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Voriconazole Use in Children: Therapeutic Drug Monitoring and Control of Inflammation as Key Points for Optimal Treatment. J Fungi (Basel) 2021; 7:jof7060456. [PMID: 34200506 PMCID: PMC8227726 DOI: 10.3390/jof7060456] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/13/2022] Open
Abstract
Voriconazole plasma concentrations (PC) are highly variable, particularly in children. Dose recommendations in 2-12-year-old patients changed in 2012. Little data on therapeutic drug monitoring (TDM) after these new recommendations are available. We aimed to evaluate voriconazole monitoring in children with invasive fungal infection (IFI) after implementation of new dosages and its relationship with safety and effectiveness. A prospective, observational study, including children aged 2-12 years, was conducted. TDM was performed weekly and doses were changed according to an in-house protocol. Effectiveness, adverse events, and factors influencing PC were analysed. A total of 229 PC from 28 IFI episodes were obtained. New dosing led to a higher rate of adequate PC compared to previous studies; still, 35.8% were outside the therapeutic range. In patients aged < 8 years, doses to achieve therapeutic levels were higher than recommended. Severe hypoalbuminemia and markedly elevated C-reactive protein were related to inadequate PC. Therapeutic PC were associated with drug effectiveness and safety. Higher doses in younger patients and a dose adjustment protocol based on TDM should be considered. Voriconazole PC variability has decreased with current updated recommendations, but it remains high and is influenced by inflammatory status. Additional efforts to control inflammation in children with IFI should be encouraged.
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Abstract
Over the past 15 years, there has been an increase in the development and utilization of newer antifungal agents. The ideal antifungal, however, in regard to spectrum of activity, pharmacokinetic/pharmacodynamic properties, development of resistance, safety, and drug interaction profile remains elusive. This article reviews pharmacologic aspects of Food and Drug Administration-approved polyenes, flucytosine, azoles, and echinocandins as well as promising pipeline antifungal agents. Unique properties of these newer agents are highlighted. The clinical role of established and investigational antifungal agents as treatment and/or prevention of invasive fungal infections is discussed.
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Affiliation(s)
- Melissa D Johnson
- Duke University Medical Center, Box 102359 DUMC, Durham NC 27710, USA.
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Abstract
Congenital cutaneous candidiasis is an infrequent invasive fungal infection that usually appears in the first days of life. Extremely low birth weight infants are the most frequently affected. Classic presentation includes diffuse extensive erythematous rash with papules, plaques, pustules and vesicles, which later undergoes desquamation. Systemic dissemination is common in extremely low birth weight infants. Blood, urine and cerebrospinal fluid evaluation should be included in the initial assessment. Early and prolonged treatment has been associated with decreased mortality. We report the case of congenital cutaneous candidiasis in a preterm infant. Early skin lesion recognition allowed establishing adequate treatment in the first hours of life.
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Candidemia in Non-neutropenic Pediatric Patients in an Intensive Care Unit. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.843796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Bury D, Tissing WJE, Muilwijk EW, Wolfs TFW, Brüggemann RJ. Clinical Pharmacokinetics of Triazoles in Pediatric Patients. Clin Pharmacokinet 2021; 60:1103-1147. [PMID: 34002355 PMCID: PMC8416858 DOI: 10.1007/s40262-021-00994-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 01/21/2023]
Abstract
Triazoles represent an important class of antifungal drugs in the prophylaxis and treatment of invasive fungal disease in pediatric patients. Understanding the pharmacokinetics of triazoles in children is crucial to providing optimal care for this vulnerable population. While the pharmacokinetics is extensively studied in adult populations, knowledge on pharmacokinetics of triazoles in children is limited. New data are still emerging despite drugs already going off patent. This review aims to provide readers with the most current knowledge on the pharmacokinetics of the triazoles: fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole. In addition, factors that have to be taken into account to select the optimal dose are summarized and knowledge gaps are identified that require further research. We hope it will provide clinicians guidance to optimally deploy these drugs in the setting of a life-threatening disease in pediatric patients.
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Affiliation(s)
- Didi Bury
- Department of Supportive Care, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J E Tissing
- Department of Supportive Care, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eline W Muilwijk
- Department of Supportive Care, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pharmacy, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Tom F W Wolfs
- Department of Infectious Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Infectious Diseases, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Roger J Brüggemann
- Department of Supportive Care, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.
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Robati Anaraki M, Nouri-Vaskeh M, Abdoli Oskoei S. Fluconazole prophylaxis against invasive candidiasis in very low and extremely low birth weight preterm neonates: a systematic review and meta-analysis. Clin Exp Pediatr 2021; 64:172-179. [PMID: 32683818 PMCID: PMC8024115 DOI: 10.3345/cep.2019.01431] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/29/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Evidence shows that fluconazole prophylaxis is an effective treatment against invasive fungal infections in preterm neonates, however, the most efficient schedule of fluconazole prophylaxis for the colonization and mortality of invasive candidiasis (IC) is unknown. PURPOSE This systematic review and meta-analysis aimed to assess the efficiency of different prophylactic fluconazole schedules in controlling IC colonization, infection, and mortality in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants in neonatal intensive care units. METHODS We searched the PubMed, Scopus, Embase, and Cochrane databases using the keywords "candida," "invasive candidiasis," "IC," "fluconazole prophylaxis," "preterm infants," "very low birth weight infants," "VLBW," "extremely low birth weight," and "ELBW." RESULTS Mortality was significantly decreased in a metaanalysis of studies using different fluconazole prophylaxis regimens. The meta-analysis also indicated a significant decrease in the incidence of IC-associated mortality in ELBW infants using the same fluconazole prophylaxis schedules. CONCLUSION Future studies should explore the effectiveness of other different fluconazole prophylaxis schedules on IC colonization, infection, and mortality.
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Affiliation(s)
- Mahmoud Robati Anaraki
- Dental and Periodontal Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Prosthodontics, Dental School, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Nouri-Vaskeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahram Abdoli Oskoei
- Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Ferreras-Antolin L, Bielicki J, Warris A, Sharland M, Hsia Y. Global Divergence of Antifungal Prescribing Patterns: Data From the Global Antimicrobial Resistance, Prescribing, and Efficacy in Neonates and Children Surveys. Pediatr Infect Dis J 2021; 40:327-332. [PMID: 33710977 DOI: 10.1097/inf.0000000000002983] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Globally, invasive fungal diseases (IFDs) have a significant impact in human health. With an increasing pediatric population at risk of IFD, effective antifungal drugs access and affordability should be ensured universally. The aim of our study was to characterize the global antifungal drug use in neonates and children and its variability between countries in different income groups. METHODS Data were extracted from the Global Antimicrobial Resistance, Prescribing and Efficacy in Neonates and Children Point Prevalence Survey project, consisting in 1 pilot and four 1-day Point Prevalence Survey between 2015 and 2017. The data had been entered through a study-specific web-based data collection tool. RESULTS From a total of 13,410 children included, 7.8% (1048/13,410) received at least 1 systemic antifungal drug: 9.5% (95% confidence interval: 8.9%-10.1%) in high income countries (HIC) versus 5.0% (95% confidence interval: 4.4%-5.6%) in low-middle income countries (LMIC) (P < 0.01). A significant proportion of patients on antifungals belonged to high-risk group for IFD (67.4%; 706/1048); most of these were managed in HIC (72.8%, P < 0.01). The likelihood of receiving antifungals being in high-risk group was higher in HIC compared with LMIC (ratio of 5.8 vs. 3.4, P < 0.01). Antifungal prophylaxis was more likely prescribed in HIC (67.2% vs. 30.4%, P < 0.01). Fluconazole was the most frequently prescribed drug. The proportional use of fluconazole was higher in LMIC compared with HIC. CONCLUSIONS A significant variability of antifungal prescribing patterns was observed. The proportional use of systemic antifungals was twice as high in HIC compared with LMIC. More detailed data on access and antifungal use in limited-resource settings should be explored.
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Affiliation(s)
- Laura Ferreras-Antolin
- From the Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, United Kingdom
| | - Julia Bielicki
- From the Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, United Kingdom
- Paediatric Pharmacology Group, University of Basel Children's Hospital, Basel, Switzerland
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, United Kingdom
- Paediatric Infectious Diseases, Great Ormond Street Hospital, London, United Kingdom
| | - Mike Sharland
- From the Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, United Kingdom
| | - Yingfen Hsia
- MRC Centre for Medical Mycology, University of Exeter, United Kingdom
- School of Pharmacy, Queens' University Belfast, Belfast, United Kingdom
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8th European Conference on Infections in Leukaemia: 2020 guidelines for the diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or post-haematopoietic cell transplantation. Lancet Oncol 2021; 22:e254-e269. [PMID: 33811813 DOI: 10.1016/s1470-2045(20)30723-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/24/2022]
Abstract
Paediatric patients with cancer and those undergoing allogeneic haematopoietic cell transplantation have an increased susceptibility to invasive fungal diseases. In addition to differences in underlying conditions and comorbidities relative to adults, invasive fungal diseases in infants, children, and adolescents are unique in terms of their epidemiology, the validity of current diagnostic methods, the pharmacology and dosing of antifungal agents, and the absence of phase 3 clinical trials to provide data to guide evidence-based interventions. To re-examine the state of knowledge and to further improve invasive fungal disease diagnosis, prevention, and management, the 8th European Conference on Infections in Leukaemia (ECIL-8) reconvened a Paediatric Group to review the literature and to formulate updated recommendations according to the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and European Confederation of Medical Mycology (ECMM) grading system, which are summarised in this Review.
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High-Dose Micafungin in Neonates and Young Infants with Invasive Candidiasis: Results of a Phase 2 Study. Antimicrob Agents Chemother 2021; 65:AAC.02494-20. [PMID: 33558294 DOI: 10.1128/aac.02494-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 01/31/2021] [Indexed: 12/20/2022] Open
Abstract
Limited data are available on the most appropriate dosing, efficacy, and safety of micafungin in neonates and young infants with invasive candidiasis (IC). This study evaluated plasma levels, efficacy, and safety of micafungin at a dose of 8 mg/kg daily for a mean of 13.3 days (±5.2 days) in 35 neonates and young infants with IC. Micafungin plasma concentrations were 5.70 mg/liter preadministration and 17.23, 15.59, and 10.27 mg/liter after 1, 2, and 8 h, respectively. The resolution of the infection was achieved in 86.7% of patients treated for ≥14 days. In 20.0% of patients, we observed a transient hypertransaminasemia. Micafungin at a dose of 8 mg/kg daily is effective and well tolerated in neonates and young infants with IC. (This study has been registered at ClinicalTrials.gov under identifier NCT03421002 and in the EU Clinical Trials Register under number 2014-003087-20.).
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Kucova P, Kantor L, Fiserova K, Lasak J, Röderova M, Kolar M. Bacterial Pathogens and Evaluation of a Cut-Off for Defining Early and Late Neonatal Infection. Antibiotics (Basel) 2021; 10:278. [PMID: 33803288 PMCID: PMC7998728 DOI: 10.3390/antibiotics10030278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/04/2021] [Accepted: 03/07/2021] [Indexed: 12/02/2022] Open
Abstract
Bacterial infections are an important cause of mortality and morbidity in newborns. The main risk factors include low birth weight and prematurity. The study identified the most common bacterial pathogens causing neonatal infections including their resistance to antibiotics in the Neonatal Department of the University Hospital Olomouc. Additionally, the cut-off for distinguishing early- from late-onset neonatal infections was assessed. The results of this study show that a cut-off value of 72 h after birth is more suitable. Only in case of early-onset infections arising within 72 h of birth, initial antibiotic therapy based on gentamicin with ampicillin or amoxicillin/clavulanic acid may be recommended. It has been established that with the 72-h cut-off, late-onset infections caused by bacteria more resistant to antibiotics may be detected more frequently, a finding that is absolutely crucial for antibiotic treatment strategy.
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Affiliation(s)
- Pavla Kucova
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (P.K.); (K.F.); (M.R.); (M.K.)
| | - Lumir Kantor
- Neonatal Department, University Hospital Olomouc, 779 00 Olomouc, Czech Republic;
| | - Katerina Fiserova
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (P.K.); (K.F.); (M.R.); (M.K.)
| | - Jakub Lasak
- Neonatal Department, University Hospital Olomouc, 779 00 Olomouc, Czech Republic;
| | - Magdalena Röderova
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (P.K.); (K.F.); (M.R.); (M.K.)
| | - Milan Kolar
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (P.K.); (K.F.); (M.R.); (M.K.)
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Invasive Candida Infections in Neonates after Major Surgery: Current Evidence and New Directions. Pathogens 2021; 10:pathogens10030319. [PMID: 33803104 PMCID: PMC7999498 DOI: 10.3390/pathogens10030319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/07/2023] Open
Abstract
Infections represent a serious health problem in neonates. Invasive Candida infections (ICIs) are still a leading cause of mortality and morbidity in neonatal intensive care units (NICUs). Infants hospitalized in NICUs are at high risk of ICIs, because of several risk factors: broad spectrum antibiotic treatments, central catheters and other invasive devices, fungal colonization, and impaired immune responses. In this review we summarize 19 published studies which provide the prevalence of previous surgery in neonates with invasive Candida infections. We also provide an overview of risk factors for ICIs after major surgery, fungal colonization, and innate defense mechanisms against fungi, as well as the roles of different Candida spp., the epidemiology and costs of ICIs, diagnosis of ICIs, and antifungal prophylaxis and treatment.
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Kazakou N, Vyzantiadis TA, Gambeta A, Vasileiou E, Tsotridou E, Kotsos D, Giantsidi A, Saranti A, Palabougiouki M, Ioannidou M, Hatzipantelis E, Tragiannidis A. Invasive fungal infections in a pediatric hematology-oncology department: A 16-year retrospective study. Curr Med Mycol 2021; 6:37-42. [PMID: 33628980 PMCID: PMC7888516 DOI: 10.18502/cmm.6.2.2840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose Invasive fungal infections (IFIs) are a major cause of morbidity and mortality in immunocompromised children. The purpose of our study was to evaluate the incidence of IFIs in pediatric patients with underlying hematologic malignancies and determine the patient characteristics, predisposing factors, diagnosis, treatment efficacy, and outcome of IFIs. Materials and Methods For the purpose of the study, a retrospective analysis was performed on cases with proven and probable fungal infections from January 2001 to December 2016 (16 years). Results During this period, 297 children with hematologic malignancies were admitted to the 2nd Pediatric Department of Aristotle University of Thessaloniki, Greece, and 24 cases of IFIs were registered. The most common underlying diseases were acute lymphoblastic leukemia (ALL; n=19,79%), followed by acute myeloid leukemia (AML; n=4, 17%) and non-Hodgkin lymphoma (NHL; n=1,4%). The crude incidence rates of IFIs in ALL, AML, and NHL were 10.5%, 18.2%, and 2.8% respectively. Based on the results, 25% (n=6) and 75% (n=18) of the patients were diagnosed as proven and probable IFI cases, respectively. The lung was the most common site of involvement in 16 (66.7%) cases. Furthermore, Aspergillus and Candida species represented 58.3% and 29.1% of the identified species, respectively. Regarding antifungal treatment, liposomal amphotericin B was the most commonly prescribed therapeutic agent (n=21), followed by voriconazole (n=9), caspofungin (n=3), posaconazole (n=3), micafungin (n=1), and fluconazole (n=1). In addition, 12 children received combined antifungal treatment. The crude mortality rate was obtained as 33.3%. Conclusion As the findings of the present study indicated, despite the progress in the diagnosis and treatment of IFIs with the use of new antifungal agents, the mortality rate of these infections still remains high.
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Affiliation(s)
- Nikoleta Kazakou
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Anastasia Gambeta
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Vasileiou
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Tsotridou
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Kotsos
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athina Giantsidi
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna Saranti
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Palabougiouki
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Ioannidou
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Emmanuil Hatzipantelis
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Tragiannidis
- nd Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Avilés-Robles M, Gaytan F, Ojeda-Diesbarroso K, Castorena I, Jimenez-Juarez RN. Allogeneic Hematopoietic Stem Cell Transplant in a Pediatric Patient with Invasive Fungal Infections: Challenges and Indications. CURRENT FUNGAL INFECTION REPORTS 2021. [DOI: 10.1007/s12281-021-00411-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hornik CD, Bondi DS, Greene NM, Cober MP, John B. Review of Fluconazole Treatment and Prophylaxis for Invasive Candidiasis in Neonates. J Pediatr Pharmacol Ther 2021; 26:115-122. [PMID: 33603574 PMCID: PMC7887891 DOI: 10.5863/1551-6776-26.2.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/17/2020] [Indexed: 01/29/2023]
Abstract
Invasive candidiasis accounts for approximately 10% of nosocomial infections in preterm infants, with an incidence of 1% to 4% among neonatal intensive care unit (NICU) admissions and a mortality as high as 20% to 30%. These outcomes warrant improved treatment and prevention strategies for infants at highest risk. The Infectious Diseases Society of America provides guidelines on antifungal medications for the prophylaxis and treatment of candidiasis in NICUs; however, there are still variations in practice on the use of fluconazole for prophylaxis and treatment of invasive candidiasis. This review provides specific information regarding fluconazole activity, pharmacokinetics, and a literature evaluation of dosing strategies and comparisons to other treatments in the neonatal population.
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Pediatric and Neonatal Invasive Candidiasis: Species Distribution and Mortality Rate in a Thai Tertiary Care Hospital. Pediatr Infect Dis J 2021; 40:96-102. [PMID: 33021588 DOI: 10.1097/inf.0000000000002912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Invasive candidiasis (IC) is a serious infection among children with underlying medical conditions. A shift from C. albicans to non-albicans Candida has been observed worldwide. This study aims to identify species of Candida and factors associated with the overall 30-day mortality rate. METHODS A retrospective chart review was conducted among children with culture-confirmed IC from birth to 15 years of age at King Chulalongkorn Memorial Hospital, Thailand. Multivariate Cox regression analysis was performed to determine associated factors with 30-day mortality. RESULTS From 2003 to 2019, 102 episodes of IC in pediatric group with a median age of 16 months (interquartile range 4-65) and 12 episodes of IC in neonatal group with a median age of 18 days (interquartile range 12-22). The species distribution were Candida albicans (35%), Candida parapsilosis (26%), Candida tropicalis (22%), Candida glabrata (6%) and other/unspecified species (11%). Antifungal treatment was given in 88% (67% Amphotericin B deoxycholate, 28% Fluconazole). Overall 30-day mortality rates were 28.5% [95% confidence interval (CI) 20.8%-38.4%] and 8.3% (95% CI 1.2%-46.1%) in pediatrics and neonates, respectively. Mortality rate among the neutropenic group was significantly higher than non-neutropenic group (46.4% vs. 20.6%, P = 0.005). Factors associated with 30-day mortality in pediatric IC were shock [adjusted hazard ratio (aHR) 4.2; 95% CI 1.8-9.4], thrombocytopenia (aHR 7.7; 95% CI 1.8-33.9) and no antifungal treatment (aHR 4.6; 95% CI 1.7-12.1). CONCLUSIONS Two-third of children with IC were diagnosed with non-albicans Candida. Children with high mortality rate included those with neutropenia, presented with shock or thrombocytopenia, such that the proper empiric antifungal treatment is recommended.
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Zajac-Spychala O, Kampmeier S, Lehrnbecher T, Groll AH. Infectious Complications in Paediatric Haematopoetic Cell Transplantation for Acute Lymphoblastic Leukemia: Current Status. Front Pediatr 2021; 9:782530. [PMID: 35223707 PMCID: PMC8866305 DOI: 10.3389/fped.2021.782530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022] Open
Abstract
Haematopoietic stem cell transplantation (HSCT) in paediatric patients with acute lymphoblastic leukaemia (ALL) is associated with a variety of infectious complications which result in significant morbidity and mortality. These patients are profoundly immunocompromised, and immune reconstitution after HSCT generally occurs in astrictly defined order. During the early phase after HSCT until engraftment, patients are at risk of infections due to presence of neutropenia and mucosal damage, with Gramme-positive and Gramme-negative bacteria and fungi being the predominant pathogens. After neutrophil recovery, the profound impairment of cell-mediated immunity and use of glucocorticosteroids for control of graft-vs.-host disease (GvHD) increases the risk of invasive mould infection and infection or reactivation of various viruses, such as cytomegalovirus, varicella zoster virus, Epstein-Barr virus and human adenovirus. In the late phase, characterised by impaired cellular and humoral immunity, particularly in conjunction with chronic GvHD, invasive infections with encapsulated bacterial infections are observed in addition to fungal and viral infections. HSCT also causes a loss of pretransplant naturally acquired and vaccine-acquired immunity; therefore, complete reimmunization is necessary to maintain long-term health in these patients. During the last two decades, major advances have been made in our understanding of and in the control of infectious complications associated with HSCT. In this article, we review current recommendations for the diagnosis, prophylaxis and treatment of infectious complications following HSCT for ALL in childhood.
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Affiliation(s)
- Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
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Apsemidou A, Füller MA, Idelevich EA, Kurzai O, Tragiannidis A, Groll AH. Candida lusitaniae Breakthrough Fungemia in an Immuno-Compromised Adolescent: Case Report and Review of the Literature. J Fungi (Basel) 2020; 6:jof6040380. [PMID: 33371186 PMCID: PMC7766689 DOI: 10.3390/jof6040380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/14/2020] [Accepted: 12/18/2020] [Indexed: 12/26/2022] Open
Abstract
Candida lusitaniae is a rare cause of candidemia that is known for its unique capability to rapidly acquire resistance to amphotericin B. We report the case of an adolescent with grade IV graft-vs.-host disease after hematopoietic cell transplantation who developed catheter-associated C. lusitaniae candidemia while on therapeutic doses of liposomal amphotericin B. We review the epidemiology of C. lusitaniae bloodstream infections in adult and pediatric patients, the development of resistance, and its role in breakthrough candidemia. Appropriate species identification, in vitro susceptibility testing, and source control are pivotal to optimal management of C. lusitaniae candidemia. Initial antifungal therapy may consist of an echinocandin and be guided by in vitro susceptibility and clinical response.
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Affiliation(s)
- Athanasia Apsemidou
- 2nd Pediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, GR-54636 Thessaloniki, Greece; (A.A.); (A.T.)
| | - Miriam Antonie Füller
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children’s Hospital Münster, D-48149 Münster, Germany;
| | - Evgeny A. Idelevich
- Institute of Medical Microbiology, University Hospital Münster, D-48149 Münster, Germany;
- Friedrich Loeffler Institute of Medical Microbiology, University Medicine Greifswald, D-17475 Greifswald, Germany
| | - Oliver Kurzai
- National Reference Center for Invasive Mycoses, Leibniz Institute for Natural Product Research and Infection Biology—Hans-Knoell-Institute, D-07745 Jena, Germany;
- Institute for Hygiene and Microbiology, Julius Maximilian University of Würzburg, D-97080 Würzburg, Germany
| | - Athanasios Tragiannidis
- 2nd Pediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, GR-54636 Thessaloniki, Greece; (A.A.); (A.T.)
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children’s Hospital Münster, D-48149 Münster, Germany;
| | - Andreas H. Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children’s Hospital Münster, D-48149 Münster, Germany;
- Correspondence: ; Tel.: +49-251-834-7742; Fax: +49-251-834-7828
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Piqueras AI, Rubio T, Lopez-Medina EM, Gimeno A, Modesto V, Cantón E, Pemán J. Recent changes in candidemia trends in a tertiary hospital (2011-2018). Rev Iberoam Micol 2020; 37:87-93. [PMID: 33279388 DOI: 10.1016/j.riam.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 08/04/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The epidemiology of candidemia has changed over the last decades and varies widely among geographic areas. AIMS We examined in children (aged 0-14) with candidemia the trends in the incidence rate of this infection, as well as the clinical characteristics of the patients, in order to optimize the prognosis and the control measures of this serious disease. METHODS A retrospective cohort study of candidemia in the period 2011-2018 in the neonatal intensive care unit (NICU), pediatric ICU (PICU) and pediatric wards of a tertiary hospital, was conducted. The clinical course, Candida species isolated, antifungal susceptibility, outcome and incidence rates were analyzed and compared. RESULTS We diagnosed 68 episodes of candidemia in 62 children, 48% occurred in the NICU, 31% in the PICU and 21% in pediatric wards. Candida albicans was the most frequent species isolated in NICU infants (53%), and Candida parapsilosis predominated among PICU patients (59%) and pediatric wards (50%). One third of NICU infants had invasive candidiasis (IC), most of them having extremely low birth weight (ELBW) (35%). All isolates were susceptible to the antifungal administered. Over time, the incidence of candidemia decreased in the PICU (from 2.2 to 0.3 episodes/1000 patient-days, OR=0.6; 95%CI 0.5-0.8), whereas in the NICU and in the wards remained stable. Mortality occurred mostly in NICU patients (26%), predominated in ELBW infants and did not change over time. CONCLUSIONS The higher incidence and mortality of candidemia and IC observed in preterm infants requires a continuous evaluation of practices and diagnostic methods which will allow improving the prognosis of this most vulnerable population.
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Affiliation(s)
- Ana I Piqueras
- Pediatric Infectious Diseases, University & Polytechnic Hospital La Fe, Valencia, Spain; Health Research Institute La Fe, Valencia, Spain.
| | - Thomas Rubio
- Infectious Diseases, Georgetown University, Washington DC, USA
| | - Eva M Lopez-Medina
- Pediatric Infectious Diseases, University & Polytechnic Hospital La Fe, Valencia, Spain
| | - Ana Gimeno
- Division of Neonatology, University & Polytechnic Hospital La Fe, Spain
| | - Vicent Modesto
- Pediatric Intensive Care Unit, University & Polytechnic Hospital La Fe, Spain
| | - Emilia Cantón
- Pediatric Intensive Care Unit, University & Polytechnic Hospital La Fe, Spain
| | - Javier Pemán
- Health Research Institute La Fe, Valencia, Spain; Microbiology Department, University & Polytechnic Hospital La Fe, Spain
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69
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Candidemia in Children with Malignancies: Report from the Infection Working Group of the Hellenic Society of Pediatric Hematology-Oncology. J Fungi (Basel) 2020; 6:jof6040276. [PMID: 33182837 PMCID: PMC7712277 DOI: 10.3390/jof6040276] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 01/22/2023] Open
Abstract
Candidemia is an important cause of morbidity and mortality especially in immunocompromised and hospitalized patients. We retrospectively collected data of candidemia cases that occurred in the seven Hematology-Oncology Departments/Units of Greece and the Stem Cell Transplant Unit between 2015 and 2019. In total, 19 episodes of candidemia in 19 patients were recorded. The majority of the patients (78.9%) had at least one risk factor for candidemia. The most frequent risk factors associated with candidemia observed in our patients were prolonged duration of hospitalization (30 days, range 1–141), presence of a central venous catheter at diagnosis of candidemia (73.7%) and antibiotics use during the last two weeks (84.2%). Candida parapsilosis was the most common species isolated accounting for 42.1%, followed by C. albicans (26.3%) and C. famata (15.8%). Nearly all of the patients (84.2%) received antifungal monotherapy with liposomal amphotericin B or echinocandins. The central venous catheter was removed in 78.6% of patients and the median time between the first positive blood culture and catheter removal was 3 days (range 1–9). Mortality at 28 days was 26.3%. In conclusion, a predominance of non-albicans species was observed in our study in conformity with the global trend.
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Abstract
Invasive fungal infections in humans are generally associated with high mortality, making the choice of antifungal drug crucial for the outcome of the patient. The limited spectrum of antifungals available and the development of drug resistance represent the main concerns for the current antifungal treatments, requiring alternative strategies. Antimicrobial peptides (AMPs), expressed in several organisms and used as first-line defenses against microbial infections, have emerged as potential candidates for developing new antifungal therapies, characterized by negligible host toxicity and low resistance rates. Most of the current literature focuses on peptides with antibacterial activity, but there are fewer studies of their antifungal properties. This review focuses on AMPs with antifungal effects, including their in vitro and in vivo activities, with the biological repercussions on the fungal cells, when known. The classification of the peptides is based on their mode of action: although the majority of AMPs exert their activity through the interaction with membranes, other mechanisms have been identified, including cell wall inhibition and nucleic acid binding. In addition, antifungal compounds with unknown modes of action are also described. The elucidation of such mechanisms can be useful to identify novel drug targets and, possibly, to serve as the templates for the synthesis of new antimicrobial compounds with increased activity and reduced host toxicity.
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71
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Paixao de Sousa da Silva AM, de Moraes-Pinto MI, Teofilo Pignati L, Barbosa Teixeira B, Cordeiro Lima AP, Costa Pimentel Germano P, Petrilli AS, Marques LMA, Carlesse F. Candida spp bloodstream infections in a Latin American Pediatric Oncology Reference Center: Epidemiology and associated factors. Mycoses 2020; 63:812-822. [PMID: 32428294 DOI: 10.1111/myc.13106] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Invasive fungal disease is a significant cause of morbidity and mortality in immunosuppressed children. The recognition of patients at risk for candidaemia is paramount to a better prognosis. OBJECTIVES To characterize Candida spp bloodstream infections (BSI) in a reference centre for paediatric oncology and to describe the most prevalent risk factors associated with candida infections. PATIENTS/METHODS This is a retrospective cohort study carried out with paediatric patients followed up with at the Institute of Pediatric Oncology, Brazil, who presented positive blood culture for Candida spp from January 2004 to December 2016. RESULTS Ninety episodes of candidaemia were analysed; patients had a median age of 4.5 years, and 57.8% were males, with a diagnosis of solid tumours in 54.5% of cases. The most common Candida species were C albicans (35.6%), C parapsilosis (30.0%) and C tropicalis (16.7%). C tropicalis BSI was associated with neutropenia and skin lesions. Therapy was successful in 67.1% of the episodes. Older age and thrombocytopenia were associated with therapeutic failure. Death within 30 days occurred in 24.4% of patients; predictive factors were older age and admission to an ICU C parapsilosis candidaemia was a protective factor for death when compared to C albicans. CONCLUSION The main species isolated were C albicans, C parapsilosis and C tropicalis. C tropicalis BSI was associated with neutropenia and skin lesions. The death rate was significant, and a worse prognosis was associated with older age, thrombocytopenia and admission to an ICU C parapsilosis infection proved to be a protective factor against mortality.
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Affiliation(s)
- Adriana Maria Paixao de Sousa da Silva
- Division of Pediatric Infectious Diseases, Federal University of Sao Paulo, Sao Paulo, Brazil.,Institute of Pediatric Oncology, Grupo de Apoio ao Adolescente e Criança com Câncer, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Luara Teofilo Pignati
- Division of Pediatric Infectious Diseases, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Bruno Barbosa Teixeira
- Division of Pediatric Infectious Diseases, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ana Paula Cordeiro Lima
- Institute of Pediatric Oncology, Grupo de Apoio ao Adolescente e Criança com Câncer, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Priscila Costa Pimentel Germano
- Institute of Pediatric Oncology, Grupo de Apoio ao Adolescente e Criança com Câncer, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Antonio Sergio Petrilli
- Division of Pediatric Infectious Diseases, Federal University of Sao Paulo, Sao Paulo, Brazil.,Institute of Pediatric Oncology, Grupo de Apoio ao Adolescente e Criança com Câncer, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Leticia Maria Acioli Marques
- Division of Pediatric Infectious Diseases, Federal University of Sao Paulo, Sao Paulo, Brazil.,Institute of Pediatric Oncology, Grupo de Apoio ao Adolescente e Criança com Câncer, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fabianne Carlesse
- Division of Pediatric Infectious Diseases, Federal University of Sao Paulo, Sao Paulo, Brazil.,Institute of Pediatric Oncology, Grupo de Apoio ao Adolescente e Criança com Câncer, Federal University of Sao Paulo, Sao Paulo, Brazil
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Arendrup MC, Friberg N, Mares M, Kahlmeter G, Meletiadis J, Guinea J. How to interpret MICs of antifungal compounds according to the revised clinical breakpoints v. 10.0 European committee on antimicrobial susceptibility testing (EUCAST). Clin Microbiol Infect 2020; 26:1464-1472. [PMID: 32562861 DOI: 10.1016/j.cmi.2020.06.007] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND EUCAST has revised the definition of the susceptibility category I from 'Intermediate' to 'Susceptible, Increased exposure'. This implies that I can be used where the drug concentration at the site of infection is high, either because of dose escalation or through other means to ensure efficacy. Consequently, I is no longer used as a buffer zone to prevent technical factors from causing misclassifications and discrepancies in interpretations. Instead, an Area of Technical Uncertainty (ATU) has been introduced for MICs that cannot be categorized without additional information as a warning to the laboratory that decision on how to act has to be made. To implement these changes, the EUCAST-AFST (Subcommittee on Antifungal Susceptibility Testing) reviewed all, and revised some, clinical antifungal breakpoints. OBJECTIVES The aim was to present an overview of the current antifungal breakpoints and supporting evidence behind the changes. SOURCES This document is based on the ten recently updated EUCAST rationale documents, clinical breakpoint and breakpoint ECOFF documents. CONTENT The following breakpoints (in mg/L) have been revised or established for Candida species: micafungin against C. albicans (ATU = 0.03); amphotericin B (S ≤/> R = 1/1), fluconazole (S ≤/> R = 2/4), itraconazole (S ≤/> R = 0.06/0.06), posaconazole (S ≤/> R = 0.06/0.06) and voriconazole (S ≤/> R = 0.06/0.25) against C. dubliniensis; fluconazole against C. glabrata (S ≤/> R = 0.001/16); and anidulafungin (S ≤/> R = 4/4) and micafungin (S ≤/> R = 2/2) against C. parapsilosis. For Aspergillus, new or revised breakpoints include itraconazole (ATU = 2) and isavuconazole against A. flavus (S ≤/> R = 1/2, ATU = 2); amphotericin B (S ≤/> R = 1/1), isavuconazole (S ≤ /> R = 1/2, ATU = 2), itraconazole (S ≤/> R = 1/1, ATU = 2), posaconazole (ATU = 0.25) and voriconazole (S ≤/> R = 1/1, ATU = 2) against A. fumigatus; itraconazole (S ≤/> R = 1/1, ATU = 2) and voriconazole (S ≤/> R = 1/1, ATU = 2) against A. nidulans; amphotericin B against A. niger (S ≤/> R = 1/1); and itraconazole (S ≤/> R = 1/1, ATU = 2) and posaconazole (ATU = 0.25) against A. terreus. IMPLICATIONS EUCAST-AFST has released ten new documents summarizing existing and new breakpoints and MIC ranges for control strains. A failure to adopt the breakpoint changes may lead to misclassifications and suboptimal or inappropriate therapy of patients with fungal infections.
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Affiliation(s)
- M C Arendrup
- Unit of Mycology, Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - N Friberg
- Division of Clinical Microbiology, Helsinki University Hospital, HUSLAB, Finland
| | - M Mares
- Laboratory of Antimicrobial Chemotherapy, Ion Ionescu de la Brad University, Iasi, Romania
| | - G Kahlmeter
- The EUCAST Development Laboratory, Clinical Microbiology, Växjö, Sweden
| | - J Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - J Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Scott BL, Hornik CD, Zimmerman K. Pharmacokinetic, efficacy, and safety considerations for the use of antifungal drugs in the neonatal population. Expert Opin Drug Metab Toxicol 2020; 16:605-616. [PMID: 32508205 DOI: 10.1080/17425255.2020.1773793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal infections are an important cause of morbidity and mortality in infants, particularly in extreme prematurity. Successful systemic treatment requires consideration of antifungal efficacy, safety, and pharmacokinetics, including optimization of dosing in this population. AREAS COVERED This review summarizes published pharmacokinetic data on four classes of antifungal agents used in the neonatal population. Alterations in absorption, distribution, drug metabolism and clearance in infants compared to adult populations are highlighted. Additionally, pharmacodynamics, safety, and therapeutic drug monitoring are discussed. Recent advancements in neonatal antifungal pharmacotherapies are examined, with emphasis on clinical application. EXPERT OPINION Over the last two decades, published studies have provided increased knowledge on pharmacokinetic considerations in the neonatal population. Future research should focus on filling in the knowledge gaps that remain regarding the benefits and risks of combination antifungal therapy, the rising use of micafungin for invasive candidiasis given its fungicidal activity against polyene and azole-resistant Candida species and its minimal adverse effect profile, and the need for pharmacokinetic and safety data of broad spectrum triazoles, like voriconazole and posaconazole, in infants. Furthermore, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations with subsequent implementation into clinical practice.
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Affiliation(s)
- Briana L Scott
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA.,Duke University School of Medicine, Duke Clinical Research Institute , Durham, NC, USA
| | - Kanecia Zimmerman
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA.,Duke University School of Medicine, Duke Clinical Research Institute , Durham, NC, USA
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Arastehfar A, Daneshnia F, Najafzadeh MJ, Hagen F, Mahmoudi S, Salehi M, Zarrinfar H, Namvar Z, Zareshahrabadi Z, Khodavaisy S, Zomorodian K, Pan W, Theelen B, Kostrzewa M, Boekhout T, Lass-Flörl C. Evaluation of Molecular Epidemiology, Clinical Characteristics, Antifungal Susceptibility Profiles, and Molecular Mechanisms of Antifungal Resistance of Iranian Candida parapsilosis Species Complex Blood Isolates. Front Cell Infect Microbiol 2020; 10:206. [PMID: 32509592 PMCID: PMC7253641 DOI: 10.3389/fcimb.2020.00206] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/16/2020] [Indexed: 11/13/2022] Open
Abstract
Clonal expansion of fluconazole resistant (FLZ-R) Candida parapsilosis isolates is increasingly being identified in many countries, while there is no study exploring the antifungal susceptibility pattern, genetic diversity, and clinical information for Iranian C. parapsilosis blood isolates. Candida parapsilosis species complex blood isolates (n = 98) were recovered from nine hospitals located in three major cities, identified by MALDI-TOF MS, and their genetic relatedness was examined by AFLP fingerprinting. Antifungal susceptibility testing followed CLSI-M27-A3 and ERG11, MRR1 and hotspots 1/2 (HS1/2) of FKS1 were sequenced to assess the azole and echinocandin resistance mechanisms, respectively. Ninety-four C. parapsilosis and four Candida orthopsilosis isolates were identified from 90 patients. Only 43 patients received systemic antifungal drugs with fluconazole as the main antifungal used. The overall mortality rate was 46.6% (42/90) and death mostly occurred for those receiving systemic antifungals (25/43) relative to those not treated (17/47). Although, antifungal-resistance was rare, one isolate was multidrug-resistant (FLZ = 16 μg/ml and micafungin = 8 μg/ml) and the infected patient showed therapeutic failure to FLZ prophylaxis. Mutations causing azole and echinocandin resistance were not found in the genes studied. AFLP revealed five genotypes (G) and G1 was the main one (59/94; 62.7%). Clinical outcome was significantly associated with city (P = 0.02, α <0.05) and Mashhad was significantly associated with mortality (P = 0.03, α <0.05). Overall, we found a low level of antifungal resistance for Iranian C. parapsilosis blood isolates, but the noted MDR strain can potentially become the source of future infections and challenge the antifungal therapy in antifungal-naïve patients. AFLP typing results warrants confirmation using other resolutive typing methods.
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Affiliation(s)
- Amir Arastehfar
- Yeast Biodiversity Department, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands
| | - Farnaz Daneshnia
- Yeast Biodiversity Department, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands
| | - Mohammad Javad Najafzadeh
- Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ferry Hagen
- Yeast Biodiversity Department, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, Netherlands.,Laboratory of Medical Mycology, Jining No. 1 People's Hospital, Jining, China
| | - Shahram Mahmoudi
- Department of Medical Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Salehi
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Zarrinfar
- Allergy Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Namvar
- Department of Microbiology, School of Biological Sciences, Islamic Azad University, Tehran, Iran
| | - Zahra Zareshahrabadi
- Basic Sciences in Infectious Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sadegh Khodavaisy
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamiar Zomorodian
- Basic Sciences in Infectious Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Weihua Pan
- Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Bart Theelen
- Yeast Biodiversity Department, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands
| | | | - Teun Boekhout
- Yeast Biodiversity Department, Westerdijk Fungal Biodiversity Institute, Utrecht, Netherlands.,Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, Netherlands
| | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
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75
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Santiago-García B, Rincón-López EM, Ponce Salas B, Aguilar de la Red Y, Garrido Colino C, Martínez Fernández-Llamazares C, Saavedra-Lozano J, Hernández-Sampelayo Matos T. Effect of an intervention to improve the prescription of antifungals in pediatric hematology-oncology. Pediatr Blood Cancer 2020; 67:e27963. [PMID: 31407514 DOI: 10.1002/pbc.27963] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of antifungals has expanded in pediatric hematology-oncology, and the need to develop pediatric-based surveillance and education activities is becoming crucial. The aims of this study were to evaluate the impact of a multidisciplinary protocol on the adequacy of antifungal prescription in a pediatric hematology-oncology unit and to assess the effect of an educational intervention to improve the knowledge of prescribing pediatricians over time. METHODS A multidisciplinary team established a protocol for the management of invasive fungal disease (IFD). The use of antifungals before (January 2012-May 2013) and after the protocol (June 2013-December 2015) was evaluated. Prescribing pediatricians attended a training course on IFD and were evaluated before 0, 6, and 12 months after the intervention. RESULTS During the study period, antifungal agents were used in 185 episodes (56 children, 39.3% females), and were administered as prophylaxis (58.9%), empiric (34.6%), or targeted therapy (6.5%). Antifungal prescriptions were inadequate in 7% of the episodes, related to drug selection (53.8%), dosage (38.5%) and route of administration (7.7%). After protocol implementation, inadequate prescriptions decreased 9.9% (15.2% vs 5.3%; P = .04). Following the educational activity, the percentage of adequate responses to the questionnaire improved significantly compared to baseline, and persisted over time (19.7% improvement at 0 months [P < .0001]; 21.1% at 6 months [P < .0001]; 16.6% at 12 months [P = .002]). CONCLUSIONS The establishment of multidisciplinary protocols and education activities improved the quality of antifungal prescription and the knowledge of prescribers regarding antifungal therapy. Therefore, these activities may be important for the implementation of antifungal stewardship programs in pediatrics.
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Affiliation(s)
- Begoña Santiago-García
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Elena María Rincón-López
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | | | | | - Carmen Garrido Colino
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Gregorio Marañón Hospital, Madrid, Spain
| | | | - Jesús Saavedra-Lozano
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Teresa Hernández-Sampelayo Matos
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
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- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
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76
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Abstract
Neonates and immunosuppressed/immunocompromised pediatric patients are at high risk of invasive fungal diseases. Appropriate antifungal selection and optimized dosing are imperative to the successful prevention and treatment of these life-threatening infections. Conventional amphotericin B was the mainstay of antifungal therapy for many decades, but dose-limiting nephrotoxicity and infusion-related adverse events impeded its use. Despite the development of several new antifungal classes and agents in the past 20 years, and their now routine use in at-risk pediatric populations, data to guide the optimal dosing of antifungals in children are limited. This paper reviews the spectra of activity for approved antifungal agents and summarizes the current literature specific to pediatric patients regarding pharmacokinetic/pharmacodynamic data, dosing, and therapeutic drug monitoring.
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Affiliation(s)
- Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 2716 South Street, Suite 10360, Philadelphia, PA, 19146, USA.
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Brian T Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 2716 South Street, Suite 10360, Philadelphia, PA, 19146, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Xie R, McFadyen L, Raber S, Swanson R, Tawadrous M, Leister-Tebbe H, Cohen-Wolkowiez M, Benjamin DK, Liu P. Population Analysis of Anidulafungin in Infants to Older Adults With Confirmed or Suspected Invasive Candidiasis. Clin Pharmacol Ther 2020; 108:316-325. [PMID: 32189334 PMCID: PMC7485140 DOI: 10.1002/cpt.1831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/28/2020] [Indexed: 11/10/2022]
Abstract
In a pooled population analysis, we investigated the pharmacokinetics of i.v. anidulafungin in four studies across a full range of adult and pediatric ages in patients with confirmed, suspected, or at high risk of invasive candidiasis (IC). Relationships between anidulafungin exposure and key efficacy end points (global response of success and all‐cause mortality) and safety end points (all‐cause hepatic or gastrointestinal adverse events) in all patients and separately in pediatric patients and the appropriate dosing regimen for IC treatment in pediatric patients were evaluated. Pediatric patients received a 3.0 mg/kg (maximum 200 mg) i.v. loading dose and 1.5 mg/kg (maximum 100 mg) daily thereafter. Adults received a 200 mg i.v. loading dose and 100 mg daily thereafter. Estimated systemic anidulafungin exposures were similar across age groups (neonates to adults) at the weight‐based doses studied in pediatric patients. No clear associations were identified between anidulafungin exposure and efficacy or safety end points.
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Affiliation(s)
- Rujia Xie
- Pharmacometrics, Pfizer Asia Manufacturing Pte Ltd, Singapore City, Singapore
| | - Lynn McFadyen
- Pharmacometrics, Pfizer Research and Development UK Ltd, Kent, UK
| | - Susan Raber
- Clinical Pharmacology, Pfizer Inc, La Jolla, California, USA
| | - Robert Swanson
- Clinical Research and Development, Pfizer Inc, Groton, Connecticut, USA
| | | | | | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Ping Liu
- Formerly Clinical Pharmacology, Development China, Pfizer Inc, Beijing, China
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78
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Arad-Cohen N, Rowe JM, Shachor-Meyouhas Y. Pharmacological prophylaxis of infection in pediatric acute myeloid leukemia patients. Expert Opin Pharmacother 2020; 21:193-205. [PMID: 31914337 DOI: 10.1080/14656566.2019.1701654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: Pediatric patients treated for acute myeloid leukemia (AML) are at high risk of developing severe infectious complications. The choice of an optimum supportive treatment should be based on local epidemiology, as well as intensity and toxicity of the anti-leukemic therapy applied.Areas covered: This review presents an overview of recently published studies focusing on the prevention of infection in pediatric AML patients. PubMed has been systematically searched for clinical trials, reviews, and meta-analyses published in the last 10 years. The focus of this article will be limited to primary prophylaxis only, while secondary prophylaxis is beyond the scope of the current review.Expert opinion: Although anti-bacterial agents may decrease the bacterial infection burden, there is no consensus regarding prophylactic use. To that end, there is a need for further randomized controlled trials to establish the precise role of anti-bacterial prophylaxis in pediatric AML patients. The prophylactic use of anti-fungal agents is strongly recommended for all AML patients. Since the contribution of hematopoietic growth factors to improved survival has not been demonstrated, they should not be routinely applied. Decisions regarding an appropriate prophylactic strategy should be taken in collaboration with the infectious disease experts and pharmacology team.
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Affiliation(s)
- Nira Arad-Cohen
- Pediatric Hematology-Oncology Department, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Jacob M Rowe
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus Haifa, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yael Shachor-Meyouhas
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,Pediatric Infectious Diseases Unit, Rambam Health Care Campus, Ruth Rappaport Children's Hospital Haifa, Israel
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79
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Villaescusa T, Vázquez L, Bergua JM, García J, Romero A, Olave MT, García Belmonte D, Queipo de Llano MP. Micafungin as antifungal prophylaxis in non-transplanted haemotological patients. REVISTA ESPANOLA DE QUIMIOTERAPIA 2019; 33:44-48. [PMID: 31865649 PMCID: PMC6987625 DOI: 10.37201/req/067.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Fungal infections are a major cause of morbidity and mortality in the haematological patients. These infections are mainly due to Candida spp. and Aspergillus spp. Mortality by these infections is high, but rates have descended in the latest series due to better antifungal agents. Echinocan-dins are, in vitro, very active against Candida and Aspergillus spp. The objective of the study is to analyse the efficacy and safety of micafungin in the antifungal prophylaxis of haema-tological patients on chemotherapy. METHODS A multicentre, observational retrospective study was performed in 7 Haematology Depart-ments in Spain. Patients admitted to these departments with chemotherapy or immunosuppressive treatment, and who had received antifungal prophylaxis with micafungin between 1 January 2009 and 31 December 2014 were included. RESULTS There were 5 cases of probable or proven fun-gal infection (4.8%) according to the 2008 EORTC criteria: 2 proven, 3 probable. The types of fungal infection were 3 as-pergillosis and 2 candidiasis. There were no drop-outs from the prophylaxis with micafungin due to toxicity. CONCLUSIONS Micafungin is an antifungal agent which, used in prophylaxis, has demonstrated good efficacy and an excellent toxicity profile, making it an apparently interesting option in patients requiring antifungal prophylaxis during their hospitalisation episode.
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Affiliation(s)
- T Villaescusa
- Teresa Villaescusa de la Rosa. Hospital Virgen de la Concha. Avda. Requejo nº 35. 49022. Zamora. Spain.
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80
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Neonatal Antifungal Consumption Is Dominated by Prophylactic Use; Outcomes From The Pediatric Antifungal Stewardship: Optimizing Antifungal Prescription Study. Pediatr Infect Dis J 2019; 38:1219-1223. [PMID: 31568253 DOI: 10.1097/inf.0000000000002463] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diagnostic challenges combined with the vulnerability of neonates to develop invasive candidiasis (IC) may lead to antifungal administration in the absence of IC. A modified point-prevalence study was performed to obtain an improved insight and understanding of antifungal prescribing in this specific patient population. METHODS Neonates and infants ≤90 days of age receiving systemic antifungals from 12 centers in England were included. Data were collected prospectively during 26 consecutive weeks and entered into an online REDCap database. RESULTS Two hundred eighty neonates and infants were included, the majority ≤1 month of age (68.2%). Prematurity was the commonest underlying condition (68.9%). Antifungals were prescribed for prophylactic reason in 79.6%; of those, 64.6% and 76.3% were extreme low birth weight infants and prematurely born neonates, respectively. Additional risk factors were present in almost all patients, but only 44.7% had ≥3 risk factors rendering them more susceptible to develop IC. Nonpremature and non extremely low birth weight premature infants only scored ≥3 risk factors in 32.6% and 15%, respectively. Fluconazole was the most common antifungal used (76.7% of all prescriptions), and commonly underdosed as treatment. The number of microbiologic proven IC was low, 5.4%. CONCLUSIONS Neonatal antifungal prophylaxis is commonly prescribed outside the recommendations based on known risk profiles. Fluconazole is the main antifungal prescribed in neonates and infants, with underdosing frequently observed when prescribed for treatment. Number of proven IC was very low. These observations should be taken into consideration to develop a national pediatric Antifungal Stewardship program aiming to guide rational prescribing.
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81
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Mark C, McGinn C. From Culture to Fungal Biomarkers: the Diagnostic Route of Fungal Infections in Children with Primary Immunodeficiencies. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-00356-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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82
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Kim J, Nakwa FL, Araujo Motta F, Liu H, Dorr MB, Anderson LJ, Kartsonis N. A randomized, double-blind trial investigating the efficacy of caspofungin versus amphotericin B deoxycholate in the treatment of invasive candidiasis in neonates and infants younger than 3 months of age. J Antimicrob Chemother 2019; 75:215-220. [DOI: 10.1093/jac/dkz398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
Objectives
Investigate the efficacy of caspofungin in participants <3 months of age with invasive Candida infection (ICI).
Methods
This multicentre, randomized, double-blind, comparator-controlled, Phase 2 study (protocol MK0991-064; NCT01945281) enrolled participants <3 months of age with culture-confirmed ICI within 96 h of study entry. Participants were randomly assigned 2:1 to once-daily intravenous 2 mg/kg caspofungin or intravenous 1 mg/kg amphotericin B deoxycholate (dAMB). The primary endpoint was fungal-free survival (FFS) 2 weeks after treatment in the full-analysis-set (FAS) population, defined as participants with culture-confirmed ICI who received ≥1 dose of therapy. Planned enrolment was 90 participants.
Results
Fifty-one participants were enrolled; 49 received treatment (caspofungin, n=33; dAMB, n=16); 2 additional participants did not have confirmed infections at study entry. The study was terminated after ∼ 3.5 years because of low enrolment. Forty-seven participants were included in the FAS population (caspofungin, n=31; dAMB, n=16). FFS rate at 2 weeks after treatment was 71.0% (22/31) in the caspofungin arm and 68.8% (11/16) in the dAMB arm [difference, stratified by weight, − 0.9% (95% CI, − 24.3%–27.7%)]. Adverse events developed in 84.8% (28/33) of participants in the caspofungin arm and 100% (16/16) in the dAMB arm.
Conclusions
Among neonates and infants with confirmed ICI, FFS at 2 weeks was similar in the caspofungin and dAMB treatment arms. A smaller proportion of participants who received caspofungin experienced adverse events.
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Affiliation(s)
- Jason Kim
- Merck & Co., Inc, Kenilworth, NJ, USA
| | - Firdose Lambey Nakwa
- Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Hong Liu
- Merck & Co., Inc, Kenilworth, NJ, USA
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83
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Govender NP, Avenant T, Brink A, Chibabhai V, Cleghorn J, du Toit B, Govind C, Lewis E, Lowman W, Mahlangu H, Maslo C, Messina A, Mer M, Pieton K, Seetharam S, Sriruttan C, Swart K, van Schalkwyk E. Federation of Infectious Diseases Societies of Southern Africa guideline: Recommendations for the detection, management and prevention of healthcare-associated Candida auris colonisation and disease in South Africa. S Afr J Infect Dis 2019; 34:163. [PMID: 34485460 PMCID: PMC8377779 DOI: 10.4102/sajid.v34i1.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/13/2019] [Indexed: 11/03/2022] Open
Abstract
Candida auris has been detected at almost 100 South African hospitals, causing large outbreaks in some facilities, and this pathogen now accounts for approximately 1 in 10 cases of candidaemia. The objective of this guideline is to provide updated, evidence-informed recommendations outlining a best-practice approach to prevent, diagnose and manage C. auris disease in public- and private-sector healthcare settings in South Africa. The 18 practical recommendations cover five focus areas: laboratory identification and antifungal susceptibility testing, surveillance and outbreak response, infection prevention and control, clinical management and antifungal stewardship.
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Affiliation(s)
- Nelesh P Govender
- National Institute for Communicable Diseases, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Theunis Avenant
- Kalafong Provincial Tertiary Hospital and Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Adrian Brink
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Ampath Laboratories, Cape Town, South Africa
| | - Vindana Chibabhai
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,National Health Laboratory Service, Johannesburg, South Africa.,Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Joy Cleghorn
- Life Healthcare Group, Johannesburg, South Africa
| | | | | | - Elsie Lewis
- Steve Biko Pretoria Academic Hospital, Pretoria, South Africa
| | - Warren Lowman
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,WITS Donald Gordon Medical Centre and Vermaak and Partners Pathologists, Johannesburg, South Africa
| | | | | | - Angeliki Messina
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Netcare Hospitals Limited, Johannesburg, South Africa
| | - Mervyn Mer
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Kim Pieton
- Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | | | - Charlotte Sriruttan
- National Institute for Communicable Diseases [Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses], a Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karin Swart
- Netcare Hospitals Limited, Johannesburg, South Africa
| | - Erika van Schalkwyk
- National Institute for Communicable Diseases [Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses], a Division of the National Health Laboratory Service, Johannesburg, South Africa
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84
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Bersani I, Piersigilli F, Goffredo BM, Santisi A, Cairoli S, Ronchetti MP, Auriti C. Antifungal Drugs for Invasive Candida Infections (ICI) in Neonates: Future Perspectives. Front Pediatr 2019; 7:375. [PMID: 31616647 PMCID: PMC6764087 DOI: 10.3389/fped.2019.00375] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 09/02/2019] [Indexed: 12/26/2022] Open
Abstract
Fungal infections may complicate the neonatal clinical course, and the spectrum of therapies for their treatment in the perinatal period is limited. Polyenes, Azoles and Echinocandins represent the three classes of antifungal drugs commonly used in the neonatal period. The present review provides an overview about the most recent therapeutic strategies for the treatment of fungal infections in neonates.
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Affiliation(s)
- Iliana Bersani
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Fiammetta Piersigilli
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Bianca Maria Goffredo
- Biochemistry Laboratory, Department of Specialist Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sara Cairoli
- Biochemistry Laboratory, Department of Specialist Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Maria Paola Ronchetti
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
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85
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Cohen JF, Ouziel A, Matczak S, Brice J, Spijker R, Lortholary O, Bougnoux ME, Toubiana J. Diagnostic accuracy of serum (1,3)-beta-d-glucan for neonatal invasive candidiasis: systematic review and meta-analysis. Clin Microbiol Infect 2019; 26:291-298. [PMID: 31539634 DOI: 10.1016/j.cmi.2019.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/23/2019] [Accepted: 09/04/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Neonatal invasive candidiasis (NIC) is a leading cause of infection-related morbidity and mortality in preterm neonates. Several studies have shown that (1,3)-Beta-d-glucan (BDG) was accurate in detecting invasive fungal infection in adults, but studies in neonates are scarce. The aim was to obtain summary estimates of the accuracy of BDG detection in serum for the diagnosis of NIC. METHODS We searched Medline, Embase, Clinicaltrials.gov, and Google Scholar (inception to July 2019). We checked the reference lists of included studies, clinical guidelines, and review articles. We included studies that assessed the accuracy of BDG against a reference standard that defined groups of patients with ordinal levels of NIC probability (e.g. proven, probable, possible) and included fungal blood culture. Participants were neonates suspected of having NIC. The intervention was BDG measurement in serum (Fungitell® assay). We assessed risk of bias and applicability using QUADAS-2. We used bivariate meta-analysis to produce summary estimates of diagnostic accuracy at prespecified positivity thresholds of 80 and 120 pg/mL. This study was registered with PROSPERO (CRD42018089545). RESULTS We included eight studies (465 participants). Of these, two were judged at low overall risk of bias. There was substantial variability across studies in the reference standards used. At a positivity threshold of 80 pg/mL, summary estimates of sensitivity and specificity of BDG were 89% (95% CI: 80-94%) and 60% (53-66%), respectively; summary sensitivity for detecting proven cases of NIC was 99% (93-100%). At a positivity threshold of 120 pg/mL, summary estimates of sensitivity and specificity were 81% (71-88%) and 80% (67-88%), respectively. CONCLUSIONS Because of high sensitivity, BDG seems promising to rule-out NIC. It might be too early to recommend its use because of the scarcity of reliable clinical data, heterogeneity in case definitions, and unstable accuracy estimates.
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Affiliation(s)
- J F Cohen
- Department of General Paediatrics and Paediatric Infectious Diseases, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, Paris, France; Inserm U1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris Descartes University, Paris, France.
| | - A Ouziel
- Department of General Paediatrics and Paediatric Infectious Diseases, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, Paris, France
| | - S Matczak
- Department of General Paediatrics and Paediatric Infectious Diseases, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, Paris, France
| | - J Brice
- Department of General Paediatrics and Paediatric Infectious Diseases, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, Paris, France
| | - R Spijker
- Cochrane Netherlands, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, the Netherlands; Medical Library, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O Lortholary
- Necker-Pasteur Centre for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France; Institut Pasteur, Molecular Mycology Unit, National Reference Centre for Invasive Mycoses and Antifungals, UMR 2000, CNRS, Paris, France
| | - M-E Bougnoux
- Department of Mycology, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, Paris, France
| | - J Toubiana
- Department of General Paediatrics and Paediatric Infectious Diseases, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, Paris, France; Institut Pasteur, Biodiversity and Epidemiology of Bacterial Pathogens, Paris, France
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86
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Aslan N, Yildizdas D, Alabaz D, Horoz OO, Yontem A, Kocabas E. Invasive Candida Infections in a Pediatric Intensive Care Unit in Turkey: Evaluation of an 11-Year Period. J Pediatr Intensive Care 2019; 9:21-26. [PMID: 31984153 DOI: 10.1055/s-0039-1695061] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/13/2019] [Indexed: 12/27/2022] Open
Abstract
The aim of this study was to evaluate the Candida species, predisposing factors, antifungal treatment approaches, and clinical outcomes of invasive Candida infections (ICIs) in a tertiary pediatric intensive care unit (PICU). A retrospective study was performed from January 2008 to January 2019 including 102 children with ICIs who were admitted to a university hospital in southeastern Turkey. Positive blood cultures were detected in 43 (42.1%) patients, and positive urine cultures were detected in 59 (57.8%). According to our results, Candida albicans (42.2%) was the most common species for all isolates followed by C. parapsilosis (17.6%). In our patient population, non- albicans Candida species were dominant (57.8%) in all isolates. The most common facilitating factor in our study was the use of mechanical ventilator support (87.3%). The mortality rate of our patients with ICIs was 13.7%. Candida albicans was found to have the highest mortality rate among all Candida species (30.7%). When we compared patients with C. albicans and those with non- albicans Candida species in terms of risk factors, we detected a significant difference between the two groups for total parenteral nutrition use ( p = 0.027). Fluconazole was the most preferred (58.8%) treatment option in our PICU for ICIs. Our results showed an increased trend in micafungin use in recent years. ICIs are a significant problem due to the high mortality and morbidity rates in critically ill pediatric patients in PICUs. In recent years, an increase in Candida infections caused by non- albicans Candida species has been reported. Multicenter prospective studies are needed to determine the risk factors for ICIs.
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Affiliation(s)
- Nagehan Aslan
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Derya Alabaz
- Department of Pediatric Infectious Disease, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ozden Ozgur Horoz
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ahmet Yontem
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Emine Kocabas
- Department of Pediatric Infectious Disease, Cukurova University Faculty of Medicine, Adana, Turkey
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87
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Abstract
Invasive fungal diseases (IFD) are an important cause of morbidity and mortality in premature neonates and immunocompromised pediatric patients. Their diagnostic and therapeutic management remains a challenge. A nationwide survey was conducted among 13 of the largest pediatric units in the United Kingdom, to obtain insight in the current management of IFD in neonates and children. All responding centers were tertiary teaching centers. The use of fungal diagnostic tools and imaging modalities varied among centers. Antifungal prophylaxis was prescribed in most centers for extreme-low birth weight (LBW) infants and high-risk hemato-oncologic patients, but with a huge variety in antifungals given. An empirical treatment was favored by most centers in case of febrile neutropenia. First line therapy for candidemia consists of either fluconazole or liposomal amphotericin B, with voriconazole being first-line therapy for invasive aspergillosis. Disseminated invasive aspergillosis was most often mentioned as a reason to prescribe combination antifungal therapy. In conclusion, this survey reinforces the fact that there are still important aspects in the management of pediatric IFD which should ideally be addressed in pediatric clinical trials. Attention needs to be given the knowledge gaps as observed in the results of our survey to optimize the management of IFD in children and neonates.
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Affiliation(s)
- Laura Ferreras-Antolín
- From the MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Paediatric Infectious Diseases Research Group, St. George's Hospital, St. George´s University London, University of London, London, United Kingdom
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St. George's Hospital, St. George´s University London, University of London, London, United Kingdom
| | - Adilia Warris
- From the MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Royal Aberdeen Children's Hospital, Aberdeen, United Kingdom
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88
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Warris A, Lehrnbecher T, Roilides E, Castagnola E, Brüggemann RJM, Groll AH. ESCMID-ECMM guideline: diagnosis and management of invasive aspergillosis in neonates and children. Clin Microbiol Infect 2019; 25:1096-1113. [PMID: 31158517 DOI: 10.1016/j.cmi.2019.05.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 01/01/2023]
Abstract
SCOPE Presenting symptoms, distributions and patterns of diseases and vulnerability to invasive aspergillosis (IA) are similar between children and adults. However, differences exist in the epidemiology and underlying conditions, the usefulness of newer diagnostic tools, the pharmacology of antifungal agents and in the evidence from interventional phase 3 clinical trials. Therefore, the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the European Confederation of Medical Mycology (ECMM) have developed a paediatric-specific guideline for the diagnosis and management of IA in neonates and children. METHODS Review and discussion of the scientific literature and grading of the available quality of evidence was performed by the paediatric subgroup of the ESCMID-ECMM-European Respiratory Society (ERS) Aspergillus disease guideline working group, which was assigned the mandate for the development of neonatal- and paediatric-specific recommendations. QUESTIONS Questions addressed by the guideline included the epidemiology of IA in neonates and children; which paediatric patients may benefit from antifungal prophylaxis; how to diagnose IA in neonates and children; which antifungal agents are available for use in neonates and children; which antifungal agents are suitable for prophylaxis and treatment of IA in neonates and children; what is the role of therapeutic drug monitoring of azole antifungals; and which management strategies are suitable to be used in paediatric patients. This guideline provides recommendations for the diagnosis, prevention and treatment of IA in the paediatric population, including neonates. The aim of this guideline is to facilitate optimal management of neonates and children at risk for or diagnosed with IA.
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Affiliation(s)
- A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands.
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University 96 School of Health Sciences, Thessaloniki, Greece; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Castagnola
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - R J M Brüggemann
- Radboud Center for Infectious Diseases, Radboud University Medical Centre, Center of Expertise in Mycology Radboudumc/CWZ, European Confederation of Medical Mycology (ECMM) Excellence Center of Medical Mycology, Nijmegen, the Netherlands; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - A H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Paediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
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Zhong X, Tong X, Ju Y, Du X, Li Y. Interpersonal Factors in the Pharmacokinetics and Pharmacodynamics of Voriconazole: Are CYP2C19 Genotypes Enough for Us to Make a Clinical Decision? Curr Drug Metab 2019; 19:1152-1158. [PMID: 29361899 PMCID: PMC6635675 DOI: 10.2174/1389200219666171227200547] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/04/2017] [Accepted: 11/26/2017] [Indexed: 02/08/2023]
Abstract
Background: Invasive mycoses are serious infections with high mortality and increasing inci-dence. Voriconazole, an important drug to treat invasive mycosis, is metabolized mainly by the cytochrome P450 family 2 subfamily C member 19 enzyme (CYP2C19) and is affected by the genotypes of CYP2C19. Objective: We reviewed studies on how genotypes affect the pharmacokinetics and pharmacodynamics of voriconazole, and attempted to determine a method to decide on dosage adjustments based on genotypes, after which, the main characteristic of voriconazole was clarified in details. The pharmacokinetics of voriconazole are influenced by various inter and intrapersonal factors, and for certain populations, such as geriatric patients and pediatric patients, these influences must be considered. CYP2C19 genotype represents the main part of the interpersonal variability related to voriconazole blood concentrations. Thus monitoring the concentration of voriconazole is needed in clinical scenarios to minimize the negative influences of inter and intrapersonal factors. Several studies provided evidence on the stable trough concentration range from 1-2 to 4-6 mg/L, which was combined to consider the efficacy and toxicity. However, the therapeutic drug concentration needs to be narrowed down and evaluated by large-scale clinical trials. Conclusion: Though there is insufficient evidence on the relationship between CYP2C19 genotypes and clinical outcomes, there is a great potential for the initial voriconazole dose selection to be guided by the CYP2C19 genotype. Finally, voriconazole therapeutic drug monitoring is essential to provide patient-specific dosing recommendations, leading to more effective anti-fungal regimens to increase clinical effica-cy and reduce adverse drug reactions.
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Affiliation(s)
- Xuefeng Zhong
- Department of Respiratory and Critical Care Medicine, National Center of Gerontology, Beijing Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Xunliang Tong
- Department of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Yang Ju
- Department of Respiratory and Critical Care Medicine, National Center of Gerontology, Beijing Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Xiaoman Du
- Department of Respiratory and Critical Care Medicine, National Center of Gerontology, Beijing Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Yanming Li
- Department of Respiratory and Critical Care Medicine, National Center of Gerontology, Beijing Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
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von Lilienfeld-Toal M, Wagener J, Einsele H, A. Cornely O, Kurzai O. Invasive Fungal Infection. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:271-278. [PMID: 31159914 PMCID: PMC6549129 DOI: 10.3238/arztebl.2019.0271] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 06/29/2018] [Accepted: 02/14/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The incidence of invasive fungal infection is approximately 6 cases per 100 000 persons per year. It is estimated that only half of such infections are detected during the patient's lifetime, making this one of the more common overlooked causes of death in intensive-care patients. The low detection rate is due in part to the complexity of the diagnostic work-up, in which the clinical, radiological, and microbiological findings must be considered. Fungi with resistance to antimycotic drugs have been found to be on the rise around the world. METHODS This review is based on pertinent publications retrieved from a selective search in PubMed, with special attention to guidelines on the diagnosis and treatment of invasive fungal infections caused by Candida spp., Aspergillus spp., Mucorales, and Fusarium spp. RESULTS The clinical risk factors for invasive fungal infection include, among others, congenital immune deficiency, protracted (>10 days) marked granulocytopenia (<0.5 x 109/L), allogeneic stem-cell transplantation, and treatment with immunosuppressive drugs or corticosteroids. High-risk groups include patients in intensive care and those with structural pulmonary disease and/or compli- cated influenza. The first line of treatment, supported by the findings of randomized clinical trials, consists of echinocandins for in- fections with Candida spp. (candidemia response rates: 75.6% for anidulafungin vs. 60.2% for fluconazole) and azole antimycotic drugs for infections with Aspergillus spp. (response rates: 52.8% for voriconazole vs. 31.6% for conventional amphotericin B). The recommended first-line treatment also depends on the local epidemiology. This challenge should be met by interdisciplinary collaboration. Therapeutic decision-making should also take account of the often severe undesired effects of antimycotic drugs (including impairment of hepatic and/or renal function) and the numerous interactions that some of them have with other drugs. CONCLUSION Invasive fungal infections are often overlooked in routine hospital care. They should be incorporated into antimicro- bial stewardship programs as an essential component. There is also a pressing need for the development of new classes of antimycotic drug.
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Affiliation(s)
- Marie von Lilienfeld-Toal
- National Reference Center for Invasive Fungal Infections, Leibniz Institute for Natural Product Research and Infection Biology – Hans Knöll Institute (HKI), Jena
- Clinic of Internal Medicine II, University Hospital Jena
| | - Johannes Wagener
- National Reference Center for Invasive Fungal Infections, Leibniz Institute for Natural Product Research and Infection Biology – Hans Knöll Institute (HKI), Jena
- Institute for Hygiene and Microbiology, University of Würzburg, Chair of Medical Microbiology and Mycology, Würzburg
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital of Würzburg
- InfectControl 2020, Jena/Würzburg
| | - Oliver A. Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Department I of Internal Medicine, at the University Hospital of Cologne, European Excellence Center for Medical Mycology (ECMM), DGerman Center for Infection Research(DZIF) Partner Site Bonn Köln, Cologne University
| | - Oliver Kurzai
- National Reference Center for Invasive Fungal Infections, Leibniz Institute for Natural Product Research and Infection Biology – Hans Knöll Institute (HKI), Jena
- Institute for Hygiene and Microbiology, University of Würzburg, Chair of Medical Microbiology and Mycology, Würzburg
- InfectControl 2020, Jena/Würzburg
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Goemaere B, Lagrou K, Spriet I, Hendrickx M, Vandael E, Becker P, Catry B. Systemic antifungal drug use in Belgium—One of the biggest antifungal consumers in Europe. Mycoses 2019; 62:542-550. [DOI: 10.1111/myc.12912] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 03/28/2019] [Accepted: 03/14/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Berdieke Goemaere
- BCCM/IHEM Fungal Collection Service of Mycology and Aerobiology Sciensano Brussels Belgium
| | - Katrien Lagrou
- Department of Microbiology and Immunology KU Leuven Leuven Belgium
- Clinical Department of Laboratory Medicine National Reference Centre for Mycosis University Hospitals Leuven Leuven Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences KU Leuven Leuven Belgium
- Pharmacy Department University Hospitals Leuven Leuven Belgium
| | - Marijke Hendrickx
- BCCM/IHEM Fungal Collection Service of Mycology and Aerobiology Sciensano Brussels Belgium
| | - Eline Vandael
- Healthcare‐Associated Infections and Antimicrobial Resistance Sciensano Brussels Belgium
| | - Pierre Becker
- BCCM/IHEM Fungal Collection Service of Mycology and Aerobiology Sciensano Brussels Belgium
| | - Boudewijn Catry
- Healthcare‐Associated Infections and Antimicrobial Resistance Sciensano Brussels Belgium
- Faculty of Medicine Université Libre de Bruxelles (ULB) Brussels Belgium
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A Prospective, Open-label Study to Assess the Safety, Tolerability and Efficacy of Anidulafungin in the Treatment of Invasive Candidiasis in Children 2 to <18 Years of Age. Pediatr Infect Dis J 2019; 38:275-279. [PMID: 30418357 DOI: 10.1097/inf.0000000000002237] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment with an echinocandin is recommended as first-line therapy for patients with invasive candidiasis (ICC) including candidemia. Little is known about the efficacy and safety of anidulafungin in children with ICC. METHODS Eligible patients with ICC 2 to <18 years old were enrolled into this prospective, open-label, noncomparative, international study (NCT00761267) and received anidulafungin for 10-35 days (3 mg/kg on day 1, 1.5 mg/kg daily thereafter). Safety was assessed through week 6 follow-up. Efficacy, measured by global response (based on clinical and microbiologic responses), was assessed at end of intravenous treatment (EOIVT), end of treatment, weeks 2 and 6 follow-up. RESULTS Forty-nine patients (n = 19, 2 to <5 years; n = 30, 5 to <18 years) received ≥1 dose of anidulafungin (median 11 days; range 1-35 days) and were assessed for safety. Among 48 patients with a Candida species isolated, C. albicans (37.5%), C. parapsilosis (25.0%), C. tropicalis (14.6%) and C. lusitaniae (10.4%) were the most frequent Candida spp. All patients reported ≥1 treatment-emergent adverse event, with diarrhea (22.4%), vomiting (24.5%) and pyrexia (18.4%) being most frequent. Five patients discontinued treatment because of adverse events, of which 4 discontinuations were considered related to anidulafungin. All-cause mortality was 8.2% (4/49) by EOIVT and 14.3% (7/49) by week 6 follow-up. None of 7 deaths during the study period were considered treatment related. Global response success rate was 70.8% at EOIVT. CONCLUSIONS These data support the use of anidulafungin as a treatment option for ICC in children 2 to <18 years old at the studied dose.
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Noni M, Stathi A, Vaki I, Velegraki A, Zachariadou L, Michos A. Changing Epidemiology of Invasive Candidiasis in Children during a 10-Year Period. J Fungi (Basel) 2019; 5:jof5010019. [PMID: 30813283 PMCID: PMC6462917 DOI: 10.3390/jof5010019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/15/2019] [Accepted: 02/21/2019] [Indexed: 11/16/2022] Open
Abstract
Candida species are a common cause of invasive infection in neonates and children. The aim of our study was to evaluate the epidemiology and microbiology of invasive candidiasis (IC) in the largest tertiary Greek pediatric hospital during a 10-year period. A retrospective cohort study was performed from January 2008 to December 2017. Identification of species and antifungal susceptibility testing was performed according to the Clinical and Laboratory Standards Institute (CLSI) methodology. During the study period, 178 cases of IC were recorded. The tissue distribution included blood (87.1%), cerebrospinal (7.9%), peritoneal (3.9%) and pleural fluids (1.1%). Candida albicans and Candida parapsilosis (sensu lato) were the most frequently isolated species (47.8% and 28.7% respectively). From period 2008⁻2012 to period 2013⁻2017, a significant decrease in IC rates was detected (0.21 cases/1000 hospitalization days VS 0.11 cases/1000 hospitalization days, P = 0.040), while median minimum inhibitory concentrations (MICs) of amphotericin B were significantly increased for both C. albicans and C. parapsilosis (sl) (P = 0.037 and P = 0.004 respectively). The decrease in IC rates may reflect the increased awareness as well as the effective infection control initiatives and antifungal interventions. However, the significant increase in the MICs for amphotericin B and echinocandins such as caspofungin, raises concerns about their common use as first-line treatment. Epidemiologic monitoring is, therefore, critically important in order to evaluate and optimize therapeutic protocols for IC in pediatric populations.
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Affiliation(s)
- Maria Noni
- First Department of Pediatrics, Division of Infectious Diseases, "Aghia Sophia" Children's Hospital, National and Kapodistrian University of Athens, 115 27 Athens, Greece.
| | - Angeliki Stathi
- Department of Microbiology, "Aghia Sophia" Children's Hospital, 115 27 Athens, Greece.
| | - Ilia Vaki
- First Department of Pediatrics, Division of Infectious Diseases, "Aghia Sophia" Children's Hospital, National and Kapodistrian University of Athens, 115 27 Athens, Greece.
| | - Aristea Velegraki
- Department of Microbiology, School of Medicine, National and Kapodistrian University of Athens, 115 27 Athens, Greece.
| | - Levantia Zachariadou
- Department of Microbiology, "Aghia Sophia" Children's Hospital, 115 27 Athens, Greece.
| | - Athanasios Michos
- First Department of Pediatrics, Division of Infectious Diseases, "Aghia Sophia" Children's Hospital, National and Kapodistrian University of Athens, 115 27 Athens, Greece.
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Kotsopoulou M, Papadaki C, Anargyrou K, Spyridonidis A, Baltadakis I, Papadaki HA, Angelopoulou M, Pappa V, Liakou K, Tzanetakou M, Moustaka M, Vassilopoulos G. Effectiveness and Safety of Micafungin in Managing Invasive Fungal Infections among Patients in Greece with Hematologic Disorders: The ASPIRE Study. Infect Dis Ther 2019; 8:255-268. [PMID: 30767170 PMCID: PMC6522581 DOI: 10.1007/s40121-019-0236-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Invasive candidiasis (IC) can be a life-threatening infection in immunocompromised patients, particularly those with cancer, hematologic diseases and/or hematopoietic stem cell transplantation (HSCT) recipients. The objective of this study was to evaluate the effectiveness of micafungin in patients with hematologic malignancies or HSCT recipients, relevant to clinical presentation of IC, in real-life practice in Greece. METHODS ASPIRE was a phase IV, multicenter, non-interventional, prospective cohort study, conducted at ten tertiary hospitals in Greece, in adults with hematologic disease. Micafungin treatment for IC or prophylaxis for Candida infection was administered per standard clinical practice until a clinical outcome (success or failure) was reached. Treatment success was defined by the EORTC/MSG criteria for invasive fungal infections (IFI) and was assessed by the investigator. Treatment discontinuation and safety were also evaluated. RESULTS One hundred forty-three patients were enrolled. Median age was 62; 85 (59.4%) patients were male, and 133 (93.0%) had Greek ethnicity. One hundred twenty-six (88.1%) patients had hematologic malignancies, and 21 (14.7%) had received HSCT. Prophylaxis was administered to 74 (51.7%) patients [median (range) dose: 50 (50-150) mg/day] with no signs of IFI. Overall, 52 (36.4%) patients with possible IFI at baseline received micafungin treatment [100 (50-125) mg/day] versus 12 (17.2%) with probable [100 (75-150) mg/day] and 5 (3.5%) with confirmed [125 (100-150) mg/day] IFI. Treatment success was 91.6% (95% CI 85.80-95.59; n = 131) overall and 90.5% (n = 67) in patients receiving prophylaxis. Median time on treatment was 13 days. Treatment discontinuation (n = 26; 18.2%) was not related to adverse events. No treatment-related serious adverse events were reported. CONCLUSION Micafungin treatment for IC or prophylaxis for Candida infection was effective and well tolerated in patients with hematologic disorders in clinical practice in Greece. These results demonstrate that micafungin could be used more widely for prophylaxis. Further work is required to determine the efficacy and safety of micafungin for the management of IFIs in hematologic settings. FUNDING Astellas Pharma Inc.
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Affiliation(s)
| | | | | | | | - Ioannis Baltadakis
- Department of Hematology and Bone Marrow Transplantation Unit, Evaggelismos Hospital, Athens, Greece
| | - Helen A Papadaki
- University of Crete School of Medicine and University General Hospital of Heraklion, Heraklion, Greece
| | - Maria Angelopoulou
- Department of Hematology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Vasiliki Pappa
- Second Department of Internal Medicine and Research Institute, Attikon University General Hospital, Athens, Greece
| | - Kleoniki Liakou
- Medical Affairs, Astellas Pharmaceuticals AEBE, Athens, Greece
| | | | - Marina Moustaka
- Medical Affairs, Astellas Pharmaceuticals AEBE, Athens, Greece
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Invasive Aspergillosis in Pediatric Leukemia Patients: Prevention and Treatment. J Fungi (Basel) 2019; 5:jof5010014. [PMID: 30754630 PMCID: PMC6463058 DOI: 10.3390/jof5010014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 12/16/2022] Open
Abstract
The purpose of this article is to review and update the strategies for prevention and treatment of invasive aspergillosis (IA) in pediatric patients with leukemia and in patients with hematopoietic stem cell transplantation. The major risk factors associated with IA will be described since their recognition constitutes the first step of prevention. The latter is further analyzed into chemoprophylaxis and non-pharmacologic approaches. Triazoles are the mainstay of anti-fungal prophylaxis while the other measures revolve around reducing exposure to mold spores. Three levels of treatment have been identified: (a) empiric, (b) pre-emptive, and (c) targeted treatment. Empiric is initiated in febrile neutropenic patients and uses mainly caspofungin and liposomal amphotericin B (LAMB). Pre-emptive is a diagnostic driven approach attempting to reduce unnecessary use of anti-fungals. Treatment targeted at proven or probable IA is age-dependent, with voriconazole and LAMB being the cornerstones in >2yrs and <2yrs age groups, respectively.
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Lamoth F, Lockhart SR, Berkow EL, Calandra T. Changes in the epidemiological landscape of invasive candidiasis. J Antimicrob Chemother 2019; 73:i4-i13. [PMID: 29304207 DOI: 10.1093/jac/dkx444] [Citation(s) in RCA: 305] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The epidemiology of invasive candidiasis has evolved in recent years, warranting a review of the changes and the implications for current and future diagnosis and treatment. The overall burden of invasive candidiasis remains high, particularly in the expanding populations of patients at risk of opportunistic infection, such as the elderly or immunosuppressed. Progressive shifts from Candida albicans to non-albicans Candida spp. have been observed globally. The recent emergence of novel, multiresistant species, such as Candida auris, amplifies the call for vigilance in detection and advances in treatment. Among the current treatment options, fluconazole is still widely used throughout the world. Increased resistance to fluconazole, both acquired and naturally emerging, has been observed. Resistance to echinocandins is presently low but this may change with increased use. Improvement of diagnostic techniques and strategies, development of international surveillance networks and implementation of antifungal stewardship programmes represent major challenges for a better epidemiological control of invasive candidiasis.
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Affiliation(s)
- Frederic Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University, Lausanne, Switzerland.,Institute of Microbiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Shawn R Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elizabeth L Berkow
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University, Lausanne, Switzerland
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Abstract
BACKGROUND Itraconazole is a broad-spectrum antifungal agent used for prophylaxis and treatment of fungal infections in immunocompromised children. Achieving the recommended target serum itraconazole trough concentration of ≥0.5 mg/L is challenging in children because of variation in itraconazole pharmacokinetics with age. We studied itraconazole use and treatment outcomes in a tertiary children's hospital. METHODS We did a 10-year retrospective review of medical records of children at the Royal Children's Hospital Melbourne who received oral itraconazole and had therapeutic drug monitoring (TDM). RESULTS Overall, 81 children received 92 courses of oral itraconazole and had TDM. Of 222 TDM samples, 183 (82.4%) were taken at the appropriate time (trough level at steady state). Patients ≤12 and >12 years of age required median doses of 6.2 and 3.9 mg/kg/d, respectively, to attain target trough levels (P < 0.001). Of children ≤12 years of age, 71.4% required doses above the recommended dose of 5 mg/kg/d to achieve therapeutic levels, compared with 17.4% of those >12 years of age. At least 1 subtherapeutic trough concentration was reported in 63 (76.8%) courses; in only 18 (28.6%) of these was the dose adjusted. Gastrointestinal symptoms [14/92 (15.2%) courses] and hepatotoxicity [6/92 (6.5%)] were the most frequent adverse events. Neither was associated with elevated trough levels. CONCLUSIONS The poor attainment of target levels with current recommended dosing in children <12 years of age suggests that higher empiric doses are needed in this age group. The poor compliance with TDM guidelines highlights the need for better education about appropriate timing of sampling and dose adjustment.
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Silva-Rios J, Camargos P, Correa L, Romanelli R. Prophylactic regimens with fluconazole for candidiasis in neonates under 1.500g: A retrospective chart review of two cohorts. J Neonatal Perinatal Med 2019; 12:29-36. [PMID: 30958318 DOI: 10.3233/npm-17121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The incidence rate of invasive candidiasis in newborns with birth weight below 1,500 g ranges from 2% to 8%, and fluconazole prophylaxis in neonatal units is recommended when the incidence of invasive candidiasis is higher than 5%. This study aimed to compare the effectiveness of targeted prophylaxis and universal prophylaxis with fluconazole in the prevention of invasive candidiasis. METHODS This was a historical cohort comparing the targeted prophylaxis for newborns weighing less than 1,500 g and the universal prophylaxis for newborns weighing less than 1,000 g. RESULTS The overall incidence rate of invasive candidiasis was 5.25% and was reduced from 7.1% to 3.72% with universal prophylaxis (p = 0.04). In a multivariate analysis, the significant factors associated with the development of candidiasis were birth weight less than 1,000 g, prolonged hospitalization, previous surgery, prolonged use of mechanical ventilation, prior exposure to antimicrobial treatments, and use of targeted prophylaxis. CONCLUSIONS Universal prophylaxis had lower incidence of invasive candidiasis, and preventive measures considering the risk factors are mandatory to reduce the incidence of invasive candidiasis.
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Affiliation(s)
- J Silva-Rios
- Hospital Sofia Feldman, Belo Horizonte, Minas Gerais, Brazil
- Post-Graduation Center, Medical School, Federal University of Minas Gerais (UFMG), Belo Horizonte, M.G., Brazil
| | - P Camargos
- Department of Pediatrics, Medical School, Federal University of Minas Gerais (UFMG), Belo Horizonte, M.G., Brazil
| | - L Correa
- Medical School Federal University of Minas Gerais (UFMG), Belo Horizonte, M.G., Brazil
| | - R Romanelli
- Department of Pediatrics, Medical School, Federal University of Minas Gerais (UFMG), Belo Horizonte, M.G., Brazil
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