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Taynton T, Allsup D, Barlow G. How can we optimize antifungal use and stewardship in the treatment of acute leukemia? Expert Rev Hematol 2024; 17:581-593. [PMID: 39037307 DOI: 10.1080/17474086.2024.2383401] [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: 04/26/2024] [Accepted: 07/18/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION The global need for antifungal stewardship is driven by spreading antimicrobial and antifungal resistance. Triazoles are the only oral and relatively well-tolerated class of antifungal medications, and usage is associated with acquired resistance and species replacement with intrinsically resistant organisms. On a per-patient basis, hematology patients are the largest inpatient consumers of antifungal drugs, but are also the most vulnerable to invasive fungal disease. AREAS COVERED In this review we discuss available and forthcoming antifungal drugs, antifungal prophylaxis and empiric antifungal therapy, and how a screening based and diagnostic-driven approach may be used to reduce antifungal consumption. Finally, we discuss components of an antifungal stewardship program, interventions that can be employed, and how impact can be measured. The search methodology consisted of searching PubMed for journal articles using the term antifungal stewardship plus program, intervention, performance measure or outcome before 1 January 2024. EXPERT OPINION Initial focus should be on implementing effective antifungal stewardship programs by developing and implementing local guidelines and using interventions, such as post-prescription review and feedback, which are known to be effective. Technologies such as microbiome analysis and machine learning may allow the development of truly individualized risk-factor-based approaches to antifungal stewardship in the future.
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Affiliation(s)
- Thomas Taynton
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Centre for Biomedical Research, Hull York Medical School, Hull, UK
| | - David Allsup
- Biomedical Institute for Multimorbidity, Hull York Medical School, Hull, UK
- Queen's Centre for Oncology and Haematology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Gavin Barlow
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
- York Biomedical Research Institute and Hull York Medical School, University of York, York, UK
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Carelli S, Posteraro B, Torelli R, De Carolis E, Vallecoccia MS, Xhemalaj R, Cutuli SL, Tanzarella ES, Dell'Anna AM, Lombardi G, Cammarota F, Caroli A, Grieco DL, Sanguinetti M, Antonelli M, De Pascale G. Prognostic value of serial (1,3)-β-D-glucan measurements in ICU patients with invasive candidiasis. Crit Care 2024; 28:236. [PMID: 38997712 PMCID: PMC11241937 DOI: 10.1186/s13054-024-05022-x] [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: 05/06/2024] [Accepted: 07/06/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND To determine whether a decrease in serum (1,3)-β-D-glucan (BDG) was associated with reduced mortality and to investigate the performance of BDG downslope in predicting clinical outcome in invasive candidiasis. METHODS Observational cohort study in ICU patients over a ten-year period (2012-2022) in Italy. Proven invasive candidiasis with at least 2 BDG determinations were considered. RESULTS In the study population of 103 patients (age 47 [35-62] years, SAPS II score 67 [52-77]) 68 bloodstream and 35 intrabdominal infections were recorded. Serial measurements showed that in 54 patients BDG decreased over time (BDG downslope group) while in 49 did not (N-BDG downslope group). Candida albicans was the pathogen most frequently isolated (61%) followed by C. parapsilosis (17%) and C. glabrata (12%), in absence of any inter-group difference. Invasive candidiasis related mortality was lower in BDG downslope than in N-BDG downslope group (17% vs 53%, p < 0.01). The multivariate Cox regression analysis showed the association of septic shock at infection occurrence and chronic liver disease with invasive candidiasis mortality (HR [95% CI] 3.24 [1.25-8.44] p = 0.02 and 7.27 [2.33-22.66] p < 0.01, respectively) while a BDG downslope was the only predictor of survival (HR [95% CI] 0.19 [0.09-0.43] p < 0.01). The area under the receiver operator characteristic curve for the performance of BDG downslope as predictor of good clinical outcome was 0.74 (p = 0.02) and our model showed that a BDG downslope > 70% predicted survival with both specificity and positive predictive value of 100%. CONCLUSIONS A decrease in serum BDG was associated with reduced mortality and a steep downslope predicted survival with high specificity in invasive candidiasis.
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Affiliation(s)
- Simone Carelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy.
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Brunella Posteraro
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Torelli
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena De Carolis
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Sole Vallecoccia
- Anesthesia and Intensive Care Unit, Department of Emergency and Critical Care, Santa Maria Nuova Hospital, Florence, Italy
| | - Rikardo Xhemalaj
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Maria Dell'Anna
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianmarco Lombardi
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabiola Cammarota
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Caroli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Luca Grieco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
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Flett L, Abdelatif R, Baz SA, Brady S, Corbacho B, Common K, Cowling A, Fairhurst C, Fitzmaurice E, Gandhi S, Hilton A, Hope W, Howard A, Laycock J, Lillie P, Mitchell G, Parker A, Peel M, Sheard L, Sneddon J, Taynton T, Tharmanathan P, Torgerson D, Wang HI, Allsup D, Barlow G. Biomarker Driven Antifungal Stewardship (BioDriveAFS) in acute leukaemia-a multi-centre randomised controlled trial to assess clinical and cost effectiveness: a study protocol for a randomised controlled trial. Trials 2024; 25:427. [PMID: 38943201 PMCID: PMC11214238 DOI: 10.1186/s13063-024-08272-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/19/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Acute leukaemias (AL) are life-threatening blood cancers that can be potentially cured with treatment involving myelosuppressive, multiagent, intensive chemotherapy (IC). However, such treatment is associated with a risk of serious infection, in particular invasive fungal infection (IFI) associated with prolonged neutropenia. Current practice guidelines recommend primary antifungal (AF) prophylaxis to be administered to high-risk patients to reduce IFI incidence. AFs are also used empirically to manage prolonged neutropenic fever. Current strategies lead to substantial overuse of AFs. Galactomannan (GM) and β-D-glucan (BG) biomarkers are also used to diagnose IFI. Combining both biomarkers may enhance the predictability of IFI compared to administering each test alone. Currently, no large-scale randomised controlled trial (RCT) has directly compared a biomarker-based diagnostic screening strategy without AF prophylaxis to AF prophylaxis (without systematic biomarker testing). METHODS BioDriveAFS is a multicentre, parallel, two-arm RCT of 404 participants from UK NHS Haematology departments. Participants will be allocated on a 1:1 basis to receive either a biomarker-based antifungal stewardship (AFS) strategy, or a prophylactic AF strategy, which includes existing standard of care (SoC). The co-primary outcomes will be AF exposure in the 12-month post randomisation and the patient-reported EQ-5D-5L measured at 12-month post randomisation. Secondary outcomes will include total AF exposure, probable/proven IFI, survival (all-cause mortality and IFI mortality), IFI treatment outcome, AF-associated adverse effects/events/complications, resource use, episodes of neutropenic fever requiring hospital admission or outpatient management, AF resistance in fungi (non-invasive and invasive) and a Desirability of Outcome Ranking. The trial will have an internal pilot phase during the first 9 months. A mixed methods process evaluation will be integrated in parallel to the internal pilot phase and full trial, aiming to robustly assess how the intervention is delivered. Cost-effectiveness analysis will also be performed. DISCUSSION The BioDriveAFS trial aims to further the knowledge of strategies that will safely optimise AF use through comparison of the clinical and cost-effectiveness of a biomarker-led diagnostic strategy versus prophylactic AF to prevent and manage IFI within acute leukaemia. The evidence generated from the study will help inform global clinical practice and approaches within antifungal stewardship. TRIAL REGISTRATION ISRCTN11633399. Registered 24/06/2022.
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Affiliation(s)
- Lydia Flett
- Department of Health Sciences, University of York, York, UK.
| | | | | | - Samantha Brady
- Department of Health Sciences, University of York, York, UK
| | - Belén Corbacho
- Department of Health Sciences, University of York, York, UK
| | - Kate Common
- Patient and Public Involvement, University of York, York, UK
| | - Abbie Cowling
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Andrea Hilton
- Faculty of Health Sciences, University of Hull, Hull, UK
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Alex Howard
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Joanne Laycock
- Department of Health Sciences, University of York, York, UK
| | | | - Gemma Mitchell
- Institute for Social Marketing and Health, University of Stirling, Stirling, UK
| | - Adwoa Parker
- Department of Health Sciences, University of York, York, UK
| | - Mary Peel
- Patient and Public Involvement, University of York, York, UK
| | - Laura Sheard
- Department of Health Sciences, University of York, York, UK
| | | | | | | | | | - Han-I Wang
- Department of Health Sciences, University of York, York, UK
| | - David Allsup
- Biomedical Institute for Multimorbidity, Hull York Medical School, University of Hull, Hull, UK
| | - Gavin Barlow
- Department of Experimental Medicine & Biomedicine, Hull York Medical School, University of York, York, UK
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4
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Huang QY, Li PC, Yue JR. Diagnostic performance of serum galactomannan and β-D-glucan for invasive aspergillosis in suspected patients: A meta-analysis. Medicine (Baltimore) 2024; 103:e37067. [PMID: 38306560 PMCID: PMC10843323 DOI: 10.1097/md.0000000000037067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/04/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Serum galactomannan (GM) and β-D-glucan (BG) are known markers of invasive aspergillosis (IA). The aim of this meta-analysis was to evaluate the efficiency of serum GM and BG as diagnostic markers of symptomatic IA infection and compare the performance of the combined tests with that of either test individually. METHODS A literature search was carried out using PubMed, Web of Science, and EMBASE databases to include relevant studies published in English up to May 2023. The quality assessment was performed using Review Manager 5.3 software. A bivariate model was applied to pool diagnostic parameters using Stata 14.0 software. We used Cochrane I2 index to assess heterogeneity and identify the potential source of heterogeneity by meta-regression. Paired t tests were used to compare the value of GM and BG for IA diagnosis when used in combination or alone. RESULTS Sixteen studies were eligible for inclusion in the meta-analysis. For proven or probable IA, serum GM and BG yielded a pooled sensitivity of 0.53 (95% CI 0.40-0.66) vs 0.72 (95% CI 0.61-0.81) and a pooled specificity of 0.94 (95% CI 0.91-0.97) vs 0.82 (95% CI 0.73-0.88). The area under the curve (AUC) of ROC was 0.90 (95% CI 0.87-0.92) vs 0.83 (95% CI 0.80-0.86) for all studies. The pooled sensitivity and specificity for IA diagnosis by combined GM and BG assays (GM/BG) were 0.84 (95% CI 0.69-0.86) and 0.76 (95% CI 0.69-0.81), respectively. The sensitivity of the combined GM/BG test to diagnose IA was higher than of the GM or BG test alone. CONCLUSION Serum GM and BG tests had a relatively high accuracy for IA diagnosis in suspected patients. The diagnostic accuracy of both assays is comparable, and the diagnostic sensitivity is further improved by the combined detection of the 2 markers.
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Affiliation(s)
- Qian-Yi Huang
- Department of Transfusion, Nanchong Central Hospital Second Clinical School of North Sichuan Medical College: Nanchong Central Hospital Affiliated to North Sichuan Medical College, Nanchong City, Sichuan Province, China
| | - Peng-Cheng Li
- Department of Neurosurgery, Nanchong Central Hospital Second Clinical School of North Sichuan Medical College: Nanchong Central Hospital Affiliated to North Sichuan Medical College, Nanchong City, Sichuan Province, China
| | - Jin-Rui Yue
- Department of Transfusion, Nanchong Central Hospital Second Clinical School of North Sichuan Medical College: Nanchong Central Hospital Affiliated to North Sichuan Medical College, Nanchong City, Sichuan Province, China
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Nyuykonge B, Siddig EE, Nyaoke BA, Zijlstra EE, Verbon A, Bakhiet SM, Fahal AH, van de Sande WWJ. Using (1,3)-β-D-glucan concentrations in serum to monitor the response of azole therapy in patients with eumycetoma caused by Madurella mycetomatis. Mycoses 2024; 67:e13664. [PMID: 37872649 DOI: 10.1111/myc.13664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/03/2023] [Accepted: 10/08/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION (1,3)-β-D-glucan is a panfungal biomarker secreted by many fungi, including Madurella mycetomatis, the main causative agent of eumycetoma. Previously we demonstrated that (1,3)-β-D-glucan was present in serum of patients with eumycetoma. However, the use of (1,3)-β-D-glucan to monitor treatment responses in patients with eumycetoma has not been evaluated. MATERIALS AND METHODS In this study, we measured (1,3)-β-D-glucan concentrations in serum with the WAKO (1,3)-β-D-glucan assay in 104 patients with eumycetoma treated with either 400 mg itraconazole daily, or 200 mg or 300 mg fosravuconazole weekly. Serial serum (1,3)-β-D-glucan concentrations were measured at seven different timepoints. Any correlation between initial and final (1,3)-β-D-glucan concentrations and clinical outcome was evaluated. RESULTS The concentration of (1,3)-β-D-glucan was obtained in a total of 654 serum samples. Before treatment, the average (1,3)-β-D-glucan concentration was 22.86 pg/mL. During the first 6 months of treatment, this concentration remained stable. (1,3)-β-D-glucan concentrations significantly dropped after surgery to 8.56 pg/mL. After treatment was stopped, there was clinical evidence of recurrence in 18 patients. Seven of these 18 patients had a (1,3)-β-D-glucan concentration above the 5.5 pg/mL cut-off value for positivity, while in the remaining 11 patients, (1,3)-β-D-glucan concentrations were below the cut-off value. This resulted in a sensitivity of 38.9% and specificity of 75.0%. A correlation between lesion size and (1,3)-β-D-glucan concentration was noted. CONCLUSION Although in general (1,3)-β-D-glucan concentrations can be measured in the serum of patients with eumycetoma during treatment, a sharp decrease in β-glucan concentration was only noted after surgery and not during or after antimicrobial treatment. (1,3)-β-D-glucan concentrations were not predictive for recurrence and seem to have no value in determining treatment response to azoles in patients with eumycetoma.
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Affiliation(s)
- Bertrand Nyuykonge
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | | | - Borna A Nyaoke
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | | | - Annelies Verbon
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Sahar M Bakhiet
- Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
| | - Ahmed H Fahal
- Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
| | - Wendy W J van de Sande
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
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Neun BW, Dobrovolskaia MA. Detection of Beta-Glucan Contamination in Nanoparticle Formulations. Methods Mol Biol 2024; 2789:101-108. [PMID: 38506995 DOI: 10.1007/978-1-0716-3786-9_10] [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] [Indexed: 03/22/2024]
Abstract
Beta-glucans with diverse chemical structures are produced by a variety of microorganisms and are commonly found in microbial cell walls. β-(1,3)-D-glucans are present in yeast and fungi, and, for this reason, their traces are commonly used as a sign of yeast or fungal infection or contamination. Despite being less immunologically active than endotoxins, beta-glucans are pro-inflammatory and can activate cytokines and other immunological responses via their cognate pattern recognition receptors. Unlike endotoxins, there is no established threshold pyrogen dose for beta-glucans; as such, their quantity in pharmaceutical products is not regulated. Nevertheless, regulatory agencies recognize the potential contribution of beta-glucans to the immunogenicity of protein-containing drug products and recommend assessing beta-glucans to aid the interpretation of immunotoxicity studies and assess the risk of immunogenicity. The protocol for the detection and quantification of β-(1,3)-D-glucans in nanoparticle formulations is based on a modified limulus amoebocyte lysate assay. The results of this test are used to inform immunotoxicity studies of nanotechnology-based drug products.
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Affiliation(s)
- Barry W Neun
- Nanotechnology Characterization Laboratory, Cancer Research Technology Program, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Marina A Dobrovolskaia
- Nanotechnology Characterization Laboratory, Cancer Research Technology Program, Frederick National Laboratory for Cancer Research, Frederick, MD, USA.
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Gaffney S, Kelly DM, Rameli PM, Kelleher E, Martin-Loeches I. Invasive pulmonary aspergillosis in the intensive care unit: current challenges and best practices. APMIS 2023; 131:654-667. [PMID: 37022291 DOI: 10.1111/apm.13316] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/02/2023] [Indexed: 04/07/2023]
Abstract
The prevalence of invasive pulmonary aspergillosis (IPA) is growing in critically ill patients in the intensive care unit (ICU). It is increasingly recognized in immunocompetent hosts and immunocompromised ones. IPA frequently complicates both severe influenza and severe coronavirus disease 2019 (COVID-19) infection. It continues to represent both a diagnostic and therapeutic challenge and can be associated with significant morbidity and mortality. In this narrative review, we describe the epidemiology, risk factors and disease manifestations of IPA. We discuss the latest evidence and current published guidelines for the diagnosis and management of IPA in the context of the critically ill within the ICU. Finally, we review influenza-associated pulmonary aspergillosis (IAPA), COVID-19-associated pulmonary aspergillosis (CAPA) as well as ongoing and future areas of research.
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Affiliation(s)
- Sarah Gaffney
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Dearbhla M Kelly
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Puteri Maisarah Rameli
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Eoin Kelleher
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Hospital Clinic, Institut D'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
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8
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Cabanilla MG, Briski MJ, Bruss Z, Saa L, Vasquez PC, Rodriguez CN, Mitchell JA, Bernauer ML, Argyropoulos CP, Crandall CS, Teixeira JP. The influence of continuous renal replacement therapy on 1,3-β-d-glucan levels in critically ill patients: a single-center retrospective propensity score study. Ren Fail 2023; 45:2255680. [PMID: 37781748 PMCID: PMC10547441 DOI: 10.1080/0886022x.2023.2255680] [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: 05/23/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023] Open
Abstract
1,3-β-d-Glucan (BDG) is commonly used for diagnosing invasive fungal infections (IFIs). While exposure to cellulose-based hemodialyzers is known to cause false-positive BDG results, the impact of modern hemofilters used in continuous renal replacement therapy (CRRT) remains unclear. This retrospective, single-center cohort study aimed to evaluate the effect of CRRT on BDG levels in critically ill patients. We included adult intensive care unit (ICU) patients with ≥1 BDG measurement between December 2019 and December 2020. The primary outcome was the rate of false-positive BDG results in patients exposed to CRRT compared to unexposed patients. Propensity score analysis was performed to control for confounding factors. A total of 103 ICU patients with ≥1 BDG level were identified. Most (72.8%) were medical ICU patients. Forty patients underwent CRRT using hemofilter membranes composed of sodium methallyl sulfonate copolymer (AN 69 HF) (82.5%) and of polyarylethersulfone (PAES) (17.5%). Among the 91 patients without proven IFI, 31 (34.1%) had false-positive BDG results. Univariable analysis showed an association between CRRT exposure and false-positive BDG results. However, the association between CRRT exposure and false-positive BDG results was no longer significant across three propensity score models employed: 1:1 match (n = 32) (odds ratio (OR) 1.65, p = .48), model-adjusted (n = 91) (OR 1.75, p = .38), quintile-adjusted (n = 91) (OR 1.78, p = .36). In this single-center retrospective analysis, exposure to synthetic CRRT membranes did not independently increase the risk of false-positive BDG results. Larger prospective studies are needed to further evaluate the association between CRRT exposure and false-positive BDG results in critically ill patients with suspected IFI.
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Affiliation(s)
- M. Gabriela Cabanilla
- Department of Internal Medicine and Department of Pharmacy, Division of Infectious Diseases, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Matthew J. Briski
- Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Zachary Bruss
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Lisa Saa
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Pamela C. Vasquez
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Chelsea N. Rodriguez
- Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jessica A. Mitchell
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | | | - Christos P. Argyropoulos
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Cameron S. Crandall
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - J. Pedro Teixeira
- Department of Internal Medicine, Division of Nephrology, Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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9
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Shafiee F, Soltani R, Meidani M. Invasive fungal infections in hematologic malignancies: Incidence, management, and antifungal therapy. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2023; 28:73. [PMID: 38116484 PMCID: PMC10729687 DOI: 10.4103/jrms.jrms_1072_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 06/25/2023] [Accepted: 07/17/2023] [Indexed: 12/21/2023]
Abstract
The incidence of invasive fungal infections (IFIs) has increased in recent years as a result of increasing the incidence of hematologic malignancies (HMs). IFIs, as the opportunistic diseases, are the most important concern in these patients with a high mortality rate. These infections are one of the leading causes of morbidity and mortality in HM patients and an important factor in increasing the costs of patients' management because of the prolonged hospitalization and the inevitable need to use antifungal agents. Due to the changes in the pattern of organisms causing IFIs, unavailability of effective and safe antifungal drugs, and high rate of drug resistance as well as lack of fast and accurate diagnostic methods, these infections have become a serious and life-threatening problem necessitating effective prevention and treatment strategies using suitable antifungal agents, especially in high-risk patients. The aim of the present study was to review the pathogens causing various types of IFIs, diagnostic methods, and novel prophylactic and therapeutic antifungal regimens in HM patients according to the new published studies and clinical trials.
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Affiliation(s)
- Fatemeh Shafiee
- Department of Pharmaceutical Biotechnology, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasool Soltani
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Meidani
- Department of Infectious Diseases, Imam Khomeini Hospital, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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10
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Bukkems LMP, van Dommelen L, Regis M, van den Heuvel E, Nieuwenhuizen L. The Use of Galactomannan Antigen Assays for the Diagnosis of Invasive Pulmonary Aspergillosis in the Hematological Patient: A Systematic Review and Meta-Analysis. J Fungi (Basel) 2023; 9:674. [PMID: 37367610 DOI: 10.3390/jof9060674] [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: 04/14/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
The optimal cut-off value of the optical density index of the galactomannan antigen assays (GM) for diagnosing invasive pulmonary aspergillosis in hematological patients is a disputed topic. This article conducts a systematic review with a meta-analysis to establish which optical density index (ODI) cut-off value should be implemented into clinical practice. Pubmed, Embase and Cochrane databases were searched (N = 27). The pooled data, using a generalized linear mixed model with binomial distribution, resulted in an overall serum sensitivity of 0.76 and a specificity of 0.92. For serum ODI 0.5 there was a pooled sensitivity of 0.92 and a specificity of 0.84. The pooled data of all broncho-alveolar lavage (BAL) studies resulted in an overall sensitivity of 0.80 and a specificity of 0.95. For BAL ODI 0.5, there was a pooled sensitivity of 0.75 and a specificity of 0.88. For the BAL ODI 1.0 pooling, the studies resulted in a sensitivity of 0.75 and a specificity of 0.96. Serum ODI of 0.5 and BAL ODI of 1.0 are the most suitable cut-offs for clinical practice. However, our study affirms that the evidence for the use of GM in clinical practice for the hematological malignancy patient is currently insufficient and more research is needed to determine the diagnostic value of GM.
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Affiliation(s)
- Lydia M P Bukkems
- Maxima Medical Centre, De Run 46000, 5504 DB Veldhoven, The Netherlands
| | - Laura van Dommelen
- Ziekenhuis Gelderse Vallei, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands
| | - Marta Regis
- Mathematics and Computer Science, Eindhoven University of Technology, Building Helix, Postbus 513, 5600 MB Eindhoven, The Netherlands
| | - Edwin van den Heuvel
- Mathematics and Computer Science, Eindhoven University of Technology, Building Helix, Postbus 513, 5600 MB Eindhoven, The Netherlands
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11
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Stemler J, Többen C, Lass-Flörl C, Steinmann J, Ackermann K, Rath PM, Simon M, Cornely OA, Koehler P. Diagnosis and Treatment of Invasive Aspergillosis Caused by Non- fumigatus Aspergillus spp. J Fungi (Basel) 2023; 9:jof9040500. [PMID: 37108955 PMCID: PMC10141595 DOI: 10.3390/jof9040500] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/27/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
With increasing frequency, clinical and laboratory-based mycologists are consulted on invasive fungal diseases caused by rare fungal species. This review aims to give an overview of the management of invasive aspergillosis (IA) caused by non-fumigatus Aspergillus spp.-namely A. flavus, A. terreus, A. niger and A. nidulans-including diagnostic and therapeutic differences and similarities to A. fumigatus. A. flavus is the second most common Aspergillus spp. isolated in patients with IA and the predominant species in subtropical regions. Treatment is complicated by its intrinsic resistance against amphotericin B (AmB) and high minimum inhibitory concentrations (MIC) for voriconazole. A. nidulans has been frequently isolated in patients with long-term immunosuppression, mostly in patients with primary immunodeficiencies such as chronic granulomatous disease. It has been reported to disseminate more often than other Aspergillus spp. Innate resistance against AmB has been suggested but not yet proven, while MICs seem to be elevated. A. niger is more frequently reported in less severe infections such as otomycosis. Triazoles exhibit varying MICs and are therefore not strictly recommended as first-line treatment for IA caused by A. niger, while patient outcome seems to be more favorable when compared to IA due to other Aspergillus species. A. terreus-related infections have been reported increasingly as the cause of acute and chronic aspergillosis. A recent prospective international multicenter surveillance study showed Spain, Austria, and Israel to be the countries with the highest density of A. terreus species complex isolates collected. This species complex seems to cause dissemination more often and is intrinsically resistant to AmB. Non-fumigatus aspergillosis is difficult to manage due to complex patient histories, varying infection sites and potential intrinsic resistances to antifungals. Future investigational efforts should aim at amplifying the knowledge on specific diagnostic measures and their on-site availability, as well as defining optimal treatment strategies and outcomes of non-fumigatus aspergillosis.
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Affiliation(s)
- Jannik Stemler
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
| | - Christina Többen
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, European Diamond Excellence Center for Medical Mycology (ECMM), Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Jörg Steinmann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, 90419 Nuremberg, Germany
- Institute of Medical Microbiology, University Hospital Essen, European Diamond Excellence Center for Medical Mycology (ECMM), 45147 Essen, Germany
| | - Katharina Ackermann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, 90419 Nuremberg, Germany
| | - Peter-Michael Rath
- Institute of Medical Microbiology, University Hospital Essen, European Diamond Excellence Center for Medical Mycology (ECMM), 45147 Essen, Germany
| | - Michaela Simon
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
| | - Oliver Andreas Cornely
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, 50935 Cologne, Germany
| | - Philipp Koehler
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
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12
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Husson J, Bork JT, Morgan D, Baddley JW. Is diagnostic stewardship possible in solid organ transplantation? Transpl Infect Dis 2022; 24:e13899. [DOI: 10.1111/tid.13899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/08/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Jennifer Husson
- Institute of Human Virology Department of Medicine University of Maryland School of Medicine Baltimore Maryland USA
| | - Jacqueline T. Bork
- Department of Medicine University of Maryland School of Medicine and VA Maryland Healthcare System Baltimore Maryland USA
| | - Daniel Morgan
- Department of Epidemiology and Public Health VA Maryland Healthcare System University of Maryland School of Medicine Baltimore Maryland USA
| | - John W. Baddley
- Department of Medicine University of Maryland School of Medicine and VA Maryland Healthcare System Baltimore Maryland USA
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13
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Pueringer J, Stephens P, Pandya NK, Zaidi S. A Case of Invasive Pulmonary Aspergillosis vs. Pulmonary Aspergilloma in Immunocompromised Patient With Preexisting Lung Cavity. Cureus 2022; 14:e28073. [PMID: 36127975 PMCID: PMC9477492 DOI: 10.7759/cureus.28073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 12/02/2022] Open
Abstract
Subacute invasive aspergillosis (SAIA) occurs in immunocompromised patients and/or patients with preexisting pulmonary pathology. An aspergilloma is a fungus ball that occurs in preexisting lung cavities and can be relatively asymptomatic without tissue invasion. In contrast to an aspergilloma, SAIA invades local tissue and parenchyma, resulting in tissue necrosis. We present a case of a 68-year-old immunocompromised female with a past medical history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), stage IIIA adenocarcinoma, and a preexisting pulmonary cavity with chronic invasive aspergillosis vs. pulmonary aspergilloma treated with oral (PO) voriconazole. This case demonstrates that invasive aspergillosis should be considered in the differential diagnosis of any pulmonary lung lesion showing tissue invasion and expansion in an immunocompromised patient.
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14
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Thompson GR, Boulware DR, Bahr NC, Clancy CJ, Harrison TS, Kauffman CA, Le T, Miceli MH, Mylonakis E, Nguyen MH, Ostrosky-Zeichner L, Patterson TF, Perfect JR, Spec A, Kontoyiannis DP, Pappas PG. Noninvasive Testing and Surrogate Markers in Invasive Fungal Diseases. Open Forum Infect Dis 2022; 9:ofac112. [PMID: 35611348 PMCID: PMC9124589 DOI: 10.1093/ofid/ofac112] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
Invasive fungal infections continue to increase as at-risk populations expand. The high associated morbidity and mortality with fungal diseases mandate the continued investigation of novel antifungal agents and diagnostic strategies that include surrogate biomarkers. Biologic markers of disease are useful prognostic indicators during clinical care, and their use in place of traditional survival end points may allow for more rapid conduct of clinical trials requiring fewer participants, decreased trial expense, and limited need for long-term follow-up. A number of fungal biomarkers have been developed and extensively evaluated in prospective clinical trials and small series. We examine the evidence for these surrogate biomarkers in this review and provide recommendations for clinicians and regulatory authorities.
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Affiliation(s)
- George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California-Davis Medical Center, Sacramento California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
| | - David R Boulware
- Division of Infectious Diseases, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection, St George’s Hospital NHS Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Carol A Kauffman
- VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center, San Antonio, Texas, USA
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Infectious Diseases, Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Dimitrios P Kontoyiannis
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter G Pappas
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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15
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Jiang Z, Chen S, Zhu Q, Xiao Y, Qu J. COVID-19-associated pulmonary aspergillosis in a tertiary care center in Shenzhen City. J Infect Public Health 2022; 15:222-227. [PMID: 35032951 PMCID: PMC8733224 DOI: 10.1016/j.jiph.2021.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 12/27/2021] [Accepted: 12/30/2021] [Indexed: 12/30/2022] Open
Abstract
Objectives The severe coronavirus disease 2019 (COVID-19) is characterized by acute respiratory distress syndrome (ARDS) and risk of fungal co-infection, pulmonary aspergillosis in particular. However, COVID-19 associated pulmonary aspergillosis (CAPA) cases remain limited due to the difficulty in diagnosis. Methods We describe presumptive invasive aspergillosis in eight patients diagnosed with COVID-19 in a single center in Shenzhen, China. Data collected include underlying conditions, mycological findings, immunodetection results, therapies and outcomes. Results Four of the eight patients had tested positive for Aspergillus by either culture or Next-generation sequencing analysis of sputum or bronchoalveolar lavage fluid (BALF), while the rest of patients had only positive results in antigen or antibody detection. Although all patients received antifungal therapies, six of these eight patients (66.7%) died. Conclusion Due to the high mortality rate of CAPA, clinical care in patients with CAPA deserves more attention.
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Affiliation(s)
- Zhaofang Jiang
- The Third People's Hospital of Shenzhen, Southern University of Science and Technology, National Clinical Research Center for Infectious Diseases, Shenzhen, China
| | - Shuyan Chen
- The Third People's Hospital of Shenzhen, Southern University of Science and Technology, National Clinical Research Center for Infectious Diseases, Shenzhen, China
| | - Qing Zhu
- The Third People's Hospital of Shenzhen, Southern University of Science and Technology, National Clinical Research Center for Infectious Diseases, Shenzhen, China
| | - Yanyu Xiao
- The Third People's Hospital of Shenzhen, Southern University of Science and Technology, National Clinical Research Center for Infectious Diseases, Shenzhen, China
| | - Jiuxin Qu
- The Third People's Hospital of Shenzhen, Southern University of Science and Technology, National Clinical Research Center for Infectious Diseases, Shenzhen, China.
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16
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Transience of interference in an immunoassay measuring serum levels of Beta-D-glucan. Diagn Microbiol Infect Dis 2022; 102:115630. [DOI: 10.1016/j.diagmicrobio.2021.115630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/23/2022]
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17
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Izumiya R, Fujita Y, Amagai T. A case of influenza-associated invasive aspergillosis with cerebral hemorrhage due to infectious vasculopathy. Radiol Case Rep 2021; 17:326-331. [PMID: 34876959 PMCID: PMC8633528 DOI: 10.1016/j.radcr.2021.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 11/19/2022] Open
Abstract
An invasive aspergillosis (IA) primarily occurs among immunocompromised patients. Recently with an influenzae infection prevalently spreading, influenzae-associated invasive aspergillosis (IAIA) has been reported occasionally. By contrast, neuroleptic malignant syndrome (NMS) occurs rarely in psychiatric patients who are treated with Olanzapine. We report a 43 years old male with psychiatric disorder who had developed IAIA followed by NMS and cerebral hemorrhage as the result of aspergillus invasion to cerebral vessels. He had also super-infection of COVID-19, 13 months later to be saved completely after invasive mechanical respiratory supports. From clinical aspects, we would emphasize that it is of importance to find earlier co-occurrence of IAIA patients with cerebral hemorrhage due to secondary infectious vasculopathy of IA.
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Affiliation(s)
- Ryou Izumiya
- Department of Medicine, Tokunoshima Tokushukai General Hospital, Kagoshima, Japan
| | - Yasuhiko Fujita
- Department of Medicine, Tokunoshima Tokushukai General Hospital, Kagoshima, Japan
| | - Teruyoshi Amagai
- Department of Medicine, Tokunoshima Tokushukai General Hospital, Kagoshima, Japan
- Faculty of Health Care Sciences, Department of Clinical Engineering, Jikei University of Health Care Sciences, Osaka, Japan
- Corresponding author.
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18
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Kimura SI, Kanda Y, Oyake T, Yamaguchi H, Fujiwara SI, Okamoto A, Fujita H, Saburi Y, Tamura K. Fungal biomarker monitoring and CT scans for early detection of invasive fungal disease in neutropenic hematological patients. J Infect 2021; 84:80-86. [PMID: 34710391 DOI: 10.1016/j.jinf.2021.10.018] [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: 09/06/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES By using data from the CEDMIC trial (n = 413), we conducted a post-hoc analysis of the diagnostic value of biomarker monitoring and chest computed tomography (CT) scans for the early detection of invasive fungal disease (IFD) in neutropenic hematological patients. METHODS IFDs were defined in accordance with the EORTC/MSG definition with some modifications. Biomarkers such as Aspergillus galactomannan (GM) and (1→3)-β-D-glucan (βDG) were measured weekly. RESULTS The positive predictive value (PPV) of GM and βDG in cases of high-risk treatment were 0.70 and 0.69, while those in low-risk treatment were 0.08 and 0, respectively. All of the positive biomarkers that were measured before the development of fever in low-risk treatment were false positives. The proportion of patients who had abnormal chest CT findings was 19% in persistent fever at 4-6 days, 57% at 7 days or later and 36% in recurrent fever. Sixty-nine percent of the patients who had abnormal findings at 7 days or later did not have abnormalities at 4-6 days. CONCLUSIONS Afebrile screening of biomarkers in low-risk treatment is not useful. Chest CT should be reevaluated in persistent fever lasting for 7 days or longer even in patients who did not have abnormalities within 6 days.
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Affiliation(s)
- Shun-Ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama-city, Saitama 330-8503, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama-city, Saitama 330-8503, Japan; Department of Internal Medicine, Division of Hematology, Jichi Medical University, Japan.
| | - Tatsuo Oyake
- Department of Internal Medicine, Division of Hematology and Oncology, Iwate Medical University School of Medicine, Japan
| | | | - Shin-Ichiro Fujiwara
- Department of Internal Medicine, Division of Hematology, Jichi Medical University, Japan
| | - Akinao Okamoto
- Department of Hematology, Fujita Health University School of Medicine, Japan
| | - Hiroyuki Fujita
- Department of Hematology, Saiseikai Yokohama Nanbu Hospital, Japan
| | - Yoshio Saburi
- Department of Hematology, Oita Prefectural Hospital, Japan
| | - Kazuo Tamura
- Clinical Hematology Oncology Treatment Study Group, Japan
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Brault C, Zerbib Y, Chouaki T, Maizel J, Nyga R. Temozolomide is a risk factor for invasive pulmonary aspergillosis: A case report and literature review. Infect Dis Now 2021; 51:630-632. [PMID: 34581280 DOI: 10.1016/j.idnow.2020.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Temozolomide is an oral alkylating agent incorporated in the treatment of glioblastoma multiforme (GBM) that can lead to lymphopenia. The standard treatment of GBM involves temozolomide chemotherapy with radiation, often with addition of corticosteroids for symptomatic management of cerebral edema. Some studies have reported an increased risk of opportunistic infections. CASE PRESENTATION A 72-year-old man receiving Temozolomide for treatment of newly diagnosed GBM associated with radiotherapy and corticosteroids was admitted in an intensive care unit because a rapid deterioration of consciousness associated with acute respiratory failure. The diagnosis of invasive pulmonary aspergillosis (IPA) was made. The patient was successfully treated with voriconazole alone. CONCLUSIONS This case shows that Temozolomide can be associated with severe invasive aspergillosis, which is in all likelihood associated with T lymphocyte immune dysfunction. Physicians should be aware of possible opportunistic infections when managing patients with glioblastoma, and patients exposed to this agent should be carefully monitored.
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Affiliation(s)
- Clément Brault
- Department of Intensive Care Medicine, CHU Amiens-Picardie, avenue Laennec, 80000 Amiens, France.
| | - Yoann Zerbib
- Department of Intensive Care Medicine, CHU Amiens-Picardie, avenue Laennec, 80000 Amiens, France
| | - Taieb Chouaki
- Parasitology and Mycology Department, Amiens University Hospital, 80000 Amiens, France
| | - Julien Maizel
- Department of Intensive Care Medicine, CHU Amiens-Picardie, avenue Laennec, 80000 Amiens, France
| | - Rémy Nyga
- Department of Intensive Care Medicine, CHU Amiens-Picardie, avenue Laennec, 80000 Amiens, France
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20
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Challenges with Utilizing the 1,3-Beta-d-Glucan and Galactomannan Assays To Diagnose Invasive Mold Infections in Immunocompromised Children. J Clin Microbiol 2021; 59:e0327620. [PMID: 33883182 DOI: 10.1128/jcm.03276-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Establishing the diagnosis of invasive mold infections (IMI) in immunocompromised children is challenging due to nonspecific clinical presentations and the limited sensitivity of traditional culture-based methods. Rapid non-culture-based diagnostics such as the 1,3-beta-d-glucan and galactomannan assays have emerged as promising adjuncts to conventional diagnostic tests in adults. Available data suggest that 1,3-beta-d-glucan has limited accuracy in the pediatric population and is not recommended to be used for the diagnosis of IMI in children. On the other hand, the diagnostic performance of the serum and bronchoalveolar lavage galactomannan in immunocompromised children is comparable to results observed in adults and can be used as a screening tool in children at high risk of developing invasive aspergillosis (IA) who are not receiving mold-active antifungal prophylaxis and as a diagnostic tool in symptomatic children suspected of having IA. Herein, we summarize the available evidence for the use of these rapid non-culture-based diagnostics in immunocompromised children. We also summarize potential causes of false positivity for the 1,3-beta-d-glucan and galactomannan assays.
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21
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Vehreschild JJ, Koehler P, Lamoth F, Prattes J, Rieger C, Rijnders BJA, Teschner D. Future challenges and chances in the diagnosis and management of invasive mould infections in cancer patients. Med Mycol 2021; 59:93-101. [PMID: 32898264 PMCID: PMC7779224 DOI: 10.1093/mmy/myaa079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/31/2020] [Accepted: 08/18/2020] [Indexed: 11/15/2022] Open
Abstract
Diagnosis, treatment, and management of invasive mould infections (IMI) are challenged by several risk factors, including local epidemiological characteristics, the emergence of fungal resistance and the innate resistance of emerging pathogens, the use of new immunosuppressants, as well as off-target effects of new oncological drugs. The presence of specific host genetic variants and the patient's immune system status may also influence the establishment of an IMI and the outcome of its therapy. Immunological components can thus be expected to play a pivotal role not only in the risk assessment and diagnosis, but also in the treatment of IMI. Cytokines could improve the reliability of an invasive aspergillosis diagnosis by serving as biomarkers as do serological and molecular assays, since they can be easily measured, and the turnaround time is short. The use of immunological markers in the assessment of treatment response could be helpful to reduce overtreatment in high risk patients and allow prompt escalation of antifungal treatment. Mould-active prophylaxis could be better targeted to individual host needs, leading to a targeted prophylaxis in patients with known immunological profiles associated with high susceptibility for IMI, in particular invasive aspergillosis. The alteration of cellular antifungal immune response through oncological drugs and immunosuppressants heavily influences the outcome and may be even more important than the choice of the antifungal treatment. There is a need for the development of new antifungal strategies, including individualized approaches for prevention and treatment of IMI that consider genetic traits of the patients. Lay Abstract Anticancer and immunosuppressive drugs may alter the ability of the immune system to fight invasive mould infections and may be more important than the choice of the antifungal treatment. Individualized approaches for prevention and treatment of invasive mold infections are needed.
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Affiliation(s)
- Jörg Janne Vehreschild
- Department of Internal Medicine, Hematology, and Oncology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany; Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany; German Centre for Infection Research, partner site Bonn-Cologne, University of Cologne, Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Excellence Center for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Institute of Microbiology, Department of Laboratories, Lausanne University Hospital, Lausanne, Switzerland
| | - Juergen Prattes
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Bart J A Rijnders
- Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Daniel Teschner
- Department of Hematology, Medical Oncology, and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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22
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Song J, Kim S, Park J, Park Y, Kim HS. Comparison of two β-D-glucan assays for detecting invasive fungal diseases in immunocompromised patients. Diagn Microbiol Infect Dis 2021; 101:115415. [PMID: 34082306 DOI: 10.1016/j.diagmicrobio.2021.115415] [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: 02/01/2021] [Revised: 04/14/2021] [Accepted: 04/24/2021] [Indexed: 11/26/2022]
Abstract
(1-3)-β-D-glucan (BDG) is a major biomarker of invasive fungal diseases (IFDs), which are life-threatening for immunodeficient patients. We compared the clinical performance of two BDG-detection assays. The precision, linearity, reference interval, and limit of quantitation of the Wako BDG assay were analyzed and the performance was compared with that of the Goldstream BDG assay using 272 clinical serum samples. The repeatability, within-laboratory imprecision, and limit of quantitation of the Wako BDG assay were 3.8%, 5.9%, and 7.35 pg/mL, respectively (linearity, 23.8-557 pg/mL; R2 = 0.998). The correlation coefficient, slope, and y-intercept for the Wako BDG assay versus Goldstream BDG assay were 0.29, 3.82, and 0.04, respectively. The sensitivity and specificity were 43.8% and 94.9% for the Wako BDG assay and 39.6% and 83.5% for the Goldstream BDG assay, respectively. In clinical settings, the Wako BDG assay is suitable for diagnosing patients with IFDs.
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Affiliation(s)
- Junhyup Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Sinyoung Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Jungyong Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Younhee Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea.
| | - Hyon-Suk Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
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23
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Lamoth F, Akan H, Andes D, Cruciani M, Marchetti O, Ostrosky-Zeichner L, Racil Z, Clancy CJ. Assessment of the Role of 1,3-β-d-Glucan Testing for the Diagnosis of Invasive Fungal Infections in Adults. Clin Infect Dis 2021; 72:S102-S108. [PMID: 33709130 DOI: 10.1093/cid/ciaa1943] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Detection of 1,3-β-d-glucan (BDG) in serum has been evaluated for its inclusion as a mycological criterion of invasive fungal infections (IFI) according to EORTC and Mycoses Study Group (MSG) definitions. BDG testing may be useful for the diagnosis of both invasive aspergillosis and invasive candidiasis, when interpreted in conjunction with other clinical/radiological signs and microbiological markers of IFI. However, its performance and utility vary according to patient population (hematologic cancer patients, solid-organ transplant recipients, intensive care unit patients) and pretest likelihood of IFI. The objectives of this article are to provide a systematic review of the performance of BDG testing and to assess recommendations for its use and interpretation in different clinical settings.
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Affiliation(s)
- F Lamoth
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - H Akan
- Ankara University, Faculty of Medicine, Cebeci Campus, Hematology Clinical Research Unit, Ankara, Turkey
| | - D Andes
- Department of Medicine and Microbiology and Immunology, University of Wisconsin, Madison, Wisconsin, USA
| | - M Cruciani
- Infectious Diseases Unit, G. Fracastoro Hospital, San Bonifacio, Verona, Italy
| | - O Marchetti
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Medicine, Ensemble Hospitalier de La Côte, Morges, Switzerland
| | - L Ostrosky-Zeichner
- Division of Infectious Diseases, McGovern Medical School, Houston, Texas, USA
| | - Z Racil
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - C J Clancy
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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24
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Neofytos D, Garcia-Vidal C, Lamoth F, Lichtenstern C, Perrella A, Vehreschild JJ. Invasive aspergillosis in solid organ transplant patients: diagnosis, prophylaxis, treatment, and assessment of response. BMC Infect Dis 2021; 21:296. [PMID: 33761875 PMCID: PMC7989085 DOI: 10.1186/s12879-021-05958-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients. Although IA has significant implications on graft and patient survival, data on diagnosis and management of this infection in SOT recipients are still limited. METHODS Discussion of current practices and limitations in the diagnosis, prophylaxis, and treatment of IA and proposal of means of assessing treatment response in SOT recipients. RESULTS Liver, lung, heart or kidney transplant recipients have common as well as different risk factors to the development of IA, thus each category needs a separate evaluation. Diagnosis of IA in SOT recipients requires a high degree of awareness, because established diagnostic tools may not provide the same sensitivity and specificity observed in the neutropenic population. IA treatment relies primarily on mold-active triazoles, but potential interactions with immunosuppressants and other concomitant therapies need special attention. CONCLUSIONS Criteria to assess response have not been sufficiently evaluated in the SOT population and CT lesion dynamics, and serologic markers may be influenced by the underlying disease and type and severity of immunosuppression. There is a need for well-orchestrated efforts to study IA diagnosis and management in SOT recipients and to develop comprehensive guidelines for this population.
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Affiliation(s)
- Dionysios Neofytos
- Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland.
| | - Carolina Garcia-Vidal
- Servicio de Enfermedades Infecciosas, Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, FungiCLINIC Research group (AGAUR), Barcelona, Spain
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
- Department of Laboratories, Institute of Microbiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Christoph Lichtenstern
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg, Germany
| | - Alessandro Perrella
- VII Department of Infectious Disease and Immunology, Hospital D. Cotugno, Naples, Italy
- CLSE-Liver Transplant Unit, Hospital A. Cardarelli, Naples, Italy
| | - Jörg Janne Vehreschild
- Medical Department II, Hematology and Oncology, University Hospital of Frankfurt, Frankfurt, Germany
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany
- German Centre for Infection Research, partner site Bonn-Cologne, University of Cologne, Cologne, Germany
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25
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Garnham K, Halliday CL, Joshi Rai N, Jayawadena M, Hasan T, Kok J, Nayyar V, Gottlieb DJ, Gilroy NM, Chen SCA. Introducing 1,3-Beta-D-glucan for screening and diagnosis of invasive fungal diseases in Australian high risk haematology patients: is there a clinical benefit? Intern Med J 2020; 52:426-435. [PMID: 32896984 DOI: 10.1111/imj.15046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Katherine Garnham
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales, Health Pathology-Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, Australia
| | - Catriona L Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales, Health Pathology-Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, Australia
| | - Neela Joshi Rai
- Clinical Trials Unit, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, Australia
| | - Menuk Jayawadena
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales, Health Pathology-Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, Australia
| | - Tasnim Hasan
- Clinical Trials Unit, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, Australia.,Department of Infectious Diseases, Westmead Hospital, Sydney, Australia
| | - Jen Kok
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales, Health Pathology-Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, Australia.,Clinical Trials Unit, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, Australia.,Department of Infectious Diseases, Westmead Hospital, Sydney, Australia
| | - Vineet Nayyar
- Department of Intensive Care Medicine, Westmead Hospital, Sydney, Australia
| | - David J Gottlieb
- Department of Haematology Medicine, Westmead Hospital, Sydney, Australia
| | - Nicole M Gilroy
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, Australia.,Clinical Trials Unit, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, Australia.,Department of Infectious Diseases, Westmead Hospital, Sydney, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales, Health Pathology-Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, Australia.,Clinical Trials Unit, Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, Australia.,Department of Infectious Diseases, Westmead Hospital, Sydney, Australia
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26
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Detection of Beta-Glucan Contamination in Nanotechnology-Based Formulations. Molecules 2020; 25:molecules25153367. [PMID: 32722261 PMCID: PMC7436117 DOI: 10.3390/molecules25153367] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
Understanding the potential contamination of pharmaceutical products with innate immunity modulating impurities (IIMIs) is essential for establishing their safety profiles. IIMIs are a large family of molecules with diverse compositions and structures that contribute to the immune-mediated adverse effects (IMAE) of drug products. Pyrogenicity (the ability to induce fever) and activation of innate immune responses underlying both acute toxicities (e.g., anaphylactoid reactions or pseudoallergy, cytokine storm) and long-term effects (e.g., immunogenicity) are among the IMAE commonly related to IIMI contamination. Endotoxins of gram-negative bacteria are the best-studied IIMIs in that both methodologies for and pitfalls in their detection and quantification are well established. Additionally, regulatory guidance documents and research papers from laboratories worldwide are available on endotoxins. However, less information is currently known about other IIMIs. Herein, we focus on one such IIMI, namely, beta-glucans, and review literature and discuss the experience of the Nanotechnology Characterization Lab (NCL) with the detection of beta-glucans in nanotechnology-based drug products.
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27
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White SK, Schmidt RL, Walker BS, Hanson KE. (1→3)-β-D-glucan testing for the detection of invasive fungal infections in immunocompromised or critically ill people. Cochrane Database Syst Rev 2020; 7:CD009833. [PMID: 32693433 PMCID: PMC7387835 DOI: 10.1002/14651858.cd009833.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Invasive fungal infections (IFIs) are life-threatening opportunistic infections that occur in immunocompromised or critically ill people. Early detection and treatment of IFIs is essential to reduce morbidity and mortality in these populations. (1→3)-β-D-glucan (BDG) is a component of the fungal cell wall that can be detected in the serum of infected individuals. The serum BDG test is a way to quickly detect these infections and initiate treatment before they become life-threatening. Five different versions of the BDG test are commercially available: Fungitell, Glucatell, Wako, Fungitec-G, and Dynamiker Fungus. OBJECTIVES To compare the diagnostic accuracy of commercially available tests for serum BDG to detect selected invasive fungal infections (IFIs) among immunocompromised or critically ill people. SEARCH METHODS We searched MEDLINE (via Ovid) and Embase (via Ovid) up to 26 June 2019. We used SCOPUS to perform a forward and backward citation search of relevant articles. We placed no restriction on language or study design. SELECTION CRITERIA We included all references published on or after 1995, which is when the first commercial BDG assays became available. We considered published, peer-reviewed studies on the diagnostic test accuracy of BDG for diagnosis of fungal infections in immunocompromised people or people in intensive care that used the European Organization for Research and Treatment of Cancer (EORTC) criteria or equivalent as a reference standard. We considered all study designs (case-control, prospective consecutive cohort, and retrospective cohort studies). We excluded case studies and studies with fewer than ten participants. We also excluded animal and laboratory studies. We excluded meeting abstracts because they provided insufficient information. DATA COLLECTION AND ANALYSIS We followed the standard procedures outlined in the Cochrane Handbook for Diagnostic Test Accuracy Reviews. Two review authors independently screened studies, extracted data, and performed a quality assessment for each study. For each study, we created a 2 × 2 matrix and calculated sensitivity and specificity, as well as a 95% confidence interval (CI). We evaluated the quality of included studies using the Quality Assessment of Studies of Diagnostic Accuracy-Revised (QUADAS-2). We were unable to perform a meta-analysis due to considerable variation between studies, with the exception of Candida, so we have provided descriptive statistics such as receiver operating characteristics (ROCs) and forest plots by test brand to show variation in study results. MAIN RESULTS We included in the review 49 studies with a total of 6244 participants. About half of these studies (24/49; 49%) were conducted with people who had cancer or hematologic malignancies. Most studies (36/49; 73%) focused on the Fungitell BDG test. This was followed by Glucatell (5 studies; 10%), Wako (3 studies; 6%), Fungitec-G (3 studies; 6%), and Dynamiker (2 studies; 4%). About three-quarters of studies (79%) utilized either a prospective or a retrospective consecutive study design; the remainder used a case-control design. Based on the manufacturer's recommended cut-off levels for the Fungitell test, sensitivity ranged from 27% to 100%, and specificity from 0% to 100%. For the Glucatell assay, sensitivity ranged from 50% to 92%, and specificity ranged from 41% to 94%. Limited studies have used the Dynamiker, Wako, and Fungitec-G assays, but individual sensitivities and specificities ranged from 50% to 88%, and from 60% to 100%, respectively. Results show considerable differences between studies, even by manufacturer, which prevented a formal meta-analysis. Most studies (32/49; 65%) had no reported high risk of bias in any of the QUADAS-2 domains. The QUADAS-2 domains that had higher risk of bias included participant selection and flow and timing. AUTHORS' CONCLUSIONS We noted considerable heterogeneity between studies, and these differences precluded a formal meta-analysis. Because of wide variation in the results, it is not possible to estimate the diagnostic accuracy of the BDG test in specific settings. Future studies estimating the accuracy of BDG tests should be linked to the way the test is used in clinical practice and should clearly describe the sampling protocol and the relationship of time of testing to time of diagnosis.
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Affiliation(s)
- Sandra K White
- Department of Pathology, University of Utah, School of Medicine, Salt Lake City, Utah, USA
| | - Robert L Schmidt
- Department of Pathology, University of Utah, School of Medicine, Salt Lake City, Utah, USA
| | | | - Kimberly E Hanson
- Director, Transplant Infectious Diseases and Immunocompromised Host Service, Section Head, Clinical Microbiology, Director, Medical Microbiology Fellowship Program, University of Utah and ARUP Laboratories, Salt Lake City, Utah, USA
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28
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Bulpa P, Duplaquet F, Dimopoulos G, Vogelaers D, Blot S. Invasive Pulmonary Aspergillosis in Chronic Obstructive Pulmonary Disease Exacerbations. Semin Respir Crit Care Med 2020; 41:851-861. [PMID: 32599634 DOI: 10.1055/s-0040-1702210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Nowadays, reports in the literature support that patients with severe chronic obstructive pulmonary disease (COPD) are at higher risk to develop invasive pulmonary aspergillosis (IPA). However, the interpretation of Aspergillus-positive cultures from the airways in critically ill COPD is still a challenge. Indeed, as the patient could be merely colonized, tissue samples are required to ascertain IPA diagnosis but they are rarely obtained before death. Consequently, diagnosis is often only suspected on the basis of a combination of three elements: clinical characteristics, radiological images (mostly thoracic CT scan), and microbiological, and occasionally serological, results. To facilitate the analysis of these data, several algorithms have been developed, and the best effectiveness has been demonstrated by the Clinical algorithm. This is of importance as IPA prognosis in these patients remains presently very poor and using such an algorithm could promote prompter diagnosis, early initiation of treatment, and subsequently improved outcome.While the most classical presentation of IPA in critically ill COPD patients features a combination of obstructive respiratory failure, antibiotic-resistant pneumonia, recent or chronic corticosteroid therapy, and positive Aspergillus cultures from the lower respiratory tract, the present article will also address less typical presentations and discuss the most appropriate treatments which could alter prognosis.
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Affiliation(s)
- Pierre Bulpa
- Department of Intensive Care Unit, Mont-Godinne University Hospital, CHU UCL Namur, Namur, Belgium
| | - Fabrice Duplaquet
- Department of Pneumology, Mont-Godinne University Hospital, CHU UCL Namur, Namur, Belgium
| | - George Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, Haidari, Greece
| | - Dirk Vogelaers
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
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29
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Diagnostic accuracy of serum (1-3)-β-D-glucan for Pneumocystis jirovecii pneumonia: a systematic review and meta-analysis. Clin Microbiol Infect 2020; 26:1137-1143. [PMID: 32479781 DOI: 10.1016/j.cmi.2020.05.024] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) can be a life-threatening opportunistic infection in immunocompromised hosts. The diagnosis can be challenging, often requiring semi-invasive respiratory sampling. The serum 1,3-β-D-glucan (BDG) assay has been proposed as a minimally invasive test for the presumptive diagnosis of PJP. METHOD We carried out a systematic review and meta-analysis using articles in the English language published between January 1960 and September 2019. We estimated the pooled sensitivity and specificity of BDG testing using a bivariate random effects approach and compared test performance in human immunodeficiency virus (HIV) and non-HIV subgroups with meta-regression. Data from the pooled sensitivity and specificity were transformed to generate pre- and post-test probability curves. RESULTS Twenty-three studies were included. The pooled sensitivity and specificity of serum BDG testing for PJP were 91% (95%CI 87-94%) and 79% (95%CI 72-84%) respectively. The sensitivity in patients with HIV was better than in patients without (94%, 95%CI 91-96%) versus 86% (95%CI 78-91%) (p 0.02), with comparable specificity (83%, 95%CI 69-92% versus 83%, 95%CI 72-90%) (p 0.10). A negative BDG was only associated with a low post-test probability of PJP (≤5%) when the pre-test probability was low to intermediate (≤20% in non-HIV and ≤50% in HIV). CONCLUSIONS Among patients with a higher likelihood of PJP, the pooled sensitivity of BDG is insufficient to exclude infection. Similarly, for most cases, the pooled specificity is inadequate to diagnose PJP. Understanding the performance of BDG in the population being investigated is therefore essential to optimal clinical decision-making.
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30
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Yu Q, He J, Xing B, Li X, Qian H, Zhang H, Xu M, Peng H. Potential value of serum Aspergillus IgG antibody detection in the diagnosis of invasive and chronic pulmonary aspergillosis in non-agranulocytic patients. BMC Pulm Med 2020; 20:89. [PMID: 32293386 PMCID: PMC7158007 DOI: 10.1186/s12890-020-1125-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 03/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND At present, serum Aspergillus IgG and IgM antibody detection is mainly used in the diagnosis of chronic pulmonary aspergillosis (CPA), but its value in the diagnosis of invasive pulmonary aspergillosis (IPA) in non-agranulocytic patients is still unclear. IgM can be used as a marker of acute infection to help diagnose acute infection-related diseases. IgG is a marker of long-term infection and is used to assist in the diagnosis of pre-existing or chronic infection-related diseases. The aim of this study was to investigate and compare the value of serum Aspergillus IgG and IgM antibody detection in the diagnosis of IPA and CPA in non-agranulocytic patients. METHODS Fifty-eight cases of pulmonary aspergillosis (37 IPA and 21 CPA cases), 15 cases of community-acquired bacterial pneumonia and 50 cases in the healthy control group were collected. The serum (1,3)-β-D-glucan test (G test) was performed with a chromogenic method, and the galactomannan test (GM test) and Aspergillus IgG and IgM antibody detection were performed by commercial enzyme-linked immunosorbent assay (ELISA) in all patients. The sensitivity and specificity, cut-off value and area under the curve (AUC) of Aspergillus IgG and IgM antibodies were further obtained by receiver operating characteristic (ROC) curves. RESULTS The positive rate of the G test, Aspergillus IgG antibody detection and the GM test also showed notable differences among the IPA, CPA, community-acquired bacterial pneumonia and healthy groups (P = 0.006, P < 0.001 and P = 0.217, respectively). Only the positive rate of the GM test showed a significant difference between the IPA and CPA groups (P = 0.04). ROC curves indicated that Aspergillus IgG antibody detection had a higher specificity in the IPA group than in the CPA group (0.952). The detection of Aspergillus IgG antibody can preferably distinguish IPA from community-acquired bacterial pneumonia and healthy controls (sensitivity = 0.923, specificity = 0.459, cut-off value = 134.46, AUC = 0.727). It can also distinguish CPA from community-acquired bacterial pneumonia and healthy controls (sensitivity = 0.952, specificity = 0.692, cut-off value = 75.46, AUC = 0.873). CONCLUSIONS Serum Aspergillus IgG antibody detection may have certain clinical value in the diagnosis of IPA and CPA in non-agranulocytic patients.
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Affiliation(s)
- Qihong Yu
- Department of Respiratory and Critical Care Medicine, Tianjin Chest Hospital, 261, Taierzhuang South Road, Jinnan District, Tianjin, 300222, China
| | - Jingdong He
- The clinical laboratory, Tianjin Chest Hospital, Tianjin, 300222, China
| | - Bin Xing
- Department of Respiratory and Critical Care Medicine, Tianjin Chest Hospital, 261, Taierzhuang South Road, Jinnan District, Tianjin, 300222, China
| | - Xin Li
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, 300222, China
| | - Hongyu Qian
- Department of Respiratory and Critical Care Medicine, Tianjin Chest Hospital, 261, Taierzhuang South Road, Jinnan District, Tianjin, 300222, China
| | - Hong Zhang
- Department of Medical Imaging, Tianjin Chest Hospital, Tianjin, 300222, China
| | - Meilin Xu
- Department of Pathology, Tianjin Chest Hospital, Tianjin, 300222, China
| | - Haiying Peng
- Department of Respiratory and Critical Care Medicine, Tianjin Chest Hospital, 261, Taierzhuang South Road, Jinnan District, Tianjin, 300222, China.
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Shah J, Dutta U, Rudramurthy S, Chakrabarti A, Sinha SK, Sharma V, Mandavdhare H, Sharma P, Kalsi D, Popli P, Radhika S, Das A, Kochhar R. Colonic mucosa-associated candida assessed by biopsy culture is associated with disease severity in ulcerative colitis: A prospective study. J Dig Dis 2019; 20:642-648. [PMID: 31626384 DOI: 10.1111/1751-2980.12825] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 10/15/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the relationship of mucosa-associated candida (MAC) and disease severity in patients with ulcerative colitis (UC). METHODS We prospectively investigated the presence, nature, and quantification of MAC in patients with UC and its relationship with disease severity. Consecutive patients with UC were assessed for clinical, endoscopic, histological features and serum markers of disease severity. All patients underwent mucosal brushing cytology, brushing culture, and biopsy culture for candida growth. MAC was considered present if mucosal biopsy culture grew candida. Candida spp. identification was performed by matrix-assisted laser desorption/ionization. Serum β-D-glucan was measured with a Fungitell assay. Patients with irritable bowel syndrome who had undergone similar investigations were included as controls. RESULTS Ninety-six patients with UC showed evidence of MAC more often than the controls (n = 20) based on biopsy culture (33.3% vs 5.0%, P = 0.011), brush cytology (30.2% vs 5.0%, P = 0.019), and brush culture (36.5% vs 10.0%, P = 0.021). Patients with UC had higher candida colony counts (≥103 CFU/mL) than controls (34.4% vs 5.0%, P = 0.007). Median β-D-glucan values were higher in patients with UC than in controls (103.26 pg/mL vs 66.51 pg/mL, P = 0.011). The UC group with MAC had a higher median total Mayo score, C-reactive protein, fecal calprotectin, β-D-glucan, and histological activity than those without MAC. CONCLUSIONS Patients with UC more often show evidence of MAC and a higher candida colony count than controls. The presence of MAC is associated with high disease severity in patients with UC.
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Affiliation(s)
- Jimil Shah
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Shivaprakash Rudramurthy
- Department of Medical Microbioloy, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbioloy, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Pankaj Sharma
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Dimple Kalsi
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Priyanka Popli
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Srinivasan Radhika
- Department of Cytology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashim Das
- Department of Pathology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post-Graduate Institute of Medical Education & Research, Chandigarh, India
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张 思, 刘 小, 张 建, 蔡 林, 周 城. [Drug-induced toxic epidermal necrolysis with secondary aspergillus fumigatus infection: a case report]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:977-980. [PMID: 31624410 PMCID: PMC7433531 DOI: 10.19723/j.issn.1671-167x.2019.05.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 05/29/2023]
Abstract
Among the various drug induced dermatological entities toxic epidermalnecrolysis (TEN) and Stevens-Johnson syndrome (SJS) occupy a primary place in terms of mortality. Toxic epidermal necrolysis also known as Lyell's syndrome was first described by Lyell in 1956. Drugs are by far the most common cause of toxic epidermal necrolysis, in which large sheets of skin are lost from the body surface making redundant the barrier function of the skin, with its resultant complications. Drug-induced toxic epidermal necrolysis are severe adverse cutaneous drug reactions to various precipitating agents that predominantly involve the skin and mucous membranes. Toxic epidermal necrolysis is rare but considered medical emergencies as they are potentially fatal. Drugs are the most common cause accounting for about 65%-80% of the cases. The most common offending agents are sulfonamides, NSAIDs, butazones and hydrantoins. An immune mechanism is implicated in the pathogenesis, but its nature is still unclear. There is a prodormal phase in which there is burning sensation all over the skin and conjunctivae, along with skin tenderness, fever, malaise and arthralgias. Early sites of cutaneous involvement are the presternal region of the trunk and the face, but also the palms and soles, rapidly spread to their maximum extent, the oral mucosa and conjunctiva being affected. Initial lesions are macular, followed by desquamateion, or may be from atypical targets with purpuriccenters that coalesce, from bullae, then slough. The earlier a causative agent is withdrawn the better is the prognosis. Several treatment modalities given in addition to supportive care are reported in the literature, such as systemicsteroids, high-dose intravenous immunoglobulins, ciclosporin, TNF antagonists. Recovery is slow over a period of 14-28 days and relapses are frequent. Mortality is 25%-50% and half the deaths occur due to secondary infection. Here we report a 50-year-old female of drug-induced toxic epidermal necrolysis. She was admitted to the dermatology ward with extensive peeling of skin over the trunk and limbs. She had taken alamotrigine for epilepsy. A week after taking the tablets, the patient developed a severe burning sensation all over the body and followed by a polymorphic erythematous dermatitis and widespread peeling of skin. We treated this patient with high dose corticosteroids, high-dose intravenous immunoglobulins and etanercept, but eventually she died of secondary aspergillus fumigatus infection.
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Affiliation(s)
- 思 张
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
| | - 小扬 刘
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
| | - 建中 张
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
| | - 林 蔡
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
| | - 城 周
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
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张 思, 刘 小, 张 建, 蔡 林, 周 城. [Drug-induced toxic epidermal necrolysis with secondary aspergillus fumigatus infection: a case report]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:977-980. [PMID: 31624410 PMCID: PMC7433531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 08/12/2024]
Abstract
Among the various drug induced dermatological entities toxic epidermalnecrolysis (TEN) and Stevens-Johnson syndrome (SJS) occupy a primary place in terms of mortality. Toxic epidermal necrolysis also known as Lyell's syndrome was first described by Lyell in 1956. Drugs are by far the most common cause of toxic epidermal necrolysis, in which large sheets of skin are lost from the body surface making redundant the barrier function of the skin, with its resultant complications. Drug-induced toxic epidermal necrolysis are severe adverse cutaneous drug reactions to various precipitating agents that predominantly involve the skin and mucous membranes. Toxic epidermal necrolysis is rare but considered medical emergencies as they are potentially fatal. Drugs are the most common cause accounting for about 65%-80% of the cases. The most common offending agents are sulfonamides, NSAIDs, butazones and hydrantoins. An immune mechanism is implicated in the pathogenesis, but its nature is still unclear. There is a prodormal phase in which there is burning sensation all over the skin and conjunctivae, along with skin tenderness, fever, malaise and arthralgias. Early sites of cutaneous involvement are the presternal region of the trunk and the face, but also the palms and soles, rapidly spread to their maximum extent, the oral mucosa and conjunctiva being affected. Initial lesions are macular, followed by desquamateion, or may be from atypical targets with purpuriccenters that coalesce, from bullae, then slough. The earlier a causative agent is withdrawn the better is the prognosis. Several treatment modalities given in addition to supportive care are reported in the literature, such as systemicsteroids, high-dose intravenous immunoglobulins, ciclosporin, TNF antagonists. Recovery is slow over a period of 14-28 days and relapses are frequent. Mortality is 25%-50% and half the deaths occur due to secondary infection. Here we report a 50-year-old female of drug-induced toxic epidermal necrolysis. She was admitted to the dermatology ward with extensive peeling of skin over the trunk and limbs. She had taken alamotrigine for epilepsy. A week after taking the tablets, the patient developed a severe burning sensation all over the body and followed by a polymorphic erythematous dermatitis and widespread peeling of skin. We treated this patient with high dose corticosteroids, high-dose intravenous immunoglobulins and etanercept, but eventually she died of secondary aspergillus fumigatus infection.
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Affiliation(s)
- 思 张
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
| | - 小扬 刘
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
| | - 建中 张
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
| | - 林 蔡
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
| | - 城 周
- />北京大学人民医院皮肤科,北京 100044Department of Dermatological, Peking University People’s Hospital, Beijing 100044, China
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Kumar M, Mugunthan M. β-d-Glucan and Aspergillus Galactomannan assays in the diagnosis of invasive fungal infections. Med J Armed Forces India 2019; 75:357-360. [PMID: 31719727 PMCID: PMC6838501 DOI: 10.1016/j.mjafi.2017.10.005] [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: 06/17/2016] [Accepted: 10/27/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND With an increase in the number of patients who are immunosuppressed or immunocompromised there has been an increase in invasive fungal infection (IFI) in the past few decades with its associated high morbidity and mortality, ranging from 60% to 90%. The critical problem is the identification of the causative fungus and initiation of appropriate therapy. Hence, there is a requirement for better diagnostic methods for IFI. Detection of markers for the presence of fungi during early stage of the infection, such as constituents of the cell wall or fungal DNA, is essential for timely diagnosis of IFI. Galactomannan (GM) which is a cell wall surface antigen is the most studied diagnostic marker, followed by 1,3 β-d-Glucan (BG) which is seen in deep layers of cell wall. METHODS We have assessed the effectiveness of Galactomannan/β-d-Glucan for the early diagnosis of IFI in immunosuppressed patients in our tertiary care setting. RESULTS The sensitivity, specificity, positive predictive value and negative predictive value of GM assay were 45%, 93%, 86% and 63% respectively, while the BG assay showed a sensitivity of 78%, specificity of 85%, Positive predictive value (PPV) 84% and Negative predictive value (NPV) 79%. CONCLUSION BG assay is better for detection of IFI in patients with immunosuppression. However, a combination of both BG and GM assays would be the best approach as BG assay is highly sensitive, while the GM assay is highly specific for diagnosing IFI.
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Affiliation(s)
- Mahadevan Kumar
- Professor, Department of Microbiology, Armed Forces Medical College, Pune 411040, India
| | - M. Mugunthan
- Resident, Department of Microbiology, Armed Forces Medical College, Pune 411040, India
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Singh S, Kaur H, Choudhary H, Sethi S, Malhotra P, Gupta KL, Rudramurthy SM, Chakrabarti A. Evaluation of biomarkers: Galactomannan and 1,3-beta-D-glucan assay for the diagnosis of invasive fungal infections in immunocompromised patients from a tertiary care centre. Indian J Med Microbiol 2019; 36:557-563. [PMID: 30880706 DOI: 10.4103/ijmm.ijmm_18_366] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Purpose Due to limitations of traditional microbiological techniques, standardised fungal biomarker tests such as Galactomannan Index (GMI) and 1,3-beta-D-glucan (BDG) are being preferred for diagnosis of invasive fungal infections (IFIs). These tests have been extensively used in developed countries but seldom in developing countries. The present study was performed to evaluate these tests for the diagnosis of IFIs in immunocompromised patients at an Indian tertiary care centre. Materials and Methods A retrospective hospital-based study was done in immunocompromised patients with clinical suspicion of IFI. The demographic, clinical, radiological and mycological details of the patients were recorded. The patients were categorised into proven, probable and no IFI (as per European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria). The sensitivity and specificity of BDG Fungitell and Platelia Aspergillus antigen assays was estimated. Results A total of 70 consecutive patients were included, of which 41 had IFI (10 proven and 31 probable) while 29 had no IFI. A significant association was found between IFI and the presence of a central venous line (P = 0.035) and history of intake of T-cell immunosuppressants (P = 0.001). Median BDG values (pg/ml) in patients with proven IFI, probable IFI and no IFI were 300 (range: 70-500), 165 (range: 53-500) and 45 (range: 31-500), respectively. The receiver operating characteristic (ROC) curve analysis for BDG revealed an area under the curve of 0.995, sensitivity: 97.4% and specificity: 96.6% for IFI diagnosis. The ROC curve analysis of GMI revealed an AUC of 0.75 and 90% patients with invasive aspergillosis (IA) had positive GMI. Conclusion BDG has good sensitivity and specificity for distinguishing IFI from no IFIs and GMI may be used for diagnosing IA.
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Affiliation(s)
- Shreya Singh
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Hansraj Choudhary
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shveta Sethi
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan Lal Gupta
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Maurer E, Aigner M, Lass-Flörl C, Binder U. Hypoxia Decreases Diagnostic Biomarkers for Aspergillosis In Vitro. J Fungi (Basel) 2019; 5:jof5030061. [PMID: 31336719 PMCID: PMC6787614 DOI: 10.3390/jof5030061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/04/2019] [Accepted: 07/09/2019] [Indexed: 11/17/2022] Open
Abstract
The aim of the study was to evaluate the influence of hypoxia on galactomannan and (1,3)-β-d-glucan release of clinically relevant Aspergilli in vitro. Hypoxia decreased biomass and consequently led to lower biomarker release. However, when normalized to biomass, hypoxia led to increased levels of biomarkers at early growth stages (24 h). Antifungals (amphotericin B and voriconazole) decreased the galactomannan amount of A. fumigatus, even more prominently in hypoxia.
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Affiliation(s)
- Elisabeth Maurer
- Department of Hygiene, Medical Microbiology and Public Health, Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020 Innsbruck, Austria
| | - Maria Aigner
- Department of Hygiene, Medical Microbiology and Public Health, Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020 Innsbruck, Austria
| | - Cornelia Lass-Flörl
- Department of Hygiene, Medical Microbiology and Public Health, Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020 Innsbruck, Austria
| | - Ulrike Binder
- Department of Hygiene, Medical Microbiology and Public Health, Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020 Innsbruck, Austria.
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Paige E, Haywood P, Xie M, Worth L, Thursky K, Urbancic K, Bajel A, Slavin M. Auditing fungal disease in leukemia patients in a tertiary care center: opportunities and challenges for an antifungal stewardship program. Leuk Lymphoma 2019; 60:2373-2383. [PMID: 31096813 DOI: 10.1080/10428194.2019.1590570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Invasive fungal disease (IFD) is responsible for significant morbidity and mortality in patients with acute leukemia. Antifungal stewardship (AFS) programs are utilized in this patient group but have been infrequently evaluated in clinical practice. Adults diagnosed with acute leukemia at an Australian tertiary center over two years were identified, with subsequent auditing of IFD prophylaxis and treatment, and identification of further opportunities for AFS activities. Proven or probable IFD occurred in 6% of cases, including 14% of acute lymphoblastic leukemia (ALL) patients and 6% of acute myeloid leukemia (AML) patients. Mold-active antifungal prophylaxis was used in 84% of cases overall, including in 94% of AML cases and 23% of ALL cases. Local auditing identified target areas for AFS in this complex patient cohort, including modification of clinical guidelines, enhanced patient screening, improved access to fungal diagnostics and therapeutic drug monitoring, and the establishment of a specialized, embedded AFS program.
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Affiliation(s)
- Emma Paige
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,Department of Infectious Diseases, Alfred Hospital , Melbourne , Australia
| | - Peter Haywood
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Mingdi Xie
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Leon Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia
| | - Karen Urbancic
- NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia.,Department of Medicine, University of Melbourne , Parkville , Australia
| | - Ashish Bajel
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia
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Heinz WJ, Vehreschild JJ, Buchheidt D. Diagnostic work up to assess early response indicators in invasive pulmonary aspergillosis in adult patients with haematologic malignancies. Mycoses 2019; 62:486-493. [PMID: 30329192 DOI: 10.1111/myc.12860] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/03/2018] [Accepted: 10/07/2018] [Indexed: 12/20/2022]
Abstract
In immunocompromised patients with acute leukaemia as well as in allogeneic hematopoietic stem cell transplant patients, pulmonary lesions are commonly seen. Existing guidelines provide useful algorithms for diagnostic procedures and treatment options, but they do not give recommendations on how to evaluate early success or failure and if or when it is best to change therapy. Here, we review the diagnostic techniques currently used in association with clinical findings and propose an approach using a combination of computer tomography, clinical and all available biomarkers and inflammation parameters, especially those positive at baseline, to assess early response in invasive pulmonary aspergillosis. Computed tomography scans should be carried out at regular intervals during early and long-term follow-up. Imaging on day seven, or even earlier in clinically unstable patients, combined with an additional testing of biomarkers and inflammatory markers in between, is needed for a reliable assessment at day 14. If no improvement is seen after 2 weeks of therapy or the clinical condition is deteriorating, a change of antifungal therapy should be considered. Alleged breakthrough infections or treatment failure should undergo early diagnostic workup, including tissue biopsies when possible, to retrieve fungal cultures for resistance testing.
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Affiliation(s)
- Werner J Heinz
- Klinikum Weiden, Weiden, Würzburg university medical center, Würzburg, Germany
| | - Jörg J Vehreschild
- Department for Internal Medicine, German Centre for Infection Research, University Hospital of Cologne, Partner Site Bonn-Cologne, University of Cologne, Köln, Germany
| | - Dieter Buchheidt
- Department of Internal Medicine-Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
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Wicaksana DA, Suheryanto R, Maharani I. Correlation Between β-Glucan and Neutrophil/Eosinophil Ratio of Paranasal Sinus Mucosa and Blood in the Diagnosis of Chronic Fungal Rhinosinusitis. Oman Med J 2018; 33:393-400. [PMID: 30210718 DOI: 10.5001/omj.2018.73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Objectives Chronic fungal rhinosinusitis is a major health problem because of the large impact on quality of life and difficult medical treatment. Its prevalence is increasing. There is currently an opportunity to establish the diagnosis without invasive intervention by utilizing β-glucan, which is the largest component of fungal cell wall and neutrophil/eosinophil ratio (NER). We sought to discover the correlation between β-glucan level and the NER of paranasal sinuses mucosa and blood as a potential diagnostic marker for patients with chronic fungal rhinosinusitis. Methods We conducted a cross-sectional study involving 20 subjects. Blood sampling and maxillary sinus surgery were performed, and fungal identification in the sinus mucosa was determined using the polymerase chain reaction. If a fungal species with β-glucan was found, then the examination was continued with the measurement of β-glucan by enzyme-linked immunosorbent assay, neutrophil, and eosinophil flow cytometry in sinus mucosa and blood. Results Aspergillus flavus is the most commonly found fungus. All subjects passed the positive β-glucan limit (3 80 pg/mL) of the mucosal sample and only one subject had intermediate results (60-79 pg/mL) from their blood sample. Seventeen subjects had mucosal eosinophilic inflammation whereas the blood of 12 subjects revealed neutrophilic inflammation. There was no significant difference between the level of β-glucan in blood and mucosal sinus (p = 0.886), so that β-glucan examination of blood can describe β-glucan levels in paranasal sinuses. There was a significant difference between mucosal NER and blood (p < 0.001). β-glucan level with NER in both paranasal sinus mucosa and blood had no significant correlation (p > 0.050). Conclusions β-glucan can be used to establish the diagnosis of chronic fungal rhinosinusitis. However, differential diagnosis of allergy or infection cannot be excluded by examination of blood NER. Still, it is hoped that the process of diagnosis can be obtained quickly and precisely without the need for invasive procedure although it requires more research, especially related to the diagnostic test.
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Affiliation(s)
- Dhaniel Abdi Wicaksana
- Otorhinolaryngology Head and Neck Surgery Department, Siloam Hospitals, Bangka, Indonesia
| | - Rus Suheryanto
- Otorhinolaryngology Head and Neck Surgery Department, Saiful Anwar General Hospital/Medical Faculty of Brawijaya University, Malang, Indonesia
| | - Iriana Maharani
- Otorhinolaryngology Head and Neck Surgery Department, Saiful Anwar General Hospital/Medical Faculty of Brawijaya University, Malang, Indonesia
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Xiaoling L, Tingyu T, Caibao H, Tian Z, Changqin C. Diagnostic Efficacy of Serum 1,3-β-D-glucan for Invasive Fungal Infection: An Update Meta-Analysis Based on 37 Case Or Cohort Studies. Open Med (Wars) 2018; 13:329-337. [PMID: 30211316 PMCID: PMC6132083 DOI: 10.1515/med-2018-0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 06/21/2018] [Indexed: 01/30/2023] Open
Abstract
Objective The aim of this study was to investigate the diagnostic performance of serum 1,3-β-D-gluan as biomarker for invasive fungal infection through meta-analysis. Methods The electronic databases of Medline, Cochrane, Embase, Web of Science, OVID and CNKI were systematic searched to identified the case-control or Cohort studies relevant to diagnostic efficacy of serum 1,3-β-D-glucan for invasive fungal infection. The data of true positive (tp), false positive (fp), false negative (fn) and true negative (tn) patients number were extracted from each of the original included studies. The diagnostic sensitivity, specificity and systematic receiver operating characteristic (SROC) curve were calculated and pooled through random or fixed effect method. The publication bias was evaluated by the Deek's funnel plot. Results Thirty-seven relevant studies were fulfilled the inclusion criteria and included in our present meta-analysis. The combined sensitivity, specificity, positive likely hood ratio (+lr), negative likely hood ratio (-lr) and diagnostic odds ratio(dor) for 1,3-β-D-glucan in diagnosis of invasive fungal infectionwere 0.83 (95%CI:0.38-0.61), 0.81 (95%CI:0.80-0.82), 5.13 (95%CI:3.98-6.62), 0.23 (95%CI:0.18-0.30), and 29.68 (95%CI:18.94-46.52) respectively. The pooled area under the ROC curve (AUC) was 0.91.The Deek's funnel plot asymmetry test showed there was no publication bias for 1,3-β-D-glucan in diagnosis of invasive fungal infection of the included 37 studies. Conclusion Serum 1,3-β-D-glucan assay was a promising biomarker for invasive fungal infection diagnosis.
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Affiliation(s)
- Lu Xiaoling
- Department of Respiratory, Zhejiang Hospital, Hangzhou, China, 310013
| | - Tang Tingyu
- Department of Respiratory, Zhejiang Hospital, Hangzhou, China, 310013
| | - Hu Caibao
- Department of ICU, Zhejiang Hospital, Hangzhou, China, 310013
| | - Zhao Tian
- Department of Respiratory, Zhejiang Hospital, Hangzhou, China, 310013
| | - Chen Changqin
- Department of ICU, Zhejiang Hospital, China 310013, Address: No.12 Lingyin Road, Hangzhou City, Zhejiang Province 310013, China
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Ruhnke M, Behre G, Buchheidt D, Christopeit M, Hamprecht A, Heinz W, Heussel CP, Horger M, Kurzai O, Karthaus M, Löffler J, Maschmeyer G, Penack O, Rieger C, Rickerts V, Ritter J, Schmidt-Hieber M, Schuelper N, Schwartz S, Ullmann A, Vehreschild JJ, von Lilienfeld-Toal M, Weber T, Wolf HH. Diagnosis of invasive fungal diseases in haematology and oncology: 2018 update of the recommendations of the infectious diseases working party of the German society for hematology and medical oncology (AGIHO). Mycoses 2018; 61:796-813. [PMID: 30098069 DOI: 10.1111/myc.12838] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/05/2018] [Indexed: 01/05/2023]
Abstract
Invasive fungal diseases (IFD) are a primary cause of morbidity and mortality in patients with haematological malignancies. These infections are mostly life-threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Most commonly, Aspergillus and Candida species are involved. However, other Non-Aspergillus moulds are increasingly identified in case of documented IFD. For definite diagnosis of IFD, a combination of diagnostic tools have to be applied, including conventional mycological culture and non-conventional microbiological tests such as antibody/antigen and molecular tests, as well as histopathology and radiology. Although varying widely in cancer patients, the risk of invasive fungal infection is highest in those with allogeneic stem cell transplantation and those with acute leukaemia and markedly lower in patients with solid cancer. Since the last edition of Diagnosis of Invasive Fungal Diseases recommendations of the German Society for Hematology and Oncology in 2012, integrated care pathways have been proposed for the management and therapy of IFDs with either a diagnostic driven strategy as opposed to a clinical or empirical driven strategy. This update discusses the impact of this additional evidence and effective revisions.
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Affiliation(s)
- Markus Ruhnke
- Department of Haematology & Oncology, Paracelsus-Klinik, Osnabrück, Germany
| | - Gerhard Behre
- Department of Haematology & Oncology, Universitätsklinik Leipzig, Leipzig, Germany
| | - Dieter Buchheidt
- Department of Internal Medicine III, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Maximilian Christopeit
- Department for Stem Cell Transplantation, University Medical Center Eppendorf, Hamburg, Germany
| | - Axel Hamprecht
- Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, Cologne, Germany
| | - Werner Heinz
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Claus-Peter Heussel
- Department of Interventional & Diagnostic Radiology, Thorax Centre, University Hospital of Heidelberg, Heidelberg, Germany
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - Oliver Kurzai
- National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knoell-Institute, Jena and Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Meinolf Karthaus
- Deparment of Haematology & Oncology, Municipal Hospital Neuperlach, Munich, Germany
| | - Jürgen Löffler
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Municipal Hospital, Potsdam, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | | | - Volker Rickerts
- Konsiliarlabor Für Kryptokokkose und Seltene Systemmykosen, Robert-Koch-Institut Berlin, Berlin, Germany
| | - Jörg Ritter
- Division of Haematology & Oncology, Department of Paediatrics, University Hospital of Münster, Münster, Germany
| | - Martin Schmidt-Hieber
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | - Nikolai Schuelper
- Department of Haematology and Medical Oncology, Göttingen University Medical Centre, Göttingen, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | - Andrew Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Jörg Janne Vehreschild
- Department of Internal Medicine I, German Centre for Infection Research, partner-site Bonn-Cologne, University Hospital of Cologne, Cologne, Germany
| | - Marie von Lilienfeld-Toal
- Department of Internal Medicine II, National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knoell-Institute, Universitätsklinik Jena, Jena, Germany
| | - Thomas Weber
- Department of Internal Medicine IV, Universitätsklinik Halle, Halle, Germany
| | - Hans H Wolf
- Department of Internal Medicine IV, Universitätsklinik Halle, Halle, Germany
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Zhang L, Guo Z, Xie S, Zhou J, Chen G, Feng J, Huang Y. The performance of galactomannan in combination with 1,3-β-D-glucan or aspergillus-lateral flow device for the diagnosis of invasive aspergillosis: Evidences from 13 studies. Diagn Microbiol Infect Dis 2018; 93:44-53. [PMID: 30279025 DOI: 10.1016/j.diagmicrobio.2018.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/03/2018] [Accepted: 08/14/2018] [Indexed: 12/11/2022]
Abstract
Galactomannan (GM), 1,3-β-D-glucan (BDG) and aspergillus-lateral flow device (LFD) are recognized as diagnostic tools for invasive aspergillosis (IA). The combined performance of these assays, however, is inconsistent in various studies. We undertook a meta-analysis of 13 studies involving 1513 patients to evaluate the utility of GM in combination with BDG or LFD for diagnosing IA. The pooled SEN, SPE, PLR, NLR and diagnostic odds ratio (DOR) were calculated and constructed to summarize the overall combined performance. Combining both positive results of GM and BDG assays leaded to the pooled SEN 0.49 (95%CI 0.27-0.72), SPE 0.98 (95%CI 0.94-1.00), PLR 31.68 (95%CI 5.36-187.37), NLR 0.52 (95%CI 0.32-0.84) and DOR 61.23 (95%CI 6.96-538.90). Comparing with GM and BDG assays, both positive results of GM and LFD leaded to high SEN, similar SPE, low PLR and NLR. At least one positive result of GM or LFD conferred great SEN 0.93 and low NLR 0.08. Both positive results of GM and BDG or LFD assay were in favor of confirming the existence of IA. And both negative results of GM and LFD were beneficial to rule out IA. Further studies with sufficient sample size should focus on the diagnostic performance and cost-effectiveness of these combined tests in clinical setting.
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Affiliation(s)
- Li Zhang
- Clinical microbiology laboratory, Tung Wah Hospital Affiliated to Sun Yat-sen University, Dongguan, Guangdong 523110, China.
| | - Zhusheng Guo
- Clinical microbiology laboratory, Tung Wah Hospital Affiliated to Sun Yat-sen University, Dongguan, Guangdong 523110, China
| | - Shujin Xie
- Clinical microbiology laboratory, Tung Wah Hospital Affiliated to Sun Yat-sen University, Dongguan, Guangdong 523110, China
| | - Jing Zhou
- Clinical microbiology laboratory, Tung Wah Hospital Affiliated to Sun Yat-sen University, Dongguan, Guangdong 523110, China
| | - Guiling Chen
- Clinical microbiology laboratory, Tung Wah Hospital Affiliated to Sun Yat-sen University, Dongguan, Guangdong 523110, China
| | - Jianbo Feng
- Clinical microbiology laboratory, Tung Wah Hospital Affiliated to Sun Yat-sen University, Dongguan, Guangdong 523110, China
| | - Ya Huang
- Clinical microbiology laboratory, Tung Wah Hospital Affiliated to Sun Yat-sen University, Dongguan, Guangdong 523110, China
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Furfaro E, Giacobbe DR, Del Bono V, Signori A, Guolo F, Minetto P, Clavio M, Ballerini F, Gobbi M, Viscoli C, Mikulska M. Performance of serum (1,3)-ß-d-glucan screening for the diagnosis of invasive aspergillosis in neutropenic patients with haematological malignancies. Mycoses 2018; 61:650-655. [PMID: 29693758 DOI: 10.1111/myc.12787] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/13/2018] [Accepted: 04/14/2018] [Indexed: 01/22/2023]
Abstract
We report our experience with the use of (1,3)-ß-d-glucan (BDG) screening for the diagnosis of invasive aspergillosis (IA) in neutropenic patients with haematological malignancies. The performance of BDG screening was assessed retrospectively in per patient and per sample analyses. Overall, 20 among 167 patients developed IA (12%). In the per patient analysis, BDG showed 60% sensitivity and 78% specificity when the criterion for positivity was the presence of at least one BDG value ≥80 pg/mL. For 2 consecutive positive results, sensitivity decreased to 40%, while specificity increased to 93% and was similar to that of a positive galactomannan (GM; 90%). The highest specificity (97%) was observed for combined positivity of at least one BDG and at least one GM. In the per sample analysis, the specificity of BDG was 100% in the best scenario, 96% in the median scenario and 89% in the worst scenario. BDG became positive before GM in 33% of IA patients with both markers positive (n = 12). Despite good specificity for 2 consecutive positive results, the BDG test offered unsatisfactory performance for the diagnosis of IA due to low sensitivity. The combination of BDG and GM showed the potential for increasing specificity.
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Affiliation(s)
- Elisa Furfaro
- Department Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Department Health Sciences (DISSAL), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Valerio Del Bono
- Infectious Diseases Unit, Department Health Sciences (DISSAL), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Fabio Guolo
- Clinic of Haematology, Department of Internal Medicine (DiMI), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Paola Minetto
- Clinic of Haematology, Department of Internal Medicine (DiMI), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Marino Clavio
- Clinic of Haematology, Department of Internal Medicine (DiMI), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Filippo Ballerini
- Clinic of Haematology, Department of Internal Medicine (DiMI), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Marco Gobbi
- Clinic of Haematology, Department of Internal Medicine (DiMI), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Claudio Viscoli
- Infectious Diseases Unit, Department Health Sciences (DISSAL), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Malgorzata Mikulska
- Infectious Diseases Unit, Department Health Sciences (DISSAL), Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
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Livio P, Alessandro B, Anna C, Marianna C, Matteo GDP, Luana F, Federica L, Francesco M, Maria TV. Risk of infection in elderly patients with AML and MDS treated with hypomethylating agents. ACTA BIO MEDICA : ATENEI PARMENSIS 2018; 89. [PMCID: PMC6502134 DOI: 10.23750/abm.v89i11-s.7988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
Abstract
The aim of this small volume is to raise awareness among Italian hematologists using hypomethylating drugs about risk - and even more important about “risk management” - and the treatment of the infectious events that may arise during therapy with these drugs. Since we wanted this review to be an extremely practical tool, we have included the most recent clinical case studies, the indications provided by the guidelines and expert opinions. Infectious complications are among the most common adverse events that can arise during treatment with hypomethylating drugs. For this reason, a large portion of the chapters of this small volume has been dedicated to a detailed description (on the basis of an attentive review of the literature) of what the hematologist can expect to encounter in terms of risk of infection, in patients treated with azacitidine or decitabine, and to the preventive investigations to carry out and the active prophylaxis measures recommended before commencing treatment with these drugs. What led us to write this book was the conviction that the critical sharing of the studies published in literature and of our personal experiences could contribute to prompting reflection on how we operate and that this, in turn, would lead to the best possible management of these treatments, both in patients with myelodysplasia and in patients with acute myeloid leukemia, preventing - and efficiently managing - infectious events - during therapy. We should not be misled by the fact that the treatments are prevalently administered on an outpatient basis; these patients due to their disease and, in particular, to their age, are extremely frail, and infectious and hemorrhagic complications are the main causes of their admissions to hospital. But expert knowledge and management of the risks of infection can guarantee better management of their needs on an outpatient basis, with undeniable advantages for the clinic but, first and foremost, for the patients. (www.actabiomedica.it)
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Affiliation(s)
- Pagano Livio
- Associate Professor of Hematology, Director UOSA “Geriatric Hematology and Rare Blood Disorders” - Department of Radiological, Radiotherapeutic and Hematological Sciences - Foundation Polyclinic University A. Gemelli - IRCCS - Catholic University of the Sacred Heart - Rome,Correspondence: Prof. Livio Pagano Department of Radiological, Radiotherapeutic and Hematological Sciences Foundation Polyclinic A. Gemelli - IRCCS Università Cattolica del Sacro Cuore, Roma E-mail:
| | - Busca Alessandro
- Department of Oncology, SSD Allogeneic Stem Cell Transplant Unit, AOU City of Health and Science University Hub, Turin
| | - Candoni Anna
- Clinical Hematology Unit, Health Authorities-University Hospital of Udine (ASUIUD)
| | - Criscuolo Marianna
- Department of Radiological Radiotherapeutic and Hematological Sciences, Foundation Polyclinic University A. Gemelli, IRCCS, Rome
| | | | - Fianchi Luana
- Department of Radiological, Radiotherapeutic and Hematological Sciences - Foundation Polyclinic University A. Gemelli, IRCCS, Rome
| | - Lessi Federica
- Division of Hematology and Clinical Immunology, Padua University Hospital
| | - Marchesi Francesco
- UOSD Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome
| | - Teresa Voso Maria
- Associate Professor of Hematology, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome
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Giacobbe DR, Del Bono V, Viscoli C, Mikulska M. Use of 1,3-β-D-glucan in invasive fungal diseases in hematology patients. Expert Rev Anti Infect Ther 2017; 15:1101-1112. [PMID: 29125373 DOI: 10.1080/14787210.2017.1401467] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFD) remain a leading cause of morbidity and mortality in hematology patients. Within a diagnostic-driven approach, the use of the serum (1,3)-ß-D-glucan (BDG) test represents a valid tool for the early diagnosis and treatment of IFD. Areas covered: The available literature on the use of BDG in hematology patients was systematically retrieved. Then, it was reviewed and discussed, to identify key issues pertaining to a clinically-oriented narrative presentation of the topic. Expert commentary: The use of BDG in hematology patients at risk for invasive aspergillosis (IA) is secondary to the use of galactomannan. However, since BDG is not specific for IA, it offers an advantage of diagnosing also other IFD, such as candidiasis and pneumocystosis. The limitations of BDG include high costs and lower sensitivity in hematology patients compared to other cohorts. The risk of false positive results is possibly lower in real life than in theory, since glucan-free equipment is available and modern dialysis membranes and blood products usually do not release BDG. Thus, in experienced hands and selected clinical situations, BDG is a useful diagnostic tool, particularly due to short turnover time to results and versatility in diagnosing different IFD.
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Affiliation(s)
- Daniele Roberto Giacobbe
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Valerio Del Bono
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Claudio Viscoli
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
| | - Malgorzata Mikulska
- a Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, DISSAL , Genoa , Italy
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Cao Y, Shao C, Song Y. Analysis of the clinical features of invasive bronchopulmonary aspergillosis. CLINICAL RESPIRATORY JOURNAL 2017; 12:1635-1643. [PMID: 29052351 DOI: 10.1111/crj.12722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/30/2017] [Accepted: 10/08/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Early diagnosis of invasive bronchopulmonary aspergillosis (IBPA) is difficult, so the mortality rate is high. OBJECTIVE To discuss the clinical features of IBPA. METHODS We retrospectively analyzed the clinical features, imaging findings, laboratory test, diagnosis and treatment of 115 patients with IBPA diagnosed from October 2004 to June 2013 in Zhongshan Hospital, Fudan University. RESULTS The main clinical manifestations were cough in 58 patients (50.4%), expectoration in 37 patients (32.2%), fever in 18 patients (15.7%), shortness of breath in 26 patients (22.6%), hemoptysis in 26 patients (22.6%) and chest pain in 7 patients (6.0%). The main CT findings were nodules in 35 patients (30.4%), consolidation shadows or patchy shadows in 62 patients (53.9%) and cavity in 14 patients (12.2%). Percutaneous pulmonary biopsy was conducted in 25 patients (21.7%), TBLB in 58 patients (50.4%) and thoracoscopic surgery in 32 patients (27.8%). The positive rate of GM test was 73.5% (72/98). Thirty patients who received lobectomy were followed up for 1-3 years. Fifty-five patients who received monotherapy with antifungal agents were followed up for 1-3 years, and 12 patients were healed. The lesions for 23 patients were obviously absorbed, 10 patients had aggravation and two patients died. CONCLUSIONS The clinical manifestations of IBPA were unspecific. The main symptoms were cough and expectorate. Patients with different immunologic function had different imaging findings. The halo sign and new moon sign for diagnosis was not as common as reported. Interventional therapy under bronchoscope is very important for patients with ATB.
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Affiliation(s)
- Yueqin Cao
- Department of Pulmonary Medicine, Shanghai Respiratory Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, People's Republic of China.,Department of Pulmonary Medicine, The Fourth People's Hospital of Taizhou, Jiangsu Province, Taizhou 225300, People's Republic of China
| | - Changzhou Shao
- Department of Pulmonary Medicine, Shanghai Respiratory Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, People's Republic of China
| | - Yuanlin Song
- Department of Pulmonary Medicine, Shanghai Respiratory Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, People's Republic of China
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McCarthy MW, Petraitiene R, Walsh TJ. Nucleic acid amplification methodologies for the detection of pulmonary mold infections. Expert Rev Mol Diagn 2017; 17:271-279. [PMID: 28218019 DOI: 10.1080/14737159.2017.1293528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The detection of pulmonary mold infections has historically required technically demanding methods obtained through invasive procedures. Nucleic acid amplification assays have the potential to circumvent the technical hurdles associated with diagnosis, but are not without potential pitfalls. Areas covered: In this paper, the authors review new assays for the diagnosis of pulmonary mold infections due to aspergillosis, mucormycosis, and hyalohyphomycoses as well as uncommon infections caused by dematiaceous molds. Expert commentary: Nucleic acid amplification assays have the potential to rapidly identify patients with invasive mycoses and could shorten the time to implementation of appropriate antimicrobial therapy. However, selection of appropriate patient populations will be crucial to ensure the highest Bayesian positive predictive value for any novel diagnostic platform.
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Affiliation(s)
- Matthew William McCarthy
- a Department of Medicine , Joan and Sanford I Weill Medical College of Cornell University - Hospital Medicine , New York , NY , USA
| | - Ruta Petraitiene
- b Department of Medicine , Cornell University , NY , New York City , USA
| | - Thomas J Walsh
- c Department of Medicine , Weill Cornell Medical Center - Transplantation, Oncology Infectious Diseases Program , New York , NY , USA
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Heinz WJ, Buchheidt D, Christopeit M, von Lilienfeld-Toal M, Cornely OA, Einsele H, Karthaus M, Link H, Mahlberg R, Neumann S, Ostermann H, Penack O, Ruhnke M, Sandherr M, Schiel X, Vehreschild JJ, Weissinger F, Maschmeyer G. Diagnosis and empirical treatment of fever of unknown origin (FUO) in adult neutropenic patients: guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2017; 96:1775-1792. [PMID: 28856437 PMCID: PMC5645428 DOI: 10.1007/s00277-017-3098-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/06/2017] [Indexed: 02/07/2023]
Abstract
Fever may be the only clinical symptom at the onset of infection in neutropenic cancer patients undergoing myelosuppressive chemotherapy. A prompt and evidence-based diagnostic and therapeutic approach is mandatory. A systematic search of current literature was conducted, including only full papers and excluding allogeneic hematopoietic stem cell transplant recipients. Recommendations for diagnosis and therapy were developed by an expert panel and approved after plenary discussion by the AGIHO. Randomized clinical trials were mainly available for therapeutic decisions, and new diagnostic procedures have been introduced into clinical practice in the past decade. Stratification into a high-risk versus low-risk patient population is recommended. In high-risk patients, initial empirical antimicrobial therapy should be active against pathogens most commonly involved in microbiologically documented and most threatening infections, including Pseudomonas aeruginosa, but excluding coagulase-negative staphylococci. In patients whose expected duration of neutropenia is more than 7 days and who do not respond to first-line antibacterial treatment, specifically in the absence of mold-active antifungal prophylaxis, further therapy should be directed also against fungi, in particular Aspergillus species. With regard to antimicrobial stewardship, treatment duration after defervescence in persistently neutropenic patients must be critically reconsidered and the choice of anti-infective agents adjusted to local epidemiology. This guideline updates recommendations for diagnosis and empirical therapy of fever of unknown origin in adult neutropenic cancer patients in light of the challenges of antimicrobial stewardship.
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Affiliation(s)
- W J Heinz
- Department of Internal Medicine II, University of Würzburg Medical Center, Würzburg, Germany
| | - D Buchheidt
- Department of Internal Medicine-Hematology and Oncology, Mannheim University Hospital, Mannheim, Germany
| | - M Christopeit
- Department of Stem Cell Transplantation, University Hospital UKE, Hamburg, Germany
| | | | - O A Cornely
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Centre for Infection Research, partner site Bonn-Cologne, Cologne, Germany.,Clinical Trials Centre Cologne, ZKS Köln, Cölogne, Germany.,Center for Integrated Oncology CIO Köln-Bonn, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Medical Faculty, University of Cologne, Cologne, Germany
| | - H Einsele
- Department of Internal Medicine II, University of Würzburg Medical Center, Würzburg, Germany
| | - M Karthaus
- Department of Hematology, Oncology and Palliative Care, Klinikum Neuperlach and Klinikum Harlaching, München, Germany.,Department of Hematology, Oncology and Palliative Care, Klinikum Harlaching, Munich, Germany
| | - H Link
- Hematology and Medical Oncology Private Practice, Kaiserslautern, Germany
| | - R Mahlberg
- Klinikum Mutterhaus der Borromäerinnen, Trier, Germany
| | - S Neumann
- Medical Oncology, AMO MVZ, Wolfsburg, Germany
| | - H Ostermann
- Department of Hematology and Oncology, University of Munich, Munich, Germany
| | - O Penack
- Internal Medicine, Hematology, Oncology and Tumor Immunology, University Hospital Charité, Campus Virchow Klinikum, Berlin, Germany
| | - M Ruhnke
- Department of Hematology and Oncology, Paracelsus-Klinik, Osnabrück, Germany
| | - M Sandherr
- Hematology and Oncology Practice, Weilheim, Germany
| | - X Schiel
- Department of Hematology, Oncology and Palliative Care, Klinikum Harlaching, Munich, Germany
| | - J J Vehreschild
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Centre for Infection Research, partner site Bonn-Cologne, Cologne, Germany
| | - F Weissinger
- Department of Internal Medicine, Hematology, Oncology and Palliative Care, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany.
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Hamdy RF, Zaoutis TE, Seo SK. Antifungal stewardship considerations for adults and pediatrics. Virulence 2017; 8:658-672. [PMID: 27588344 PMCID: PMC5626349 DOI: 10.1080/21505594.2016.1226721] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/05/2016] [Accepted: 08/11/2016] [Indexed: 10/21/2022] Open
Abstract
Antifungal stewardship refers to coordinated interventions to monitor and direct the appropriate use of antifungal agents in order to achieve the best clinical outcomes and minimize selective pressure and adverse events. Antifungal utilization has steadily risen over time in concert with the increase in number of immunocompromised adults and children at risk for invasive fungal infections (IFI). Challenges in diagnosing IFI often lead to delays in treatment and poorer outcomes. There are also emerging data linking prior antifungal exposure and suboptimal dosing to the emergence of antifungal resistance, particularly for Candida. Antimicrobial stewardship programs can take a multi-pronged bundle approach to ensure suitable prescribing of antifungals via post-prescription review and feedback and/or prior authorization. Institutional guidelines can also be developed to guide diagnostic testing in at-risk populations; appropriate choice, dose, and duration of antifungal agent; therapeutic drug monitoring; and opportunities for de-escalation and intravenous-to-oral conversion.
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Affiliation(s)
- Rana F. Hamdy
- Division of Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Theoklis E. Zaoutis
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan K. Seo
- Department of Medicine, Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Mohindra R, Capoor MR, Puri S, Raheja H, Gupta DK, Gupta B, Chowdhury R. Evaluation of serum galactomannan enzyme immunoassay at two different cut-offs for the diagnosis of invasive aspergillosis in patients with febrile neutropenia. Indian J Med Microbiol 2017; 35:237-242. [PMID: 28681812 DOI: 10.4103/ijmm.ijmm_17_47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Invasive aspergillosis (IA) is an increasingly common and fatal opportunistic fungal infection in patients with haematological diseases. Early diagnosis is difficult as mycological culture techniques have low sensitivity and the radiological tools have low specificity. Galactomannan enzyme immunoassay (GEI) detects galactomannan in the human serum with a reported sensitivity and specificity between 30% and 100%. AIMS The aim of this study was to analyse the role of GEI in diagnosis of IA in patients with febrile neutropenia and to evaluate the role of GEI in the diagnosis of IA as per the revised (2008) European Organization for Research and Treatment of Cancer-Mycoses Study Group (EORTC-MSG) criteria at two different optical density (OD) cut-offs of 0.5 and 1.0. SETTING This prospective study was conducted in Safdarjung Hospital, New Delhi, India. METHODS GEI testing was performed in adult patients of febrile neutropenia with evidence of IA. Results at two different OD indices (ODIs) of 0.5 and 1.0 were analysed. The evaluation of the diagnostic parameter, that is, GEI was measured in terms of sensitivity, specificity and positive and negative predictive value and was validated with the revised (2008) EORTC-MSG diagnostic criteria of IA. RESULTS One hundred and eleven patients had evidence of IA, of which 79 patients were GEI positive when cut-off ODI was 0.5, whereas with cut-off ODI 1.0, 55 patients were GEI positive. CONCLUSION ODI of 1.0 should be considered as positive while in patients with OD between 0.5 and 1.0, repeat sampling from the patient is recommended.
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Affiliation(s)
- Ritin Mohindra
- Department of Hematology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Malini R Capoor
- Department of Microbiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Shikha Puri
- Department of Microbiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Hitesh Raheja
- Department of Hematology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Dinesh K Gupta
- Department of Hematology, VMMC and Safdarjung Hospital, New Delhi, India
| | - B Gupta
- Department of Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Ranadip Chowdhury
- Department of Medicine, VMMC and Safdarjung Hospital, New Delhi, India
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