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Balogh J, Gordon Burroughs S, Boktour M, Patel S, Saharia A, Ochoa RA, McFadden R, Victor DW, Ankoma-Sey V, Galati J, Monsour HP, Fainstein V, Li XC, Grimes KA, Gaber AO, Aloia T, Ghobrial RM. Efficacy and cost-effectiveness of voriconazole prophylaxis for prevention of invasive aspergillosis in high-risk liver transplant recipients. Liver Transpl 2016; 22:163-70. [PMID: 26515643 DOI: 10.1002/lt.24365] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 08/28/2015] [Accepted: 09/19/2015] [Indexed: 12/13/2022]
Abstract
Aspergillus infection remains a significant and deadly complication after liver transplantation (LT). We sought to determine whether the antifungal prophylactic use of voriconazole reduces the incidence of invasive aspergillosis (IA) in high-risk LT recipients without prohibitively increasing cost. During the study era (April 2008 to April 2014), 339 deceased donor LTs were performed. Of those patients, 174 high-risk recipients were administered antifungal prophylaxis with voriconazole. The median biological Model for End-Stage Liver Disease score at the time of LT was 33 (range, 18-49) with 56% requiring continuous renal replacement therapy and 50% requiring ventilatory support immediately before transplantation. Diagnosis of IA was stratified as proven, probable, or possible according to previously published definitions. No IA was documented in patients receiving voriconazole prophylaxis. At 90 days after LT, the institutional cost of prophylaxis was $5324 or 5.6% of the predicted cost associated with post-LT aspergillosis. There was no documentation of resistant strains isolated from any recipient who received voriconazole. In conclusion, these data suggest that voriconazole prophylaxis is safe, clinically effective, and cost-effective in high-risk LT recipients.
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Affiliation(s)
- Julius Balogh
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
| | - Sherilyn Gordon Burroughs
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
| | - Maha Boktour
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
| | - Samir Patel
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
| | - Ashish Saharia
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
| | - Robert A Ochoa
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
| | - Robert McFadden
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Hepatology
| | - David W Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Hepatology
| | - Victor Ankoma-Sey
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Hepatology
| | - Joseph Galati
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Hepatology
| | - Howard P Monsour
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Hepatology
| | - Victor Fainstein
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Infectious Disease, Department of Medicine, Houston Methodist Hospital, Houston, TX
| | - Xian C Li
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
| | - Kevin A Grimes
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Infectious Disease, Department of Medicine, Houston Methodist Hospital, Houston, TX
| | - A Osama Gaber
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
| | - Thomas Aloia
- MD Anderson Cancer Center, University of Texas, Houston, TX
| | - R Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation.,Divisions of Transplantation, Department of Surgery
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52
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Epidemiology of invasive fungal infections after liver transplantation and the risk factors of late-onset invasive aspergillosis. J Infect Chemother 2016; 22:84-9. [DOI: 10.1016/j.jiac.2015.11.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/20/2015] [Accepted: 11/01/2015] [Indexed: 01/25/2023]
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53
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Gonçalves SS, Souza ACR, Chowdhary A, Meis JF, Colombo AL. Epidemiology and molecular mechanisms of antifungal resistance in CandidaandAspergillus. Mycoses 2016; 59:198-219. [DOI: 10.1111/myc.12469] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/14/2015] [Accepted: 12/18/2015] [Indexed: 12/15/2022]
Affiliation(s)
- Sarah Santos Gonçalves
- Laboratório Especial de Micologia, Disciplina de Infectologia, Escola Paulista de Medicina; Universidade Federal de São Paulo; São Paulo SP Brazil
| | - Ana Carolina Remondi Souza
- Laboratório Especial de Micologia, Disciplina de Infectologia, Escola Paulista de Medicina; Universidade Federal de São Paulo; São Paulo SP Brazil
| | - Anuradha Chowdhary
- Department of Medical Mycology; Vallabhbhai Patel Chest Institute; University of Delhi; Delhi India
| | - Jacques F. Meis
- Department of Medical Microbiology and Infectious Diseases; Canisius Wilhelmina Hospital; Nijmegen the Netherlands
- Department of Medical Microbiology; Radboud University Medical Centre; Nijmegen the Netherlands
| | - Arnaldo Lopes Colombo
- Laboratório Especial de Micologia, Disciplina de Infectologia, Escola Paulista de Medicina; Universidade Federal de São Paulo; São Paulo SP Brazil
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54
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Cornberg M, Schlevogt B, Rademacher J, Schwarz A, Sandherr M, Maschmeyer G. [Specific infections in organ transplantation]. Internist (Berl) 2016; 57:38-48. [PMID: 26782282 DOI: 10.1007/s00108-015-3807-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This article is concerned with the important topic of infections associated with organ transplantation and includes a discussion on four subtopics. The first section describes the current options in the prevention and therapy of viral hepatitis in association with liver transplantation. Infections with hepatitis B, C, D (delta) and E are discussed with special emphasis on the interferon-free treatment of hepatitis C with the new antiviral drugs.The second section deals with Pseudomonas aeruginosa (PA) infections following lung transplantation (LuTx), which is one of the most frequently detected pathogens in the airway after LuTx. Patients with cystic fibrosis are particularly affected. This is important because studies have shown a clear correlation between chronic PA infections after LuTx and development of chronic transplant failure. Even if the data are still sparse, recommendations on prevention and therapeutic strategies are given. The theme of the third section is the high importance of viral infections after kidney transplantation. In addition to acquired infections, the transplanted organ as well as the recipient can be the source of the infection. The better the transplanted organ is tolerated under moderate immunosuppression, the less common and severe virus infections are. The focus of this section is on three common pathogens: cytomegalovirus, polyomavirus BK and hepatitis viruses.The final section deals with Aspergillus infections following transplantation of various organs. In this context Aspergillus spp. are one of the most commonly occurring fungal diseases. The epidemiology, risk factors, diagnostics, prophylaxis and therapy of invasive aspergillosis are presented.
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Affiliation(s)
- M Cornberg
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland.
| | - B Schlevogt
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30623, Hannover, Deutschland
| | - J Rademacher
- Klinik für Pneumologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - A Schwarz
- Klinik für Nieren- und Hochdruckerkrankungen, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - M Sandherr
- Gemeinschaftspraxis für Hämatologie und Onkologie, Röntgenstr. 4, 82362, Weilheim, Deutschland.
| | - G Maschmeyer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
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Worsening renal function in patients with baseline renal impairment treated with intravenous voriconazole: A systematic review. Int J Antimicrob Agents 2015; 46:362-6. [PMID: 26253129 DOI: 10.1016/j.ijantimicag.2015.05.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 05/14/2015] [Accepted: 05/14/2015] [Indexed: 11/21/2022]
Abstract
The objective of this paper was to review the risk of worsening renal function in patients with pre-existing renal impairment receiving intravenous voriconazole (IVV). Controversy exists regarding the cause and risk of renal dysfunction in patients treated with IVV. Whilst some studies implicate renally excreted cyclodextrin, a pharmaceutical formulation stabiliser, as the cause of renal dysfunction following voriconazole administration, others provide contradicting evidence. Here we analyse the available literature to gain an insight into the significance of renal toxicity in patients treated with IVV. PubMed was searched for relevant studies to December 2014. To account for publication bias, abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy, the Infectious Diseases Society of America/ID Week, and the European Congress of Clinical Microbiology and Infectious Diseases from 2008-2014 were reviewed. Bibliographies of all identified articles were reviewed and cross-referenced for additional sources. Seven retrospective studies were identified for inclusion in the review; no prospective studies were identified. Based on the available evidence, we conclude that there is no strong evidence suggesting an increased incidence of worsening renal function with IVV use. No study thus far has provided direct conclusive evidence for cellular and physiological renal toxicity due to IVV at clinically prevalent doses.
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Abstract
Voriconazole is an azole useful for the prophylaxis and the treatment of aspergillosis and other fungal infections in immunosuppressed subjects, as those found in aplasia after aggressive polychemotherapy treatments, after hematopoietic stem cell, liver or lung transplantation. Its administration in therapeutic doses lead to extremely varied serum levels from patient to patient and even to the same patient. The explanations are varied: nonlinear pharmacokinetics, certain patient-related factors, including genetic polymorphisms in the cytochrome P450 2C19 gene, the kidney and liver function, simultaneous administration with other drugs metabolised by the same cytochrome. It is recommended to maintain the serum concentrations of voriconazole between 1.5 and 4 μg/mL. At lower values its efficacy decreases and at higher values the risk of neurological toxicity increases. Even at these concentrations it is not excluded the possible appearance of a variety of toxic effects, including on the liver, manifested by cholestasis, hepatocytolisis, or their combination. It is recommended to monitor the clinical and laboratory evolution of all patients treated with voriconazole, and of the serum levels of the drug of those who belong to risk groups, even if there is still no consensus on this issue, given the lack of correlation between the serum level and the occurrence of adverse effects in many patients.
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cspA influences biofilm formation and drug resistance in pathogenic fungus Aspergillus fumigatus. BIOMED RESEARCH INTERNATIONAL 2015; 2015:960357. [PMID: 25821832 PMCID: PMC4363613 DOI: 10.1155/2015/960357] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/09/2015] [Indexed: 11/17/2022]
Abstract
The microbial cell wall plays a crucial role in biofilm formation and drug resistance. cspA encodes a repeat-rich glycophosphatidylinositol-anchored cell wall protein in the pathogenic fungus Aspergillus fumigatus. To determine whether cspA has a significant impact on biofilm development and sensitivity to antifungal drugs in A. fumigatus, a ΔcspA mutant was constructed by targeted gene disruption, and we then reconstituted the mutant to wild type by homologous recombination of a functional cspA gene. Deletion of cspA resulted in a rougher conidial surface, reduced biofilm formation, decreased resistance to antifungal agents, and increased internalization by A549 human lung epithelial cells, suggesting that cspA not only participates in maintaining the integrity of the cell wall, but also affects biofilm establishment, drug response, and invasiveness of A. fumigatus.
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