Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America

A Clinical Review of Echinocandins in Pediatric Patients

OBJECTIVE

To identify and evaluate available data on pediatric echinocandin use.

DATA SOURCES

A PubMed search, limited to English-language articles, was conducted (1990-August 2009) using the search terms echinocandin, pediatric, child, pharmacokinetics, caspofungin, micafungin, and anidulafungin. Additional articles were retrieved from citations of selected references.

STUDY SELECTION AND DATA EXTRACTION

Relevant information on the pharmacology, pharmacokinetics, efficacy, and safety of echinocandins in children was selected. Clinical trials, retrospective reviews, and case series were identified and evaluated. Data from these sources were included in this review.

DATA SYNTHESIS

Caspofungin is the only echinocandin approved by the Food and Drug Administration for use in children. Pediatric pharmacokinetics has been evaluated with all 3 echinocandins but is limited with anidulafungin. Micafungin is the most well-studied agent in prospective clinical trials for antifungal prophylaxis in stem cell transplantation and treatment of invasive fungal infections. Caspofungin has been studied prospectively for febrile neutropenia and treatment of invasive fungal infections, but most published data are from retrospective reviews or case reports. One case report of anidulafungin for neonatal candidiasis has been published. The role of echinocandins in the management of invasive pediatric fungal infections has expanded. Micafungin and caspofungin are recommended as primary or alternative treatment of candidemia and esophageal or invasive candidiasis, and as salvage therapy for invasive aspergillosis. Micafungin is recommended for neutropenic prophylaxis in stem cell transplantation, while caspofungin may be used in febrile neutropenia as an alternative to azoles. Dosing has been well established for caspofungin only in children 3 months of age and above. Anidulafungin should be avoided in children until more pharmacokinetic and clinical data become available.

CONCLUSIONS

Further comparative trials are needed to more clearly define the role of echinocandins, either as monotherapy or in combination for difficult-to-treat infections, in the pediatric population.

Diffuse alveolar hemorrhage following itraconazole injection

Diffuse alveolar hemorrhage (DAH) syndrome is potentially fatal. We encountered a nearly fatal case of DAH possibly due to intravenous itraconazole (ITCZ). A 53-year-old man with chronic pulmonary aspergillosis underwent pneumonectomy of the left lung 15 days prior to the onset of DAH, which was confirmed by bronchoalveloar lavage. The battery of diagnostic evaluations performed revealed no other positive etiological factor, leading to the diagnosis of DAH possibly induced by intravenous ITCZ with a positive drug lymphocyte stimulation test. The patient did not respond to pulse methylprednisolone therapy, but responded dramatically to direct hemoperfusion using a polymyxin B-immobilized fiber column (PMX) therapy.

Successful management of a simultaneous Aspergillus fumigatus and Absidia corymbifera invasive fungal infection

Considering the poor prognosis of pediatric patients with invasive fungal infections due to zygomycosis, we present the case of a female adolescent with acute lymphoblastic leukemia, who successfully completed her chemotherapy despite a disseminated double infection with Aspergillus fumigatus and Absidia corymbifera.

A case of Aspergillus empyema successfully treated with combination therapy of voriconazole and micafungin: excellent penetration of voriconazole and micafungin into pleural fluid

A 62-year-old man with empyema caused by Aspergillus fumigatus was successfully treated with a combination of voriconazole (VRCZ) and micafungin (MCFG). Data regarding the penetration of antifungal agents into pleural fluid are limited. Thus, we measured the concentration of VRCZ and MCFG in his plasma and pleural fluid. Penetration of VRCZ and MCFG into the pleural fluid was excellent. Therefore, the combination therapy using VRCZ and MCFG may contribute to successful management of Aspergillus empyema.

Chronic fungal sinusitis leading to disastrous cerebral aspergillosis: a case report

Cerebral angioinvasion is a fatal complication of disseminated aspergillosis and has been rarely described in diabetic population in the absence of ketoacidosis. We present a case of invasive fungal sinusitis in a 79 year old diabetic man who presented with chronic frontal headaches. Despite appropriate medical and surgical treatment, the disease progressed and the patient eventually succumbed to a fatal ruptured mycotic aneurysm. We emphasize that clinicians should consider this in the differential diagnoses of all diabetics who present with chronic sinusitis, as early diagnosis could be the key in the successful treatment.

Comparative pharmacodynamics of amphotericin B lipid complex and liposomal amphotericin B in a murine model of pulmonary mucormycosis

We compared the kinetics of amphotericin B (AMB) lung accumulation and fungal clearance by liposomal amphotericin B (L-AMB) and amphotericin B lipid complex (ABLC) in a neutropenic murine model of invasive pulmonary mucormycosis (IPM). Immunosuppressed BALB/c mice were inoculated with 1 x 10(6) Rhizopus oryzae spores and administered L-AMB or ABLC at daily intravenous doses of 1, 5, or 10 mg/kg of body weight for 5 days starting 12 h after infection. At a dose of 10 mg/kg/day, both L-AMB and ABLC were effective at reducing the R. oryzae lung fungal burden and achieved lung tissue concentrations exceeding the isolate mean fungicidal concentration (MFC) of 8 microg/ml by 72 h. When ABLC was dosed at 5 mg/kg/day, the ABLC-treated animals had significantly higher AMB lung concentrations than the L-AMB treated animals at 24 h (6.64 and 1.44 microg/g, respectively; P = 0.013) and 72 h (7.49 and 1.03 microg/g, respectively; P = 0.005), and these higher concentrations were associated with improved fungal clearance, as determined by quantitative real-time PCR (mean conidial equivalent of R. oryzae DNA per lung, 4.44 +/- 0.44 and 6.57 +/- 0.74 log(10), respectively; P < 0.001). Analysis of the AMB tissue concentration-response relationships revealed that the suppression of R. oryzae growth in the lung required tissue concentrations that approached the MFC for the infecting isolate (50% effective concentration, 8.19 microg/g [95% confidence interval, 2.81 to 18.1 microg/g]). The rates of survival were similar in the animals treated with L-AMB and ABLC at 10 mg/kg/day. These data suggest that higher initial doses may be required during L-AMB treatment than during ABLC treatment of experimental IPM.

Azole resistance in Aspergillus fumigatus: a side-effect of environmental fungicide use?

Invasive aspergillosis due to multi-azole-resistant Aspergillus fumigatus has emerged in the Netherlands since 1999, with 6.0-12.8% of patients harbouring resistant isolates. The presence of a single resistance mechanism (denoted by TR/L98H), which consists of a substitution at codon 98 of cyp51A and a 34-bp tandem repeat in the gene-promoter region, was found in over 90% of clinical A fumigatus isolates. This is consistent with a route of resistance development through exposure to azole compounds in the environment. Indeed, TR/L98H A fumigatus isolates were cultured from soil and compost, were shown to be cross-resistant to azole fungicides, and genetically related to clinical resistant isolates. Azoles are abundantly used in the environment and the presence of A fumigatus resistant to medical triazoles is a major challenge because of the possibility of worldwide spread of resistant isolates. Reports of TR/L98H in other European countries indicate that resistance might already be spreading.

[Effects of voriconazole and vascular lesions in invasion of aspergillosis into the central nerve system]

We report 2 patients showing invasion of aspergillosis into the central nerve system (CNS). Patient 1, an 81-year-old woman, underwent surgery for sphenoidal sinusitis. She developed cerebral infarction with unconsciousness on 12th postoperative day. CSF examination demonstrated pleocytosis with increased protein and aspergillus antigen. She was diagnosed as having invasion of aspergillosis into the CNS, and was treated with voriconazole. Her clinical manifestations and CSF findings markedly improved. However, the effects of voriconazole gradually attenuated and she demonstrated recurrence of the cerebral infarction. After 2 months, she died of systemic aspergillosis and sepsis. Autopsy studies. Severe atherosclerotic changes with calcification were demonstrated in the bilateral carotid and basilar arteries, and many aspergillus were clustered in the vessel walls. Granulomatous inflammatory lesions with aspergillus were also demonstrated in the area surrounding the chiasm. There were no massive infarcts or bleeding in the brain, but multiple small infarcts were present. Patinet 2, a 64-year-old man, showing bilateral visual loss, was receiving treatment with corticosteroids under a diagnosis of optic neuritis. Two weeks later, he developed cerebral infarction. CSF examination showed pleocytosis with increased protein and aspergillus antigen. He was diagnosed as having invasive aspergillosis from the sphenoidal sinusitis into the CNS. He was treated with voriconazole, and unconsciousness and CSF findings improved transiently. However, he developed a recurrence of the brain infarction and pneumonia and finally died 6 months later. Treatment by voriconazole was definitely effective in both patients, but both patients died of recurrent cerebral infarction, possibly due to resistance for voriconazole, or developing multicellular filamentous biofilms. Voriconazole is recommended as the first choice of antifungal agents for aspergillosis. Aspergillus infection is strongly invasive into arterial vessels. It is important to consider the possible occurrence of cerebrovascular disease when treating invasion of aspergillosis into the CNS.

Chronic invasive aspergillosis caused by Aspergillus viridinutans

Aspergillus viridinutans, a mold phenotypically resembling A. fumigatus, was identified by gene sequence analyses from 2 patients. Disease was distinct from typical aspergillosis, being chronic and spreading in a contiguous manner across anatomical planes. We emphasize the recognition of fumigati-mimetic molds as agents of chronic or refractory aspergillosis.

Invasive fungal infections in the ICU

Invasive fungal infections are major causes of morbidity and mortality in critically ill patients. Foremost among these is invasive candidiasis. In recent years, invasive aspergillosis (IA) and zygomycosis have emerged as major problems in susceptible, critically ill patients. Risk factors for invasive fungal infections, including disrupted anatomic barriers, suppressed antifungal host responses, and exposure to potentially opportunistic fungi are common in critically ill patients. The expanded antifungal armamentarium and advent of rapid diagnostic techniques are altering the approach to invasive fungal infections in the intensive care unit (ICU). Herein, we review recent developments in the field of antifungal host defenses, the changing epidemiology of fungal infections in the ICU, the pharmacology of antifungal agents of importance to critically ill patients, and the evolving approaches to therapy in this setting.

The current role of amphotericin B lipid complex in managing systemic fungal infections

BACKGROUND

An increase in the number of immunocompromised patients has led to a rising burden of systemic fungal infections. Historically, conventional amphotericin B has been used to treat these infections due to its broad spectrum of activity. The development of lipid-based amphotericin B agents, such as Abelcet * (ABLC), has allowed clinicians to take advantage of the broad spectrum of activity of amphotericin B while reducing adverse events. As well as this, a number of new antifungal agents have been developed in recent years which have significantly added to the treating physician's antifungal armamentarium. * Abelcet is a registered trade name of Cephalon Ltd, Herts, UK.

OBJECTIVES

Review the clinical data that support the use of ABLC and discuss the evidence for its continuing role in the treatment of invasive fungal infections in light of the introduction of newer antifungal agents.

METHODS

Published studies were identified by searching the MEDLINE database and the Cochrane Centre for Reviews up to August 2009. The search was conducted using the following key words: Amphotericin, Lipid, Abelcet, AmBisome, Efficacy, Nephrotoxicity, Renal, Toxicity.

FINDINGS

ABLC is effective and well-tolerated in the treatment of systemic fungal infections and remains a valuable therapeutic option in a variety of immunocompromised patients due to its broad antifungal spectrum and rarity of resistance.

LIMITATIONS

Data from randomised controlled trials of lipid-based amphotericin B formulations, as well as head-to-head comparison studies between ABLC and other antifungal agents are limited. In addition, the review uses a narrative approach and relies to a great extent on the authors' personal views and experiences.

Fungus ball in HIV-infected patients

Aspergillus is a phagocyte opportunistic fungus that causes aspergillosis, an unusual disease in patients with AIDS. Six cases of fungal ball in patients with AIDS are reported here. In this group, all patients had hemoptysis and tuberculosis as the underlying lung disease. The diagnosis of pulmonary fungus ball was based on the clinical and radiographic feature, combined with serological and mycological evidence of Aspergillus fumigatus.

Prospective monitoring for invasive aspergillosis using galactomannan and polymerase chain reaction in high risk pediatric patients

BACKGROUND

The diagnosis of invasive aspergillus remains a challenge in the care of high-risk patients. Outcomes are improved when invasive aspergillus is diagnosed early, prompting the initiation of appropriate antifungal therapy. We evaluated the utility of prospective monitoring for invasive aspergillosis (IA) using biomarkers such as serum galactomannan (GM) and/or blood polymerase chain reaction (PCR) in high-risk pediatric patients.

METHODS

Patients with high-risk leukemia (HRL) or allogenic hematopoietic cell transplant (HCT) recipients were prospectively monitored twice weekly for IA using GM and PCR for Aspergillus species.

RESULTS

Sixty-eight patients had collected >or=2 specimens. The 1086 specimens were collected; 627 from HRL (58%) and 459 (42%) from HCT recipients. Median specimens/patient was 11.0 (2 to 58), and median follow-up/patient was 98.5 days (14 to 437). Fifty-six percent of samples were obtained from patients receiving mold-active agents; 32% HRL and 89% HCT. There were no proven, 3 probable, and 20 possible episodes of IA. Thirteen specimens (1.2%) from 4 patients (5%) were GM+. None were positive by PCR.

CONCLUSIONS

The prospective use of GM and PCR in this high-risk pediatric population did not identify cases of proven IA. A high false positive rate was not detected. It is speculated that changes in clinical practice, such as early use of empiric and/or prophylactic mold-active agent and frequent imaging studies have impacted the epidemiology of IA. In a population with low incidence of IA, the use of these assays as a screening device on blood may not further enhance current outcomes.

Invasive aspergillosis presenting with a painless complete ophthalmoplegia

OBJECTIVE

We report on a patient who presented with complete ophthalmoplegia as a first symptom of fatal invasive aspergillosis.

CASE REPORT

We present the clinical course of an immunocompromised 68-year-old man with unclear painless loss of vision, ptosis and ophthalmoplegia of the right eye lasting for 10 days which was referred from an ophthalmological outpatient clinic. He had a history of kidney transplantation after renal failure, diabetes mellitus II, and coronary heart disease. He was on immunosuppressive therapy with tacrolimus, mycophenolate and prednisolone since renal transplantation. The initial cranial magnetic resonance imaging (MRI) was unremarkable. The additional thin section computed tomography (CT) of the paranasal sinuses was suspicious for bone erosion of the superior wall of the right sphenoidal sinus. Initial laboratory testing and cerebrospinal fluid were without pathological findings. When the patient showed signs of generalised sepsis he was transferred to the intensive care unit. Due to fulminant sepsis it was not possible to perform the planned biopsy. The patient died a few days later of cardio-respiratory insufficiency. The consecutive autopsy revealed invasive aspergillosis of paranasal sinuses with infiltration into the orbita and intracranial spreading into sinus cavernous. Autopsy also showed aspergillus pneumonia.

DISCUSSION

Invasive aspergillosis of the paranasal sinuses and the skull base is most often a lethal condition in immunocompromised patients. Therefore, rapid diagnostics applying radiological (CT and MRI) and surgical procedures (biopsy) and immediate ignition of antimycotic treatment can be life-saving.

Clinical itraconazole-resistant strains of Aspergillus fumigatus, isolated serially from a lung aspergilloma patient with pulmonary tuberculosis, can be detected with real-time PCR method

The invasive aspergillosis, which is commonly caused by Aspergillus fumigatus (A. fumigatus), has increased in recent years. Traditional methods for finding out antifungal resistant strains would take more than 2 weeks, which cannot satisfy the needs of rapid detection. In this study, a real-time PCR method for detection of the serial itraconazole-resistant strains of A. fumigatus isolated from a lung aspergilloma patient was developed. The results showed that the TacMAN-MGB probes, which were covered the loci Gly54, Leu98, Gly138, and Met220 of the enzyme CYP51A coded by the gene cyp51A, as well as the 34-bp tandem repeated sequence in the promoter region (-288 and -322 from the start codon) of this gene, could detect the serial itraconazole-resistant strains of A. fumigatus in our study. Besides, this method takes just 6 h to complete the whole detection.

Invasive fungal infections in the paediatric and neonatal population: diagnostics and management issues

Invasive fungal infections in children appear to have increased over the past few decades. Especially neonates and children with primary and secondary immunodeficiencies are at risk. Candida and Aspergillus spp. are the most commonly isolated organisms. In addition, Malassezia may cause systemic infections in newborns and zygomycosis is important because of its rising incidence and high case fatality rate. Timely diagnosis and initiation of appropriate antifungal therapy is imperative for improving outcomes. However, traditional techniques are time-consuming and representative sample material, using invasive procedures, may be difficult to obtain in the paediatric setting. This review provides an overview of the advances in detection and rapid species identification, with a focus on issues relevant in these settings. Subsequently, the current antifungal treatment options for neonates and children are discussed in light of the antifungal spectrum of the available agents and the specific pharmacokinetic properties in different age groups. Although a multitude of newer antifungal compounds have become available within the last decade, further studies are necessary to clearly establish the role for each of these agents among neonates and children.

An unusual case of Aspergillus fibrosing mediastinitis

Fibrosing mediastinitis due to Aspergillus is rare, particularly in the immunocompetent host. Fibrosing mediastinitis due to Aspergillus species in the immunocompetent patient can be indolent and may be treated with antifungal therapy rather than surgery. We present a 78-year-old nonsmoking, nondiabetic woman with chronic fibrosing mediastinitis due to Aspergillus. Multiple attempts at securing a tissue diagnosis were inconclusive. Ultimately, Aspergillus infection was diagnosed by a video-assisted thoracoscopic surgical biopsy. The patient was started on oral voriconazole, and she remains clinically stable with radiographic improvement. A prolonged, perhaps lifelong, course of antifungal therapy is planned.

Activity of MGCD290, a Hos2 histone deacetylase inhibitor, in combination with azole antifungals against opportunistic fungal pathogens

We report on the in vitro activity of the Hos2 fungal histone deacetylase (HDAC) inhibitor MGCD290 (MethylGene, Inc.) in combination with azoles against azole-resistant yeasts and molds. Susceptibility testing was performed by the CLSI M27-A3 and M38-A2 broth microdilution methods. Testing of the combinations (MGCD290 in combination with fluconazole, posaconazole, or voriconazole) was performed by the checkerboard method. The fractional inhibitory concentrations were determined and were defined as <0.5 for synergy, >or=0.5 but <4 for indifference, and >or=4 for antagonism. Ninety-one isolates were tested, as follows: 30 Candida isolates, 10 Aspergillus isolates, 15 isolates of the Zygomycetes order, 10 Cryptococcus neoformans isolates, 8 Rhodotorula isolates, 8 Fusarium isolates, 5 Trichosporon isolates, and 5 Scedosporium isolates. MGCD290 showed modest activity when it was used alone (MICs, 1 to 8 microg/ml) and was mostly active against azole-resistant yeasts, but the MICs against molds were high (16 to >32 microg/ml). MGCD290 was synergistic with fluconazole against 55 (60%) of the 91 isolates, with posaconazole against 46 (51%) of the 91 isolates, and with voriconazole against 48 (53%) of the 91 isolates. Synergy between fluconazole and MGCD290 was observed against 26/30 (87%) Candida isolates. All 23 of the 91 Candida isolates that were not fluconazole susceptible demonstrated a reduced fluconazole MIC that crossed an interpretive breakpoint (e.g., resistant [MIC, >or=64 microg/ml] to susceptible [MIC, <or=8 microg/ml]) when fluconazole was combined with MGCD290 at 0.12 to 4 microg/ml. The activity of fluconazole plus MGCD290 was also synergistic against 6/10 Aspergillus isolates. Posaconazole plus MGCD290 demonstrated synergy against 14/15 Zygomycetes (9 Rhizopus isolates and 5 Mucor isolates). Voriconazole plus MGCD290 demonstrated synergy against six of eight Fusarium isolates. Thus, MGCD290 demonstrated in vitro synergy with azoles against the majority of clinical isolates tested, including many azole-resistant isolates and genera inherently resistant to azoles (e.g., Mucor and Fusarium). Further evaluation of fungal HDAC inhibitor-azole combinations is indicated.

Frequency and evolution of Azole resistance in Aspergillus fumigatus associated with treatment failure

An increase in the frequency of azole-resistant Aspergillus fumigatus has emerged.

Azoles are the mainstay of oral therapy for aspergillosis. Azole resistance in Aspergillus has been reported infrequently. The first resistant isolate was detected in 1999 in Manchester, UK. In a clinical collection of 519 A. fumigatus isolates, the frequency of itraconazole resistance was 5%, a significant increase since 2004 (p<0.001). Of the 34 itraconazole-resistant isolates we studied, 65% (22) were cross-resistant to voriconazole and 74% (25) were cross-resistant to posaconazole. Thirteen of 14 evaluable patients in our study had prior azole exposure; 8 infections failed therapy (progressed), and 5 failed to improve (remained stable). Eighteen amino acid alterations were found in the target enzyme, Cyp51A, 4 of which were novel. A population genetic analysis of microsatellites showed the existence of resistant mutants that evolved from originally susceptible strains, different cyp51A mutations in the same strain, and microalterations in microsatellite repeat number. Azole resistance in A. fumigatus is an emerging problem and may develop during azole therapy.

Bronchopulmonary disposition of intravenous voriconazole and anidulafungin given in combination to healthy adults

Voriconazole and anidulafungin in combination are being investigated for use for the treatment of pulmonary aspergillosis. We determined the pulmonary disposition of these agents. Twenty healthy participants received intravenous voriconazole (at 6 mg/kg of body weight every 12 h [q12h] on day 1 and then at 4 mg/kg q12h) and anidulafungin (200 mg on day 1 and then 100 mg every 24 h) for 3 days. Five participants each were randomized for collection of bronchoalveolar lavage samples at times of 4, 8, 12, and 24 h. Drug penetration was determined by the ratio of the total drug area under the concentration-time curve during the dosing interval (AUC(0-tau)) for epithelial lining fluid (ELF) and alveolar macrophages (AM) to the total drug AUC(0-tau) in plasma. The mean (standard deviation) half-life and AUC(0-tau) were 6.9 (2.1) h and 39.5 (19.8) microg h/ml, respectively, for voriconazole and 20.8 (3.1) h and 101 (21.8) microg h/ml, respectively, for anidulafungin. The AUC(0-tau) values for ELF and AM were 282 and 178 microg h/ml, respectively, for voriconazole, and 21.9 and 1,430 microg h/ml, respectively, for anidulafungin. This resulted in penetration ratios into ELF and AM of 7.1 and 4.5, respectively, for voriconazole and 0.22 and 14.2, respectively, for anidulafungin. The mean total concentrations of both drugs in ELF and AM at 4, 8, 12, and 24 h remained above the MIC(90)/90% minimum effective concentration for most Aspergillus species. In healthy adult volunteers, voriconazole achieved high levels of exposure in both ELF and AM, while anidulafungin predominantly concentrated in AM.

Caspofungin: in pediatric patients with fungal infections

Caspofungin is the first echinocandin to be approved for the treatment of fungal infections in pediatric patients. The antifungal properties of caspofungin result from interference with fungal cell-wall integrity. In vitro, caspofungin is fungicidal against Candida spp. and fungistatic against Aspergillus spp., but has little or no fungicidal or fungistatic activity against Cryptococcus neoformans, the Zygomycetes, Fusarium spp., or Trichosporon beigelii. Caspofungin was effective as empirical antifungal therapy in pediatric patients with persistent fever and neutropenia. Almost half (46%) of caspofungin recipients and one-third (32%) of liposomal amphotericin B recipients achieved an overall favorable response in a randomized, double-blind trial. Caspofungin was also effective in pediatric patients with fungal infections (invasive candidiasis, invasive aspergillosis refractory to or intolerant of standard antifungal agents, or esophageal candidiasis). Positive responses to treatment were seen in 30 of 37 patients with invasive candidiasis, 5 of 10 patients with invasive aspergillosis, and in the one patient with esophageal candidiasis, in a noncomparative, open-label trial. Caspofungin was generally well tolerated in the clinical trials in pediatric patients with febrile neutropenia requiring empirical antifungal treatment, or with fungal infections. Few caspofungin recipients reported serious drug-related adverse events or discontinued treatment as a result of drug-related adverse events.

Report from the European Congress of Clinical Microbiology and Infectious Diseases

With its cool climate, Finland has a lower prevalence of fungal infections than many other European countries that have hosted the annual congress of the European Society of Clinical Microbiology and Infectious Diseases. However, changing patterns of infection and drug resistance, and their impact on treatment decisions, are as important to Nordic infectious disease specialists as to their colleagues in warmer countries. Similarly, developments in diagnostic techniques that enable fungal invasion to be identified before there is clinical evidence of infection will be a major step forward for physicians wherever they practise. It should therefore come as no surprise that this year's European Congress of Clinical Microbiology and Infectious Diseases was as well attended as previous meetings, with over 8000 participants arriving from all parts of Europe.

Echinocandins: The Newest Class of Antifungals

Objective:

To review the mechanism of action, antifungal spectrum of activity, pharmacodynamics, pharmacokinetics, clinical efficacy, and safety of the echinocandins.

Data Sources:

A MEDLINE search (1982–May 2009) was conducted for articles published in the English language using the key words caspofungin, micafungin, anidulafungin, and echinocandins.

Study Selection and Data Extraction:

Medicinal chemistry, in vitro, and animal studies, as well as human trials were reviewed for information on the pharmacodynamics, pharmacokinetics, efficacy, and safety of each echinocandin. Clinical trials were reviewed and included to compare and contrast the available echinocandins.

Data Synthesis:

Three echinocandin antifungal agents are currently approved for use in the US: caspofungin, micafungin, and anidulafungin. The echinocandins have a unique mechanism of action, inhibiting β-(1,3)-d-glucan synthase, an enzyme that is necessary for the synthesis of an essential component of the cell wall of several fungi. The echinocandins display fungistatic activity against Aspergillus spp. and fungicidal activity against most Candida spp., including strains that are fluconazole-resistant. The echinocandins have been shown to be efficacious for the treatment of esophageal candidiasis, candidemia, and invasive candidiasis. In addition, caspofungin has demonstrated efficacy as empiric treatment of febrile neutropenia and salvage therapy for the treatment of invasive aspergillosis, and it is the only echinocandin approved for use in pediatric patients. Micafungin is the only echinocandin approved for use as prophylaxis against Candida infections in patients undergoing hematopoietic stem cell transplantation. Overall, resistance to echinocandins is still rare, and all agents are well tolerated, with similar adverse effect profiles and few drug–drug interactions.

Conclusions:

Echinocandins, the newest addition to the arsenal of antifungals, offer potential advantages over other classes of agents. Clinicians should assess their distinguishing characteristics, including route of metabolism, drug interaction profile, and approved indications for use, when determining which agent to include on a formulary.

Antifungal prophylaxis with voriconazole or itraconazole in lung transplant recipients: hepatotoxicity and effectiveness

Invasive fungal infections (IFI) are common after lung transplantation and there are limited data for the use of antifungal prophylaxis in these patients. Our aim was to compare the safety and describe the effectiveness of universal prophylaxis with two azole regimens in lung transplant recipients. This is a retrospective study in lung transplant recipients from July 2003 to July 2006 who received antifungal prophylaxis with itraconazole or voriconazole plus inhaled amphotericin B to compare the incidence of hepatotoxicity. Secondary outcomes include describing the incidence of IFI, clinical outcomes after IFI and mortality. Sixty-seven consecutive lung transplants received antifungal prophylaxis, 32 itraconazole and 35 voriconazole and inhaled amphotericin B. There were no significant differences between groups in the acute physiology and chronic health evaluation (APACHE) score at the time of transplantation, demographic characteristics, comorbidities and concomitant use of hepatotoxic medications. Hepatotoxicity occurred in 12 patients receiving voriconazole and inhaled amphotericin B and in no patients receiving itraconazole (p < 0.001). There was no significant difference between groups with regard to the percentage of transplants with IFI, but one case of zygomycosis occurred in a transplant treated with voriconazole. Voriconazole prophylaxis after lung transplantation was associated with a higher incidence of hepatotoxicity and similar clinical effectiveness when compared to itraconazole.

Increasing incidence of invasive aspergillosis in pediatric hematology oncology patients over the last decade: a retrospective single centre study

There is scanty information about invasive aspergillosis (IA) in the pediatric population. A review of IA at Hospital Infantil Universitario Niño Jesús between 1996 and 2006 was undertaken to analyze incidence, risk factors, and treatment response. Twenty patients were diagnosed with probable or proven IA during the study period, with a cumulative incidence of 1.96%. Incidence was higher in hematopoietic stem cell transplantation (HSCT) recipients: 2.26% (3.5% in allogeneic HSCT and 1.2% in autologous HSCT). A significative increase in IA incidence was observed along the study period (P=0.013), although this increase did not reach signification if only proven cases were compared (P=0.058). Most patients presented multiple risk factors for IA (87% more than 1, and 47% more than 3). The most frequently described risk factor was chemotherapy (90%), after by long-term neutropenia (90%), and corticotherapy (75%). Main locations of the infection were pulmonary (8 patients), cutaneous (3 patients) and intestinal (3 patients). Six patients presented disseminated IA. Initial response to treatment was 55%, although 3 of these cases had a subsequent episode. Global antifungal response, at the end of the follow-up, was 45%. IA-related mortality was 55%. Global mortality was 90%. Only 2 patients (isolated cutaneous IA cases) survived. Seven patients died due to their underlying malignant disease without active fungal disease. Incidence of IA in oncology children is increasing, and in adults. In our experience, IA is a marker of poor outcome even for patients who initially respond to antifungal treatment.

Predicting survival in adults with invasive aspergillosis during therapy for hematological malignancies or after hematopoietic stem cell transplantation: Single-center analysis and validation of the Seattle, French, and Strasbourg prognostic indexes

In this retrospective monocenter study, we analyzed the outcomes of 130 adult hematological patients who developed a proven (n = 23), probable (n = 71), and possible (n = 36) invasive aspergillosis (IA) in a 13-year period. Forty-nine patients (38%) were recipients of an allogeneic hematopoietic stem cell transplantation (AlloHSCT). The main goal of the study was the identification of prognostic factors for 4-month aspergillosis free survival (AFS) and overall survival (OS). IA was identified as the main cause of death in 27/49 recipients of an AlloHSCT (55%) and 28/81 nontransplanted patients (35%). Diagnosis of IA at or before 2000 had a negative impact in both 4-month AFS and 4-month OS in the entire group. In multivariate analysis performed separately for nontransplanted and allo-HSCT patients, five variables (excluding the year of diagnosis) decreased 4-month AFS: (i) impairment of one organ function (OF), (ii) impairment of two or more OFs (two points), (iii) disseminated IA, (iv) neutropenia lasting more than 10 days (non-AlloHSCT group only) or monocytopenia (<0.1 x 10(9)/l) [AlloHSCT group only], and (v) high-dose steroids (non-AlloHSCT group only) or an alternative donor (AlloHSCT group only). According to the number of adverse risk factors, three prognostic subgroups were defined in non-transplanted and alloHSCT patients with good (97% and 78% AFS), intermediate (73% and 32% AFS) and poor prognosis (20% and 11% AFS) of IA [P < 0.01]. In addition, we validated the French and Seattle prognostic indexes for allo-HSCT recipients and the Strasbourg model for all hematological patients with IA.

Advances and challenges in infectious diseases supportive care of patients with hematologic malignancies, hematopoietic stem cell transplantation, and severe aplastic anemia

Infectious diseases are important causes of morbidity and mortality in immunocompromised patients with hematological malignancies, severe aplastic anemia (SAA), and myelodysplasia. Major advances in infectious diseases supportive care have been critical to improving the outcome of patients suffering from these life-threatening diseases. Advances in diagnosis, treatment, and prevention of life-threatening infections have reduced morbidity and mortality, improved quality of life, and enabled the use of potentially curative chemotherapy, radiation, hematopoietic stem cell transplantation (HSCT), and immunosuppressive therapy to patients battling these devastating diseases. Despite these advances, the continued development of antimicrobial resistance, emergence of new pathogens, and the evolution of host factors present evolving challenges to the successful management of infectious complications in this expanding patient population.

Recent advances in antifungal prevention and treatment

Invasive fungal infections are important causes of morbidity and mortality in patients with bone marrow failure syndromes and hematological malignancies, or who are undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Current epidemiological trends indicate a shift toward infections by Aspergillus spp., non-albicans Candida spp., and previously uncommon fungal pathogens that have decreased susceptibility to the available antifungal agents. The last two decades have seen substantial improvements in the clinical, laboratory, and radiological diagnosis of these infections and the development of new antifungal compounds. Progress has been made in establishing disease definitions and paradigms for antifungal intervention and in the design and conduct of interventional clinical trials. Collectively, these advances have led to major but ongoing changes in the management of patients at risk of or being affected by invasive fungal infections. This article reviews current approaches to prevention and treatment of opportunistic fungal infections in immunocompromised patients with hematological disorders and discusses novel approaches to antifungal chemotherapy and adjunctive treatments.

[Current status of invasive fungal infections. New diagnostic techniques and antifungal agents]

In the last few years, major advances in the treatment of transplant recipients, with hemato-oncological diseases or admitted to the intensive care unit, has been accompanied by an increase in classical fungal infections and by the emergence of uncommon fungal infections. Despite the development of new diagnostic techniques such as galactomannan detection and the availability of new antifungal agents, these opportunistic infections continue to pose a diagnostic challenge, prolong length of hospital stay, and increase costs. In addition, mortality from these infections is high. The present chapter provides a brief review of the epidemiology of these infections, diagnostic advances, and the new antifungal agents that have been developed in the last few years.

Prevention and treatment of invasive fungal diseases in neutropenic patients

PURPOSE OF REVIEW

Despite advances in the diagnosis and management, invasive fungal diseases contribute substantially to the morbidity and mortality of patients with prolonged neutropenia.

RECENT FINDINGS

Major advances in the prevention, diagnosis, and treatment of invasive fungal diseases have occurred with the introduction of fungal markers and new antifungal agents over the past decade. The newer broad-spectrum azoles and echinocandins, due to their acceptable safety profiles and efficacy, have emerged as valuable options as antifungal prophylaxis and therapy. Empirical antifungal therapy, a strategy in which persistent neutropenic fever triggers the addition of an antifungal agent, remains a common practice. However, the development of fungal diagnostic markers (e.g. galactomannan and beta-glucan assays) combined with radiologic imaging has given potential to more targeted preemptive antifungal strategies.

SUMMARY

With the validation of preemptive strategies in clinical trials, we will likely have evidence-based targeted use of antifungals. PCR-based techniques are also promising tools for preemptive strategies and are undergoing evaluation. Knowledge of host genetic factors may be important in stratifying the risk for fungal disease during periods of high risk.

Invasive mould infections in the setting of hematopoietic cell transplantation: current trends and new challenges

PURPOSE OF REVIEW

Invasive mould infections remain major causes of infection-related mortality following hematopoietic stem cell transplantation (HSCT). In this review, we summarize the recent advances in the diagnosis, prevention, and management of invasive mould infections in HSCT recipients.

RECENT FINDINGS

The evolving epidemiologic characteristics of post-HSCT invasive mould infections, specifically the rising incidence of Aspergillus and non-Aspergillus mould infections in the postengraftment period, necessitate the development of preventive strategies. The efficacy of prophylactic broad-spectrum triazoles against invasive mould infections in HSCT recipients has now been demonstrated in two large prospective studies. However, concerns over drug absorption, interactions, and costs may shift attention from universal prophylaxis to risk stratification and preemptive strategies. In this regard, recent studies have highlighted the potential of genetic polymorphism analysis to identify HSCT recipients at risk for invasive aspergillosis, and efforts are underway to improve the predictive values of antigen and nucleic acid detection assays. Emerging data on risk factors for invasive aspergillosis relapse after HSCT, antifungal drug monitoring, and the use of galactomannan testing to monitor treatment response may help inform therapeutic decisions for HSCT recipients.

SUMMARY

Evidence-driven management of invasive mould infections in HSCT recipients is becoming increasingly individualized, integrating host factors and pharmacologic and epidemiologic considerations. However, the optimal approach to invasive mould infection prevention in HSCT recipients remains to be resolved by prospective clinical studies.

In vitro susceptibility of clinical isolates of Aspergillus spp. to anidulafungin, caspofungin, and micafungin: a head-to-head comparison using the CLSI M38-A2 broth microdilution method

We determined the in vitro activities of anidulafungin, caspofungin, and micafungin against 526 isolates of Aspergillus spp. (64 A. flavus, 391 A. fumigatus, 46 A. niger, and 25 A. terreus isolates) collected from over 60 centers worldwide from 2001 through 2007. Susceptibility testing was performed according to the CLSI M38-A2 method. All three echinocandins--anidulafungin (50% minimum effective concentration [MEC50], 0.007 microg/ml; MEC90, 0.015 microg/ml), caspofungin (MEC50, 0.015 microg/ml; MEC90, 0.03 microg/ml), and micafungin (MEC50, 0.007 microg/ml; MEC90, 0.015 microg/ml)-were very active against Aspergillus spp. More than 99% of all isolates were inhibited by < or = 0.06 microg/ml of all three agents.