Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium

Identification of factors predicting low-risk febrile neutropenia admissions in adults with acute myeloid leukemia

ABSTRACT

Febrile neutropenia (FN) is the most common reason for hospital readmission after chemotherapy for acute myeloid leukemia (AML) and is a major driver of health care resource utilization. Although FN risk models exist, they have largely been developed and validated for solid tumors. We therefore examined whether baseline characteristics could predict which patients with AML and FN have a lower risk of progression to severe illness. We identified adults with high-grade myeloid neoplasms (≥10% blasts in the blood/marrow) who received intensive chemotherapy and who were admitted for FN between 2016 and 2023. We collected baseline clinical and disease variables. Outcomes were: infections identified, hospital length of stay (LOS), intensive care unit (ICU) admission, and survival. A lower-risk (LR) outcome was defined as LOS <72 hours without ICU admission or inpatient death. Univariate and multivariable (MV) logistic regression models were used to assess covariate associations with outcomes. We identified 397 FN admissions in 248 patients (median age, 61; [range, 29-77] years). The median hospital LOS was 6 days (range, 1-56) days; 10% required ICU admission, and 3.5% died inpatient. Only 15% of admissions were LR. Infection was identified in 59% of admissions. Physiologic parameters, including heart rate, blood pressure, and fever height, were the best predictors of LR admission and infection. We developed MV models to predict LR admission and infection with area under the curve (AUC) of 0.82 and 0.72, respectively. Established FN and critical illness models were not predictive of outcomes in AML, and we could not identify a LR group; thus, an AML-specific FN risk model requires further development and validation.

Systemic Scedosporium apiospermum Infection Affecting Multiple Sites After Near-Drowning: A Case Report

Scedosporium apiospermum (S. apiospermum) can cause fungal infections in near-drowning victims, and an increasing number of cases have been reported. However, cases of bone and joint infections caused by S. apiospermum are rare. In this case, a 35-year-old otherwise healthy Chinese female presented with aspiration pneumonia and knee arthritis after accidentally falling into sewage and near-drowning and underwent macrogenomic second-generation sequencing of arthrocentesis fluid, which showed S. apiospermum. However, new lesions involving the hip joint and spine continued to develop under voriconazole monotherapy. The patient was treated with voriconazole combined with amphotericin B cholesterol sulfate lipid complex for 30 consecutive days. The patient's symptoms improved significantly. This case highlights the robust invasiveness of S. apiospermum and the extensive spread of infection, underscoring the importance of prompt diagnosis and treatment. A combined therapeutic approach may offer a safe and efficacious option for managing S. apiospermum infection.

Epidemiology, Clinical, Radiological and Biological Characteristics, and Outcomes of Mucormycosis: A Retrospective Study at a French University Hospital

PURPOSE

Mucormycosis is a rare but emerging and life-threatening infection caused by environmental mold, with a mortality rate of 30-70% despite progress in management. A better understanding could improve its management.

METHOD

We conducted a single-center retrospective study of all cases of mucormycosis observed over a decade at the University Hospital of Caen.

RESULTS

Between 2014 and 2024, 18 cases of mucormycosis were identified, predominantly in males (n = 11, 65%). Most patients had hematological malignancies (n = 16, 89%). Seven cases were proven, and eleven were classified as probable. The main locations of infection were pulmonary (n = 12, 67%). Since 2021, we have observed an increase in the number of cases, rising from three between 2014 and 2021 to fifteen between 2021 and 2024. Among the 12 patients with pulmonary mucormycosis, all presented with fever except 1, and 67% required oxygen therapy. Chest computed tomography scans revealed an inverse halo sign in one-third of the patients. The first-line treatment consisted of amphotericin B in seventeen patients, posaconazole in one patient, and isavuconazole in one patient. Surgery was performed on seven patients. In cases of cutaneous mucormycosis, all patients underwent surgery, and none died within three months after the diagnosis. Overall, the three-month mortality rate was 39%. Surgical management was associated with a reduction in mortality (0% vs. 64%, p = 0.013).

CONCLUSIONS

This study highlights the role of PCR for early diagnosis and the key role of surgery in improving clinical outcomes while underscoring the need for better-adapted therapeutic protocols for these rare infections.

Comparing the Performance of Two Cryptococcal Antigen Detection Tests: Chemiluminescence vs Colloidal Gold Methods

Objective

To compare the performance of a new chemiluminescence method with that of the traditional colloidal gold method for cryptococcal antigen (CrAg) detection.

Methods

Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. Cryptococcal antigen (CrAg) testing from serum and cerebrospinal fluid (CSF) has been regarded as the gold standard for early diagnosis. In this study, a total of 140 samples (92 serum and 48 cerebrospinal fluid samples) from 140 patients with suspected cryptococcosis collected between January 2022 and September 2023 at Zhejiang Provincial People's Hospital were tested via a fully automated chemiluminescent immunoassay analyser (SuperFlex) from Suzhou Xinbo and a cryptococcal antigen detection kit (colloidal gold method) from the IMMY Company of the United States.

Results

According to the diagnostic criteria for cryptococcosis, 55 of the 140 suspected patients were diagnosed with cryptococcosis (39.3%), including 47 with pulmonary cryptococcosis (PC) and 8 with cryptococcal meningitis (CM). The degree of agreement between chemiluminescence and the colloidal gold method was analysed via Cohen's kappa coefficient, which was 0.970 (P<0.01). The sensitivities of the chemiluminescence and colloidal gold methods were 98.2% and 96.4%, respectively, and their specificities were 100% and 98.8%, respectively. The area under the receiver operating characteristic (ROC) curve were 0.996 for chemiluminescence and 0.9759 for the colloidal gold method. The area under the curve (AUC) of the two methods did not differ significantly (P=0.086).

Conclusion

For the detection of CrAg, the new chemiluminescence method is highly consistent with the traditional colloidal gold method and has higher sensitivity and specificity for the diagnosis of cryptococcosis.

Candida albicans Horizontal Transmission in COVID-19 Patients Hospitalized in Intensive Care Unit

BACKGROUND

Invasive candidiasis is a predominant mycosis in hospitalized patients, and Candida albicans is the species most often responsible for this infection. Most candidiasis cases originate from endogenous mycobiota; therefore, Candida strains can easily be transferred among hospital patients and personnel. The aim of this study was to assess the possible horizontal transmission of C. albicans in patients with severe COVID-19 infection requiring hospitalization in the intensive care unit.

METHODS

In total, 59 C. albicans strains from 36 patients were collected from blood and lower-respiratory samples. The strains were genotyped using the RAPD method with the OPA-18 primer (5'-AGCTGACCGT-3'). Antifungal susceptibility testing was performed for amphotericin B (AMB), fluconazole (FCZ), voriconazole (VCZ), and anidulafungin (ANF) using the EUCAST method.

RESULTS

C. albicans strains were separated into 13 different groups according to their RAPD pattern. Two predominant clonal clusters of 17 strains isolated from 12 patients and 12 strains from 7 patients were identified, followed by clusters with 6, 4, and 8 strains isolated from 5, 4, and 3 patients, respectively. C. albicans strains were sensitive to AMB, FCZ, VCZ, and ANF, and antifungal susceptibility profiles were similar in all genetic clusters.

CONCLUSIONS

Our study indicates that C. albicans strains can spread horizontally. The routes of transmission for strains in the ward have not been explained due to there being insufficient data. The transmission could have been caused by the unintentional spread of pathogens by medical personnel.

Diagnosis and management of invasive fungal diseases by next-generation sequencing: are we there yet?

INTRODUCTION

Invasive fungal diseases (IFDs) are a serious threat to immunocompromised patients. Routine diagnostic methods have limited performance in identifying IFDs. Next-generation sequencing (NGS), including metagenomic NGS (mNGS) and whole-genome sequencing (WGS), recently emerged as diagnostic methods that could provide more accurate and timely diagnoses and management of IFDs.

AREAS COVERED

This article describes the emergence of NGS as a diagnostic tool to address the limitations of current tests. The literature regarding its application and clinical utility in the diagnosis of IFDs is reviewed. Practical considerations, challenges, and opportunities as they relate to the development and implementation of mNGS and WGS for fungal pathogens are discussed.

EXPERT OPINION

NGS emerged over a decade ago with the potential to solve many of the challenges in diagnosing infectious diseases, including IFDs. However, published literature has yielded conflicting data about its clinical utility. The increased clinical adoption of NGS is improving our understanding of how to interpret and use its results to guide actionable decisions. Still, several gaps remain. As the cost, effort, and expertise involved in performing NGS decrease and the reporting of its results becomes standardized, NGS is poised to fill current gaps in the diagnosis of IFDs.

CT imaging findings of invasive pulmonary fungal infections in hemato-oncologic children

Hemato-oncologic children form a heterogeneous group with a wide spectrum of ages, malignancy types, and immunosuppression grades during the different phases of their treatment. Immunosuppression is caused by multiple factors, including the malignancy itself, bone marrow suppression secondary to therapy, and wide use of steroids and antibiotics, among others. At the same time, the risk of infections in these patients remains high because of prolonged hospitalizations or the need for long-timing implanted devices between other features. In this context, a pulmonary fungal infection can rapidly turn into a life-threatening condition that requires early diagnosis and appropriate management. This pictorial essay illustrates the main imaging findings detected in chest computed tomography examinations performed in pediatric hemato-oncologic patients with proven pulmonary invasive fungal infections caused by Candida, Aspergillus, or Mucor. In addition, it describes useful clues for limiting differential diagnoses, reviews the literature on pediatric patients, and compares imaging findings in adults and children. CRITICAL RELEVANCE STATEMENT: The main fungal pathogens causing invasive fungal infections (IFI) in hemato-oncologic children are Candida, Aspergillus, and Mucor. This review describes the most frequently affected organs and the most common imaging findings detected in chest CT exams in children with pulmonary IFI. KEY POINTS: To review the main computed tomography imaging findings suggesting pulmonary invasive fungal infection (IFI) in hemato-oncologic children. To describe differences between pediatric and adult patients with proven pulmonary IFI. To provide useful clues for limiting the differential diagnosis of pulmonary IFI in pediatric patients.

Serum antigen tests for the diagnosis of invasive aspergillosis: a retrospective comparison of five Aspergillus antigen assays and one beta-D-glucan assay

Invasive aspergillosis (IA) is a life-threatening infection. Early and specific diagnosis is pivotal to ensure adequate therapy. Antigen testing from blood is a widespread and convenient diagnostic approach. Various tests for the detection of Aspergillus antigen as well as for the panfungal antigen β-1,3-D-glucan (BDG) are available, for which comprehensive comparisons are still lacking. Blood samples of 82 proven/probable (11/71) IA patients and 52 controls were tested using two enzyme-linked immunosorbent assays (ELISAs) (Bio-Rad and Euroimmun), one chemiluminescent immunoassay (CLIA) (Vircell), one BDG assay (Fujifilm Wako), and two point of care (PoC) assays (Immy sōna and OLM). PoC assays were evaluated visually and used automated read out systems. Of the 82 IA patients, 37 had received solid organ transplantation (SOT) and 25 hematopoietic stem cell transplant (HSCT). Sensitivities and specificities for the eight test systems ranged from 27% to 71% and from 64% to 100%. Estimating a 10% prevalence of IA, test performance would have resulted in positive and negative predictive values of 14%-100% and 91%-95%. Areas under the curve (AUCs) for all tests except GM were below 0.7. When the cut-off values for quantitative tests were normalized to a specificity close to 95%, sensitivities ranged from 14% to 40%. The use of automated read out systems for the PoC assays had a significant impact. Combining different tests did not result in better test strategies. Sensitivity of Aspergillus antigen testing from single serum samples is low. Due to specificity issues, the majority of tests is not suited for screening purposes. The different assays can meet different needs in different diagnostic settings.

Nomenclature for human and animal fungal pathogens and diseases: a proposal for standardized terminology

Medically important pathogenic fungi invade vertebrate tissue and are considered primary when part of their nature life cycle is associated with an animal host and are usually able to infect immunocompetent hosts. Opportunistic fungal pathogens complete their life cycle in environmental habitats or occur as commensals within or on the vertebrate body, but under certain conditions can thrive upon infecting humans. The extent of host damage in opportunistic infections largely depends on the portal and modality of entry as well as on the host's immune and metabolic status. Diseases caused by primary pathogens and common opportunists, causing the top approximately 80% of fungal diseases [D. W. Denning, Lancet Infect Dis, 24:e428-e438, 2024, https://doi.org/10.1016/S1473-3099(23)00692-8], tend to follow a predictive pattern, while those by occasional opportunists are more variable. For this reason, it is recommended that diseases caused by primary pathogens and the common opportunists are named after the etiologic agent, for example, histoplasmosis and aspergillosis, while this should not be done for occasional opportunists that should be named as [causative fungus] [clinical syndrome], for example, Alternaria alternata cutaneous infection. The addition of a descriptor that identifies the location or clinical type of infection is required, as the general name alone may cover widely different clinical syndromes, for example, "rhinocerebral mucormycosis." A list of major recommended human and animal disease entities (nomenclature) is provided in alignment with their causative agents. Fungal disease names may encompass several genera of etiologic agents, consequently being less susceptible to taxonomic changes of the causative species, for example, mucormycosis covers numerous mucormycetous molds.

Predictors of breakthrough invasive fungal infections (BIFI) in pediatric acute leukemia: a retrospective analysis and predictive model development

Objective

This study aims to identify key risk factors associated with the development of breakthrough invasive fungal infections (BIFI) in pediatric acute leukemia patients to improve early detection and intervention strategies.

Method

A retrospective analysis was conducted on 160 pediatric patients with acute leukemia admitted to Anhui Provincial Children's Hospital between October 2018 and June 2022. The study evaluated the impact of various clinical parameters on BIFI risk using univariate and multivariable analyses, with data including patient demographics, treatment regimens, and infection outcomes. The predictive model was assessed using receiver operating characteristic (ROC) curve analysis, calibration plots, and decision curve analysis (DCA).

Result

Among the 160 pediatric acute leukemia patients, 34 (22.22%) developed BIFI. Univariate analysis identified longer durations of neutrophil deficiency (P < 0.001), broad-spectrum antibiotic use (P < 0.001), higher volumes of red blood cell transfusions (P = 0.001), and elevated C-reactive protein (CRP) levels (P < 0.001) as significant factors associated with BIFI. Multivariable analysis confirmed these as significant predictors, with odds ratios for neutrophil deficiency (OR = 1.38, 95% CI [1.15, 1.69]), antibiotic use (OR = 1.41, 95% CI [1.10, 1.84]), transfusions (OR = 2.54, 95% CI [1.39, 5.13]), and CRP levels (OR = 1.10, 95% CI [1.04, 1.17]). The model validation showed strong predictive performance with an AUC of 0.890 (95% CI: 0.828-0.952), good calibration (Brier score = 0.099), and demonstrated clinical utility across a range of risk thresholds.

Conclusion

The study highlights the importance of considering these key predictors in the management of pediatric acute leukemia patients to mitigate the risk of BIFI. Incorporating these factors into personalized treatment strategies could enhance early intervention, reduce infection rates, and improve overall patient outcomes.

Safety, outcomes, and pharmacokinetics of isavuconazole as a treatment for invasive fungal diseases in pediatric patients: a non-comparative phase 2 trial

Invasive aspergillosis (IA) and mucormycosis (IM) cause significant morbidity and mortality in immunocompromised and/or hospitalized patients. Isavuconazonium sulfate, a prodrug of the antifungal triazole isavuconazole, has been approved for treatment of IA and IM in adults; and was recently approved in children. This study describes the outcomes, safety, and pharmacokinetics of isavuconazole for the treatment of proven, probable, or possible IA or IM in children. In this phase 2, open-label, non-comparative study, patients aged 1 to <18 years with at least possible invasive mold disease were enrolled across 10 centers in the US, Spain, and Belgium from 2019 to 2022. Patients received 10 mg/kg isavuconazonium sulfate daily (maximum 372 mg; equivalent to 5.4 mg/kg or 200 mg isavuconazole) for up to 84 (IA) or 180 days (IM). Outcomes included rates of all-cause case fatality, overall response, treatment-emergent adverse events (TEAEs), and pharmacokinetics. Of 31 patients enrolled, 61.3% were 1-<12 years old; 58.1% had underlying hematologic malignancies. The successful overall response rate at the end of treatment was 54.8%. Day 42 all-cause case fatality was 6.5%; 93.5% experienced TEAEs, and two patients discontinued treatment due to drug-related TEAEs. Dosing at 10 mg/kg (maximum dose: 372 mg) met the pre-defined exposure threshold of above the 25th percentile for the area under the concentration-time curve (≥60 mg·h/L). Simulated doses of 15 mg/kg improved drug exposures in patients aged 1-<3 years. Isavuconazole was well tolerated in children, with exposure consistent with adult studies. Successful response was documented in 54.8% of patients.CLINICAL TRIALSThis study is registered at ClinicalTrials.gov as NCT03816176.

Albumin orchestrates a natural host defense mechanism against mucormycosis

Mucormycosis is an emerging, life-threatening human infection caused by fungi of the order Mucorales. Metabolic disorders uniquely predispose an ever-expanding group of patients to mucormycosis via poorly understood mechanisms. Therefore, it is highly likely that uncharacterized host metabolic effectors confer protective immunity against mucormycosis. Here, we uncover a master regulatory role of albumin in host defense against Mucorales through the modulation of the fungal pathogenicity program. Our initial studies identified severe hypoalbuminemia as a prominent metabolic abnormality and a biomarker of poor outcome in independent cohorts of mucormycosis patients. Strikingly, we found that purified albumin selectively inhibits Mucorales growth among a range of human pathogens, and albumin-deficient mice display susceptibility specifically to mucormycosis. The antifungal activity of albumin is mediated by the release of bound free fatty acids (FFAs). Importantly, albumin prevents FFA oxidation, which results in loss of their antifungal properties. A high degree of FFA oxidation is found in the sera of patients with mucormycosis. Physiologically, albumin-bound FFAs blocks the expression of the mycotoxin mucoricin and renders Mucorales avirulent in vivo. Overall, we discovered a novel host defense mechanism that directs the pathogen to suppress its growth and the expression of virulence factors in response to unfavorable metabolic cues regulated by albumin. These findings have major implications for the pathogenesis and management of mucormycosis.

Novel Monoclonal Antibodies 1D2 and 4E4 Against Aspergillus Glycoprotein Antigens Detect Early Invasive Aspergillosis in Mice

Due to the high morbidity and mortality rates of invasive aspergillosis (IA) and the importance of early IA detection for successful treatment and subsequent outcome, this study aimed to determine a time course of detectable antigen in a mouse model of IA and correlate it with tissue invasion by using two novel monoclonal antibodies, 1D2 and 4E4, that can be used to detect the Aspergillus-derived glycoproteins. Immunocompromised mice were randomly divided into five groups: uninfected control, and inoculation with conidia from Aspergillus fumigatus, Aspergillus flavus, Aspergillus niger, and Aspergillus terreus. Conidia (2 × 106 cells/mL) were administered intravenously via tail vein injection. Three mice from each group were euthanised at each time point (6 h, 12 h, 18 h, 24 h, and 48 h) after inoculation. Urine and blood were collected for analysis using a double-sandwich ELISA using 1D2 and 4E4. Liver, spleen, and kidney tissues were harvested for tissue staining. The levels of liver injury in the IA mice progressively increased with time after inoculation with Aspergillus conidia. Following inoculation with A. fumigatus, swollen conidia were identified in the spleen, as well as antigens in blood after 18 h. Hyphae were detected in the spleen, liver, and kidney after 48 h. For A. flavus, the antibodies detected hyphae in the liver and spleen as well as circulating antigens in blood samples 48 h after inoculation. Tissue injury was observed in the mice inoculated with A. terreus and A. niger, but there was no evidence of fungal invasion or antigens in the blood. Antigens were not detectable in mouse urine but could be detected in glomeruli of the kidney by immunofluorescence. In conclusion, the mAb-based antigen detection double-sandwich ELISA results were consistent with the IHC results in this study. Novel monoclonal antibodies 1D2 and 4E4 can serve as tools for the early identification of IA in mice infected by A. fumigatus and A. flavus. This study also suggests the potential usefulness of this approach in human disease.

The Influence of Invasive Candida Infections on Prognosis and Analysis of Their Risk Factors After Liver Transplantation

PURPOSE

This study aimed to investigate the incidence, timing, risk factors, and impacts of invasive Candida infections (ICIs) within 3 months after liver transplantation (LT) on LT recipients' prognosis.

METHODS

Patients undergoing LT from January 2015 to December 2022 in a tertiary university hospital were investigated the incidence, onset, and risk factors of ICIs and the effects of ICIs on the outcome of LT recipients using statistical methods.

FINDINGS

The mean age of involved 389 LT recipients was 47.3 ± 10.5 years, with 322 (82.8%) being men. The incidence of ICIs was 3.3% (13/389), and the median time between LT and onset of ICIs was 5.0 days. The univariate analysis of predictors of ICIs identified that massive blood loss, prolonged duration of central line and urethral catheter, and prophylactic antifungal therapy were related to post-LT ICI risk. Multivariate logistic regression analysis adjusted for men and age identified that intraoperative blood loss ≥5000 mL (odds ratio [OR] = 7.005, 95% CI: 2.084-23.542, P = 0.002) and central line duration >14 days (OR = 5.270, 95% CI: 1.556-17.854, P = 0.008) were independently associated with the development of post-LT ICIs. Post-LT prophylactic antifungal therapy >3 days reduced ICIs (OR = 0.103, 95% CI: 0.021-0.501, P = 0.005). Regarding clinical outcomes, patients with ICIs were more likely to stay in the intensive care unit for 7 days or longer compared with those without ICIs (OR = 6.910, 95% CI: 1.737-27.493, P = 0.006). ICIs had no impact on hospitalization stay and 1-month all-cause mortality after LT.

IMPLICATIONS

ICIs are frequent and occur early after LT. Predictors of post-LT ICIs were massive intraoperative blood loss and prolonged duration of the central line. However, post-LT prophylactic antifungal therapy reduced ICIs. Patients with ICIs stayed longer in the intensive care unit than those without ICIs.

Progress on nonculture based diagnostic tests for invasive mould infection

PURPOSE OF REVIEW

This review describes the current status of diagnosing invasive mould disease and Pneumocystis pneumonia using nonconventional diagnostics methods.

RECENT FINDINGS

There has been significant development in the range of nonculture mycological tests. Lateral flow tests (LFTs) for diagnosing aspergillosis complement galactomannan ELISA testing, and LFTs for other fungal diseases are in development. Rapid and low through-put B-D-Glucan assays increase access to testing and there has been significant progress in the standardization/development of molecular tests. Despite this, no single perfect test exists and combining tests (e.g., antigen and molecular testing) is likely required for the optimal diagnosis of most fungal diseases.

SUMMARY

Based on established clinical performance few mycological tests can be used alone for optimal diagnosis of fungal disease (FD) and combining tests, including classical approaches is the preferred route for confirming and excluding disease. Next-generation sequencing will likely play an increasing role in how we diagnose disease, but optimization, standardization and validation of the entire molecular process is needed and we must consider how host biomarkers can stratify risk. Given the burden of FD in low- and medium-income countries, improved access to novel but more so existing diagnostic testing is critical along with simplification of testing processes.

Epidemiology, pathogenesis, clinical characteristics, and treatment of mucormycosis: a review

AIM

This review aims to summarize the epidemiology, etiology, pathogenesis, clinical manifestations, and current diagnostic and therapeutic approaches for mucormycosis. The goal is to improve understanding of mucormycosis and promote early diagnosis and treatment to reduce mortality.

METHODS

A comprehensive literature review was conducted, focusing on recent studies and data on mucormycosis. The review includes an analysis of the disease's epidemiology, etiology, and pathogenesis, as well as current diagnostic techniques and therapeutic strategies.

RESULTS

Mucormycosis is increasingly prevalent due to the growing immunocompromised population, the COVID-19 pandemic, and advances in detection methods. The pathogenesis is closely associated with the host immune status, serum-free iron levels, and the virulence of Mucorales. However, the absence of typical clinical manifestations complicates diagnosis, leading to missed or delayed diagnoses and higher mortality.

CONCLUSION

An enhanced understanding of the epidemiology, pathogenesis, and clinical presentation of mucormycosis, along with the adoption of improved diagnostic and therapeutic approaches, is essential for reducing mortality rates associated with this opportunistic fungal infection. Early diagnosis and prompt treatment are critical to improving patient outcomes.

Posaconazole gastro-resistant tablets for preventing invasive fungal disease after haematopoietic stem cell transplantation: a propensity-matched cohort study

OBJECTIVES

To evaluate posaconazole (POS) gastro-resistant tablets for preventing invasive fungal disease (IFD) in haematopoietic stem cell transplantation (HSCT) patients and analyse POS plasma concentrations.

METHODS

A single-arm trial was designed with a historical cohort as a control. Patients aged 13 years and older undergoing HSCT at the HSCT Center of Blood Diseases Hospital, Chinese Academy of Medical Sciences between December 2020 and May 2022 were enrolled, prospectively taking POS gastro-resistant tablets orally from day 1 to day 90 post-transplant and monitoring plasma concentrations. We also identified a retrospective cohort treated with alternative antifungal prophylaxis between January 2018 and December 2020, matched using propensity score methods. The primary outcome was the cumulative incidence of IFD at day 90 post-transplant.

RESULTS

The prospective study involved 144 patients receiving POS gastro-resistant tablets for IFD prevention, contrasting with 287 patients receiving non-POS tablets. By day 90 post-transplant, the POS tablet group exhibited a significantly lower cumulative incidence of IFD (2.81%; 95% CI, 0.09-5.50% vs. 7.69%; 95% CI, 4.60-10.78%; p 0.044). Adverse events were comparable between the groups with liver changes in 33/144 (22.92%) vs. 84/287 (29.27%) (p 0.162), and renal injuries in 15/144 (10.41%) vs. 37/287 (12.89%) (p 0.457). Mean POS plasma concentrations on days 4, 8, 15, and 22 post-administration were 930.97 ng/mL, 1143.97 ng/mL, 1569.8 ng/mL, and 1652.57 ng/mL, respectively.

DISCUSSION

Patients administered POS gastro-resistant tablets for antifungal prophylaxis experienced a lower cumulative incidence of IFD. POS plasma concentrations in HSCT patients stabilized by day 15 of medication.

Pediatric dermatologic emergencies

PURPOSE OF REVIEW

Provide an overview of recent findings and recommendations for the presentation, diagnosis, and management of pediatric dermatologic emergencies.

RECENT FINDINGS

Updated information on optimal diagnosis and treatments for pediatric dermatologic emergencies because of infection, reactive infectious mucocutaneous eruption, and serious cutaneous adverse reactions are covered.

SUMMARY

Pediatric dermatologic emergencies require prompt diagnosis and management. This review covers new agents and techniques for management and diagnosis.

Occurrence of coccidioidomycosis in a tertiary hospital in the Brazilian semi-arid region: diagnostic challenges

Coccidioidomycosis is a systemic fungal infection that primarily affects the lungs in mammals. It is endemic to certain areas of the Americas. In Brazil, the disease occurs exclusively in the Northeast of the country, and the only etiological agent described is Coccidioides posadasii, typically found in the soil of arid regions with low rainfall. Given the scarcity of cases in Brazil, a descriptive study was conducted based on cases diagnosed with coccidioidomycosis between 2012 and 2022 at a tertiary hospital in the northeastern region of Brazil. The study analyzed medical records to identify cases of coccidioidomycosis diagnosed by clinical and/or laboratory data, discussing their clinical-epidemiological aspects. Thirteen patients were identified from seven municipalities in Ceará, all of whom were male, with a mean age of 19 years. The main risk factor was armadillo hunting, and the clinical manifestations included cough, fever, and chest pain. In this study, two patients were diagnosed by serology, one by microscopy, and ten suspected cases were diagnosed based on the clinical and epidemiological picture. Twelve patients were treated with antifungals. Clinical improvement with hospital discharge occurred in twelve patients, while one patient died. The data corroborate information from the scientific literature that the area covered by the referral hospital is endemic for coccidioidomycosis. However, local resources for diagnosing this disease were found to be deficient, with a high rate of presumptive diagnoses. This study highlights the need for actions by health surveillance systems and greater efficiency in diagnosing coccidioidomycosis in endemic areas of Brazil.

Infections following chimeric antigen receptor T cell therapy: 2018-2022

BACKGROUND

Chimeric antigen receptor (CAR) T-cell therapy is an emerging therapeutic modality for relapsed and refractory hematological malignancies. Infectious complications following CAR T-cell therapy are not well defined.

METHODS

This is a retrospective analysis of data on patients who received CAR T-cell therapy between April 2018 and December 2022 at the Karmanos Cancer Center, Detroit. Patients' data were collected up to their last known clinic or inpatient follow-up visit. An infectious episode was defined as any microbiologically proven or clinically documented infection.

RESULTS

Seventy-six patients received therapy with FDA-approved CAR T-cell products. Thirty-three patients (43.4%) had at least one infectious episode. There were 61 infectious episodes during a median follow-up of 184 (96-340) days. Median duration for the onset of infection was 59 (22-209) days. Bacterial and viral infections occurred in 42.6% and 41% of the infectious episodes, respectively. COVID-19 was the most common infectious complication (14.8%). Time-to-event analysis showed that most infections occurred within the first 100 days. Empirical antibiotic use during Cytokine Release Syndrome/Immune effector Cell-Associated Neurotoxicity Syndrome (CRS/ICANS) in the absence of documented bacterial infection was reported in 85.7% of patients. Clostridioides difficile accounted for 11.5% of all infectious episodes. Five of six patients with C. difficile infection had CRS/ICANS and received antibiotics.

CONCLUSION

COVID-19 and C. difficile infection were the most common infections following CAR T-cell therapy. Most infections occurred within the first 100 days. Empiric antibiotic use and C. difficile infection were common in patients with CRS/ICANS, in the absence of documented bacterial infection, thus providing an excellent opportunity for antimicrobial stewardship in this population.

Infections and antimicrobial prophylaxis in patients with myelodysplastic syndromes

Infectious complications are an important cause of morbidity and mortality in patients with myelodysplastic syndromes (MDS). Preventing infections could significantly improve both survival and quality of life. Unfortunately, both infections and antimicrobial prophylaxis in patients with MDS are incompletely assessed due to the heterogeneity of disorders included in each publication, changing definitions over time, and lack of standardized prophylaxis practices. Despite these limitations, some basic statements can be made. Infections in MDS are associated with neutropenia. Patients with lower-risk (LR) MDS tend to have fewer infections compared to patients with higher-risk (HR) MDS, which may be related to the different prevalence of neutropenia in the 2 groups. Pneumonia is the most common infection, and bacteria are the most common pathogens. Invasive fungal infections (IFI) are uncommon. Reactivation of latent viruses are rare. With the limited data available, we agree that antibacterial prophylaxis can be considered in patients with HR-MDS during severe neutropenia and early cycles of therapy when infections are most likely to occur. Given the low prevalence of IFI and viral reactivation, antimicrobial prophylaxis for these pathogens is less likely to be advantageous for most patients, although antifungal prophylaxis with activity against mold is commonly used in patients with persistent, profound neutropenia. Ultimately, improved data collection regarding infections and antimicrobial prophylaxis is needed to improve care for patients with MDS.

Comparison of performances of laboratory methods in diagnosing pulmonary cryptococcosis in 1508 patients having lung biopsy tissues collected: a 6-year retrospective study

PURPOSE

The diagnosis of pulmonary cryptococcosis (PC) remains challenging, particularly in patients presenting with lobar or patchy consolidation on chest radiographs. Biopsies are sometimes performed for histopathologic examination and microbiological culture to differentiate infections, including PC, from lung cancers. However, to date, the clinical value of small biopsy samples and their reasonable processing methods for detecting Cryptococcus are rarely evaluated. Furthermore, the cryptococcal antigen (CrAg) test has been widely used in cryptococcosis diagnosis due to its high specificity. This 6-year retrospective study aimed to assess the efficacy of four tests commonly used for detecting Cryptococcus in the diagnosis of pulmonary cryptococcosis, and reveal that the combination of 2 or 3 methods would raise diagnosis sensitivity.

METHODS

The results of CrAg test, histopathologic examination and routine cryptococcal culture of sputum/bronchoalveolar lavage fluid (BALF) were collected from hospitalized patients between June 2019 to May 2024. Additionally, the results of 4 above-mentioned methods were analyzed to compare their effectiveness in PC diagnosis.

RESULTS

Among 1508 patients whose biopsy specimens were sent for pathogen detection, 63 PC cases were diagnosed, and 24 C. neoformans strains were cultivated using the Myco/F Lytic culture, which was more than those by sputum/BALF culture (9 strains). CrAg was positive in 82.5% (52/63) PC patients and remained the most sensitive method. The combination of CrAg and biopsy culture will increase the overall diagnostic yield to 95.2% (60/63).

CONCLUSIONS

In summary, for those having biopsy tissue collected, the combination of CrAg and biopsy culture using Myco/F could effectively identify most PC cases.

Two cases of fungemia due to Lomentospora prolificans in haematological patients with different outcome

Lomentospora prolificans is an uncommon cause of invasive fungal disease, but it is associated with high mortality because it is difficult to treat. Most of severe cases are produced in immunossupressed patients, especially in those with neutropenia and/or hematological malignancies. Resistance to the majority of antifungal agents can be still observed. Here we report two cases of L. prolificans fungemia with different outcome, since in one of these patients treatment with one of the new antifungals could be applied. Both patients were treated with different antifungal drugs, but only the second one survived due to therapy with fosmanogepix®. The current treatment is still based on a combination of conventional antifungal drugs, although in much cases this strategy is not sufficient. The introduction of new promising antifungal agents such as fosmanogepix® and olorofim® may open new perspectives in the treatment of invasive infections caused by L. prolificans, as in our patient.

Using staged tree models for health data: Investigating invasive fungal infections by aspergillus and other filamentous fungi

Machine learning models are increasingly used in the medical domain to study the association between risk factors and diseases to support practitioners in understanding health outcomes. In this paper, we showcase the use of machine-learned staged tree models for investigating complex asymmetric dependence structures in health data. Staged trees are a specific class of generative, probabilistic graphical models that formally model asymmetric conditional independence and non-regular sample spaces. An investigation of the risk factors in invasive fungal infections demonstrates the insights staged trees provide to support medical decision-making.

Delayed Diagnosis of Disseminated Invasive Aspergillosis with Purulent Myocarditis in an Immunocompromised Host

Introduction: Invasive aspergillosis (IA) is an opportunistic fungal infection that typically occurs in the immunocompromised host and is associated with severe morbidity and mortality. Myocardial abscess formation is seldomly described. Detailed Case Description: We present a case of IA with purulent myocarditis. The patient was on long-term high-dose corticosteroid and mycophenolate mofetil therapy for severe lupus nephritis. After multiple visits to his general practitioner and nephrologist for general malaise, he was admitted to our hospital with visual complaints. Within several days, he developed atrial fibrillation, respiratory insufficiency, and, finally, a decreased level of consciousness. After admission to the intensive care unit, the broncho alveolar lavage (BAL) fluid galactomannan (GM) index was normal, but the serum GM index was severely elevated. Despite initiation of antifungal therapy, the patient passed away shortly thereafter. Autopsy revealed massive intracranial hemorrhage and disseminated IA affecting the lungs, brain, and myocardium, with macroscopic myocardial abscess formation. Discussion: This classic case of diagnostic uncertainty illustrates how invasive fungal infections can progress to disseminated disease while showing nonspecific symptoms only. It emphasizes the importance of vigilance for opportunistic fungal infections in a growing category of immunocompromised patients. Conclusion: Clinicians should have a low threshold of suspicion for fungal infections in patients on combination immunosuppressive medication, such as high-dose corticosteroid therapy in combination with T-cell inhibitors like MMF.

Current Analytical Methods and Challenges for the Clinical Diagnosis of Invasive Pulmonary Aspergillosis Infection

In the last decade, pulmonary fungal infections such as invasive pulmonary aspergillosis (IPA) have increased in incidence due to the increased number of immunocompromised individuals. This increase is especially problematic when considering mortality rates associated with IPA are upwards of 70%. This high mortality rate is due to, in part, the length of time it takes to diagnose a patient with IPA. When diagnosed early, mortality rates of IPA decrease by as much as 30%. In this review, we discuss current technologies employed in both medical and research laboratories to diagnose IPA, including culture, imaging, polymerase chain reaction, peptide nucleic acid-fluorescence in situ hybridization, enzyme-linked immunosorbent assay, lateral flow assay, and liquid chromatography mass spectrometry. For each technique, we discuss both promising results and potential areas for improvement that would lead to decreased diagnosis time for patients suspected of contracting IPA. Further study into methods that offer increased speed and both analytical and clinical sensitivity to decrease diagnosis time for IPA is warranted.

Antifungal Prophylaxis Utilization and the Associated Clinical Outcomes Among Pediatric Patients with Hematological Malignancies or Undergoing Hematopoietic Stem Cell Transplantation

Background/Objectives: Invasive fungal infections (IFIs) are a prevalent complication of intensive chemotherapy and hematopoietic stem cell transplantation (HSCT) in the pediatric population and are associated with high morbidity and mortality. We aimed to identify the utilization of antifungal prophylaxis prescriptions and the associated clinical outcomes. Methods: A retrospective study included children (≤18 years old) diagnosed with hematological malignancies or undergoing HSCT who are at high risk for developing IFI and received systemic antifungal therapy between January 2018 and April 2024 at Sultan Qaboos University Hospital (SQUH), Oman. Results: A powered sample of 222 patients was included, and 208 (93.69%) received antifungal prophylaxis. Among those who received prophylaxis, 148 (66.67%) received appropriate prophylaxis, 86.06% (n = 179) received appropriate dosage. The patients who did not receive antifungal prophylaxis had higher rates of inpatient IFI requiring treatment (85.71% versus 12.02%, p < 0.01), a longer median length of hospital stay (LOS) (67.5 days versus 10 days, p = 0.015), and more incidence of 90-day all-cause mortality (21.43% versus 2.88%, p < 0.01) than those who received antifungal prophylaxis. Survival analysis demonstrated that these patients had a 12% higher risk for earlier death. Also, being on antifungal prophylaxis reduces the odds of inpatient IFI requiring treatment, with an adjusted odds ratio (aOR) of 0.13 [95% CI: 0.019-0.801]. Conclusions: Antifungal prophylaxis utilization was high, and it markedly decreases the occurrence and enhances the prognosis of IFI. Nonetheless, inconsistencies in practice and a lack of pediatric-specific data underscore the necessity for uniform guidelines and additional research to strengthen preventative methods in this population, and proper TDM utilization could provide more robust insights.

Rare case pulmonary aspergillosis in a patient with acute myeloid leukemia at King Abdulaziz University Hospital, Jeddah, Saudi Arabia: A case report

Invasive fungal infections are considered a threat to hematological malignancy patients (HM). We report here a rare case of pulmonary aspergillosis in a patient diagnosed with leukemia at King Abdulaziz University Hospital. The patient received three cycles of chemotherapy and presented with febrile neutropenia and his fungal culture was repeatedly negative while signs of aspergillosis in a computed topography (CT) scan were evident. The patient was successfully recovered after 6 weeks of voriconazole treatment.

Phaeohyphomycosis Due to Verruconis gallopava: Rare Indolent Pulmonary Infection or Severe Cerebral Fungal Disease?

INTRODUCTION

Phaeohyphomycoses are uncommon and poorly understood opportunistic fungal infections, characterized by a wide spectrum of clinical manifestations ranging from localized skin lesions to disseminated disease. Most frequent genera are Alternaria, Cladophialophora, Exophiala or Curvularia. Less common ones, such as Verruconis gallopava, initially described as responsible of encephalitis of turkeys, pose significant challenges for diagnosis and treatment.

MATERIAL AND METHODS

Following the description of a clinical case, we performed a comprehensive review of 48 cases of V. gallopava infection, a rarely reported species from 1986 to 2024.

RESULTS

Solid organ transplant recipients and patients with hematological malignancies are the population most at-risk. Clinical presentation is nonspecific but can be divided in two main entities, pulmonary and cerebral localizations. This later is associated with a mortality rate over 80% and was significantly more frequently reported in liver transplant recipients (p = 0.03). When tested, ß-D-glucans were positive in all cases. Antifungal susceptibility testing demonstrated low MICs for amphotericin B and all azoles but isavuconazole and fluconazole. Clinical outcomes support the use of amphotericin B, voriconazole, itraconazole and posaconazole as valid treatment options.

DISCUSSION

It is not known whether the cerebral cases are primary or secondary to pulmonary lesions. The indolent pulmonary lesions should prompt a complete work-up including biopsy with pathology and mycology expertise since the differential diagnosis is a cancer lesion.

Treatment of Invasive Pulmonary Aspergillosis and Preventive and Empirical Therapy for Invasive Candidiasis in Adult Pulmonary and Critical Care Patients. An Official American Thoracic Society Clinical Practice Guideline

BACKGROUND

The incidence of invasive fungal infections is increasing in immune-competent and immune-compromised patients. An examination of the recent literature related to the treatment of fungal infections was performed to address two clinical questions. First, in patients with proven or probable invasive pulmonary aspergillosis, should combination therapy with a mold-active triazole plus echinocandin be administered vs. mold-active triazole monotherapy? Second, in critically ill patients at risk for invasive candidiasis who are non-neutropenic and are not transplant recipients, should systemic antifungal agents be administered either as prophylaxis or as empiric therapy?

METHODS

A multidisciplinary panel reviewed the available data concerning the two questions. The evidence was evaluated, and recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

A conditional recommendation was made for patients with proven or probable invasive pulmonary aspergillosis to receive either initial combination therapy with a mold-active triazole plus an echinocandin or initial mold-active triazole monotherapy based on low-quality evidence. Further, a conditional weak recommendation was made against routine administration of prophylactic or empiric antifungal agents targeting Candida species for critically ill patients without neutropenia or a history of transplant based on low-quality evidence.

CONCLUSIONS

The recommendations presented in these Guidelines are the result of an analysis of currently available evidence. Additional research and new clinical data will prompt an update in the future.

The Rising Threat of Mucormycosis: Oman's Experience Before and During the COVID-19 Pandemic

Mucormycosis is a rare, severe fungal infection mainly affecting immunocompromised individuals. Because of limited data on its epidemiology in Oman, we present this national, multicentric, retrospective review that includes all cases of proven mucormycosis between 2006 and 2022 in Oman. There were 51 cases of mucormycosis reported in Oman. The annual incidence of mucormycosis was 0.38-0.69 cases per million population before COVID-19. During the pandemic, the incidence rose significantly to 1.76 in 2020, 5.31 in 2021, then decreased to 0.87 per million population in 2022. Diabetes was observed in 82.4% (n = 42) of the cases, COVID-19 in 47.1% (n = 24), and other chronic diseases in 72.6%. The use of steroids was reported in 33.3% (n = 17) and many patients (64.7%, n = 33) had multiple risk factors. The overall mortality rate was 41.2% (n = 21) and most deaths occurred within a month of diagnosis. Mortality rate among patients diagnosed with COVID-19 was 58.3% (14/24). Survival analysis showed a statistically significant association between COVID-19 status and patient survival (p = 0.024). Annual incidence of mucormycosis in Oman rose during the pandemic. This study highlights the epidemiological features of mucormycosis and emphasizes the importance of its inclusion in the national notifiable communicable diseases priority list as well as the importance of enhancing diagnostic capacities to detect and improve patient outcomes.

Profiling Bacteria in the Lungs of Patients with Severe Influenza Versus COVID-19 with or without Aspergillosis

Rationale: The influence of the lung bacterial microbiome, including potential pathogens, in patients with influenza-associated pulmonary aspergillosis (IAPA) or coronavirus disease (COVID-19)-associated pulmonary aspergillosis (CAPA) has yet to be explored. Objectives: To explore the composition of the lung bacterial microbiome and its association with viral and fungal infection, immunity, and outcome in severe influenza versus COVID-19 with or without aspergillosis. Methods: We performed a retrospective study in mechanically ventilated patients with influenza and COVID-19 with or without invasive aspergillosis in whom BAL for bacterial culture (with or without PCR) was obtained within 2 weeks after ICU admission. In addition, 16S rRNA gene sequencing data and viral and bacterial load of BAL samples from a subset of these patients, and of patients requiring noninvasive ventilation, were analyzed. We integrated 16S rRNA gene sequencing data with existing immune parameter datasets. Measurements and Main Results: Potential bacterial pathogens were detected in 20% (28/142) of patients with influenza and 37% (104/281) of patients with COVID-19, whereas aspergillosis was detected in 38% (54/142) of patients with influenza and 31% (86/281) of patients with COVID-19. A significant association between bacterial pathogens in BAL fluid and 90-day mortality was found only in patients with influenza, particularly patients with IAPA. Patients with COVID-19, but not patients with influenza, showed increased proinflammatory pulmonary cytokine responses to bacterial pathogens. Conclusions: Aspergillosis is more frequently detected in the lungs of patients with severe influenza than bacterial pathogens. Detection of bacterial pathogens associates with worse outcome in patients with influenza, particularly in those with IAPA, but not in patients with COVID-19. The immunological dynamics of tripartite viral-fungal-bacterial interactions deserve further investigation.

Evaluation of a New Automated Mono-Test for the Detection of Aspergillus Galactomannan: Comparison of Aspergillus Galactomannan Ag VirCLIA® Mono-Test with PlateliaTMAspergillus Ag ELISA Assay

The analytical performance of the new Aspergillus Galactomannan Ag VirCLIA® mono-test (Vircell S.L.) was compared to the Platelia™ Aspergillus Ag ELISA assay (Bio-Rad). Prospective serum and bronchoalveolar lavage (BAL) samples from patients at risk of invasive aspergillosis (IA) were tested using both the Aspergillus Galactomannan Ag VirCLIA® mono-test and the Platelia™ Aspergillus Ag ELISA assay. Concordance, sensitivity, specificity, and positive and negative predictive values were calculated using the manufacturer-recommended cutoff levels. Receiver operating characteristic (ROC) analysis and the Youden index were performed to determine the optimal cutoff. A total of 187 serum samples and 73 BAL samples were analyzed with both assays. The concordance between the Aspergillus Galactomannan Ag VirCLIA® mono-test and the Platelia™ Aspergillus Ag ELISA assay was 87.8%, with a Cohen's kappa of 0.75. The sensitivity and specificity of the Aspergillus Galactomannan Ag VirCLIA® mono-test were 78.6% and 96.2%, respectively, with positive and negative predictive values of 94.8% and 83.3%. The ROC curve for the Aspergillus Galactomannan Ag VirCLIA® mono-test demonstrated an area under the curve (AUC) of 0.87, and the Youden index at the manufacturer's established cutoff was 0.73. This new Aspergillus Galactomannan Ag VirCLIA® mono-test exhibited adequate analytical and clinical performance, showing good correlation with the Platelia™ Aspergillus Ag ELISA assay. The single-sample, semi-automated test is user-friendly, allowing small laboratories to perform the test on demand without the need for batch evaluations, providing a useful solution for timely diagnostic support for clinicians.

The effectiveness and safety of posaconazole enteric-coated tablet versus oral suspension in invasive fungal infections

Posaconazole enteric-coated tablet and oral suspension are two oral drugs in the treatment of invasive fungal infections (IFIs). This study compared the effectiveness and safety between posaconazole enteric-coated tablet and oral suspension, and provided a real world basis for the clinical practice. A retrospective cohort study was performed on IFIs patients treated with posaconazole enteric-coated tablet or oral suspension. The primary endpoints were in-hospital mortality, treatment discontinuation rate and clinical effective rate. The secondary endpoints were adverse events incidence (liver dysfunction, renal dysfunction and hypokalemia). One hundred and forty-four patients were totally included and divided into enteric-coated tablet group (n = 46) and oral suspension group (n = 98). There was no significant difference in effectiveness and safety between two groups. The female (OR = 0.130, P = 0.018) and diabetes mellitus (OR = 4.242, P = 0.003) were independently associated with combined in-hospital mortality/treatment discontinuation rate. The renal replacement therapy (OR = 10.071, P = 0.006), hypoalbuminemia (OR = 6.646, P = 0.002) and posaconazole duration (OR = 1.119, P = 0.002) were risk factors for liver dysfunction. The posaconazole enteric-coated tablet has comparable effectiveness and safety with oral suspension in IFIs, which need large-scale cases studies to confirm in the future.

Reverse-transcriptase real-time PCR in the diagnostic strategy for invasive infections caused by Aspergillus fumigatus

The aim was to develop an RT-qPCR targeting Aspergillus fumigatus and compare its performance to that of Aspergillus fumigatus qPCR for the diagnosis of invasive aspergillosis (IA). Samples from patients of the Lyon University hospitals for whom a suspicion of IA led to the realization of an Aspergillus fumigatus qPCR molecular diagnostic test over a 2-year period were included. The patients were classified according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC-MSGERC) criteria for suspected IA; RT-qPCR and qPCR assays were performed on all included samples. The sensitivities and specificities of RT-qPCR and qPCR were calculated and compared using the results of the EORTC-MSGERC classification as reference. The cycle threshold (Ct) results were compared according to IA classification and sample type. Among the 193 samples analyzed, 91 were classified as IA excluded, 46 as possible IA, 53 as probable IA, and 3 as proven IA. For all sample types, RT-qPCR was significantly more sensitive than qPCR for all IA classifications with an additional 17/102 samples detected (P-value < 0.01). For plasma samples, sensitivity was significantly higher and specificity significantly lower using RT-qPCR for all IA classifications (P-value < 0.001). The mean Ct obtained with RT-qPCR were significantly lower than those obtained with qPCR for all IA classifications and all sample types (P-value < 0.001 and P-value < 0.0001, respectively). RT-qPCR presents a higher sensitivity than qPCR for the diagnosis of IA due to Aspergillus fumigatus, particularly in samples with an intrinsically low fungal load.IMPORTANCEAspergillus fumigatus belongs to the critical priority group of the World Health Organization fungal priority pathogens list. Invasive aspergillosis (IA) is a life-threatening infection with poor prognosis and challenging diagnosis. PCR has been integrated into the 2020 European Organization for Research and Treatment of Cancer/Mycoses Study Group consensus definitions for IA diagnosis. However, due to frequent low fungal burdens, its sensitivity needs to be improved. This work presents an innovative method for detecting total nucleic acids, corresponding to both ribosomal RNA and DNA, that enables IA diagnosis with greater sensitivity than conventional techniques, especially in non-invasive samples such as blood, enhancing the monitoring of this infection in high-risk patients.

High histoplasmosis incidence in kidney transplant recipients in Santa Fe city, Argentina

Histoplasmosis is endemic in the central/northeast region of Argentina. It is estimated that the incidence of this mycosis is low in solid organ transplant recipients. This work aims to describe the epidemiology, clinical forms, and evolution of kidney transplant recipients diagnosed with histoplasmosis in Santa Fe city, Argentina. A retrospective study was carried out between 2015 and 2020 on kidney transplant patients with symptoms associated with histoplasmosis in Santa Fe. Histoplasmosis diagnosis was performed through histopathology, recovery of Histoplasma spp., by culture, and/or positive nested Polimerase Chain Reaction (PCR) specific for the Histoplasma Hc100 gene. During the study period, 360 kidney transplantations were performed. Of these patients, 12 were diagnosed with histoplasmosis (3.3%). The patients' median age was 51 years, and 75% were male. Eleven patients (92%) presented the disseminated form of the disease. Thirty-three percent were diagnosed with histoplasmosis in their first year post-transplantation (mostly 6-12 months), while 42% received their diagnosis 3 years after transplantation. Laboratory diagnosis was performed by histopathology, culture, and PCR in four cases (33%), by culture and PCR in three cases (25%), and by PCR alone in three cases (25%). Thus, all 12 patients showed positive nested PCR results. All patients received amphotericin B as initial treatment. A good response was observed in 83% of patients. We found a high incidence of histoplasmosis in kidney transplant recipients (up to 10 times higher than reports from other endemic areas). Diagnosis by histopathology/culture showed 75% sensitivity, while nested PCR showed better sensitivity and diagnostic speed.

The epidemiological characteristics of invasive pulmonary aspergillosis and risk factors for treatment failure: a retrospective study

OBJECTIVE

The incidence of invasive pulmonary aspergillosis (IPA) is increasing gradually. This study analysed the epidemiological characteristics and prognostic factors of patients with IPA and explored the risk factors affecting prognosis.

MATERIALS AND METHODS

The clinical data and treatment of 92 patients with IPA were retrospectively analysed, and the patients were followed for 12 weeks. Patients were divided into an effective treatment group and an ineffective treatment group, and the risk factors affecting prognosis were discussed.

RESULTS

A total of 92 patients met the IPA inclusion criteria, and the most common genus of Aspergillus was Aspergillus fumigatus. The incidence of IPA was highest in patients with malignant tumours. IPA often coexisted with infections caused by other pathogens. We divided the patients into an effective treatment group and an ineffective treatment group according to prognosis. Compared with those in the effective treatment group, the procalcitonin (PCT) level, lactate dehydrogenase-to-albumin ratio (LDH/ALB) and neutrophil-to-lymphocyte ratio (NLR) in the ineffective treatment group were greater, the serum albumin level was lower, and the imaging findings revealed less nodules and bronchial wall thickening (P < 0.05). Among these factors, a decrease in the serum albumin concentration, an increase in the PCT level, coinfection and less bronchial wall thickening on imaging were independent risk factors for aspergillosis treatment failure.

CONCLUSION

A decreased albumin level, an elevated PCT level, coinfection, and less bronchial wall thickening were independent risk factors for treatment failure in patients with IPA. Attention should be given to the albumin level, coinfection status and imaging findings of patients.

Therapeutic drug monitoring and safety of voriconazole in patients with liver dysfunction

This study aims to describe the distribution characteristics of voriconazole (VRC) plasma trough concentrations (Ctrough) in patients with liver dysfunction, identify factors influencing VRC Ctrough, and provide recommendations for the use of VRC in this population. We retrospectively collected medical records of hospitalized patients with liver dysfunction who used VRC and underwent therapeutic drug monitoring (TDM) at the First Hospital of Changsha. The severity of liver dysfunction was assessed by the Child-Pugh (CP) score. Multiple linear regression was employed to explore factors affecting VRC Ctrough in these patients. A total of 147 Ctrough from 102 patients with liver dysfunction were analyzed. Patients were categorized into a control group (n = 40), CP-A (n = 39), CP-B (n = 11), and CP-C group (n = 12). The initial probability of target attainment of Ctrough was 70.6%, with 6.9% of patients obtaining subtherapeutic Ctrough and 22.5% obtaining supertherapeutic Ctrough. The initial Ctrough in CP-A and B were 5.05 (0.64-9.57) mg/L and 5.37 (0.26-10.01) mg/L, respectively, significantly higher than the control group (P = 0.021 and P = 0.010). The proportion of VRC Ctrough of >5.5 mg/L in CP-A and B was 33.3% and 45.5%, respectively. Multiple linear regression analysis revealed that factors such as age ≥70 years, CP class, C-reactive protein (CRP), and direct bilirubin were significantly related to the initial VRC Ctrough. Among all measurements, patients with severe inflammation (CRP >100 mg/L), aged ≥70 years, and albumin levels of <30 or <25 g/L had significantly higher VRC Ctrough. The treatment success rate of VRC was 69.6% (71 of 102), and the rate of VRC-related adverse drug reactions was 29.4% (30 of 102). The recommended half-maintenance dose may lead to elevated VRC Ctrough in patients with CP-A and CP-B. TDM is essential for patients with advanced age, severe infections, or hypoalbuminemia to prevent excessive VRC trough levels.

Seroprevalence and prognostic value of Aspergillus-specific IgG among non-neutropenic invasive pulmonary aspergillosis patients: a prospective multicenter study

BACKGROUND

This study aimed to assess the diagnostic and prognostic value of Aspergillus-specific IgG (Asp-IgG) for invasive pulmonary aspergillosis (IPA) in non-neutropenic non-hematologic patients.

METHODS

Between November 2019 and February 2022, we recruited 40 non-neutropenic, non-hematologic IPA patients from Taiwan and measured serum Asp-IgG levels using Phadia, Thermofisher. A positive Asp-IgG test was defined as a level > 40 mgA/L. We evaluated the association between Asp-IgG levels and overall survival, as well 90-day mortality rate of IPA patients.

RESULTS

Of the 40 participants, 11 (27.5%) tested positive for Asp-IgG, while 16 (40%) had positive galactomannan antigen (optical density > 1). Higher Asp-IgG levels were associated with improved overall survival (HR: 0.22, 95% CI: 0.05-0.99, p = 0.035) in multivariable Cox regression. The overall 90-day mortality rate was 65% (26/40). We found that patients with low Asp-IgG levels (≤ 40 mgA/L) had a borderline higher 90-day mortality rate compared to patients with high Asp-IgG levels (OR: 3.15, 95% CI: 0.75-13.28, p = 0.118). Stratifying by serum galactomannan and Aspergillus IgG levels, patients with elevated serum GM and low Asp-IgG had the highest 90-day mortality (80%, 8/10), followed by patients with low serum GM and low Asp-IgG (68.4%, 13/19).

CONCLUSIONS

Asp-IgG was positive in approximately one-fourth of non-neutropenic IPA patients. Asp-IgG may hold potential as a clinical prognostic factor for IPA. Further studies are required to validate this finding.

Use of echinocandin outpatient parenteral antimicrobial therapy for the treatment of infection caused by Candida spp.: utilization, outcomes and impact of a change to weekly dosing

BACKGROUND

Outpatient parenteral antimicrobial therapy (OPAT) can deliver extended parenteral treatment of fungal infections in an ambulatory setting, whilst minimizing treatment burden and cost. The extended dosing interval of rezafungin may potentiate the benefits of OPAT.

METHODS

This retrospective cohort study includes all adult patients who received echinocandin therapy in a large OPAT programme between 2012 and 2022. Patient characteristics, treatment and outcomes were studied. Data were analysed to determine the effects of replacing daily dosing with weekly dosing of echinocandin.

RESULTS

Across the study period, 11% (44/386) of all patients in our Health Service treated with ≥7 days of echinocandin were managed via OPAT. All were Candida and related 'yeast-like' species infections. Nakaseomyces glabrata (20/41; 49%) was the most common pathogen, fungaemia the most common presentation (17/41; 41%) and azole resistance the most frequent indication for echinocandin use (21/41; 51%).In total, 633 days of echinocandin were administered as OPAT. Thirteen patients (13/41; 32%) received concurrent parenteral antibacterials. Treatment success was achieved in 30/41 (73%) patients. If daily echinocandin dosing was replaced with weekly dosing, a potential 52% (633 to 326) reduction in the total number of treatments (for any therapy) delivered by the OPAT team is possible. The ongoing need for daily antibacterial administration mitigated the benefit in some of this cohort.

CONCLUSIONS

Echinocandin therapy can be safely delivered via OPAT with outcomes equivalent to bed-based care. The extended dosing interval of rezafungin will allow for a substantial reduction in the number of treatments required across the patient cohort.

The pathobiology of human fungal infections

Human fungal infections are a historically neglected area of disease research, yet they cause more than 1.5 million deaths every year. Our understanding of the pathophysiology of these infections has increased considerably over the past decade, through major insights into both the host and pathogen factors that contribute to the phenotype and severity of these diseases. Recent studies are revealing multiple mechanisms by which fungi modify and manipulate the host, escape immune surveillance and generate complex comorbidities. Although the emergence of fungal strains that are less susceptible to antifungal drugs or that rapidly evolve drug resistance is posing new threats, greater understanding of immune mechanisms and host susceptibility factors is beginning to offer novel immunotherapeutic options for the future. In this Review, we provide a broad and comprehensive overview of the pathobiology of human fungal infections, focusing specifically on pathogens that can cause invasive life-threatening infections, highlighting recent discoveries from the pathogen, host and clinical perspectives. We conclude by discussing key future challenges including antifungal drug resistance, the emergence of new pathogens and new developments in modern medicine that are promoting susceptibility to infection.

Isavuconazole Versus Voriconazole as the First-line Therapy for Solid Organ Transplant Recipients With Invasive Aspergillosis: Comparative Analysis of 2 Multicenter Cohort Studies

BACKGROUND

Isavuconazole (ISA) and voriconazole (VORI) are recommended as the first-line treatment for invasive aspergillosis (IA). Despite theoretical advantages of ISA, both triazole agents have not been compared in solid organ transplant recipients.

METHODS

We performed a post hoc analysis of 2 retrospective multicenter cohorts of solid organ transplant recipients with invasive fungal disease (the SOTIS [Solid Organ Transplantation and ISavuconazole] and DiasperSOT [DIagnosis of ASPERgillosis in Solid Organ Transplantation] studies). We selected adult patients with proven/probable IA that were treated for ≥48 h with ISA (n = 57) or VORI (n = 77) as first-line therapy, either in monotherapy or combination regimen. The primary outcome was the rate of clinical response at 12 wk from the initiation of therapy. Secondary outcomes comprised 12-wk all-cause and IA-attributable mortality and the rates of treatment-emergent adverse events and premature treatment discontinuation.

RESULTS

Both groups were comparable in their demographics and major clinical and treatment-related variables. There were no differences in the rate of 12-wk clinical response between the ISA and VORI groups (59.6% versus 59.7%, respectively; odds ratio [OR], 0.99; 95% confidence interval [CI], 0.49-2.00). This result was confirmed after propensity score adjustment (OR, 0.81; 95% CI, 0.32-2.05) and matching (OR, 0.79; 95% CI, 0.31-2.04). All-cause and IA-attributable mortality were also similar. Patients in the ISA group were less likely to experience treatment-emergent adverse events (17.5% versus 37.7%; P = 0.011) and premature treatment discontinuation (8.8% versus 23.4%; P = 0.027).

CONCLUSIONS

Front-line treatment with ISA for posttransplant IA led to similar clinical outcomes than VORI, with better tolerability and higher treatment completion.

From Hemorrhagic Shock to Postoperative Complications: Anesthesia, Intensive Care, and Surgical Management of a Young Male With Pulmonary Aspergillosis

Pulmonary aspergillosis is a life-threatening condition, especially for individuals with predisposing factors such as prior tuberculosis, smoking, and immune impairment. This case report describes the management of a 33-year-old male with a history of cured tuberculosis and active pulmonary aspergillosis who developed hemorrhagic shock following severe hemoptysis. Initial management included blood transfusion and the administration of tranexamic acid. Surgical prehabilitation was performed, and the patient underwent bilobectomy. Post-surgery, the patient developed respiratory failure due to a bronchopleural fistula, which was surgically repaired. The patient was managed in the intensive care unit (ICU) and subsequently discharged in good health. This case highlights the complexity of managing severe hemoptysis and its complications, and the importance of early multidisciplinary intervention and preoperative optimization.

CAF to the Rescue! Potential and Challenges of Combination Antifungal Therapy for Reducing Morbidity and Mortality in Hospitalized Patients With Serious Fungal Infections

The global burden of invasive fungal disease is substantial and escalating. Combination antifungal therapy (CAF) may improve patient outcomes by reducing development of resistance, improving drug penetration and rate of fungal clearance, and allowing for lower and less toxic antifungal drug doses; yet, increased cost, antagonism, drug-drug interactions, and toxicity are concerns. Clinical practice guidelines recommend antifungal monotherapy, rather than CAF, for most invasive fungal diseases due to a lack of comparative randomized clinical trials. An examination of the existing body of CAF research should frame new hypotheses and determine priorities for future CAF clinical trials. We performed a systematic review of CAF clinical studies for invasive candidiasis, cryptococcosis, invasive aspergillosis, and mucormycosis. Additionally, we summarized findings from animal models of CAF and assessed laboratory methods available to evaluate CAF efficacy. Future CAF trials should be prioritized according to animal models showing improved survival and observational clinical data supporting efficacy and safety.

Reappraising Cladophialophora bantiana phaeohyphomycosis in France: retrospective nation-based study

BACKGROUND

Cladophialophora bantiana is one of the most virulent phaeohyphomycetes, typically causes non-angiogenic single (or sometimes multiple) cystic brain lesions, and has resulted in a mortality rate of up to 70%. Most C bantiana cases are described either in a series of isolated reports or in very small cohorts. The aim of this retrospective nation-based study was to share the data on C bantiana phaeohyphomycosis cases reported in France and French overseas territories over the past two decades to improve understanding of this disease.

METHODS

Patients with C bantiana infection were processed through the active surveillance programme of invasive fungal infections launched by the National Reference Center for Mycoses and Antifungals, Institut Pasteur (Paris, France), and the French Surveillance Network of Invasive Fungal Infections, which involved 29 hospitals from mainland France and overseas French territories. Only proven and probable cases of infection, according to the revised and updated consensus definitions from the European Organization for Research and Treatment of Cancer and Mycoses Study Group, were included in the study. Patients were diagnosed or confirmed, or both, using a polyphasic approach at the Institut Pasteur between 2002 and 2022. Patients were separated into two groups: those with CNS involvement and those with no CNS involvement. The primary outcome was the survival rate.

FINDINGS

A total of 23 patients with a C bantiana invasive infection were included during the study period (Jan 1, 2002, to Dec 31, 2022). The median age was 56 years in the CNS involvement group and 65 years in the non-CNS involvement group. Until 2021, the annual number of cases varied between zero and two, with six cases observed in 2022, the warmest year recorded in France since 1900. CNS involvement was observed in 15 (65%) patients, including three disseminated cases; skin and soft tissue involvement in seven (30%) patients and an isolated lung infection in one case. Diabetes was observed in five patients, and any immunodepression factor was observed in 14 (61%) of 23 patients. When considering only patients with CNS involvement, 9-month survival appeared higher in patients who underwent exeresis or large drainage (three [75%] of four patients vs three [27%] of 11 patients; p=0·24) and significantly higher in those treated for 2 or more weeks with triple antifungal therapy (liposomal amphotericin B plus posaconazole and flucytosine; seven [78%] of nine patients vs one [17%] of six patients; p=0·040). Two patients were treated with excision surgery alone (one patient with success, and the other patient lost to follow-up).

INTERPRETATION

This study shows that the clinical presentations and underlying medical conditions of C bantiana infections are more diverse than previously described. It also emphasises a significant difference in mortality rate between those with and without CNS involvement. The prognosis improved when surgery was performed and triple antifungal therapy was administered. Such rare and devastating invasive fungal infections should be managed by a multidisciplinary team.

FUNDING

Santé Publique France.

Identifying Gaps in the International Consensus Case Definitions for Invasive Aspergillosis: A Review of Clinical Cases Not Meeting These Definitions

Background

International consensus definitions for invasive aspergillosis (IA) in research are rigorous, yet clinically significant cases are often excluded from clinical studies for not meeting proven/probable IA case definitions. To better understand reasons for the failure to meet criteria for proven/probable infection, we herein review 47 such cases for their clinical and microbiological characteristics and outcomes.

Methods

Data on 47 cases that did not meet consensus IA definitions but were deemed significant were derived from a retrospective, observational, multicenter survey of 382 presumed IA cases across Australasia, of which findings of 221 proven/probable infections were recently published. The clinical, microbiological, and radiologic characteristics of these cases were analyzed. Mortality outcomes were compared with those of 221 proven/probable cases.

Results

Of 47 cases studied, 15 lacked classical host factors; 22 exhibited only a single positive Aspergillus polymerase chain reaction result; 7 lacked typical IA radiologic findings on chest computed tomography; and 3 had borderline galactomannan optical density indices (<1.0 but ≥0.5) in bronchoalveolar lavage fluid. The median age of patients was 61 years (IQR, 52-68); 34 were male (72%). Seven patients (15%) required intensive care admission. All patients had lung as the primary site of infection. Antifungal treatment was initiated in 42 patients (89%). All-cause 90-day mortality was 33%, similar to the 30% mortality in the comparative cohort (n = 221).

Conclusions

Our findings highlight the limitations of current consensus definitions for IA. Notably, the mortality of patients not meeting these definitions was similar to that of patients with proven/probable IA. Further studies, especially of patients with a single positive Aspergillus polymerase chain reaction result and those without host factors, are needed to determine if future consensus definitions may benefit from modifications.

Invasive fungal disease and antifungal prophylaxis in children with acute leukaemia: a multicentre retrospective Australian cohort study

Background

Invasive fungal disease (IFD) is a significant complication for children receiving treatment for leukaemia, contributing to morbidity and mortality. Recent regional paediatric epidemiological IFD data are lacking. Additionally uncertainty remains regarding the optimal prophylactic approach in this context.

Methods

In a multi-centre Australian cohort study of children diagnosed with de novo acute leukaemia between 1st January 2017 and 30th June 2020, we characterised antifungal prophylaxis prescribing and IFD prevalence. Impact of antifungal prophylaxis was assessed using Kaplan Meier curves and Cox-proportional hazards regression adjusting for known IFD risk factors.

Findings

A total of 434 children were included (47.2% female; median age 5.0 years, median follow-up 240 days). This cohort included 351 children with ALL (214 high-risk [HR-ALL]; 137 standard-risk [SR-ALL]), and 73 with AML. The prevalence of proven/probable IFD was 6.8% for AML, 14.0% for HR-ALL and 4.4% for SR-ALL. A mould was implicated as the causative pathogen in almost two thirds of cases. Antifungal prophylaxis was prescribed in 98.7% of chemotherapy cycles for AML, 56.7% for HR-ALL and 14.9% for SR-ALL. A mould-active agent was used in 77.4% of AML cycles and 21.2% of HR-ALL cycles. Mould-active prophylaxis was associated with a lower risk of IFD overall and increased IFD-free survival in AML.

Interpretation

These data demonstrate the persistent high regional burden of IFD in children with HR-ALL, and the potential for mould-active prophylaxis to ameliorate this. Strategies to increase uptake of appropriate prophylaxis are required in this cohort.

Funding

This study was supported by a Perth Children's Hospital Foundation grant (PCHF9973).

Invasive aspergillosis in liver transplant recipients in the current era

Invasive aspergillosis (IA) is a rare but fatal disease among liver transplant recipients (LiTRs). We performed a multicenter 1:2 case-control study comparing LiTRs diagnosed with proven/probable IA and controls with no invasive fungal infection. We included 62 IA cases and 124 matched controls. Disseminated infection occurred only in 8 cases (13%). Twelve-week all-cause mortality of IA was 37%. In multivariate analyses, systemic antibiotic usage (adjusted odds ratio [aOR], 4.74; P = .03) and history of pneumonia (aOR, 48.7; P = .01) were identified as independent risk factors associated with the occurrence of IA. Moreover, reoperation (aOR, 5.99; P = .01), systemic antibiotic usage (aOR, 5.03; P = .04), and antimold prophylaxis (aOR, 11.9; P = .02) were identified as independent risk factors associated with the occurrence of early IA. Among IA cases, Aspergillus colonization (adjusted hazard ratio [aHR], 86.9; P < .001), intensive care unit stay (aHR, 3.67; P = .02), disseminated IA (aHR, 8.98; P < .001), and dialysis (aHR, 2.93; P = .001) were identified as independent risk factors associated with 12-week all-cause mortality, while recent receipt of tacrolimus (aHR, 0.11; P = .001) was protective. Mortality among LiTRs with IA remains high in the current era. The identified risk factors and protective factors may be useful for establishing robust targeted antimold prophylactic and appropriate treatment strategies against IA.

Diagnosing fungal infections in clinical practice: a narrative review

BACKGROUND

Invasive fungal infections (IFI) present a major medical challenge, with an estimated 6.5 million cases annually, resulting in 3.8 million deaths. Pathogens such as Aspergillus spp. Candida spp. Mucorales spp. Cryptococcus spp. and other fungi species contribute to these infections, posing risks to immunocompromised individuals. Early and accurate diagnosis is crucial for effective treatment and better patient outcomes.

AREAS COVERED

This narrative review provides an overview of the current methods and challenges associated with diagnosing fungal diseases, including invasive aspergillosis and invasive candidiasis, as well as rare and endemic fungal infections. Various diagnostic techniques, including microscopy, culture, molecular diagnostics, and serological tests, are reviewed, highlighting their respective advantages and limitations and role in clinical guidelines. To illustrate, the need for improved diagnostic strategies to overcome existing challenges, such as the low sensitivity and specificity of current tests and the time-consuming nature of traditional culture-based methods, is addressed.

EXPERT OPINION

Current advancements in fungal infection diagnostics have significant implications for healthcare outcomes. Improved strategies like molecular testing and antigen detection promise early detection of fungal pathogens, enhancing patient management. Challenges include global access to advanced technologies and the need for standardized, user-friendly point-of-care diagnostics to improve diagnosis of fungal infections globally.