Call for Action: Invasive Fungal Infections Associated With Ibrutinib and Other Small Molecule Kinase Inhibitors Targeting Immune Signaling Pathways

Serious Infections in Patients Receiving Ibrutinib for Treatment of Lymphoid Cancer

Background

Ibrutinib is a Bruton tyrosine kinase inhibitor that is used for the treatment of lymphoid cancers, including chronic lymphocytic leukemia, Waldenström macroglobulinemia, and mantle cell lymphoma. Several case series have described opportunistic infections among ibrutinib recipients, but the full extent of these infections is unknown. We sought to determine the spectrum of serious infections associated with ibrutinib treatment.

Methods

We reviewed the electronic medical records of patients with lymphoid cancer at Memorial Sloan Kettering Cancer Center who received ibrutinib during a 5-year period from 1 January 2012 to 31 December 2016. Serious infections were identified by review of the relevant microbiology, clinical laboratory, and radiology data. Risk factors for infection were determined by means of univariate and multivariate analyses.

Results

We analyzed findings in 378 patients with lymphoid cancer who received ibrutinib. The most common underlying cancers were chronic lymphocytic leukemia and mantle cell lymphoma. 84% of patients received ibrutinib as monotherapy. Serious infection developed in 43 patients (11.4%), primarily during the first year of ibrutinib treatment. Invasive bacterial infections developed in 23 (53.5%) of these patients, and invasive fungal infections (IFIs) in 16 (37.2%) .The majority of patients with IFIs during ibrutinib therapy (62.5%) lacked classic clinical risk factors for fungal infection (ie, neutropenia, lymphopenia, and receipt of corticosteroids). Infection resulted in death in 6 of the 43 patients (14%).

Conclusions

Patients with lymphoid cancer receiving ibrutinib treatment are at risk for serious infections, including IFIs.

Ibrutinib-associated invasive fungal diseases in patients with chronic lymphocytic leukaemia and non-Hodgkin lymphoma: An observational study

BACKGROUND

Invasive fungal diseases (IFD) are life-threatening infections most commonly diagnosed in acute leukaemia patients with prolonged neutropenia and are uncommonly diagnosed in patients with lymphoproliferative diseases.

OBJECTIVES

Following the initial report of aspergillosis diagnosed shortly after beginning ibrutinib for chronic lymphocytic leukaemia, a survey was developed to seek additional cases of IFD during ibrutinib treatment.

METHODS

Local and international physicians and groups were approached for relevant cases. Patients were included if they met the following criteria: diagnosis of chronic lymphocytic leukaemia/non-Hodgkin lymphoma; proven or probable IFD; and ibrutinib treatment on the date IFD were diagnosed. Clinical and laboratory data were captured using REDCap software.

RESULT

Thirty-five patients with IFD were reported from 22 centres in eight countries: 26 (74%) had chronic lymphocytic leukaemia. The median duration of ibrutinib treatment before the onset of IFD was 45 days (range 1-540). Aspergillus species were identified in 22 (63%) of the patients and Cryptococcus species in 9 (26%). Pulmonary involvement occurred in 69% of patients, cranial in 60% and disseminated disease in 60%. A definite diagnosis was made in 21 patients (69%), and the mortality rate was 69%. Data from Israel regarding ibrutinib treated patients were used to evaluate a prevalence of 2.4% IFD.

CONCLUSIONS

The prevalence of IFD among chronic lymphocytic leukaemia/non-Hodgkin lymphoma patients treated with ibrutinib appears to be higher than expected. These patients often present with unusual clinical features. Mortality from IFD in this study was high, indicating that additional studies are urgently needed to identify patients at risk for ibrutinib-associated IFD.

Management of human immunodeficiency virus-associated cryptococcal meningitis: Current status and future directions

Cryptococcal meningitis (CM) is one of the most common opportunistic infections of acquired immunodeficiency syndrome (AIDS), as well as an important cause of hospitalisation and death. In recent years, the mortality of CM has remained high in HIV/AIDS population, with up to 30%, including within developed countries. The treatment usually encompasses controls of Cryptococcus, HIV, and increased intracranial pressure. Recent progress on the management of HIV-associated CM mainly centres in optimising induction regimens, looking for appropriate timing of initiating antiretroviral therapy and prevention of symptomatic onset and adverse consequences. This review compared several international guidelines combined with the results from some clinical researches to illustrate the similarities, differences and potential in CM treatment. The present practice is still far from satisfactory, and there remains much to explore due to our limited understanding of the pathogenesis of HIV-associated CM. Thus, screening and monitoring should be strengthened, and better therapies in line with the actual situation of each country should be discovered.

Invasive fungal infections in the immunocompromised host: Mechanistic insights in an era of changing immunotherapeutics

The use of cytotoxic chemotherapy in the treatment of malignant and inflammatory disorders is beset by considerable adverse effects related to nonspecific cytotoxicity. Accordingly, a mechanistic approach to therapeutics has evolved in recent times with small molecular inhibitors of intracellular signaling pathways involved in disease pathogenesis being developed for clinical use, some with unparalleled efficacy and tolerability. Nevertheless, there are emerging concerns regarding an association with certain small molecular inhibitors and opportunistic infections, including invasive fungal diseases. This is perhaps unsurprising, given that the molecular targets of such agents play fundamental and multifaceted roles in orchestrating innate and adaptive immune responses. Nevertheless, some small molecular inhibitors appear to possess intrinsic antifungal activity and may therefore represent novel therapeutic options in future. This is particularly important given that antifungal resistance is a significant, emerging concern. This paper is a comprehensive review of the state-of-the-art in the molecular immunology to fungal pathogens as applied to existing and emerging small molecular inhibitors.

Mucormycosis of the Central Nervous System

Mucormycosis involves the central nervous system by direct extension from infected paranasal sinuses or hematogenous dissemination from the lungs. Incidence rates of this rare disease seem to be rising, with a shift from the rhino-orbital-cerebral syndrome typical of patients with diabetes mellitus and ketoacidosis, to disseminated disease in patients with hematological malignancies. We present our current understanding of the pathobiology, clinical features, and diagnostic and treatment strategies of cerebral mucormycosis. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability. Emerging molecular diagnostics, advances in experimental systems and the establishment of large patient registries are key components of ongoing efforts to provide a timely diagnosis and effective treatment to patients with cerebral mucormycosis.

Fungal Infections with Ibrutinib and Other Small-Molecule Kinase Inhibitors

Purpose of review

Small molecule kinase inhibitors (SMKIs) have revolutionized the management of malignant and autoimmune disorders. Emerging clinical reports point toward an increased risk for invasive fungal infections (IFIs) in patients treated with certain SMKIs. In this mini-review, we highlight representative examples of SMKIs that have been associated with or are expected to give rise to IFIs.

Recent findings

The clinical use of the Bruton's tyrosine kinase inhibitor ibrutinib as well as other FDA-approved SMKIs has been associated with IFIs. The fungal infection susceptibility associated with the clinical use of certain SMKIs underscores their detrimental effects on innate and adaptive antifungal immune responses.

Summary

The unprecedented development and clinical use of SMKIs is expected to give rise to an expansion of iatrogenic immunosuppressive factors predisposing to IFIs (and other opportunistic infections). Beyond increased clinical surveillance, better understanding of the pathogenesis of SMKI-associated immune dysregulation should help devising improved risk stratification and prophylaxis strategies in vulnerable patients.

Long-term safety of single-agent ibrutinib in patients with chronic lymphocytic leukemia in 3 pivotal studies

Ibrutinib, a first-in-class once-daily oral Bruton tyrosine kinase inhibitor indicated for chronic lymphocytic leukemia (CLL), is continued until progressive disease or unacceptable toxicity. We conducted an integrated safety analysis of single-agent ibrutinib from randomized phase 3 studies PCYC-1112 (RESONATE, n = 195) and PCYC-1115/1116 (RESONATE-2, n = 135), and examined longer-term safety separately in the phase 1b/2 PCYC-1102/1103 study (n = 94, 420 mg/d). In the integrated analysis (ibrutinib treatment up to 43 months), the most common adverse events (AEs) were primarily grade 1/2; diarrhea (n = 173, 52% any-grade; n = 15, 5% grade 3) and fatigue (n = 119, 36% any-grade; n = 10, 3% grade 3). The most common grade 3/4 AEs were neutropenia (n = 60, 18%) and pneumonia (n = 38, 12%). Over time, prevalence of AEs of interest (diarrhea, fatigue, grade ≥3 infection, bleeding, and neutropenia) trended down; prevalence of hypertension increased, but incidence decreased after year 1. AEs led to dose reductions in 42 (13%) patients and permanent discontinuations in 37 (11%); dose modifications due to AEs were most common during year 1 and decreased in frequency thereafter. The most common AEs (preferred term) contributing to discontinuation included pneumonia (n = 4), anemia (n = 3), and atrial fibrillation (n = 3). With long-term follow-up on PCYC-1102/1103 (ibrutinib treatment up to 67 months), grade 3/4 AEs were generally similar to those in the integrated analysis. Overall, AEs were primarily grade 1/2 and manageable during prolonged ibrutinib treatment in patients with CLL. These trials were registered at www.clinicaltrials.gov as #NCT01578707, #NCT01722487, #NCT01724346, #NCT01105247, and #NCT01109069.

Cranial aspergillosis in a patient receiving ibrutinib for chronic lymphocytic leukemia

Cerebral abscess due to Aspergillus species is a relatively uncommon presentation, even amongst immunocompromised patients. However it is increasingly being recognized as a complication of ibrutinib therapy in patients with chronic lymphocytic leukemia. We present a case of cerebral abscesses caused by Aspergillus felis in a patient receiving ibrutinib for chronic lymphocytic leukemia.

Estimated Burden of Serious Fungal Infections in Ghana

Fungal infections are increasingly becoming common and yet often neglected in developing countries. Information on the burden of these infections is important for improved patient outcomes. The burden of serious fungal infections in Ghana is unknown. We aimed to estimate this burden. Using local, regional, or global data and estimates of population and at-risk groups, deterministic modelling was employed to estimate national incidence or prevalence. Our study revealed that about 4% of Ghanaians suffer from serious fungal infections yearly, with over 35,000 affected by life-threatening invasive fungal infections. Incidence of cryptococcal meningitis, Pneumocystis jirovecii pneumonia, and disseminated histoplasmosis cases in AIDS was estimated at 6275, 12,610 and 724, respectively. Oral and esophageal candidiasis collectively affect 27,100 Ghanaians and 42,653 adult asthmatics are estimated to have fungal asthma. We estimate a prevalence of 12,620 cases of chronic pulmonary aspergillosis (CPA and an incidence of 1254 cases of invasive aspergillosis (IA). Estimated cases of candidemia and candida peritonitis cases were 1446 and 217, respectively. The estimated prevalence of recurrent vulvovaginal candidiasis (RVVC) and tinea capitis was 442,621 and 598,840, respectively. Mucormycosis and fungal keratitis each may affect 58 and 810 Ghanaians. These data highlight the urgent need for intensified awareness to improve diagnosis and management.

Infection control in patients treated for chronic lymphocytic leukemia with ibrutinib or idelalisib: recommendations from Italian society of hematology

The introduction of new therapeutic agents in chronic lymphocytic leukemia (CLL), including the new kinase inhibitors (KIs) ibrutinib and idelalisib, has changed the therapeutic landscape of the disease. The new KIs have also changed frequency and epidemiology of infections, that represent a major cause of morbidity and mortality of the disease. Hence, the great strides in the indications and use of new KIs need parallel amelioration of prophylaxis and supportive treatment for infections. Moving from the recognition that infection control represents an unmet need, the Italian Society of Hematology (SIE) convened a panel of experts who had published and/or expressed an interest in infection complications in CLL. The goal of the project was to provide practice recommendations for the management of the infectious complications of CLL during ibrutinib or idelalisib therapy. The present publication represents the results of a series of email correspondences and meetings held during 2017 and 2018. Three domains of infectious complications during KIs therapy for CLL were explored: risk assessment, risk management and risk monitoring. We hope these recommendations will help to minimize infectious adverse events, and we believe that an optimal management of them will be rewarded by better outcomes, and better quality of life.

Is hospital-acquired pneumonia different in transplant recipients?

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are serious complications in transplant patients. The aim of this review is to summarize the evidence regarding nosocomial pneumonia in transplant recipients, including HAP in non-ventilated patients and VAP, and to identify future directions for improvement.A comprehensive literature search in the PubMed/MEDLINE database was performed. Articles written in English and published between 1990 and November 2018 were included. HAP/VAP in transplant patients usually occurs early post-transplant, particularly during neutropenia in haematopoietic stem cell transplant recipients. Bacteria are the leading cause of nosocomial pneumonia for both immunocompetent and transplant recipients, being Gram negative organisms, and especially Pseudomonas aeruginosa, highly prevalent. Multidrug-resistant bacteria are of special concern. Pneumonia in the transplant setting may be caused by opportunistic pathogens, and the differential diagnosis needs to be extended to other non-infectious complications. The most relevant opportunistic pathogens are Aspergillus fumigatus, Pneumocystis jirovecii and cytomegalovirus. Nevertheless, they are an exceptional cause of nosocomial pneumonia, and usually occur in severely immunosuppressed patients not receiving antimicrobial prophylaxis. Performing bronchoalveolar lavage may improve the rate of aetiological diagnosis, leading to a change in therapeutic management and improved outcomes. The optimal length of antibiotic therapy for bacterial HAP/VAP has not been well defined, but it should perhaps be longer than in the general population. Mortality associated with HAP/VAP is high. HAP/VAP in transplant patients is frequent and is associated with increased mortality. There is room for improvement in gaining knowledge about the management of HAP/VAP in this population.

Antibody immunity and natural resistance to cryptococcosis

The encapsulated fungus Cryptococcus neoformans (Cn) causes cryptococcal meningitis (CM). There are ~180,000 deaths per year worldwide attributed to CM, which is the most common cause of meningitis in adults with HIV in sub-Saharan Africa. HIV infection with advanced immunodeficiency is the most important predisposing risk factor for CM, highlighting the critical role that T cell mediated immunity plays in disease prevention. Numerous studies in the past decade demonstrate that antibody immunity also plays a role in resistance to CM, although its role has taken more time to establish. In mice, B cells reduce early dissemination from lungs to brain, and naïve mouse IgM can enhance fungal containment in the lungs. In concert with these findings, human studies show that patients with CM have lower IgM memory B cell levels and/or different serological profiles than controls. In this article, we review recent data on the role that B cells and/or antibody-based immunity play in host defense against Cn and natural resistance to CM.

Menacing Mold: Recent Advances in Aspergillus Pathogenesis and Host Defense

The genus Aspergillus is ubiquitous in the environment and contains a number of species, primarily A. fumigatus, that cause mold-associated disease in humans. Humans inhale several hundred to several thousand Aspergillus conidia (i.e., vegetative spores) daily and typically clear these in an asymptomatic manner. In immunocompromised individuals, Aspergillus conidia can germinate into tissue-invasive hyphae, disseminate, and cause invasive aspergillosis. In this review, we first discuss novel concepts in host defense against Aspergillus infections and emphasize new insights in fungal recognition and signaling, innate immune activation, and fungal killing. Second, the review focuses on novel concepts of Aspergillus pathogenesis and highlights emerging knowledge regarding fungal strain heterogeneity, stress responses, and metabolic adaptations on infectious outcomes. Mechanistic insight into the host-pathogen interplay is thus critical to define novel druggable fungal targets and to exploit novel immune-based strategies to improve clinical outcomes associated with aspergillosis in vulnerable patient populations.

The Muddied Waters of Ibrutinib Therapy

A 37-year-old male was admitted with an atypical presentation of central nervous system (CNS) aspergillosis while on ibrutinib therapy for a CNS relapse of mantle cell lymphoma. This case highlights the importance of a high clinical suspicion of opportunistic infections in patients receiving small-molecule kinase inhibitors. This report includes a review of reported cases of Aspergillus infections in patients receiving ibrutinib and the shared features of these cases.

Infections associated with immunotherapeutic and molecular targeted agents in hematology and oncology. A position paper by the European Conference on Infections in Leukemia (ECIL)

A multitude of new agents for the treatment of hematologic malignancies has been introduced over the past decade. Hematologists, infectious disease specialists, stem cell transplant experts, pulmonologists and radiologists have met within the framework of the European Conference on Infections in Leukemia (ECIL) to provide a critical state-of-the-art on infectious complications associated with immunotherapeutic and molecular targeted agents used in clinical routine. For brentuximab vedotin, blinatumomab, CTLA4- and PD-1/PD-L1-inhibitors as well as for ibrutinib, idelalisib, HDAC inhibitors, mTOR inhibitors, ruxolitinib, and venetoclax, a detailed review of data available until August 2018 has been conducted, and specific recommendations for prophylaxis, diagnostic and differential diagnostic procedures as well as for clinical management have been developed.

A population-based analysis of invasive fungal disease in haematology-oncology patients using data linkage of state-wide registries and administrative databases: 2005 - 2016

BACKGROUND

Little is known about the morbidity and mortality of invasive fungal disease (IFD) at a population level. The aim of this study was to determine the incidence, trends and outcomes of IFD in all haematology-oncology patients by linking Victorian hospital data to state-based registries.

METHODS

Episodes of IFD complicating adult haematological malignancy (HM) and haematopoietic stem cell transplantation (HSCT) patients admitted to Victorian hospitals from 1st July 2005 to 30th June 2016 were extracted from the Victorian Admitted Episodes Dataset and linked to the date of HM diagnosis from the Victorian Cancer Registry and mortality from the Victorian Death Index. Descriptive analyses and regression modelling were used.

RESULTS

There were 619,702 inpatient-episodes among 32,815 HM and 1,765 HSCT-patients. IFD occurring twelve-months from HM-diagnosis was detected in 669 (2.04%) HM-patients and 111 (6.29%) HSCT-recipients, respectively. Median time to IFD-diagnosis was 3, 5, 15 and 22 months in acute myeloid leukaemia, acute lymphoblastic leukaemia, Hodgkin lymphoma and multiple myeloma, respectively. Median survival from IFD-diagnosis was 7, 7 and 3 months for invasive aspergillosis, invasive candidiasis and mucormycosis, respectively. From 2005-2016, IFD incidence decreased 0.28% per 1,000 bed-days. Fungal incidence coincided with spring peaks on time-series analysis.

CONCLUSIONS

Data linkage is an efficient means of evaluating the epidemiology of a rare disease, however the burden of IFD is likely underestimated, arguing for better quality hospital level surveillance data to improve management strategies.

Development and Applications of Prognostic Risk Models in the Management of Invasive Mold Disease

Prognostic models or risk scores are frequently used to aid individualize risk assessment for diseases with multiple, complex risk factors and diagnostic challenges. However, relatively little attention has been paid to the development of risk models for invasive mold diseases encountered in patients with hematological malignancies, despite a large body of epidemiological research. Herein we review recent studies that have described the development of prognostic models for mold disease, summarize our experience with the development and clinical use of one such model (BOSCORE), and discuss the potential impact of prognostic risk scores for individualized therapy, diagnostic and antifungal stewardship, as well as clinical and epidemiological research.

Antibody Responses in HIV-Infected Patients With Advanced Immunosuppression and Asymptomatic Cryptococcal Antigenemia

Background

There are no host biomarkers of risk for HIV-associated cryptococcal meningitis (CM) except CD4+ T-cell deficiency. At present, serum cryptococcal antigen (CrAg) screening of those with CD4 <100 cells/µL is used to identify persons at risk for HIV-associated CM. We determined if plasma antibody profiles could discriminate CrAg+ from CrAg- patients.

Methods

We performed serological analyses of 237 HIV-infected asymptomatic Zimbabwean patients with CD4 <100 cells/µL; 125 CrAg- and CrAg+ but cerebrospinal fluid CrAg- by CrAg lateral flow assay. We measured plasma immunoglobulin M (IgM), immunoglobulin G (IgG) 1, and IgG2 concentrations by Luminex, and titers of Cryptococcus neoformans (Cn) glucuronoxylomannan (GXM) polysaccharide and naturally occurring Laminarin (natural Lam, a β-(1–3)-glucan linked polysaccharide)-binding IgM and IgG by enzyme-linked immunosorbent assay.

Results

GXM-IgG, -IgM, and -IgG2 levels were significantly higher in CrAg+ patients, whereas natural Lam-IgM and Lam-IgG were higher in CrAg- patients before and after adjustment for age, sex, and CD4 T-cell count, despite overlap of values. To address this variability and better discriminate the groups, we used Akaike Information Criteria to select variables that independently predicted CrAg+ status and included them in a receiver operating characteristic curve to predict CrAg status. By inclusion of CD4, GXM-IgG, GXM-IgM, and Lam-IgG, -IgG2, and -IgM, this model had an 80.4% probability (95% confidence interval, 0.75–0.86) of predicting CrAg+ status.

Conclusions

Statistical models that include multiple serological variables may improve the identification of patients at risk for CM and inform new directions in research on the complex role that antibodies may play in resistance and susceptibility to CM.

A pilot study of lower doses of ibrutinib in patients with chronic lymphocytic leukemia

Ibrutinib is highly efficacious and used at 420 mg/d for treatment of chronic lymphocytic leukemia (CLL). We previously demonstrated a decline in Bruton's tyrosine kinase (BTK) protein levels in CLL cells after 1 cycle of ibrutinib, suggesting ibrutinib dose could be lowered after the first cycle without loss of biological effect. To test this postulate, a pilot study (NCT02801578) was designed to systematically reduce ibrutinib dosing within the same patient with CLL over the course of three 28-day cycles. After an initial cycle of 420 mg/d, the dose was reduced to 280 mg/d in cycle 2, and then to 140 mg/d in cycle 3. Eleven patients began study treatment, and 9 completed the 3 cycles. Plasma and intracellular pharmacokinetics (PK), BTK occupancy, and pharmacodynamic (PD) response at different doses of ibrutinib were compared. Plasma and intracellular levels of ibrutinib were dose-dependent, and even the lowest dose was sufficient to occupy, on average, more than 95% of BTK protein. In concert, BTK downstream signaling inhibition was maintained with 140 mg/d ibrutinib in cycle 3, and there were comparable reductions in total and phospho-BTK (Tyr223) protein levels across 3 cycles. Reductions of plasma chemokine CCL3 and CCL4 levels, considered to be biomarkers of ibrutinib response, were similar during the 3 cycles. These PK/PD data demonstrate that after 1 cycle of ibrutinib at the standard 420 mg/d dose, the dose can be reduced without losing biological activity. Clinical efficacy of lower doses needs to be systematically evaluated. Such dose reductions would lower drug cost, lessen untoward toxicity, and facilitate rationale-based combinations. This trial was registered at www.clinicaltrials.gov as #NCT02801578.

[Current therapeutic options in invasive mycosis and potential therapeutic role of isavuconazole]

The treatment of invasive fungal infections has deeply evolved in recent years with the inclusion of new antifungals to the therapeutic treatment arsenal. A new azole, isavuconazole, has been recently approved. This review focuses on the role of isavuconazole for treating the most important invasive fungal infections: invasive candidiasis, aspergillosis, mucormicosis, infections caused by other filamentous fungi and those caused by dimorphic fungi.

Invasive Fungal Infections in Patients with Chronic Lymphoproliferative Disorders in the Era of Target Drugs

This review summarizes the more recent evidence about epidemiology and risk factors for invasive fungal infections (IFI) in patients affected by Chronic Lymphocytic Leukemia (CLL), indolent Non Hodgkin Lymphoma (iNHL) and Multiple Myeloma (MM). Despite advances in the prognosis and treatment of hematological malignancies in recent years, susceptibility to infection remains a significant challenge to patient care. A large amount of data regarding patients with acute leukemia has been published while little information is available on the incidence of IFI in chronic lymphoproliferative disorders (CLD). New drugs are now available for treatment of lymphoproliferative disorders which may cause suppression of humoral immunity, cellular immunity, and deficiency of white blood cells, increasing the risk for infections which remain the leading cause of mortality in these patients.

Update in Infectious Diseases 2018

VIII Updating Course of Antimicrobials and Infectious Diseases has reviewed useful microbiological, epidemiological and clinical aspects for a current approach of infectious pathology. Present manuscript summarizes a chronicle about the main infection related meetings during 2017 (ECCMID, IAS, ASM and ID Week). In addition, the course proposed a practical approach for understanding different type of pathogens and our selected topics this year were the epidemiology of bacterial nosocomial infection, a practical approach to Clostridium difficile infection patients, a two year selection of the top ten papers about fungal infection and an update in fungal biofilms. Finally, proffesors made a practical approach by main clinical syndromes like sepsis, infections in oncohematological patients, CNS infections in immunosuppressed patients and reviewed the top ten papers in transplant infectious diseases and infection control during the last two years.

Top-ten infections in onco-hematological patients (2015-2017)

To choose the most relevant ten papers constitutes a challenge in several ways. We have elaborated this selection based on the papers we find to be most useful and ground-breaking for the clinician faced daily by the infectious problems in onco-hematological patients. The selection has been structured in four parts: bacterial infections, viral infections, fungal infections and infections related with new drugs in onco-hematological patients.

Top-ten papers in fungal infection (2015-2017)

We have clustered the published articles in fungal infection between 2016 and 2017 in four categories. First, the emergence of Candida auris as a nosocomial pathogen associated to high antifungal resistance and high mortality. Second, the growing importance of fungal infections associated to the use of biologic therapies. Third, the approval of isavuconazole for the treatment of filamentous fungi and dymorphic mycoses with positive results and less side effects. And finally, a mix of other important news regarding empiric therapy, fluconazole toxicity and difficult-to-treat fungal infections..

Global guidelines and initiatives from the European Confederation of Medical Mycology to improve patient care and research worldwide: New leadership is about working together

Invasive mycoses present a global challenge with expansion into new hosts, emergence of new pathogens, and development of multidrug resistance. In parallel, new antifungal agents and advanced laboratory diagnostic systems are being developed. In response to these evolving challenges, the European Confederation of Medical Mycology (ECMM) is committed to providing international expertise, guidance, and leadership with the key objectives of improving diagnosis, treatment, outcome, and survival of persons with invasive fungal diseases. Representing 25 affiliated National Medical Mycology Societies, the ECMM has developed several major ways to achieving these critical objectives: (a) tasking specific medical mycology working groups; (b) founding the ECMM Academy and Fellow program (FECMM); (c) expanding the goals of ECMM beyond the European region; (d) implementing the ECMM Excellence Centre Initiative in Europe; and (e) the ECMM Global Guidelines and Neglected Orphan Disease Guidance Initiatives focusing on mucormycosis, rare mould diseases, rare yeast diseases, and endemic mycoses. We believe that these important initiatives and other strategies of the ECMM will advance the field of medical mycology and improve the outcome of patients with invasive mycoses worldwide.

Treatment of Aspergillosis

Infections caused by Aspergillus spp. remain associated with high morbidity and mortality. While mold-active antifungal prophylaxis has led to a decrease of occurrence of invasive aspergillosis (IA) in those patients most at risk for infection, breakthrough IA does occur and remains difficult to diagnose due to low sensitivities of mycological tests for IA. IA is also increasingly observed in other non-neutropenic patient groups, where clinical presentation is atypical and diagnosis remains challenging. Early and targeted systemic antifungal treatment remains the most important predictive factor for a successful outcome in immunocompromised individuals. Recent guidelines recommend voriconazole and/or isavuconazole for the primary treatment of IA, with liposomal amphotericin B being the first alternative, and posaconazole, as well as echinocandins, primarily recommended for salvage treatment. Few studies have evaluated treatment options for chronic pulmonary aspergillosis (CPA), where long-term oral itraconazole or voriconazole remain the treatment of choice.

Cerebral aspergillosis in a patient on ibrutinib therapy-A predisposition not to overlook

Ibrutinib has revolutionized the treatment of B-cell malignancies since its approval for chronic lymphocytic leukemia. It is also used in mantle cell lymphoma, diffuse large B-cell lymphoma, Waldenstrom's macroglobulinemia, among others. It is a Bruton's tyrosine kinase inhibitor that acts on B-cell receptor signaling pathway and predisposes to various infections due to its effects on neutrophils, monocytes and T cells. We present a case of cerebral invasive aspergillosis in a patient being treated with ibrutinib for relapsed chronic lymphocytic leukemia. It was hard to associate the condition to ibrutinib versus the chronic lymphocytic leukemia. The patient was successfully treated with a combination of voriconazole and micafungin, resulting in complete recovery and no residual deficits. This highlights the importance of recognizing the rare complication in those on ibrutinib and initiating the treatment immediately with appropriate antifungal agents to improve prognosis of this potentially fatal condition.

Ibrutinib Therapy and Mycobacterium chelonae Skin and Soft Tissue Infection

Ibrutinib is an irreversible inhibitor of Bruton’s tyrosine kinase approved for the treatment of B-cell malignancies. There is growing concern about the risk of opportunistic infections following ibrutinib therapy. Herein, we describe the first case of Mycobacterium chelonae skin and soft tissue infection in a patient receiving ibrutinib and recount the challenges in treating this infection.

The role of neutrophils in host defense against invasive fungal infections

Purpose of Review

Invasive fungal infections caused by the commensal yeast Candida and the ubiquitous, inhaled mold Aspergillus have emerged as major causes of morbidity and mortality in critically ill and immunosuppressed patient populations. Here, we review how neutrophils contribute to effective immunity against these infections.

Recent Findings

Studies in mouse models of invasive candidiasis and aspergillosis, and observations in hematological patients with chemotherapy-induced neutropenia and in patients with primary immunodeficiency disorders that manifest with these infections have highlighted the critical role of neutrophils and have identified key immune factors that promote neutrophil-mediated effective host defense against invasive fungal disease.

Summary

Neutrophils are crucial in host protection against invasive candidiasis and aspergillosis. Recent advances in our understanding of the molecular cues that mediate protective neutrophil recruitment and effector function against these infections hold promise for developing immune-based strategies to improve the outcomes of affected patients.

Invasive fungal infections in high-risk patients: report from TIMM-8 2017

Trends in Medical Mycology (TIMM) is the biennial meeting of the Infectious Disease Group of the European Organisation for Research and Treatment of Cancer (EORTC) and the European Confederation of Medical Mycology (ECMM). It brings together clinicians and researchers from across the world to share the latest R&Ds in medical mycology. Despite advances in treatment, invasive fungal infections remain a major cause of morbidity and mortality in certain high-risk groups of patients, particularly in immunocompromised patients, including those undergoing solid organ transplantation and those with acute leukemia. The challenges for clinicians are now compounded by the rapid development of multidrug resistance. The latest data and approaches to identifying patients at high risk for invasive fungal infections, ensuring early diagnosis and achieving effective treatment, including when and how to use therapeutic drug monitoring with azoles, were shared with >1000 clinicians and researchers from around the world attending the eighth TIMM, held in Belgrade, Serbia, in October 2017 (TIMM-8 2017).

Cutaneous Mucormycosis Following a Bullous Pemphigoid Flare in a Chronic Lymphocytic Leukemia Patient on Ibrutinib

While the recent development of novel therapeutics in oncology, such as small molecule kinase inhibitors (SMKIs), has enabled our ability to target disease-specific molecular pathways, the prolonged impact of these agents on the immune system and infectious risk remains to be seen. We present a 68-year-old male with refractory chronic lymphocytic leukemia (CLL) on ibrutinib monotherapy for 3 years who developed extensive cutaneous mucormycosis following a severe bullous pemphigoid (BP) flare. He received amphotericin B for 4 weeks and was continued on posaconazole with resolution of his mucormycosis infection. Consistent with a growing evidence of literature identifying opportunistic fungal infections in patients on ibrutinib therapy, providers should be cognizant of medical comorbidities that may predispose to such infections and explore methods of prevention before starting ibrutinib and other SMKIs.