactic regimen for graft-versus-host disease (GVHD). However, it is sometimes difficult to continue CIs due to adverse effects, such as renal impairment and fluid overload. In such cases, we replace CIs with corticosteroids, considering that full dose of CIs is equivalent to prednisolone (PSL) at 1 mg/kg. We retrospectively evaluated the clinical significance of replacement of CIs with corticosteroids after allogeneic hematopoietic cell transplantation (HCT). We evaluated 42 patients switched from CIs to corticosteroids within 90 days among the 479 patients who underwent allogeneic HCT at our center between 2007 and 2019. Renal impairment (n = 33), fluid overload (n = 13), and thrombotic microangiopathy (n = 3) were the main reasons for switching. Although creatinine and body weight returned to baseline at 4 weeks after switching, 100-day non-relapse mortality was high (57.1%). Grade II-IV acute GVHD was seen in 10 (24.4%) patients who did not have it before switching treatment (n = 41). In conclusion, CIs were switched to corticosteroids in patients with severe clinical conditions. The incidence of acute GVHD was acceptable. Although the short-term mortality rate was high, improvement of renal function or fluid overload was observed in a certain proportion of the patients.
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Affiliation(s)
- Shimpei Matsumi
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yuhei Nakamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Masakatsu Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Junko Takeshita
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Shunto Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Nozomu Yoshino
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yukiko Misaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Kazuki Yoshimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Ayumi Gomyo
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yosuke Okada
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yu Akahoshi
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Masaharu Tamaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Machiko Kusuda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Kazuaki Kameda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Hidenori Wada
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Aki Tanihara
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Miki Sato
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama, 330-8503, Japan.
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Gavriilaki E, Dolgyras P, Dimou-Mpesikli S, Poulopoulou A, Evangelidis P, Evangelidis N, Demosthenous C, Zachrou E, Siasios P, Mallouri D, Vardi A, Bousiou Z, Panteliadou A, Batsis I, Masmanidou M, Lalayanni C, Yannaki E, Sotiropoulos D, Anagnostopoulos A, Vyzantiadis TA, Sakellari I. Risk Factors, Prevalence, and Outcomes of Invasive Fungal Disease Post Hematopoietic Cell Transplantation and Cellular Therapies: A Retrospective Monocenter Real-Life Analysis. Cancers (Basel) 2023; 15:3529. [PMID: 37444639 DOI: 10.3390/cancers15133529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
(1) Background: Autologous, allogeneic hematopoietic cell transplantation (HCT) and other cellular therapies, including CAR T cell and gene therapy, constitute a cornerstone in the management of various benign and malignant hematological disorders. Invasive fungal infections (IFD) remain a significant cause of morbidity and mortality in HCT recipients. Therefore, we investigated the prevalence and risk factors of IFD following HCT and other cellular therapies in an era of novel antifungal prophylaxis. (2) Methods: In this study, we retrospectively enrolled adult HCT recipients who were treated at our JACIE-accredited center according to standard operating procedures over the last decade (2013-2022). (3) Results: 950 patients who received cellular therapies were studied. None of the 19 CAR T cell and neither of the two gene therapy recipients developed IFD whereas 3/456 autologous HCT recipients who suffered from primary refractory/relapsed lymphomas presented with probable IFD. Overall, 11 patients who received allogeneic HCT experienced probable IFD, possible IFD was found in 31/473, and IFD was proven in 10/473. A second IFD episode was present in three patients. Four-year OS was significantly lower in proven compared to probable IFD (p = 0.041) and was independently associated with HCT-CI (p = 0.040) and chronic GVHD (p = 0.045). (4) Conclusions: In this real-world cohort, the prevalence of proven and probable IFD in an era of novel antifungal prophylaxis was found to be relatively low. However, IFDs were associated with poor outcomes for patients who received allogeneic HCT.
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Affiliation(s)
- Eleni Gavriilaki
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Panagiotis Dolgyras
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Sotiria Dimou-Mpesikli
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Aikaterini Poulopoulou
- Department of Microbiology, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Paschalis Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Nikolaos Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Christos Demosthenous
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Evangelia Zachrou
- Department of Microbiology, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Panagiotis Siasios
- Department of Microbiology, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Despina Mallouri
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Anna Vardi
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Zoi Bousiou
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Alkistis Panteliadou
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Ioannis Batsis
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Marianna Masmanidou
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Chrysavgi Lalayanni
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Evangelia Yannaki
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Damianos Sotiropoulos
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | - Achilles Anagnostopoulos
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
| | | | - Ioanna Sakellari
- Bone Marrow Transplantation Unit, Haematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
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Jaime-Pérez JC, Meléndez-Flores JD, Ramos-Dávila EM, Gutiérrez-Aguirre CH, Cantú-Rodríguez OG, Marfil-Rivera LJ, Áncer-Rodríguez J, Gómez-Almaguer D. Infection-related mortality after HLA-identical and haploidentical hematopoietic cell transplantation using reduced-intensity conditioning in an outpatient setting. Clin Transplant 2023:e14972. [PMID: 36943871 DOI: 10.1111/ctr.14972] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/03/2023] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Despite the improvements in supportive care for allogeneic-hematopoietic cell transplantation (allo-HCT) recipients, infectious complications and infection-related mortality (IRM) continue to be a major issue for transplantation centers. METHODS We herein report the infectious complications and IRM of 107 and 89 patients that underwent haploidentical (haplo-HCT) or HLA-identical HCT at a tertiary referral center during 2013-2020. Patients in the haplo-HCT group received post-transplant cyclophosphamide (PT-Cy), and all received reduced-intensity conditioning regimens. RESULTS More haplo-HCT recipients presented severe infections in the pre-engraftment period (22.4% vs. 6.7%, p = 0.003). Viral (14.9% vs. 4.5%, p = 0.016) and fungal (12.1% vs. 1.1%, p = 0.003) etiologies were more common in this period in this group. The 100-day and 2-year cumulative incidence of IRM was 15% and 21% for the haplo-HCT and 5.6% and 17% for the HLA-identical group; no significant differences were observed between the groups. Fungal pathogens mainly contributed to IRM (33.3%). Infections were the most common cause of mortality (40/81, 49.4%). There were significant differences in donor/recipient CMV serostatus between transplant groups (0.002). CONCLUSIONS No differences in IRM were observed based on allo-HCT type, with more haplo-HCT patients suffering from severe infections in the pre-engraftment period. Studies to assess future prevention, diagnostic, and treatment strategies to reduce IRM are warranted.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Jesús D Meléndez-Flores
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Eugenia M Ramos-Dávila
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - César Homero Gutiérrez-Aguirre
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Olga G Cantú-Rodríguez
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Luis Javier Marfil-Rivera
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Jesús Áncer-Rodríguez
- Pathology Department, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - David Gómez-Almaguer
- Hematology Department, Internal Medicine Division, Dr. José Eleuterio González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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Zhang Y, Lu X, Tang LV, Xia L, Hu Y. Nanopore-Targeted Sequencing Improves the Diagnosis and Treatment of Patients with Serious Infections. mBio 2023; 14:e0305522. [PMID: 36651731 PMCID: PMC9979620 DOI: 10.1128/mbio.03055-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/20/2022] [Indexed: 01/19/2023] Open
Abstract
Serious infections are characterized by rapid progression, poor prognosis, and difficulty in diagnosis. Recently, a new technique known as nanopore-targeted sequencing (NTS) was developed that facilitates the rapid and accurate detection of pathogenic microorganisms and is extremely suitable for patients with serious infections. The aim of our study was to evaluate the clinical application of NTS in the diagnosis and treatment of patients with serious infections. We developed an NTS technology that could detect microorganisms within a 6-h window based on the amplification of the 16S rRNA gene of bacteria, the internal transcribed spacer region of fungi, and the rpoB gene of Mycobacterium. The NTS detection results were compared with those of blood cultures and anal swabs from 50 patients with blood diseases suffering serious infections. The patient's condition before and after NTS was compared. The response rate and the infection-related mortality after the adjustment of antibiotics based on NTS were calculated. The positivity rate of pathogens was highest in NTS (90%), followed by blood culture (32.6%) and anal swabs (14.6%). After adjusting antibiotics for bacteria and fungi detected by NTS, the patients' condition improved significantly. Moreover, the response rate of anti-infective treatment based on NTS was 93.02% (40/43), and infection-related mortality was reduced to 0. NTS is an effective method to identify pathogens in the blood specimens of patients with serious infections and can guide anti-infection treatment and reduce infection-related mortality. IMPORTANCE We introduce the application of NTS in blood samples of patients with serious infections and expound the efficiency and accuracy of NTS in detecting pathogenic microorganisms. Our work builds on the considerable interest of the scientific community in the management of serious infection. This issue is becoming more pressing, especially since the incidence of blood diseases is increasing year by year and hematopoietic stem cell transplantation (HSCT) has been widely used in benign and malignant blood diseases in recent years. The infection progression of these patients is faster, and the study further demonstrates the effectiveness of NTS in guiding the diagnosis and treatment of patients with severe infections. We firmly believe that this method will guide clinicians to adjust anti-infection strategies and bring significant benefits to patients, and our study will have implications for the future clinical application of NTS in all kinds of patients with serious infections.
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Affiliation(s)
- Yi Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuan Lu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang V. Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Linghui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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8
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Early pulmonary complications related to cancer treatment in children. Pediatr Radiol 2022; 52:2017-2028. [PMID: 35778572 DOI: 10.1007/s00247-022-05403-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/01/2022] [Accepted: 05/14/2022] [Indexed: 10/17/2022]
Abstract
In this review, we summarize early pulmonary complications related to cancer therapy in children and highlight characteristic findings on imaging that should be familiar to a radiologist reviewing imaging from pediatric cancer patients.
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Herpesvirus Screening in Childhood Hematopoietic Transplant Reveals High Systemic Inflammation in Episodes of Multiple Viral Detection and an EBV Association with Elevated IL-1β, IL-8 and Graft-Versus-Host Disease. Microorganisms 2022; 10:microorganisms10081685. [PMID: 36014102 PMCID: PMC9414306 DOI: 10.3390/microorganisms10081685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/14/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Infections remain a major cause of morbidity and mortality among hematopoietic stem cell transplant (HSCT) recipients. Unlike Epstein–Barr Virus (EBV) and Human Cytomegalovirus (HCMV), Human Herpesvirus (HHV) 6, HHV7 and HHV8 are not routinely monitored in many centers, especially in the pediatric population of low–medium income countries. We screened EBV, HCMV, HHV6, HHV7 and HHV8 in 412 leukocytes-plasma paired samples from 40 pediatric patients assisted in a tertiary hospital in Mexico. Thirty-two underwent allo-HSCT, whereas eight received auto-HSCT. Overall viral detection frequencies in allo- and auto-HSCT were: EBV = 43.7% and 30.0%, HCMV = 5.0% and 6.7%, HHV6 = 7.9% and 20.0% and HHV7 = 9.7% and 23.3%. HHV8 was not detected in any sample. Interestingly, HHV6 and HHV7 were more frequent in auto-HSCT, and HHV6 was observed in all episodes of multiple detection in auto-HSCT patients. We found EBV DNA in plasma samples, whereas HCMV, HHV6 and HHV7 DNA were predominantly observed in leukocytes, indicative of their expansion in cellular compartments. We also found that IL-1β, IL-2, IL-6 and IL-8 were significantly increased in episodes in which multiple viruses were simultaneously detected, and samples positive for EBV DNA and graft-versus-host disease had a further increase of IL-1β and IL-8. In conclusion, the EBV, HCMV, HHV6 and HHV7 burdens were frequently detected in allo- and auto-HSCT, and their presence associated with systemic inflammation.
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Revisit of the Association between Cytomegalovirus Infection and Invasive Fungal Infection after Allogeneic Hematopoietic Stem Cell Transplantation: A Real-World Analysis from a High CMV Seroprevalence Area. J Fungi (Basel) 2022; 8:jof8040408. [PMID: 35448639 PMCID: PMC9029330 DOI: 10.3390/jof8040408] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/07/2022] [Accepted: 04/14/2022] [Indexed: 11/16/2022] Open
Abstract
Infection is a major complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT) especially cytomegalovirus (CMV) infection and invasive fungal infection (IFI). Taiwan is a high CMV seroprevalence area. Our study aimed to evaluate the incidence, risk factors, the impact on survival of CMV infection (including reactivation and disease) and the association of CMV infection and IFI in recipients after allo-HSCT during the first 100 days after transplantation. This was a retrospective study including 180 recipients of allo-HSCT. A total of 99 patients had CMV reactivation, and nine patients had CMV diseases. There were more mismatched donors, more ATG usage and more transplantation from CMV IgG-negative donor in patients with CMV reactivation. There was no survival difference in patients with or without CMV reactivation. A total of 34 patients had IFIs, and IFI after allo-HSCT was associated with significantly inferior survival. Patients with CMV reactivation did not increase the incidence of overall IFI, but they did result in more late-onset (>40 days) IFI (p = 0.056). In this study, we demonstrated real-world data of CMV infection and IFI from a high CMV seroprevalence area.
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Michallet M, Cheikh JE, Herbrecht R, Yakoub-Agha I, Caillot D, Gangneux JP. Systemic antifungal strategies in allogeneic hematopoietic stem cell recipients hospitalized in french hematology units: a post-hoc analysis of the cross-sectional observational AFHEM study. BMC Infect Dis 2022; 22:352. [PMID: 35397492 PMCID: PMC8994341 DOI: 10.1186/s12879-022-07216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Invasive fungal diseases (IFD) remain a major complication of allogeneic hematopoietic stem cell transplantation (alloHSCT) and are associated with high mortality rates in patients receiving alloHSCT. Antifungal prophylaxis is increasingly being used in the management of IFDs in patients receiving alloHSCT.
Methods
A post-hoc analysis of the cross-sectional observational AFHEM study was carried out to describe the use of antifungal drugs in real-life clinical practice in alloHSCT recipients hospitalized in French hematological units.
Results
A total of 147 alloHSCT recipients were enrolled; most were adults (n = 135; 92%) and had received alloHSCT < 6 months prior to enrollment (n = 123; 84%). Overall, 119 (81%) patients received a systemic antifungal therapy; of these, 95 (80%) patients received antifungal prophylaxis. Rates of patients receiving systemic antifungal treatment were similar irrespective of transplant time, neutropenic, and graft-versus-host disease status. Among patients on systemic antifungal treatment, 83 (70%) received an azole, 22 (18%) received an echinocandin, and 16 (13%) received a polyene.
Conclusions
This work provides evidence of the antifungal strategies used in alloHSCT recipients hospitalized in French hematological units. Unlike earlier studies, the AFHEM study showed that prophylaxis appears to be the leading antifungal strategy used in alloHSCT recipients in France.
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Perez P, Patiño J, Franco AA, Rosso F, Beltran E, Manzi E, Castro A, Estacio M, Valencia DM. Prophylaxis for invasive fungal infection in pediatric patients with allogeneic hematopoietic stem cell transplantation. Blood Res 2022; 57:34-40. [PMID: 35256547 PMCID: PMC8958374 DOI: 10.5045/br.2021.2021127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 01/21/2022] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background Antifungal prophylaxis is recommended for hematopoietic stem cell transplantation (HSCT) to decrease the incidence of invasive fungal infections (IFI). This study aimed to compare the two groups of antifungal prophylaxis in pediatric patients undergoing allogeneic HSCT. Methods This observational, analytic, retrospective cohort study compared the incidence of IFI with antifungal prophylaxis with voriconazole vs. other antifungals in the first 100 days after allogeneic HSCT in patients aged <18 years between 2012 and 2018. The statistical analysis included univariate and multivariate analyses and determination of the cumulative incidence of invasive fungal infection by the Kaplan‒Meier method using STATA 14 statistical software. Results A total of 139 allogeneic HSCT were performed. The principal diagnosis was acute leukemia (63%). The 75% had haploidentical donors, and 50% used an antifungal in the month before transplantation. Voriconazole (69%) was the most frequently administered antifungal prophylaxis. The cumulative incidence of IFI was 5% (7 cases). Of the patients with IFIs, four began prophylaxis with voriconazole, one with caspofungin, and one with fluconazole. Additionally, six were possible cases, one was proven (Candida parapsilosis), and 1/7 died. Conclusion There were no differences in the incidence of IFI between patients who received prophylaxis with voriconazole and other antifungal agents.
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Affiliation(s)
- Paola Perez
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Servicio de Infectología Pediátrica, Departamento Materno-infantil, Cali, Colombia
| | - Jaime Patiño
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Servicio de Infectología Pediátrica, Departamento Materno-infantil, Cali, Colombia
| | - Alexis A. Franco
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Unidad de trasplante de médula ósea, Departamento Materno-infantil, Cali, Colombia
| | - Fernando Rosso
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Estefania Beltran
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Eliana Manzi
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Andrés Castro
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Mayra Estacio
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Diego Medina Valencia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Unidad de trasplante de médula ósea, Departamento Materno-infantil, Cali, Colombia
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Rahi MS, Jindal V, Pednekar P, Parekh J, Gunasekaran K, Sharma S, Stender M, Jaiyesimi IA. Fungal infections in hematopoietic stem-cell transplant patients: a review of epidemiology, diagnosis, and management. Ther Adv Infect Dis 2021; 8:20499361211039050. [PMID: 34434551 PMCID: PMC8381463 DOI: 10.1177/20499361211039050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/24/2021] [Indexed: 12/18/2022] Open
Abstract
The advent of bone marrow transplant has opened doors to a different approach and
offered a new treatment modality for various hematopoietic stem-cell-related
disorders. Since the first bone marrow transplant in 1957, there has been
significant progress in managing patients who undergo bone marrow transplants.
Plasma-cell disorders, lymphoproliferative disorders, and myelodysplastic
syndrome are the most common indications for hematopoietic stem-cell transplant.
Despite the advances, invasive fungal infections remain a significant cause of
morbidity and mortality in this high-risk population. The overall incidence of
invasive fungal infection in patients with hematopoietic stem-cell transplant is
around 4%, but the mortality in patients with allogeneic stem-cell transplant is
as high as 13% in one study. Type of stem-cell transplant, conditioning regimen,
and development of graft-versus-host disease are some of the
risk factors that impact the risk and outcomes in patients with invasive fungal
infections. Aspergillus and candida remain the two most common organisms causing
invasive fungal infections. Molecular diagnostic methods have replaced some
traditional methods due to their simplicity of use and rapid turnaround time.
Primary prophylaxis has undoubtedly shown to improve outcomes even though
breakthrough infection rates remain high. The directed treatment has seen a
significant shift from amphotericin B to itraconazole, voriconazole, and
echinocandins, which have shown better efficacy and fewer adverse effects. In
this comprehensive review, we aim to detail epidemiology, risk factors,
diagnosis, and management, including prophylaxis, empiric and directed
management of invasive fungal infections in patients with hematopoietic
stem-cell transplant.
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Affiliation(s)
- Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA
| | - Vishal Jindal
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Prachi Pednekar
- Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Jay Parekh
- Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Sorabh Sharma
- Department of Internal Medicine, Banner University Medical Center, Tucson, AZ, USA
| | - Michael Stender
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ishmael A Jaiyesimi
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
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Barlas T, İnci K, Aygencel G, Türkoğlu M, Tunçcan ÖG, Can F, Aydın Kaynar L, Özkurt ZN, Yeğin ZA, Yağcı M. Infections in hematopoietic stem cell transplant patients admitted to Hematology intensive care unit: a single-center study. ACTA ACUST UNITED AC 2021; 26:328-339. [PMID: 33818297 DOI: 10.1080/16078454.2021.1905355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the data of HSCT patients who were admitted to our Hematology ICU due to infections or infectious complications. MATERIALS AND METHODS HSCT patients who were admitted to our Hematology ICU between 01 January 2014 and 01 September 2017 were analyzed retrospectively. RESULTS 62 HSCT patients were included in this study. The median age was 55.5 years and 58% of the patients were allogeneic HSCT patients. Major underlying hematologic disorders were multiple myeloma (29%) and lymphoma (27.4%). The most common reasons for ICU admission were sepsis/septic shock (61.3%) and acute respiratory failure (54.8%). Overall ICU mortality rate was 45.2%. However, a lot of factors were related with ICU mortality of HSCT patients in univariate analysis, only APACHE II score was found to be an independent risk factor for ICU mortality. While there was infection in 58 patients at ICU admission, new infections developed in 38 patients during ICU stay. The most common new infection was pneumonia/VAP, while the most frequently isolated bacteria were Acinetobacter baumannii. Length of ICU stay, sepsis/septic shock as a reason for ICU admission and the presence of urinary catheter at ICU admission were determined factors for ICU-acquired infections. There was no difference between autologous and allogeneic stem cell transplant patients in terms of ICU morbidities and mortality. However, pneumonia/VAP developed in the ICU was higher in autologous HSCT patients, while bloodstream/catheter-related bloodstream infection was higher in allogeneic HSCT patients. CONCLUSION It was concluded that early or late post-HSCT infections and related complications (sepsis, organ failure, etc.) constituted a major part of the reasons for ICU admission, ICU mortality and ICU morbidities.
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Affiliation(s)
- Tuğba Barlas
- Department of Internal Medicine, Division of Intensive Care Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Kamil İnci
- Department of Internal Medicine, Division of Intensive Care Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Gulbin Aygencel
- Department of Internal Medicine, Division of Intensive Care Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Melda Türkoğlu
- Department of Internal Medicine, Division of Intensive Care Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Özlem Güzel Tunçcan
- Department of Infectious Diseases and Clinical Microbiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ferda Can
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Lale Aydın Kaynar
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Zübeyde Nur Özkurt
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Arzu Yeğin
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Münci Yağcı
- Department of Internal Medicine, Division of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
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Chu S, McCormick TS, Lazarus HM, Leal LO, Ghannoum MA. Invasive fungal disease and the immunocompromised host including allogeneic hematopoietic cell transplant recipients: Improved understanding and new strategic approach with sargramostim. Clin Immunol 2021; 228:108731. [PMID: 33892201 DOI: 10.1016/j.clim.2021.108731] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/12/2021] [Accepted: 04/17/2021] [Indexed: 12/17/2022]
Abstract
In hosts with damaged or impaired immune systems such as those undergoing hematopoietic cell transplant (HCT) or intensive chemotherapy, breakthrough fungal infections can be fatal. Risk factors for breakthrough infections include severe neutropenia, use of corticosteroids, extended use of broad-spectrum antibiotics, and intensive care unit admission. An individual's cumulative state of immunosuppression directly contributes to the likelihood of experiencing increased infection risk. Incidence of invasive fungal infection (IFI) after HCT may be up to 5-8%. Early intervention may improve IFI outcomes, although many infections are resistant to standard therapies (voriconazole, caspofungin, micafungin, amphotericin B, posaconazole or itraconazole, as single agents or in combination). We review herein several contributing factors that may contribute to the net state of immunosuppression in recipients of HCT. We also review a new approach for IFI utilizing adjunctive therapy with sargramostim, a yeast-derived recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF).
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Affiliation(s)
- Sherman Chu
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA; College of Osteopathic Medicine of the Pacific, Northwest (COMP), Lebanon, OR, USA.
| | - Thomas S McCormick
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA.
| | - Hillard M Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, USA.
| | - Luis O Leal
- Partner Therapeutics, Inc., 19 Muzzey St, Lexington, MA, USA.
| | - Mahmoud A Ghannoum
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA; Center for Medical Mycology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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16
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Sun Y, Hu J, Huang H, Chen J, Li J, Ma J, Li J, Liang Y, Wang J, Li Y, Yu K, Hu J, Jin J, Wang C, Wu D, Xiao Y, Huang X. Clinical risk score for predicting invasive fungal disease after allogeneic hematopoietic stem cell transplantation: Analysis of the China Assessment of Antifungal Therapy in Hematological Diseases (CAESAR) study. Transpl Infect Dis 2021; 23:e13611. [PMID: 33825274 DOI: 10.1111/tid.13611] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/03/2021] [Accepted: 03/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Invasive fungal disease (IFD) is associated with a high mortality for patients with hematological malignancies undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). This study aimed not only to develop a proven/probable IFD risk-scoring model but to identify high-risk populations that would benefit from anti-fungal prophylaxis. METHODS Data from the China Assessment of Antifungal Therapy in Hematological Diseases (CAESAR) study were retrieved, and all patients (n = 1053) undergoing allo-HSCT were randomly divided into the training set (n = 685) for model development and the validation set (n = 368) for model verification. A weighted risk score for proven or probable IFD was established through multivariate logistic regression analysis. RESULTS The study population had a mean age of 28.95 years and the majority underwent myeloablative transplantation in complete remission 1 (53.4%). Five risk factors of IFD were identified, namely neutropenia lasting longer than 14 days, corticosteroid use, diabetes, haploidentical donor, and unrelated donor. Based on the risk score for IFD, the patients were categorized into three groups: low risk (score 0-4, 1.5%-4.0%), intermediate risk (score 5-8, 9.8%), and high risk (score>8, 24.7%-14.0%). Anti-fungal prophylaxis may provide benefits for patients with intermediate (8.5% vs. 18.5%, P = .0085) or high risk (19.4% vs. 30.8%, P = .4651) but not low risk (2.1% vs. 3.8%, P = .6136) of IFD. CONCLUSION A practical weighted risk score for IFD in patients receiving allo-HSCT was established, which can aid decision-making regarding the administration of anti-fungal prophylaxis.
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Affiliation(s)
- Yuqian Sun
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University, People's Hospital, Beijing, People's Republic of China
| | - Jiong Hu
- Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - He Huang
- The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, People's Republic of China
| | - Jing Chen
- Department of Hematology and Oncology, Shanghai Children's Medical Center, Shanghai, People's Republic of China
| | - Jianyong Li
- Jiangsu Province Hospital, Nanjing, People's Republic of China
| | - Jun Ma
- Harbin Hematologic Tumor Institution, Harbin, People's Republic of China
| | - Juan Li
- The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Yingmin Liang
- Tangdu Hospital, Fourth Military Medical University, Xi'an, People's Republic of China
| | - Jianmin Wang
- Changhai Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Yan Li
- The First Affiliated Hospital of China Medical University, Shengyang, People's Republic of China
| | - Kang Yu
- The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, People's Republic of China
| | - Jianda Hu
- Fujian Medical University Union Hospital, Fuzhou, People's Republic of China
| | - Jie Jin
- The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, People's Republic of China
| | - Chun Wang
- The First People's Hospital of Shanghai, Shanghai, People's Republic of China
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Yang Xiao
- The General Hospital of Guangzhou Military Command of PLA, Guangzhou, People's Republic of China
| | - Xiaojun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University Institute of Hematology, Peking University, People's Hospital, Beijing, People's Republic of China
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17
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How I perform hematopoietic stem cell transplantation on patients with a history of invasive fungal disease. Blood 2021; 136:2741-2753. [PMID: 33301030 DOI: 10.1182/blood.2020005884] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/13/2020] [Indexed: 02/08/2023] Open
Abstract
Hematopoietic transplantation is the preferred treatment for many patients with hematologic malignancies. Some patients may develop invasive fungal diseases (IFDs) during initial chemotherapy, which need to be considered when assessing patients for transplantation and treatment posttransplantation. Given the associated high risk of relapse and mortality in the post-hematopoietic stem cell transplantation (HSCT) period, IFDs, especially invasive mold diseases, were historically considered a contraindication for HSCT. Over the last 3 decades, advances in antifungal drugs and early diagnosis have improved IFD outcomes, and HSCT in patients with a recent IFD has become increasingly common. However, an organized approach for performing transplantation in patients with a prior IFD is scarce, and decisions are highly individualized. Patient-, malignancy-, transplantation procedure-, antifungal treatment-, and fungus-specific issues affect the risk of IFD relapse. Effective surveillance to detect IFD relapse post-HSCT and careful drug selection for antifungal prophylaxis are of paramount importance. Antifungal drugs have their own toxicities and interact with immunosuppressive drugs such as calcineurin inhibitors. Immune adjunct cytokine or cellular therapy and surgery can be considered in selected cases. In this review, we critically evaluate these factors and provide guidance for the complex decision making involved in the peri-HSCT management of these patients.
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Bacigalupo A, Metafuni E, Amato V, Marquez Algaba E, Pagano L. Reducing infectious complications after allogeneic stem cell transplant. Expert Rev Hematol 2020; 13:1235-1251. [PMID: 32996342 DOI: 10.1080/17474086.2020.1831382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Infections remain a significant problem, in patients undergoing an allogeneic hematopoietic stem-cell transplant (HSCT) and efforts have been made over the years, to reduce the incidence, morbidity and mortality of infectious complications. AREAS COVERED This manuscript is focused on the epidemiology, risk factors and prevention of infections after allogeneic HSCT. A systematic literature review was performed using the PubMed database, between November 2019 and January 2020, with the following MeSH terms: stem-cell transplantation, infection, fungal, bacterial, viral, prophylaxis, vaccines, prevention. The authors reviewed all the publications, and following a common revision, a summary report was made and results were divided in three sections: bacterial, fungal and viral infections. EXPERT OPINION Different infections occur in the early, intermediate and late post-transplant period, due to distinct risk factors. Improved diagnostic techniques, pre-emtive therapy and better prophylaxis of immunologic complications, have reduced the morbidity and mortality of infections. The role of the gut microbiota is under careful scrutiny and may further help us to identify high-risk patients.
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Affiliation(s)
- Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Viviana Amato
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Ester Marquez Algaba
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona , Barcelona, Spain
| | - Livio Pagano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica Del Sacro Cuore , Rome, Italy
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Hazar V, Karasu GT, Uygun V, Öztürk G, Kiliç SÇ, Küpesiz A, Daloglu H, Aksoylar S, Atay D, Ince EÜ, Karakükçü M, Özbek N, Tayfun F, Kansoy S, Özyürek E, Akçay A, Gürsel O, Haskologlu S, Kaya Z, Yilmaz S, Tanyeli A, Yesilipek A. Risks and outcomes of invasive fungal infections in pediatric allogeneic hematopoietic stem cell transplant recipients receiving fluconazole prophylaxis: a multicenter cohort study by the Turkish Pediatric Bone Marrow Transplantation Study Group. Med Mycol 2019; 57:161-170. [PMID: 29608706 DOI: 10.1093/mmy/myy015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/04/2018] [Indexed: 12/23/2022] Open
Abstract
Invasive fungal infections (IFIs) are a major cause of infection-related morbidity and mortality in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Data from pediatric settings are scarce. To determine the incidence, risk factors and outcomes of IFIs in a 180-day period post-transplantation, 408 pediatric patients who underwent allogeneic HSCT were retrospectively analyzed. The study included only proven and probable IFIs. The cumulative incidences of IFI were 2.7%, 5.0%, and 6.5% at 30, 100, and 180 days post-transplantation, respectively. According to the multivariate analysis, the factors associated with increased IFI risk in the 180-day period post-HSCT were previous HSCT history (hazard ratio [HR], 4.57; 95% confidence interval [CI] 1.42-14.71; P = .011), use of anti-thymocyte globulin (ATG) (HR, 2.94; 95% CI 1.27-6.80; P = .012), grade III-IV acute graft-versus-host-disease (GVHD) (HR, 2.91; 95% CI 1.24-6.80; P = .014) and late or no lymphocyte engraftment (HR, 2.71; 95% CI 1.30-5.62; P = .007). CMV reactivation was marginally associated with an increased risk of IFI development (HR, 1.91; 95% CI 0.97-3.74; P = .063). IFI-related mortality was 1.5%, and case fatality rate was 27.0%.The close monitoring of IFIs in pediatric patients with severe acute GVHD who receive ATG during conditioning is critical to reduce morbidity and mortality after allogeneic HSCT, particularly among those with prior HSCT and no or late lymphocyte engraftment.
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Affiliation(s)
- Volkan Hazar
- Department of Pediatric Hematology&Oncology and BMT Unit, Medical Park Göztepe Hospital, Istanbul
| | - Gülsün Tezcan Karasu
- Department of Pediatric Hematology&Oncology and BMT Unit, Medical Park Göztepe Hospital, Istanbul
| | - Vedat Uygun
- Department of Pediatric Hematology&Oncology and BMT Unit, Medical Park Antalya Hospital, Antalya
| | - Gülyüz Öztürk
- Department of Pediatric Hematology&Oncology and BMT Unit, Acibadem University Faculty of Medicine, Acibadem Atakent Hospital, Istanbul
| | - Suar Çaki Kiliç
- Department of Pediatric Hematology&Oncology and BMT Unit, Medical Park Göztepe Hospital, Istanbul
| | - Alphan Küpesiz
- Department of Pediatric Hematology&Oncology and BMT Unit, Akdeniz University Faculty of Medicine, Antalya
| | - Hayriye Daloglu
- Department of Pediatric Hematology&Oncology and BMT Unit, Medical Park Antalya Hospital, Antalya
| | - Serap Aksoylar
- Department of Pediatric Hematology&Oncology and BMT Unit, Ege University Faculty of Medicine, Izmir
| | - Didem Atay
- Department of Pediatric Hematology&Oncology and BMT Unit, Acibadem University Faculty of Medicine, Acibadem Atakent Hospital, Istanbul
| | - Elif Ünal Ince
- Department of Pediatric Hematology&Oncology and BMT Unit, Ankara University Faculty of Medicine, Ankara
| | - Musa Karakükçü
- Department of Pediatric Hematology&Oncology and BMT Unit, Erciyes University Faculty of Medicine, Kayseri
| | - Namik Özbek
- Department of Pediatric Hematology&Oncology and BMT Unit, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara
| | - Funda Tayfun
- Department of Pediatric Hematology&Oncology and BMT Unit, Akdeniz University Faculty of Medicine, Antalya
| | - Savas Kansoy
- Department of Pediatric Hematology&Oncology and BMT Unit, Ege University Faculty of Medicine, Izmir
| | - Emel Özyürek
- Department of Pediatric Hematology&Oncology and BMT Unit, Medical Park Samsun Hospital, Samsun
| | - Arzu Akçay
- Department of Pediatric Hematology&Oncology and BMT Unit, Acibadem University Faculty of Medicine, Acibadem Atakent Hospital, Istanbul
| | - Orhan Gürsel
- Department of Pediatric Hematology&Oncology and BMT Unit, Gülhane Military Medical Academy, Ankara
| | - Sule Haskologlu
- Department of Pediatric Hematology&Oncology and BMT Unit, Ankara University Faculty of Medicine, Ankara
| | - Zühre Kaya
- Department of Pediatric Hematology&Oncology and BMT Unit, Gazi University Faculty of Medicine, Ankara
| | - Sebnem Yilmaz
- Department of Pediatric Hematology&Oncology and BMT Unit, Dokuz Eylül University Faculty of Medicine, Izmir
| | - Atila Tanyeli
- Department of Pediatric Hematology&Oncology and BMT Unit, Çukurova University Faculty of Medicine, Adana
| | - Akif Yesilipek
- Department of Pediatric Hematology&Oncology and BMT Unit, Medical Park Antalya Hospital, Antalya.,The Chief of the Turkish Pediatric BMT Study Group
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20
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Qiu KY, Liao XY, Fang JP, Xu HG, Li Y, Huang K, Zhou DH. Combination antifungal treatment for invasive fungal disease after hematopoietic stem cell transplantation in children with hematological disorders. Transpl Infect Dis 2019; 21:e13066. [PMID: 30859662 DOI: 10.1111/tid.13066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/22/2019] [Accepted: 03/04/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Invasive fungal disease (IFD) has a poor prognosis in children with hematological disorders after hematopoietic stem cell transplantation (HSCT). We assessed if drug combinations with different targets may improve the outcome. METHODS Retrospective study to assess the outcome of combination antifungal therapy (CAT) for proven-probable IFD (PP-IFD) in children with hematological disorders after HSCT from January 2008 to June 2018. RESULTS Over the 10-year period, 95 PP-IFD were diagnosed in pediatric recipients, median age of 5.6 years. Twenty-seven patients received combinations of caspofungin and voriconazole, 28 patients received combinations of caspofungin and amphotericin B, and 40 patients received combinations of voriconazole and amphotericin B. The overall response rate of PP-IFD was 77.9%, while the 100-day overall survival rates were 66.8%. Univariate analysis showed that factors that significantly affected the response to combination treatments were type of combination (P = 0.02), the stem cell source (P = 0.04), the donor type (P = 0.03), HLA-match (P = 0.03), aGVHD (P = 0.02), period of treatment (P = 0.044), use of corticosteroids (0.036), CD4:CD8 ratio (P = 0.014), and CMV viremia (P = 0.033). In addition, multivariate analysis demonstrated that only the type of combination remained a significant factor (odds ratio = 0.335, 95% confidence interval: 0.071-0.812, P = 0.042). Forty-three children suffered from mild and reversible adverse reactions, no serious side effects during treatment. CONCLUSION A variety of factors can affect the outcome of CAT. Combination of caspofungin with voriconazole is a safe and helpful treatment option for HSCT recipients with IFD.
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Affiliation(s)
- Kun-Yin Qiu
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiong-Yu Liao
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian-Pei Fang
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hong-Gui Xu
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yang Li
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ke Huang
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Dun-Hua Zhou
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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21
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Mariotti J, De Philippis C, Bramanti S, Sarina B, Tordato F, Pocaterra D, Casari E, Carlo-Stella C, Santoro A, Castagna L. Caspofungin for primary antifungal prophylaxis after T-cell-replete haploidentical stem cell transplantation with post-transplant cyclophosphamide. Eur J Haematol 2019; 102:357-367. [PMID: 30672611 PMCID: PMC7163667 DOI: 10.1111/ejh.13214] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/05/2019] [Accepted: 01/07/2019] [Indexed: 12/18/2022]
Abstract
Objectives T‐cell–replete haploidentical stem cell transplantation (Haplo‐SCT) with post‐transplant cyclophosphamide (PT‐Cy) is at high risk of invasive fungal infections (IFI), and anti‐mold–active drug is required for primary antifungal prophylaxis (PAP) according to international guidelines. No data are available on the efficacy of caspofungin as PAP in this setting. Methods Here, we report our retrospective experience with 103 consecutive patients treated with caspofungin as PAP after Haplo‐SCT. Caspofungin was administered only during the pre‐engraftment phase. Results Hundred‐day cumulative incidence of proven‐probable IFI (PP‐IFI) was 8.7% and median day of onset was 19 post‐SCT. No patient died of PP‐IFI, and overall survival (OS) and non‐relapse mortality (NRM) hazard ratio (HR) for patients experiencing IFI were 1.02 (P = 0.9) and 0.7 (P = 0.7), respectively. Three‐year overall survival (OS) and 1‐year non‐relapse mortality (NRM) were 55% and 19%, respectively. By univariate analysis, duration of neutropenic phase and partial remission pre‐transplant disease status were associated with increased incidence of IFI, but were not confirmed by multivariate analysis. Conclusion In summary, PAP with caspofungin is an effective strategy for preventing IFI in the context of Haplo‐SCT with PT‐Cy. Further efforts are required in order to identify more potent strategies able to avoid the occurrence of breakthrough infections.
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Affiliation(s)
- Jacopo Mariotti
- Bone Marrow Unit, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Italy
| | - Chiara De Philippis
- Bone Marrow Unit, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Italy
| | - Stefania Bramanti
- Bone Marrow Unit, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Italy
| | - Barbara Sarina
- Bone Marrow Unit, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Italy
| | - Federica Tordato
- Infectious Diseases Unit, Hospital Health Direction, IRCCS Istituto Clinico Humanitas, Rozzano, Italy
| | - Daria Pocaterra
- Infectious Diseases Unit, Hospital Health Direction, IRCCS Istituto Clinico Humanitas, Rozzano, Italy
| | - Erminia Casari
- Infectious Diseases Unit, Hospital Health Direction, IRCCS Istituto Clinico Humanitas, Rozzano, Italy
| | - Carmelo Carlo-Stella
- Hematology Department, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Italy
| | - Armando Santoro
- Hematology Department, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Italy
| | - Luca Castagna
- Bone Marrow Unit, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Italy
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22
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Invasive fungal disease is associated with chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplant: a single center, retrospective study. Infection 2019; 47:275-284. [PMID: 30734248 DOI: 10.1007/s15010-018-01265-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/29/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Invasive fungal disease (IFD) and graft-versus-host disease (GVHD) are major causes of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, the impacts of IFD on chronic GVHD remain unknown. METHODS We conducted a retrospective study of 510 patients with hematologic malignancy undergoing allo-HSCT to explore the effects of IFD on chronic GVHD. RESULTS The 2-year cumulative incidences of overall (limited and extensive) and extensive chronic GVHD post-transplantation were higher in patients with IFD compared with those without IFD (69.5% ± 4.2% versus 32.9% ± 2.4%, P < .001; 43.0% ± 5.2% versus 6.6% ± 1.4%, P < .001, respectively). Moreover, the patients with IFD had higher 5-year transplant-related mortality, lower 5-year overall survival and lower 5-year disease-free survival (29.8% ± 4.3% versus 9.8% ± 1.6%, P < .001; 50.5% ± 4.9% versus 71.3% ± 2.4%, P < .001 and 48.8% ± 4.7% versus 71.8% ± 2.3%, P < .001, respectively). Multivariable analyses demonstrated that IFD increased the risk of chronic GVHD. CONCLUSION Our results suggest that IFD significantly contributes to the development of chronic GVHD after allo-HSCT.
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23
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Christen D, Sohlbach K, Metzelder SK, Wollmer E, Hoeffkes HG, Naumann R, Burchardt A, Rummel M, Trenker C, Dohse M, Mack E, Klameth A, Mann C, Kostrewa P, Brendel C, Wündisch T, Neubauer A, Wilhelm C, Burchert A. Outcome of non-mold effective anti-fungal prophylaxis in patients at high-risk for invasive fungal infections after allogenic stem cell transplantation. Leuk Lymphoma 2019; 60:2056-2061. [PMID: 30644334 DOI: 10.1080/10428194.2018.1553303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Patients who develop severe graft-versus-host disease (GvHD) after allogeneic stem cell transplantation (alloSCT) have a higher risk for invasive fungal infection (IFI). At our center, fluconazole prophylaxis is standard and upfront mold-effective prophylaxis performed only in patients with specific risk constellations. A total of 290 patients undergoing alloSCT between May 2002 and August 2011 were analyzed. Patients were regarded as high-risk if they suffered from acute GvHD II-IV° or extensive chronic GvHD. The 2-year incidence of an IFI after alloSCT was 8.97% (26/290) in the entire cohort and 7.78% (7/90) in the high-risk group. Mortality due to IFI was 3.85% (1/26) without including a high-risk patient. In the multivariate analysis a pre-transplant fungal infection was the only significant risk factor for developing an IFI after alloSCT (HR = 5.298; p = .001). A fluconazole prophylaxis in patients with GvHD after alloSCT is feasible in facilities with HEPA filtration and high awareness of clinical signs for IFI.
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Affiliation(s)
- Deborah Christen
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Kristina Sohlbach
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Stephan K Metzelder
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Ellen Wollmer
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | | | - Ralph Naumann
- c Department of Hematology , Oncology and Palliative Care, St. Marien Krankenhaus Siegen , Siegen , Germany
| | - Alexander Burchardt
- d Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Gießen , Germany
| | - Mathias Rummel
- d Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Gießen , Germany
| | - Corinna Trenker
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Marius Dohse
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Elisabeth Mack
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Andreas Klameth
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Christoph Mann
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Philippe Kostrewa
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Cornelia Brendel
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Thomas Wündisch
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Andreas Neubauer
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Christian Wilhelm
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
| | - Andreas Burchert
- a Department of Hematology, Oncology and Immunology , University Hospital Giessen and Marburg , Marburg , Germany
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24
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Invasive fungal infections in high-risk patients: report from TIMM-8 2017. Future Sci OA 2018; 4:FSO307. [PMID: 30057784 PMCID: PMC6060393 DOI: 10.4155/fsoa-2018-0019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/08/2018] [Indexed: 02/08/2023] Open
Abstract
Trends in Medical Mycology (TIMM) is the biennial meeting of the Infectious Disease Group of the European Organisation for Research and Treatment of Cancer (EORTC) and the European Confederation of Medical Mycology (ECMM). It brings together clinicians and researchers from across the world to share the latest R&Ds in medical mycology. Despite advances in treatment, invasive fungal infections remain a major cause of morbidity and mortality in certain high-risk groups of patients, particularly in immunocompromised patients, including those undergoing solid organ transplantation and those with acute leukemia. The challenges for clinicians are now compounded by the rapid development of multidrug resistance. The latest data and approaches to identifying patients at high risk for invasive fungal infections, ensuring early diagnosis and achieving effective treatment, including when and how to use therapeutic drug monitoring with azoles, were shared with >1000 clinicians and researchers from around the world attending the eighth TIMM, held in Belgrade, Serbia, in October 2017 (TIMM-8 2017).
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25
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Gomez SM, Caniza M, Fynn A, Vescina C, Ruiz CD, Iglesias D, Sosa F, Sung L. Fungal infections in hematopoietic stem cell transplantation in children at a pediatric children's hospital in Argentina. Transpl Infect Dis 2018; 20:e12913. [PMID: 29679436 DOI: 10.1111/tid.12913] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/24/2017] [Accepted: 01/07/2018] [Indexed: 12/12/2022]
Abstract
Our primary objective was to describe the incidence of proven or probable invasive fungal infections (IFIs), a devastating complication of hematopoietic stem cell transplant (HSCT), in HCST in a middle-income country. Secondary objectives were to describe factors associated with IFIs and outcomes. In this single center retrospective study, pediatric patients who underwent a first allogeneic or autologous HSCT from 1998 to 2016 were included. Of the 251 HSCT recipients: 143 transplants were allogeneic and 108 were autologous. Overall, 23 (9%) experienced an IFI, mostly due to yeasts (83%). IFIs were more common in allogeneic HSCT (18/143, 13%) than in autologous HSCT (5/108, 5%; P = .045). Of the 23 patients with IFIs, 14 (61%) died, but only 1 directly from IFI (pulmonary aspergillosis). Overall survival at 3 years was 0.42 ± 0.11 in patients with IFIs and 0.60 ± 0.37 in those without IFIs (P = .049). In Argentina, IFIs during HSCT are common. Recipients of allogeneic HSCT are at higher risk, and IFI is associated with reduced overall survival. Future work should focus on interventions to reduce and improve IFI outcomes in children undergoing transplants in low- and middle-income countries.
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Affiliation(s)
- Sergio M Gomez
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Miguela Caniza
- Global Pediatric Medicine, Infectious Diseases. St. Jude Children's Cancer Research Hospital, Memphis, TN, USA
| | - Alicira Fynn
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Cecilia Vescina
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Clau-Dia Ruiz
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Daniela Iglesias
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Fernanda Sosa
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
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26
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César-Arce A, Volkow-Fernández P, Valero-Saldaña LM, Acosta-Maldonado B, Vilar-Compte D, Cornejo-Juárez P. Infectious Complications and Multidrug-Resistant Bacteria in Patients With Hematopoietic Stem Cell Transplantation in the First 12 Months After Transplant. Transplant Proc 2018; 49:1444-1448. [PMID: 28736021 DOI: 10.1016/j.transproceed.2017.03.081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/14/2017] [Accepted: 03/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) has been used as treatment in different hematologic and solid malignancies. The aim of this study was to describe the frequency of infectious complications, microbiology, and outcome in patients undergoing HSCT in Mexico during the pre-engraftment period and the impact on mortality rates at 12 months. METHODS We conducted a retrospective study of all hematologic malignancies that received HSCT from January 2009 and December 2014, at an oncology reference center. RESULTS We included 210 patients: 144 autologous (69%) and 66 allogeneic HSCT (31%). There were 184 infections documented in 109 patients; incidence rate was 47.2 per 1000 neutropenia/days and 22.4 per 1000 hospitalization/days. The main infections reported were pneumonia (n = 40, 19%), bloodstream infections (n = 36, 17.1%), and central line-associated bloodstream infections (n = 28, 13.3%). There were 110 bacteria isolated, 31 were multidrug-resistant (26 were extended-spectrum beta-lactamase; Escherichia coli). There were 25 disseminated or complicated viral infections and 20 invasive fungal diseases. Fourteen patients died in the first 30 days (all related to the infectious process). In multivariate analysis leukemia, more than 2 chemotherapy regimens before transplant and pneumonia were related to 12-month mortality rates. CONCLUSIONS Even though infectious processes are frequent in patients with HSCT, multidrug-resistant bacteria were not as frequent as supposed; however, when these microorganisms are involved, mortality rate is increased. It is important to be alert that patients with pneumonia have a significantly increased mortality risk in the first year.
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Affiliation(s)
- A César-Arce
- Department of Infectious Disease, Instituto Nacional de Cancerología (INCan), México City, México
| | - P Volkow-Fernández
- Department of Infectious Disease, Instituto Nacional de Cancerología (INCan), México City, México
| | - L M Valero-Saldaña
- Department of Hematology, Instituto Nacional de Cancerología (INCan), México City, México
| | - B Acosta-Maldonado
- Department of Hematology, Instituto Nacional de Cancerología (INCan), México City, México
| | - D Vilar-Compte
- Department of Infectious Disease, Instituto Nacional de Cancerología (INCan), México City, México
| | - P Cornejo-Juárez
- Department of Infectious Disease, Instituto Nacional de Cancerología (INCan), México City, México.
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27
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Atilla E, Atilla PA, Bozdağ SC, Demirer T. A review of infectious complications after haploidentical hematopoietic stem cell transplantations. Infection 2017; 45:403-411. [PMID: 28417421 DOI: 10.1007/s15010-017-1016-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/05/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation from haploidentical donor is a feasible option for patients with hematological diseases who lack a suitable HLA-matched donor, but viral and fungal infections are still the most common causes of morbidity and mortality in haploidentical transplantation setting because of delayed immune reconstitution, increased risk of graft vs host disease (GvHD) or systemic steroid use. Therefore, this review will focus on the infectious complications after haploidentical hematopoietic stem cell transplantation (HSCT). MATERIALS AND METHODS Electronic publications were searched until February 2017 throughout databases, including Pubmed, Cochrane, and Embase. The following keywords were used 'haploidentical transplantation', 'infection', 'T cell replete', and 'T cell deplete'. RESULTS An increased incidence of bacterial, fungal, or viral infections is detected in haplo-HSCT compared to related, unrelated, or cord blood transplantations. Neutropenia and use of systemic steroid for GvHD and delayed immune reconstitution are important risk factors for infection after haplo-HSCT. CONCLUSION A shift towards T cell repletes haplo-HSCT with post-transplant cyclophosphamide (CY) for GvHD has been emerged in recent years, in which the incidence of viral and fungal infections is detected to be lower. Prophylaxis and pre-emptive treatment strategies should be applied according to patient status.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University Medical School, Cebeci, 06590, Ankara, Turkey
| | - Pinar Ataca Atilla
- Department of Hematology, Ankara University Medical School, Cebeci, 06590, Ankara, Turkey
| | - Sinem Civriz Bozdağ
- Department of Hematology, Ankara University Medical School, Cebeci, 06590, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University Medical School, Cebeci, 06590, Ankara, Turkey.
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28
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Clinical and Microbiological Characteristics of Breakthrough Candidemia in Allogeneic Hematopoietic Stem Cell Transplant Recipients in a Japanese Hospital. Antimicrob Agents Chemother 2017; 61:AAC.01791-16. [PMID: 28115352 DOI: 10.1128/aac.01791-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 01/14/2017] [Indexed: 12/29/2022] Open
Abstract
Few data on breakthrough candidemia (BC), defined as candidemia that develops on administration of antifungal agents (AFAs), in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients are available. The medical and microbiological records of recipients of an allo-HSCT obtained between December 2008 and December 2014 were reviewed. Of 768 allo-HSCT cases, 26 developed BC. Among the 26 causative strains, 22 strains were stored and identified by sequencing. The following species were isolated: Candida parapsilosis (9 strains), C. glabrata (4 strains), C. guilliermondii (3 strains), and other Candida species (6 strains). The AFAs being used when BC developed were micafungin (17 cases), liposomal amphotericin B (5 cases), itraconazole (2 cases), and voriconazole (2 cases). All 17 cases who developed BC during micafungin administration were administered 150 mg/day of micafungin. The susceptibilities of the causative Candida species to the administered AFAs when breakthrough occurred ranged from susceptible to resistant. Especially, 85% of the Candida species that caused BC during micafungin administration were susceptible to micafungin. Additionally, 75% of the strains were wild type for susceptibility to the administered AFAs when breakthrough occurred. Systemic steroid administration and a longer severe neutropenic phase (≥5 days) were independent risk factors for BC (P = 0.016 and P = 0.015, respectively). BC developed in allo-HSCT recipients even when they received a sufficient dose of AFA, including micafungin, to which the causative Candida species were susceptible and/or had wild-type susceptibility in vitro Systemic steroid administration and a longer severe neutropenic phase were host-based factors associated with BC.
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29
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Marks DI, Liu Q, Slavin M. Voriconazole for prophylaxis of invasive fungal infections after allogeneic hematopoietic stem cell transplantation. Expert Rev Anti Infect Ther 2017; 15:493-502. [PMID: 28335642 DOI: 10.1080/14787210.2017.1305886] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Invasive fungal infections (IFIs) following allogeneic hematopoietic stem cell transplantation (alloHSCT) are associated with a high mortality, and accordingly most alloHSCT recipients receive prophylaxis with antifungal agents. Despite some improvement in outcomes of IFIs over time, they continue to represent substantial clinical risk, mortality, and financial burden. Areas covered: We review the main pathogens responsible for IFIs in recipients of alloHSCT, current treatment recommendations, and discuss clinical and economic considerations associated with voriconazole prophylaxis of IFIs in these patients. Expert commentary: The clinical efficacy of voriconazole appears to be at least equivalent to other antifungal treatments, and generally well tolerated. Overall, benefit-risk balance is favorable, and findings from cost-effectiveness analyses support the use of voriconazole prophylaxis of IFIs in recipients of alloHSCT.
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Affiliation(s)
- David I Marks
- a Adult BMT Unit, Bristol Haematology and Oncology Centre , University Hospitals Bristol NHS Foundation Trust , Bristol , UK
| | - Qifa Liu
- b Department of Hematology , Nanfang Hospital, Southern Medical University , Guangzhou , China
| | - Monica Slavin
- c Department of Infectious Diseases , Victorian Infectious Diseases Service, Royal Melbourne Hospital , Melbourne , Australia
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Miceli MH, Churay T, Braun T, Kauffman CA, Couriel DR. Risk Factors and Outcomes of Invasive Fungal Infections in Allogeneic Hematopoietic Cell Transplant Recipients. Mycopathologia 2017; 182:495-504. [PMID: 28124219 DOI: 10.1007/s11046-017-0115-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/11/2017] [Indexed: 01/12/2023]
Abstract
Allogeneic hematopoietic cell transplant (HCT) recipients are at increased risk of invasive fungal infections (IFI), which are associated with a high mortality rate. We evaluated the impact of IFI in allogeneic HCT patients. In total, 541 consecutive allogeneic HCT recipients were included. The cumulative incidence of any IFI and mold infections at 1-year post-HCT was 10 and 7%, respectively. Median times to IFI and mold infection were 200 and 210 days, respectively. There was a trend toward fewer IFI and mold infections in the last several years. Both acute graft-versus-host disease (GVHD) (OR 1.83, p = 0.05) and corticosteroid duration (OR 1.0, p = 0.026) were significantly associated with increased risk of IFI, acute GVHD (OR 2.3, p = 0.027) emerged as the most important association with mold infections. Any IFI [HR 4.1 (2.79-6.07), p < 0.0001] and mold infections [HR 3.34 (2.1-5.1), p < 0.0001] were independently associated with non-relapse mortality (NRM). This association persisted in the setting of both acute and chronic GVHD. Corticosteroid treatment for >90 days was also significantly associated with higher NRM [HR 1.9 (1.3-2.6), p < 0.0001]. This study highlights the impact of IFI on NRM among HCT patients. The decrease in number of IFI and mold infections over the last several years may reflect the benefit of prophylaxis with mold-active antifungal agents.
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Affiliation(s)
- Marisa H Miceli
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, 3119 Taubman Center, Ann Arbor, MI, 48109, USA.
| | - Tracey Churay
- Adult Blood and Marrow Transplantation Program, Ann Arbor, MI, USA
| | - Thomas Braun
- Department of Biostatistics, University of Michigan Health System, Ann Arbor, MI, USA
| | - Carol A Kauffman
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, 3119 Taubman Center, Ann Arbor, MI, 48109, USA.,Division of Infectious Diseases, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Daniel R Couriel
- Huntsman Cancer Center, University of Utah, Salt Lake City, UT, USA
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Boğa C, Bolaman Z, Çağırgan S, Karadoğan İ, Özcan MA, Özkalemkaş F, Saba R, Sönmez M, Şenol E, Akan H, Akova M. Recommendations for Risk Categorization and Prophylaxis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of Evidence and Expert Opinion (TEO-4). Turk J Haematol 2017; 32:100-17. [PMID: 26316478 PMCID: PMC4451478 DOI: 10.4274/tjh.2014.0277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This is the last of a series of articles on invasive fungal infections prepared by opinion leaders in Turkey. The aim of these articles is to guide clinicians in managing invasive fungal diseases in hematological malignancies and stem cell transplantation based on the available best evidence in this field. The previous articles summarized the diagnosis and treatment of invasive fungal disease and this article aims to explain the risk categorization and guide the antifungal prophylaxis in invasive fungal disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Hamdi Akan
- Ankara University Faculty of Medicine, Department of Hematology, Ankara, Turkey Phone: +90 532 424 26 40 E-mail:
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Park S, Kim K, Jang JH, Kim SJ, Kim WS, Chung DR, Kang CI, Peck KR, Jung CW. Randomized trial of micafungin versus fluconazole as prophylaxis against invasive fungal infections in hematopoietic stem cell transplant recipients. J Infect 2016; 73:496-505. [DOI: 10.1016/j.jinf.2016.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/01/2016] [Accepted: 06/20/2016] [Indexed: 01/17/2023]
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Douglas AP, Slavin MA. Risk factors and prophylaxis against invasive fungal disease for haematology and stem cell transplant recipients: an evolving field. Expert Rev Anti Infect Ther 2016; 14:1165-1177. [PMID: 27710140 DOI: 10.1080/14787210.2016.1245613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Due to increasing intensity and complexity of therapies and longer survivorship, many patients with haematologic malignancy (HM) are at risk of invasive fungal disease (IFD). Mortality from IFD is high and treatment of an episode of IFD results in an excess length of hospital stay and costs and delays delivery of curative therapy of the underlying haematologic condition. Therefore, prevention and early recognition and treatment of IFD are crucial. Areas covered: Risk factors particular to certain HMs and haematopoietic stem cell transplantation, as well as those risk factors universal to all HM groups are examined. Expert commentary: Risk stratification identifies those patients who would benefit most from mould active versus yeast active prophylaxis and those who can be safely managed with monitoring and clinically driven interventions for IFD. This approach aids in antifungal stewardship.
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Affiliation(s)
- Abby P Douglas
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia.,b Victorian Infectious Diseases Service , Royal Melbourne Hospital , Melbourne , VIC , Australia.,c Department of Medicine , University of Melbourne , Melbourne , VIC , Australia
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Gao L, Sun Y, Meng F, Han M, Huang H, Wu D, Yu L, Ren H, Huang X, Zhang X. Antifungal prophylaxis of patients undergoing allogenetic hematopoietic stem cell transplantation in China: a multicenter prospective observational study. J Hematol Oncol 2016; 9:97. [PMID: 27663309 PMCID: PMC5035465 DOI: 10.1186/s13045-016-0305-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 08/24/2016] [Indexed: 11/28/2022] Open
Abstract
Background Antifungal prophylaxis is currently regarded as the gold standard in situations with allo-genetic hematopoietic stem cell transplantation (allo-HSCT). However, the epidemiological information regarding prophylaxis of invasive fungal diseases (IFDs) is not clear in China. Methods We report the first large-scale (1053 patients) observational study of the prophylaxis and management of IFDs among patients with allo-HSCT in China. Results The incidence rates of IFD after primary antifungal prophylaxis (PAP), secondary antifungal prophylaxis (SAP), and non-prophylaxis were 22.7 vs. 38.6 vs. 68.6 %, respectively (P = 0.0000). The median time from transplantation to IFD was 45 days in PAP patients, 18 days in SAP patients, and 12 days in non-prophylaxis patients. Aspergillus spp. represents the most common type of fungal infection. Independent risk factors for IFD in allo-HSCT patients with PAP were age, having human leukocyte antigen (HLA)-haploidentical or matched unrelated donor, decreased albumin levels, and the use of itraconazole as the prophylactic antifungal agent. Among SAP transplant recipients, there was no significant risk factor for IFDs. The incidence rates of overall survival (OS) in the PAP, SAP, and no prophylaxis groups were 85.07, 78.80, and 74.82, respectively (P = 0.01). Conclusions This observational study indicates that prophylaxis of IFD is helpful to reduce the incidence of IFDs and improve the OS of patients after allo-HSCT.
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Affiliation(s)
- Lei Gao
- Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Yuqian Sun
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Fanyi Meng
- Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - Mingzhe Han
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin, China
| | - He Huang
- The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, China
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Li Yu
- Chinese PLA General Hospital (301 Hospital), Beijing, China
| | - Hanyun Ren
- The First Hospital of Peking University, Beijing, China
| | - Xiaojun Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Xi Zhang
- Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
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Pagano L, Busca A, Candoni A, Cattaneo C, Cesaro S, Fanci R, Nadali G, Potenza L, Russo D, Tumbarello M, Nosari A, Aversa F. Risk stratification for invasive fungal infections in patients with hematological malignancies: SEIFEM recommendations. Blood Rev 2016; 31:17-29. [PMID: 27682882 DOI: 10.1016/j.blre.2016.09.002] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/05/2016] [Accepted: 09/09/2016] [Indexed: 11/17/2022]
Abstract
Invasive fungal infections (IFIs) are an important cause of morbidity and mortality in immunocompromised patients. Patients with hematological malignancies undergoing conventional chemotherapy, autologous or allogeneic hematopoietic stem cell transplantation are considered at high risk, and Aspergillus spp. represents the most frequently isolated micro-organisms. In the last years, attention has also been focused on other rare molds (e.g., Zygomycetes, Fusarium spp.) responsible for devastating clinical manifestations. The extensive use of antifungal prophylaxis has reduced the infections from yeasts (e.g., candidemia) even though they are still associated with high mortality rates. This paper analyzes concurrent multiple predisposing factors that could favor the onset of fungal infections. Although neutropenia is common to almost all hematologic patients, other factors play a key role in specific patients, in particular in patients with AML or allogeneic HSCT recipients. Defining those patients at higher risk of IFIs may help to design the most appropriate diagnostic work-up and antifungal strategy.
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Affiliation(s)
- Livio Pagano
- Istituto di Ematologia, Università Cattolica S. Cuore, Roma, Italy.
| | - Alessandro Busca
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Anna Candoni
- Clinica Ematologica, Azienda Ospedaliero-Universitaria Santa Maria Misericordia, Udine, Italy
| | | | - Simone Cesaro
- Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rosa Fanci
- Unità Funzionale di Ematologia, Azienda Ospedaliero-Universitaria Careggi e Università di Firenze, Italy
| | - Gianpaolo Nadali
- Unità Operativa Complessa di Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Leonardo Potenza
- UOC Ematologia, Dipartimento di Scienze Mediche e Chirurgiche Materno Infantili e dell'Adulto, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Domenico Russo
- Cattedra di Ematologia, Unità di Malattie del Sangue e Trapianto di Midollo Osseo, Dipartimento di Scienze Cliniche e Sperimentali, Università di Brescia e ASST Spedali Civili, Brescia, Italy
| | - Mario Tumbarello
- Istituto di Malattie Infettive, Università Cattolica S. Cuore, Roma, Italy
| | - Annamaria Nosari
- Divisione di Ematologia e Centro Trapianti Midollo, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Franco Aversa
- Hematology and BMT Unit, Department of Clinical and Experimental Medicine, University of Parma, Italy
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36
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Antifungal Therapy in Hematopoietic Stem Cell Transplant Recipients. Mediterr J Hematol Infect Dis 2016; 8:e2016039. [PMID: 27648202 PMCID: PMC5016011 DOI: 10.4084/mjhid.2016.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/20/2016] [Indexed: 11/08/2022] Open
Abstract
Invasive fungal infections (IFI) represent a major hindrance to the success of hematopoietic stem cell transplantation (HSCT), contributing substantially to morbidity and infection-related mortality. During the most recent years several reports indicate an overall increase of IFI among hematologic patients, in particular, invasive aspergillosis, that may be explained, at least partially, by the fact that diagnoses only suspected in the past, are now more easily established due to the application of serum biomarkers and early use of CT scan. Along with new diagnostic options, comes the recent development of novel antifungal agents that expanded the spectrum of activity over traditional treatments contributing to the successful management of fungal diseases. When introduced in 1959, Amphotericin B deoxycholate (d-AmB) was a life-saving drug, and the clinical experience over 50 years has proven that this compound is effective although toxic. Given the superior safety profile, lipid formulations of AmB have now replaced d-AmB in many circumstances. Similarly, echinocandins have been investigated as initial therapy for IA in several clinical trials including HSCT recipients, although the results were moderately disappointing leading to a lower grade of recommendation in the majority of published guidelines. Azoles represent the backbone of therapy for treating immunocompromised patients with IFI, including voriconazole and the newcomer isavuconazole; in addition, large studies support the use of mold-active azoles, namely voriconazole and posaconazole, as antifungal prophylaxis in HSCT recipients. The aim of the present review is to summarize the clinical application of antifungal agents most commonly employed in the treatment of IFI.
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37
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Liu YC, Chien SH, Fan NW, Hu MH, Gau JP, Liu CJ, Yu YB, Liu CY, Hsiao LT, Liu JH, Chiou TJ, Chen PM, Tzeng CH. Incidence and risk factors of probable and proven invasive fungal infection in adult patients receiving allogeneic hematopoietic stem cell transplantation. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 49:567-74. [DOI: 10.1016/j.jmii.2015.01.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 12/19/2014] [Accepted: 01/12/2015] [Indexed: 10/24/2022]
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38
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Ballen K, Woo Ahn K, Chen M, Abdel-Azim H, Ahmed I, Aljurf M, Antin J, Bhatt AS, Boeckh M, Chen G, Dandoy C, George B, Laughlin MJ, Lazarus HM, MacMillan ML, Margolis DA, Marks DI, Norkin M, Rosenthal J, Saad A, Savani B, Schouten HC, Storek J, Szabolcs P, Ustun C, Verneris MR, Waller EK, Weisdorf DJ, Williams KM, Wingard JR, Wirk B, Wolfs T, Young JAH, Auletta J, Komanduri KV, Lindemans C, Riches ML. Infection Rates among Acute Leukemia Patients Receiving Alternative Donor Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1636-1645. [PMID: 27343716 DOI: 10.1016/j.bbmt.2016.06.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/06/2016] [Indexed: 12/16/2022]
Abstract
Alternative graft sources (umbilical cord blood [UCB], matched unrelated donors [MUD], or mismatched unrelated donors [MMUD]) enable patients without a matched sibling donor to receive potentially curative hematopoietic cell transplantation (HCT). Retrospective studies demonstrate comparable outcomes among different graft sources. However, the risk and types of infections have not been compared among graft sources. Such information may influence the choice of a particular graft source. We compared the incidence of bacterial, viral, and fungal infections in 1781 adults with acute leukemia who received alternative donor HCT (UCB, n= 568; MUD, n = 930; MMUD, n = 283) between 2008 and 2011. The incidences of bacterial infection at 1 year were 72%, 59%, and 65% (P < .0001) for UCB, MUD, and MMUD, respectively. Incidences of viral infection at 1 year were 68%, 45%, and 53% (P < .0001) for UCB, MUD, and MMUD, respectively. In multivariable analysis, bacterial, fungal, and viral infections were more common after either UCB or MMUD than after MUD (P < .0001). Bacterial and viral but not fungal infections were more common after UCB than MMUD (P = .0009 and <.0001, respectively). The presence of viral infection was not associated with an increased mortality. Overall survival (OS) was comparable among UCB and MMUD patients with Karnofsky performance status (KPS) ≥ 90% but was inferior for UCB for patients with KPS < 90%. Bacterial and fungal infections were associated with poorer OS. Future strategies focusing on infection prevention and treatment are indicated to improve HCT outcomes.
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Affiliation(s)
- Karen Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Min Chen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Ibrahim Ahmed
- Department of Hematology, Oncology and Bone Marrow Transplantation, The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh, Saudi Arabia
| | - Joseph Antin
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ami S Bhatt
- Stanford University School of Medicine, Stanford, California
| | - Michael Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - George Chen
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | | | | | - Mary J Laughlin
- Medical Director, Cleveland Cord Blood Center, Cleveland, Ohio
| | - Hillard M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Margaret L MacMillan
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - David A Margolis
- Section of Hematology, Oncology and BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Maxim Norkin
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | | | - Ayman Saad
- Division of Hematology/Oncology Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bipin Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Harry C Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, Netherlands
| | - Jan Storek
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Szabolcs
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Michael R Verneris
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Kirsten M Williams
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institute of Health, Bethesda, Maryland
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Tom Wolfs
- Division of Pediatrics, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Jo-Anne H Young
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey Auletta
- Host Defense Program, Divisions of Hematology/Oncology/Bone Marrow Transplant and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Krishna V Komanduri
- Adult Stem Cell Transplantation Program, University of Miami, Miami, Florida
| | - Caroline Lindemans
- Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marcie L Riches
- Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Sahin U, Toprak SK, Atilla PA, Atilla E, Demirer T. An overview of infectious complications after allogeneic hematopoietic stem cell transplantation. J Infect Chemother 2016; 22:505-14. [PMID: 27344206 DOI: 10.1016/j.jiac.2016.05.006] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/05/2016] [Accepted: 05/20/2016] [Indexed: 12/31/2022]
Abstract
Infections are the most common and significant cause of mortality and morbidity after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The presence of neutropenia and mucosal damage are the leading risk factors in the early pre-engraftment phase. In the early post-engraftment phase, graft versus host disease (GvHD) induced infection risk is increased in addition to catheter related infections. In the late phase, in which reconstitution of cellular and humoral immunity continues, as well as the pathogens seen during the early post-engraftment phase, varicella-zoster virus and encapsulated bacterial infections due to impaired opsonization are observed. An appropriate vaccination schedule following the cessation of immunosuppressive treatment after transplantation, intravenous immunoglobulin administration, and antimicrobial prophylaxis with penicillin or macrolide antibiotics during immunosuppressive treatment for GvHD might decrease the risk of bacterial infections. Older age, severe mucositis due to toxicity of chemotherapy, gastrointestinal tract colonization, prolonged neutropenia, unrelated donor and cord blood originated transplantations, acute and chronic GvHD are among the most indicative clinical risk factors for invasive fungal infections. Mold-active anti-fungal prophylaxis is suggested regardless of the period of transplantation among high risk patients. The novel serological methods, including Aspergillus galactomannan antigen and beta-D-glucan detection and computed tomography are useful in surveillance. Infections due to adenovirus, influenza and respiratory syncytial virus are encountered in all phases after allo-HSCT, including pre-engraftment, early post-engraftment and late phases. Infections due to herpes simplex virus-1 and -2 are mostly seen during the pre-engraftment phase, whereas, infections due to cytomegalovirus and human herpes virus-6 are seen in the early post-engraftment phase and Epstein-Barr virus and varicella-zoster virus infections often after +100th day. In order to prevent mortality and morbidity of infections after allo-HSCT, the recipients should be carefully followed-up with appropriate prophylactic measures in the post-transplant period.
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Affiliation(s)
- Ugur Sahin
- Ankara University Medical School, Department of Hematology, Ankara, Turkey
| | | | - Pinar Ataca Atilla
- Ankara University Medical School, Department of Hematology, Ankara, Turkey
| | - Erden Atilla
- Ankara University Medical School, Department of Hematology, Ankara, Turkey
| | - Taner Demirer
- Ankara University Medical School, Department of Hematology, Ankara, Turkey.
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40
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Shi JM, Pei XY, Luo Y, Tan YM, Tie RX, He JS, Zheng WY, Zhang J, Cai Z, Lin MF, Huang H. Invasive fungal infection in allogeneic hematopoietic stem cell transplant recipients: single center experiences of 12 years. J Zhejiang Univ Sci B 2016; 16:796-804. [PMID: 26365122 DOI: 10.1631/jzus.b1500005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Invasive fungal infection (IFI) is a growing cause of morbidity and mortality among patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We retrospectively reviewed the records of 408 patients undergoing allo-HSCTs during the period November 1998 to December 2009, analyzed the incidence and risk factors of IFI, and examined the impact of IFI on overall survival. A total of 92 (22.5%) episodes suffered proven or probable IFI (4 patients were proven, 88 patients were probable). Candida was the most common pathogen for early IFI, and mold was the most frequent causative organism for late IFI. A prior history of IFI, human leukocyte antigen (HLA) mismatch, long-time neutropenia, and acute graft-versus-host-disease (GVHD) were risk factors for early IFI. A prior history of IFI, corticosteroid therapy, cytomegalovirus (CMV) disease, and chronic GVHD were risk factors for late IFI. IFI-related mortality was 53.26%. The 12-year overall survival (OS) rate for IFI was significantly lower than that of patients without IFI (41.9% vs. 63.6%, P<0.01).
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Affiliation(s)
- Ji-min Shi
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Xu-ying Pei
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Yi Luo
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Ya-min Tan
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Ru-xiu Tie
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jing-song He
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Wei-yan Zheng
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jie Zhang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Zhen Cai
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Mao-fang Lin
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - He Huang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
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Harrison N, Mitterbauer M, Tobudic S, Kalhs P, Rabitsch W, Greinix H, Burgmann H, Willinger B, Presterl E, Forstner C. Incidence and characteristics of invasive fungal diseases in allogeneic hematopoietic stem cell transplant recipients: a retrospective cohort study. BMC Infect Dis 2015; 15:584. [PMID: 26715563 PMCID: PMC4696168 DOI: 10.1186/s12879-015-1329-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/18/2015] [Indexed: 11/10/2022] Open
Abstract
Background Allogeneic hematopoietic stem cell transplant (HSCT) recipients experience an increased risk for invasive fungal diseases (IFDs). Methods This retrospective cohort study at the Medical University of Vienna aspired to assess the incidence, characteristics and the outcome of IFDs as well as the associated risk factors in a setting where only 43 % of patients were given systemic antifungal prophylaxis during aplasia. IFDs were classified as probable or proven according to the EORTC/MSG consensus group. All adult patients (n = 242) receiving an allogeneic HSCT at the University Hospital of Vienna from January 2009 to December 2013 were enrolled. Results The primary outcome of this study was the one-year incidence for IFDs after HSCT, which was 10.3 % (25/242). Overall 28 patients experienced an IFD – 20 probable and 8 proven – with invasive aspergillosis being the predominant IFD (n = 18), followed by invasive candidiasis (n = 7) and pneumocystis pneumonia (n = 3). Patients with an IFD were more likely to be admitted to an intensive care unit (64 % versus 12 %, p < 0.0001) and had a significantly higher mortality in the first year after HSCT (48 % versus 25 %, p = 0.02). Multivariate regression analysis revealed that intensified immunosuppressive therapy (high-dose cortisone and basiliximab or etanercept) because of severe graft-versus-host disease (adjusted odds ratio (AOR) 3.6, p = 0.01) and transplant-associated microangiopathy (AOR 3.7, p = 0.04) were associated with an increased risk for IFD, while antifungal prophylaxis given during aplasia and post-engraftment was associated with a decreased risk (AOR 0.3, p = 0.02). Conclusions We documented a one-year incidence for IFDs of 10.3 % and no selection of rare pathogens at a centre with moderate use of antifungal prophylaxis. Intensified immunosuppressive therapy and transplant-associated microangiopathy were significant risk factors for IFDs.
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Affiliation(s)
- Nicole Harrison
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Margit Mitterbauer
- Department of Medicine I, Bone Marrow Transplantation, Medical University of Vienna, Vienna, Austria
| | - Selma Tobudic
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Peter Kalhs
- Department of Medicine I, Bone Marrow Transplantation, Medical University of Vienna, Vienna, Austria
| | - Werner Rabitsch
- Department of Medicine I, Bone Marrow Transplantation, Medical University of Vienna, Vienna, Austria
| | - Hildegard Greinix
- Department of Medicine I, Bone Marrow Transplantation, Medical University of Vienna, Vienna, Austria.,Division of Hematology, Medical University of Graz, Graz, Austria
| | - Heinz Burgmann
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Birgit Willinger
- Department of Laboratory Medicine, Division of Clinical Microbiology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Presterl
- Department of Hospital Hygiene and Infection Control, Medical University of Vienna, Vienna, Austria
| | - Christina Forstner
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria. .,Center of Infectious Diseases, Jena University Hospital, Jena, Germany.
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Yan CH, Xu LP, Wang FR, Chen H, Han W, Wang Y, Wang JZ, Liu KY, Huang XJ. Causes of mortality after haploidentical hematopoietic stem cell transplantation and the comparison with HLA-identical sibling hematopoietic stem cell transplantation. Bone Marrow Transplant 2015; 51:391-7. [DOI: 10.1038/bmt.2015.306] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 10/15/2015] [Accepted: 10/16/2015] [Indexed: 01/04/2023]
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Yáñez L, Insunza A, Ibarrondo P, de Miguel C, Bermúdez A, Colorado M, López-Duarte M, Richard C, Conde E. Experience with anidulafungin in patients with allogeneic hematopoietic stem cell transplantation and graft-versus-host disease. Transpl Infect Dis 2015; 17:761-7. [PMID: 26250790 DOI: 10.1111/tid.12429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 05/29/2015] [Accepted: 07/19/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND It is well known that both acute and chronic graft-versus-host disease (GVHD) are associated with invasive fungal disease (IFD). Because the galactomannan antigen diagnostic test has low specificity and sensitivity outside of the neutropenic period, many institutions use posaconazole or voriconazole for IFD prophylaxis during GVHD treatment. Moreover, several factors, mainly hepatic impairment, can limit the use of extended spectrum azoles, both in prophylaxis or treatment. METHODS We retrospectively analyzed 25 patients with allogeneic hematopoietic stem cell transplantation (HSCT) and GVHD - grade III-IV acute GHVD (n = 15), progressive chronic GVHD (n = 7), and "overlap" GVHD (n = 3) - who received intravenous anidulafungin (200 mg on day 1, followed by 100 mg once daily). If necessary, anidulafungin treatment was followed by oral administration of 200 mg voriconazole twice a day or 200 mg posaconazole 3 times daily until patients were considered not at risk for IFD. RESULTS Twenty-one patients (85%) received anidulafungin as prophylaxis and 5 patients (15%) received it as treatment. Median duration of intravenous anidulafungin administration was 8 days (range 6-17). Seven patients (28%) presented mild adverse effects, with no significant interactions with calcineurin inhibitors. Sequentially, 4 patients received voriconazole and 6 posaconazole. Two patients (8%) developed IFD after anidulafungin withdrawal: 1 with Candida albicans and the other with Mucor, 8 and 5 days after withdrawal, respectively. CONCLUSIONS Our results are of interest owing to the absence of data in the literature on anidulafungin use in HSCT patients with GVHD, and suggest that anidulafungin, because of its spectrum, pharmacological profile, low toxicity, and absence of interactions with immunosuppressants, could be a drug of choice in this setting.
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Affiliation(s)
- L Yáñez
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - A Insunza
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - P Ibarrondo
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - C de Miguel
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - A Bermúdez
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - M Colorado
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - M López-Duarte
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - C Richard
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - E Conde
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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Epidemiology and risk factors for invasive fungal diseases in hematopoietic stem cell transplantation. Curr Opin Hematol 2015; 21:459-65. [PMID: 25295743 DOI: 10.1097/moh.0000000000000086] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Knowledge of the epidemiology and the risk factors of invasive fungal diseases (IFDs) in hematopoietic stem cell transplant (HSCT) recipients is a critical determinant of the prevention, diagnosis and therapeutic antifungal strategy. Transplant procedures are characterized by a continuous evolution; therefore, an update of the epidemiological findings of IFDs in HSCT populations is needed. RECENT FINDINGS In the last few years, the incidence and the clinical risk factors of IFD, mainly in allogeneic HSCT populations, have been investigated in prospective, multicenter studies. New findings in the different types and phases of transplant may be considered for a redefinition of the level of risk of IFD after HSCT. Furthermore, recent studies have uncovered associations between host's and/or donor's genetic variants and immunological risk for IFDs, in particular invasive aspergillosis. SUMMARY Evolution of the transplant procedures was followed by an important change in the epidemiology and clinical risk of IFD after allogeneic HSCT. A new stratification of subpopulations according to different clinical infectious risk and genetic susceptibility may be considered to predict those patients most vulnerable to IFD and update tailored antifungal strategies.
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Peng XG, Dong Y, Zhang TT, Wang K, Ma YJ. Immune Reconstitution of CD4+T Cells after Allogeneic Hematopoietic Stem Cell Transplantation and its Correlation with Invasive Fungal Infection in Patients with Hematological Malignancies. Asian Pac J Cancer Prev 2015; 16:3137-40. [DOI: 10.7314/apjcp.2015.16.8.3137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Ziakas PD, Zervou FN, Zacharioudakis IM, Mylonakis E. Graft-versus-host disease prophylaxis after transplantation: a network meta-analysis. PLoS One 2014; 9:e114735. [PMID: 25485632 PMCID: PMC4259365 DOI: 10.1371/journal.pone.0114735] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 11/13/2014] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Graft-versus-host Disease (GvHD) prophylaxis after allogeneic hematopoietic stem-cell transplantation (HSCT) is an ongoing effort but relative effects of different policies are not systematically explored. METHODS We systematically reviewed 30-year evidence on GvHD prophylaxis and quantified the relative effect of different policies using a network meta-analysis. We searched PubMed and the Cochrane Library for randomized studies on the topic. The primary outcome of interest was grade II-IV acute GvHD over 0 or I (with odds ratio OR <1 denoting benefit). FINDINGS Thirty-three eligible studies that enrolled 3,440 patients (published up to June 2014), provided data on seven immunosuppressive drugs namely cyclosporin A (CsA), methotrexate (MTX), anti-thymocyte globulin (ATG), mycophenolate mofetil (MMF), tacrolimus, sirolimus or corticosteroids and their combinations to calculate 14 direct and 21 indirect effects. The majority of trials (32/33) referred to myeloablative conditioning and sibling transplants (25/33). Tacrolimus/MTX (OR 0.44; 95% 0.27-0.70, number needed to treat to benefit, i.e. to avert a case of II-IV GvHD, NNTB = 5) and ATG/CsA/MTX (OR 0.45; 95%CI 0.26-0.78; NNTB = 5) were superior over CsA/MTX. ATG/CsA/MTX did not differ from tacrolimus/MTX (indirect evidence). Sirolimus-based prophylaxis outperformed CsA/MTX (OR 0.10; 95%CI 0.02-0.49, NNTB = 4) and marginally outperformed tacrolimus/MTX (OR 0.22; 95%CI 0.05-1.11). Add-on corticosteroids had no benefit over CsA/MTX. CONCLUSIONS Tacrolimus/MTX and ATG/CsA/MTX were the outperformers over CsA/MTX, but sirolimus-based regimens showed also potential. More randomized data are needed for reduced-intensity conditioning, as well as for MMF and sirolimus-containing regimens.
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Affiliation(s)
- Panayiotis D. Ziakas
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Fainareti N. Zervou
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Ioannis M. Zacharioudakis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
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Initial fluconazole prophylaxis may not be required in adults with acute leukemia or myelodysplastic/myeloproliferative disorders after reduced intensity conditioning peripheral blood stem cell allogeneic transplantation. Ann Hematol 2014; 94:663-9. [DOI: 10.1007/s00277-014-2259-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 11/10/2014] [Indexed: 10/24/2022]
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PCR in diagnosis of invasive aspergillosis: a meta-analysis of diagnostic performance. J Clin Microbiol 2014; 52:3731-42. [PMID: 25122854 DOI: 10.1128/jcm.01365-14] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Invasive aspergillosis is a difficult-to-diagnose infection with a high mortality rate that affects high-risk groups such as patients with neutropenia and hematologic malignancies. We performed a bivariate meta-analysis of diagnostic data for an Aspergillus sp. PCR assay with blood specimens from high-risk hematology patients. We included all studies involving human subjects that assessed the performance of any PCR assay for invasive aspergillosis in whole blood or serum and that used the European Organization for the treatment of Cancer/Mycoses Study Group criteria as a reference standard. Three investigators independently searched the literature for eligible studies and extracted the data. Out of a total of 37 studies, 25 met strict quality criteria and were included in our evidence synthesis. Twenty-five studies with 2,595 patients were analyzed. The pooled diagnostic performance of whole-blood and serum PCR assays was moderate, with a sensitivity and specificity of 84% (95% confidence interval [CI], 75 to 91%) and 76% (95% CI, 65 to 84%), respectively, suggesting that a positive or negative result is unable, on its own, to confirm or exclude a suspected infection. The performance of a PCR assay of serum was not significantly different from that of whole blood. Notably, at least two positive PCR test results were found to have a specificity of 95% and a sensitivity of 64% for invasive infection, achieving a high positive likelihood ratio of 12.8. Importantly, the European Aspergillus PCR Initiative (EAPCRI) recommendations improved the performance of the PCR even further when at least two positive specimens were used to define PCR positivity. In conclusion, two positive PCR results should be considered highly indicative of an active Aspergillus sp. infection. Use of the EAPCRI recommendations by clinical laboratories can further enhance PCR performance.
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Takaoka K, Nannya Y, Shinohara A, Arai S, Nakamura F, Kurokawa M. A novel scoring system to predict the incidence of invasive fungal disease in salvage chemotherapies for malignant lymphoma. Ann Hematol 2014; 93:1637-44. [PMID: 24908330 DOI: 10.1007/s00277-014-2093-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 04/21/2014] [Indexed: 11/28/2022]
Abstract
The requirement of antifungal prophylaxis has not been established in the chemotherapies for malignant lymphoma. This study was conducted to explore the incidence of invasive fungal diseases (IFD) and their risk factors in patients receiving salvage therapies for malignant lymphoma. We retrospectively analyzed 177 consecutive patients who received these therapies (705 courses in total) at our institute. IFD were observed in 16 courses and the incidence was 2.3 %. A multivariate analysis showed that the factors associated with IFD were primary refractoriness (adjusted odds ratio (aOR), 4.22; 95 % confidence interval (CI), 1.38-13.0; p value = 0.012), two (aOR, 10.5, 95 % CI, 1.20-91.7; p = 0.033) or more (aOR, 26.2; 95 % CI, 3.27-210; p = 0.002) previous treatment lines, and the minimum neutrophil count during the therapies equal to or less than 500/μL (aOR, 9.69; 95 % CI, 1.25-74.9; p = 0.030). Using these factors, we created the IFD scoring model by assigning one point to each of primary refractoriness, two previous treatment lines and treatment that caused neutropenia (≤500/μL minimal neutrophil count) and two points to three or more previous treatment lines. The IFD incidence of lower risk group (IFD score <3) was 0.19 % and that of higher (IFD score ≥3) was 9.0 %. In conclusion, adequate prophylaxis for IFD might be required for patients with primary refractoriness, repeated therapies, or therapies which cause neutropenia. Furthermore, the IFD scoring model of this study underscores the need to account for disease and host factors in determining administration of adequate prophylaxis in salvage treatments for malignant lymphoma.
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Affiliation(s)
- Kensuke Takaoka
- Department of Hematology & Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo City, Tokyo, 1138655, Japan
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Lin R, Xu X, Li Y, Sun J, Fan Z, Jiang Q, Huang F, Zhou H, Nie D, Guo Z, Mao Y, Xiao Y, Liu Q. Comparison of long-term and short-term administration of itraconazole for primary antifungal prophylaxis in recipients of allogeneic hematopoietic stem cell transplantation: a multicenter, randomized, open-label trial. Transpl Infect Dis 2014; 16:286-94. [PMID: 24593273 DOI: 10.1111/tid.12192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/19/2013] [Accepted: 09/07/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal agents and duration of primary antifungal prophylaxis in recipients of allogeneic hematopoietic stem cell transplantation (allo-HSCT) remain a matter of discussion. OBJECTIVE Our objective was to compare the efficacy and safety of long-term and short-term administration of itraconazole (ITCZ) for primary antifungal prophylaxis in allo-HSCT recipients. METHODS This multicenter, randomized, open-label pilot study was performed in 4 transplant centers in China. Recipients of allo-HSCT without a history of invasive fungal disease (IFD) were randomly assigned to the long-term or the short-term arm. Randomization was carried out by a center computer system. Intravenous ITCZ was given to the patients in both study arms with a loading dose of 400 mg/day for 2 days followed by 200 mg/day until day +14 or when the white blood cell count was >1.0 × 10(9) /L, and then switched to oral ITCZ solution; prophylaxis was continued until day +30 post transplantation in the short-term arm or until day +90 in the long-term arm. The trough serum concentrations of ITCZ also were measured. The primary study endpoint was the incidence of IFD (proven, probable, and possible) within day +90 post transplantation. RESULTS A total of 128 recipients were enrolled in this study; 59 of them were randomized to the long-term arm and 62 were randomized to the short-term arm, forming the modified intent-to-treat (mITT) set. The incidence of IFD within day +90, the primary endpoint, was not significantly different between the 2 arms for the mITT set (6.78% in the long-term arm vs. 6.45% in the short-term arm, P = 0.94), or for the per-protocol set (6.90% in the long-term arm vs. 6.67% in the short-term arm, P = 0.96). From day +30 to day +90, the incidence of IFD was 0% and 6.45%, respectively, in the patients with long-term and short-term prophylaxis for the mITT set (P = 0.11). The mean trough serum concentrations of ITCZ was maintained at >500 ng/mL throughout administration. The incidences of withdrawal because of drug-related adverse events in patients with long-term and short-term prophylaxis were 6.78% and 0%, respectively (P = 0.05). CONCLUSIONS Long-term and short-term administration of ITCZ both seemed effective in preventing IFD in recipients of allo-HSCT. Further study with large sample size should be performed to evaluate this result. ITCZ shows the same pharmacokinetics in recipients of allo-HSCT as in non-recipients.
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Affiliation(s)
- R Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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