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How we treat invasive fungal diseases in patients with acute leukemia: the importance of an individualized approach. Blood 2014; 124:3858-69. [DOI: 10.1182/blood-2014-04-516211] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
AbstractInvasive fungal diseases (IFDs) represent an important cause of treatment failure in adults with acute leukemia. Because of leukemia’s heterogeneity, the risk for IFDs is highly variable. We therefore apply a risk-adapted antifungal strategy with strong emphasis on pretreatment and day-15 posttreatment to allow earlier and more individualized interventions. We determine pretreatment risks for IFDs based on 4 factors: (1) host fitness for standard therapy (ie, fit, unfit, or frail); (2) leukemia resistance (high vs low probability of achieving complete remission [CR]); (3) anticipated treatment-related toxicity such as neutropenia, mucositis, and steroid-induced immunosuppression; and (4) patient exposure to opportunistic fungi. Accordingly, we stratify patients as high, intermediate, or low risk for IFDs and apply risk-adapted antifungal strategies, including primary or secondary prophylaxis and diagnostic-based preemptive or empiric therapy. Prevention of IFDs also relies on optimizing organ function, decreasing exposure to opportunistic fungi, and improving net state of immunosuppression with use of better-tolerated and investigational agents for unfit patients and those with adverse leukemia biology. Novel targeted and safe therapies that can achieve higher rates of sustained CR among patients with adverse genetics offer the best promise for reducing the burden of IFDs in these patients.
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202
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Delwarde B, Schmitt Z, Bienvenu AL, Duperret S, Aubrun F. [Cerebral aspergillosis and liver transplantation: about one case]. J Mycol Med 2014; 24:332-6. [PMID: 25442922 DOI: 10.1016/j.mycmed.2014.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 06/10/2014] [Accepted: 06/30/2014] [Indexed: 10/24/2022]
Abstract
Cerebral invasive aspergillosis is a rare but serious infection. Mortality is still high despite appropriate treatment. We report the case of a patient with liver transplantation in the context of alcoholic cirrhosis and transplanted back seven years later consequently to an ischemic cholangitis. Following an acquired active viral infection by HCV and treated by antiviral combination therapy the patient presented six months after this second operation a cerebral aspergillosis of tumour-like presentation. It rapidly evolved to an unfavourable outcome with intracranial hypertension state. If the therapeutic management is well established, the diagnosis is difficult. This observation allows us to discuss the various diagnostic criteria of cerebral aspergillosis.
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Affiliation(s)
- B Delwarde
- Service d'anesthésie-réanimation, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France.
| | - Z Schmitt
- Service d'anesthésie-réanimation, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - A L Bienvenu
- Service de microbiologie, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - S Duperret
- Service d'anesthésie-réanimation, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - F Aubrun
- Service d'anesthésie-réanimation, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France
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203
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Hoyo I, Sanclemente G, de la Bellacasa JP, Cofán F, Ricart M, Cardona M, Colmenero J, Fernández J, Escorsell A, Navasa M, Moreno A, Cervera C. Epidemiology, clinical characteristics, and outcome of invasive aspergillosis in renal transplant patients. Transpl Infect Dis 2014; 16:951-957. [DOI: 10.1111/tid.12301] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- I. Hoyo
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - G. Sanclemente
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - J. Puig de la Bellacasa
- Microbiology, “Centre Diagnòstic Biomèdic” (CDB); Centre for International Health Research (CRESIB); Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - F. Cofán
- Renal Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M.J. Ricart
- Renal Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M. Cardona
- Heart Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - J. Colmenero
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - J. Fernández
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - A. Escorsell
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - M. Navasa
- Liver Transplant Unit; Hospital Clinic of Barcelona - IDIBAPS - University of Barcelona; Barcelona Spain
| | - A. Moreno
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
| | - C. Cervera
- Department of Infectious Diseases; Hospital Clinic of Barcelona - Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona; Barcelona Spain
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Crabol Y, Lortholary O. Invasive mold infections in solid organ transplant recipients. SCIENTIFICA 2014; 2014:821969. [PMID: 25525551 PMCID: PMC4261198 DOI: 10.1155/2014/821969] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/03/2014] [Indexed: 05/13/2023]
Abstract
Invasive mold infections represent an increasing source of morbidity and mortality in solid organ transplant recipients. Whereas there is a large literature regarding invasive molds infections in hematopoietic stem cell transplants, data in solid organ transplants are scarcer. In this comprehensive review, we focused on invasive mold infection in the specific population of solid organ transplant. We highlighted epidemiology and specific risk factors for these infections and we assessed the main clinical and imaging findings by fungi and by type of solid organ transplant. Finally, we attempted to summarize the diagnostic strategy for detection of these fungi and tried to give an overview of the current prophylaxis treatments and outcomes of these infections in solid organ transplant recipients.
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Affiliation(s)
- Yoann Crabol
- Université Paris Descartes, Sorbonne Paris Cité, Centre d'Infectiologie Necker Pasteur, Institut Imagine, Hôpital Universitaire Necker-Enfants Malades, APHP, 75015 Paris, France
| | - Olivier Lortholary
- Université Paris Descartes, Sorbonne Paris Cité, Centre d'Infectiologie Necker Pasteur, Institut Imagine, Hôpital Universitaire Necker-Enfants Malades, APHP, 75015 Paris, France
- Institut Pasteur, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, CNRS URA3012, 75015 Paris, France
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205
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Sugui JA, Kwon-Chung KJ, Juvvadi PR, Latgé JP, Steinbach WJ. Aspergillus fumigatus and related species. Cold Spring Harb Perspect Med 2014; 5:a019786. [PMID: 25377144 DOI: 10.1101/cshperspect.a019786] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The genus Aspergillus contains etiologic agents of aspergillosis. The clinical manifestations of the disease range from allergic reaction to invasive pulmonary infection. Among the pathogenic aspergilli, Aspergillus fumigatus is most ubiquitous in the environment and is the major cause of the disease, followed by Aspergillus flavus, Aspergillus niger, Aspergillus terreus, Aspergillus nidulans, and several species in the section Fumigati that morphologically resemble A. fumigatus. Patients that are at risk for acquiring aspergillosis are those with an altered immune system. Early diagnosis, species identification, and adequate antifungal therapy are key elements for treatment of the disease, especially in cases of pulmonary invasive aspergillosis that often advance very rapidly. Incorporating knowledge of the basic biology of Aspergillus species to that of the diseases that they cause is fundamental for further progress in the field.
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Affiliation(s)
- Janyce A Sugui
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Kyung J Kwon-Chung
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Praveen R Juvvadi
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina 27715
| | - Jean-Paul Latgé
- Unité des Aspergillus, Institut Pasteur, Paris 75724, France
| | - William J Steinbach
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina 27715 Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina 27710
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Lerolle N, Raffoux E, Socie G, Touratier S, Sauvageon H, Porcher R, Bretagne S, Bergeron A, Azoulay E, Molina JM, Lafaurie M. Breakthrough invasive fungal disease in patients receiving posaconazole primary prophylaxis: a 4-year study. Clin Microbiol Infect 2014; 20:O952-9. [DOI: 10.1111/1469-0691.12688] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 05/12/2014] [Accepted: 05/17/2014] [Indexed: 01/28/2023]
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Facilitating surveillance of pulmonary invasive mold diseases in patients with haematological malignancies by screening computed tomography reports using natural language processing. PLoS One 2014; 9:e107797. [PMID: 25250675 PMCID: PMC4175456 DOI: 10.1371/journal.pone.0107797] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 08/23/2014] [Indexed: 01/22/2023] Open
Abstract
Purpose Prospective surveillance of invasive mold diseases (IMDs) in haematology patients should be standard of care but is hampered by the absence of a reliable laboratory prompt and the difficulty of manual surveillance. We used a high throughput technology, natural language processing (NLP), to develop a classifier based on machine learning techniques to screen computed tomography (CT) reports supportive for IMDs. Patients and Methods We conducted a retrospective case-control study of CT reports from the clinical encounter and up to 12-weeks after, from a random subset of 79 of 270 case patients with 33 probable/proven IMDs by international definitions, and 68 of 257 uninfected-control patients identified from 3 tertiary haematology centres. The classifier was trained and tested on a reference standard of 449 physician annotated reports including a development subset (n = 366), from a total of 1880 reports, using 10-fold cross validation, comparing binary and probabilistic predictions to the reference standard to generate sensitivity, specificity and area under the receiver-operating-curve (ROC). Results For the development subset, sensitivity/specificity was 91% (95%CI 86% to 94%)/79% (95%CI 71% to 84%) and ROC area was 0.92 (95%CI 89% to 94%). Of 25 (5.6%) missed notifications, only 4 (0.9%) reports were regarded as clinically significant. Conclusion CT reports are a readily available and timely resource that may be exploited by NLP to facilitate continuous prospective IMD surveillance with translational benefits beyond surveillance alone.
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208
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Panackal AA, Parisini E, Proschan M. Salvage combination antifungal therapy for acute invasive aspergillosis may improve outcomes: a systematic review and meta-analysis. Int J Infect Dis 2014; 28:80-94. [PMID: 25240416 DOI: 10.1016/j.ijid.2014.07.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 07/02/2014] [Accepted: 07/04/2014] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE A meta-analysis was performed to compare mold-active triazoles or lipid amphotericin B plus an echinocandin to non-echinocandin monotherapy for acute invasive aspergillosis (IA). METHODS We searched PubMed, EMBASE, and other databases through May 2013 unrestricted by language. We included observational and experimental studies wherein patients with proven or probable IA by EORTC/MSG criteria underwent our comparative intervention. PRISMA and MOOSE guidelines were followed and quality was assessed using the Jadad and Newcastle-Ottawa criteria. Meta-regression with fixed and random effects and sensitivity analyses were performed. The primary study outcome measure was 12-week overall mortality. The secondary outcome assessed was complete and partial response. RESULTS Only observational studies of primary 12-week survival showed heterogeneity (I(2)=48.96%, p=0.05). For salvage IA therapy, fixed effects models demonstrated improved 12-week survival (Peto odds ratio (OR) 1.80, 95% confidence interval (CI) 1.08-3.01) and success (Peto OR 2.17, 95% CI 1.21-3.91) of combination therapy. Significance remained after applying random effects as a sensitivity analysis (12-week survival: Peto OR 1.90, 95% CI 1.04-3.46, and unchanged value for success). Restriction to high quality studies and including echinocandins as the comparator for refractory IA revealed an adjusted OR of 1.72 (95% CI 0.96-3.09; p=0.07) for global success, while the survival endpoint remained unaltered. CONCLUSIONS Combination antifungals for IA demonstrate improved outcomes over monotherapy in the salvage setting. Clinicians should consider this approach in certain situations.
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Affiliation(s)
- Anil A Panackal
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Clinical Research Center, Building 10, Room 11N222, 10 Center Drive, Bethesda, MD 20892, MSC 1888, USA; Division of Infectious Diseases, Department of Medicine, F. Hèbert School of Medicine, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA.
| | - Emilio Parisini
- Center for Nano Science and Technology, Politecnico di Milano, Istituto Italiano di Tecnologia, Milan, Italy
| | - Michael Proschan
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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209
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Dignani MC. Epidemiology of invasive fungal diseases on the basis of autopsy reports. F1000PRIME REPORTS 2014; 6:81. [PMID: 25343038 PMCID: PMC4166943 DOI: 10.12703/p6-81] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Invasive fungal diseases (IFDs) are a major cause of morbidity and mortality among immunocompromised patients and cost to health services. They are difficult to prevent, diagnose, and treat. This difficulty in diagnosis leads us to treat them empirically by using several tools, including epidemiological data, non-culture methods and images. Most of the available epidemiological information may not be accurate because we are dealing with a disease that only has an estimated 50% chance of being diagnosed before death. Therefore, autopsy reports become a valuable tool, not only to define the real epidemiology, but also to address the trend in pre-mortem diagnosis, which is the best marker available to prove the efficiency of the research in IFD. This article reviews and analyzes the data on IFD obtained from 11 single-center, multi-center and nationwide autopsy reports published between 2008 and 2013, and also discusses the issues we need to address in order to improve the quality of the epidemiological data on invasive fungal disease obtained from autopsy reports.
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Affiliation(s)
- María Cecilia Dignani
- Registro de Micosis Invasoras REMIIN (Invasive Mycoses' Registry)Yerbal 315 App 2B, 1405, Buenos AiresArgentina
- Argentinean Society of Infectious DiseasesAv. De Mayo 1370, Floor 11, Of. 300, 1085, Buenos AiresArgentina
- Italian Hospital of MendozaEast Access 1070, San José, 5519, MendozaArgentina
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210
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Gavaldà J, Meije Y, Fortún J, Roilides E, Saliba F, Lortholary O, Muñoz P, Grossi P, Cuenca-Estrella M. Invasive fungal infections in solid organ transplant recipients. Clin Microbiol Infect 2014; 20 Suppl 7:27-48. [DOI: 10.1111/1469-0691.12660] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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211
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Wang C, Zhan P, Wang L, Zeng R, Shen Y, Lv G, Li D, Deng S, Liu W. The application of laser microdissection in molecular detection and identification of aspergillus fumigatus from murine model of acute invasive pulmonary aspergillosis. Mycopathologia 2014; 178:53-61. [PMID: 24973974 DOI: 10.1007/s11046-014-9777-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/19/2014] [Indexed: 01/14/2023]
Abstract
Invasive aspergillosis (IA) is a major concern in patients with severe immune deficiency. As antifungal susceptibility varies in different fungal pathogens, accurate and timely identification of species is becoming imperative for guidance of therapy and reducing high mortality rates in patients with IA. But, in fact, the diagnosis is challenging and new validated techniques are required for the detection and identification of clinically relevant isolates. The laser capture microdissection (LCM) system enables analysis of cytologically and/or phenotypically defined cell types from heterogeneous tissue and has been used in diagnosis and fungal species identification in pulmonary aspergillosis of white storks. To establish the experimental foundation for clinical application of the system, we microdissected and collected Blankophor-stained single hyphal strands from tissue cryosections of murine model of invasive pulmonary aspergillosis (IPA) with A. fumigatus by LCM, subsequently processed for DNA extraction, PCR sequencing, and species molecular identification. The sensitivity of LCM-PCR sequencing was 89 % (89/100), and the specificity was 100 %. Moreover, the positive predictive value and negative predictive value were 100 and 78.43 %, respectively. The result approved that the LCM-based methods had the potential for accurately diagnosis and rapidly identification fungal pathogens of IPA.
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Affiliation(s)
- Chong Wang
- Department of Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, No. 12, Jiang Wangmiao Street, Nanjing, 210042, People's Republic of China
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212
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Ruiz-Camps I, Jarque I. [Invasive mould disease in haematological patients]. Rev Iberoam Micol 2014; 31:249-54. [PMID: 25434346 DOI: 10.1016/j.riam.2014.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022] Open
Abstract
Invasive mould infections (IMI) are a persistent problem with high morbidity and mortality rates among patients receiving chemotherapy for hematological malignancies and hematopoietic stem cell transplant recipients. Management of IMI in this setting has become increasingly complex with the advent of new antifungal agents and diagnostic tests, which have resulted in different therapeutic strategies (prophylactic, empirical, pre-emptive, and directed). A proper assessment of the individual risk for IMI appears to be critical in order to use the best prophylactic and therapeutic approach and increase the survival rates. Among the available antifungal drugs, the most frequently used in the hematologic patient are fluconazole, mould-active azoles (itraconazole, posaconazole and voriconazole), candins (anidulafungin, caspofungin and micafungin), and lipid formulations of amphotericin B. Specific recommendations for their use, and criteria for selecting the antifungal agents are discussed in this paper.
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Affiliation(s)
- Isabel Ruiz-Camps
- Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - Isidro Jarque
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
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213
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First detection of TR46/Y121F/T289A and TR34/L98H alterations in Aspergillus fumigatus isolates from azole-naive patients in Denmark despite negative findings in the environment. Antimicrob Agents Chemother 2014; 58:5096-101. [PMID: 24936595 DOI: 10.1128/aac.02855-14] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Azole-resistant Aspergillus fumigatus harboring the TR34/L98H or TR46/Y121F/T289A alterations is increasingly found in Europe and Asia. Here, we present the first clinical cases of TR46/Y121/T289A and three cases of TR34/L98H outside the cystic fibrosis (CF) population in Denmark and the results of environmental surveys. Four patients (2012 to 2014) with 11 A. fumigatus and 4 Rhizomucor pusillus isolates and 239 soil samples (spring 2010 and autumn 2013, respectively) with a total of 113 A. fumigatus isolates were examined. Aspergillus isolates were screened for azole resistance using azole-containing agar. Confirmatory susceptibility testing was done using the EUCAST microbroth dilution EDEF 9.1 reference method. For relevant A. fumigatus isolates, CYP51A sequencing and microsatellite genotyping were performed. Three patients harbored TR34/L98H isolates. Two were azole naive at the time of acquisition and two were coinfected with wild-type A. fumigatus or R. pusillus isolates, complicating and delaying diagnosis. The TR46/Y121F/T289A strain was isolated in 2014 from a lung transplant patient. Genotyping indicated that susceptible and resistant Aspergillus isolates were unrelated and that no transmission between patients occurred. Azole resistance was not detected in any of the 113 soil isolates. TR34/L98H and TR46/Y121F/T289A alterations appear to be emerging in the clinical setting in Denmark and now involve azole-naive patients. Two recent soil-sampling surveys in Denmark were unable to indicate any increased prevalence of azole-resistant A. fumigatus in the environment. These findings further support the demand for real-time susceptibility testing of all clinically relevant isolates and for studies investigating the seasonal variation and ecological niches for azole-resistant environmental A. fumigatus.
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Abstract
Understanding the tissue penetration of systemically administered antifungal agents is critical for a proper appreciation of their antifungal efficacy in animals and humans. Both the time course of an antifungal drug and its absolute concentrations within tissues may differ significantly from those observed in the bloodstream. In addition, tissue concentrations must also be interpreted within the context of the pathogenesis of the various invasive fungal infections, which differ significantly. There are major technical obstacles to the estimation of concentrations of antifungal agents in various tissue subcompartments, yet these agents, even those within the same class, may exhibit markedly different tissue distributions. This review explores these issues and provides a summary of tissue concentrations of 11 currently licensed systemic antifungal agents. It also explores the therapeutic implications of their distribution at various sites of infection.
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215
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Houdouin V, Pouessel G, Angoulvant F, Brouard J, Derelle J, Fayon M, Ferroni A, Gangneux JP, Hau I, Le Bourgeois M, Lorrot M, Menotti J, Nathan N, Vabret A, Wallet F, Bonacorsi S, Cohen R, de Blic J, Deschildre A, Gandemer V, Pin I, Labbe A, Le Roux P, Martinot A, Rammaert B, Dubus JC, Delacourt C, Marguet C. Recommandations sur l’utilisation des nouveaux outils diagnostiques étiologiques des infections respiratoires basses de l’enfant de plus de trois mois. Arch Pediatr 2014; 21:418-23. [DOI: 10.1016/j.arcped.2014.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/16/2013] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
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Desplanques PY, Burlacu R, Poinsignon V, Boussion H, Borget I, Wyplosz B, de Botton S, Billaud E, Chachaty E, Gachot B, Netzer F, Micol JB. Factors influencing posaconazole plasmatic concentrations in patients presenting with acute myeloid leukemia. Med Mal Infect 2014; 44:174-9. [PMID: 24656841 DOI: 10.1016/j.medmal.2014.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/08/2014] [Accepted: 02/12/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE The effectiveness of posaconazole (PSZ) prophylaxis on invasive fungal infections, in patients presenting with acute myeloid leukemia (AML), seems to be correlated to its blood plasma concentration. Our goal was to identify the risk factors for underdosing. PATIENTS AND METHODS We retrospectively reviewed the records of patients treated for AML treated with PSZ, during a 2-year period. Assays<500ng/mL were considered as under dosed. RESULTS Fifty-nine assays (43 patients) were performed during induction (n=22) or consolidation (n=37) chemotherapy. PSZ treatment was initiated within a median of 3 days before neutropenia with a first assay performed at 8 days (3-28). The median PSZ blood plasma concentration was 375ng/mL (<200-1900). Forty-one (69%) treatment were maintained until the end of neutropenia. One patient presented with candidemia, 9 with possible invasive aspergillosis, without any significant association with underdosing. The univariate analysis showed that co-administration of proton pump inhibitors (PPIs) (P=0.01) and cause of hospitalization (induction chemotherapy vs consolidation, P=0.008) were associated with underdosing, contrary to feeding difficulties (P=0.07) and digestive disorders (P=0.5). The multivariate analysis confirmed the impact of PPI use (P=0.01) and the cause of hospitalization (P=0.003). CONCLUSION This study highlights the major impact of PPI administration on PSZ blood plasma levels and stresses the risk of non-effective prophylaxis during induction treatment of AML.
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Affiliation(s)
- P-Y Desplanques
- Service de pharmacie clinique, Institut Gustave-Roussy, 94805 Villejuif cedex, France
| | - R Burlacu
- Service d'hématologie, Institut Gustave Roussy, 94805 Villejuif cedex, France
| | - V Poinsignon
- Service de pharmacologie et toxicologie, Hôpital Européen George-Pompidou, 75015 Paris, France
| | - H Boussion
- Service d'hématologie, Institut Gustave Roussy, 94805 Villejuif cedex, France
| | - I Borget
- Service de biostatistique et d'épidémiologie, Institut Gustave-Roussy, université Paris-Sud, 94805 Villejuif cedex, France
| | - B Wyplosz
- Service de maladies infectieuses, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - S de Botton
- Service d'hématologie, Institut Gustave Roussy, 94805 Villejuif cedex, France
| | - E Billaud
- Service de pharmacologie et toxicologie, Hôpital Européen George-Pompidou, 75015 Paris, France
| | - E Chachaty
- Service de microbiologie, Institut Gustave-Roussy, 94805 Villejuif cedex, France
| | - B Gachot
- Département de soins aigus, Institut Gustave-Roussy, 94805 Villejuif cedex, France
| | - F Netzer
- Service de pharmacie clinique, Institut Gustave-Roussy, 94805 Villejuif cedex, France
| | - J-B Micol
- Service d'hématologie, Institut Gustave Roussy, 94805 Villejuif cedex, France.
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217
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Brenier-Pinchart MP, Abaibou H, Berendsen T, Szymanski G, Beghri M, Bailly S, Lasnet F, Thiebaut-Bertrand A, Mabilat C, Pelloux H. Usefulness of pan-fungal NASBA test for surveillance of environmental fungal contamination in a protected hematology unit. Med Mycol 2014; 52:433-7. [PMID: 24577010 DOI: 10.1093/mmy/myt017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A pan-fungal nucleic acid sequence based applification (NASBA) test was adapted and used for the first time to detect and quantify the level of filamentous fungi in environmental samples. Surface samples (n = 356) collected in a controlled air flow hematology ward were tested by mycological culture and the pan-fungal NASBA test. The overall percentage of agreement between culture and NASBA was 88%, the Kappa coefficient was equal to 0.61 (95%CI = [0.51; 0.72]). This pan-fungal NASBA test could be a promising tool to rapidly monitor the absence of molds in controlled environments.
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Desoubeaux G, Bailly É, Chandenier J. Diagnosis of invasive pulmonary aspergillosis: Updates and recommendations. Med Mal Infect 2014; 44:89-101. [DOI: 10.1016/j.medmal.2013.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 09/15/2013] [Accepted: 11/18/2013] [Indexed: 01/26/2023]
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Nosari AM, Pioltelli ML, Riva M, Marbello L, Nichelatti M, Greco A, Molteni A, Vismara E, Gabutti C, Volonterio A, Lombardi P, Morra E. Invasive fungal infections in lymphoproliferative disorders: a monocentric retrospective experience. Leuk Lymphoma 2014; 55:1844-8. [PMID: 24138328 DOI: 10.3109/10428194.2013.853299] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Invasive fungal infections (IFIs) seem to be a relevant cause of morbidity and mortality in patients with chronic lymphoproliferative disorders. We studied retrospectively the epidemiology, clinical manifestations and outcome of invasive fungal infections in 42 patients with lymphoproliferative diseases, treated between January 2004 and February 2012 for probable or proven IFI. In our entire population (1355 patients) of chronic lymphoproliferative malignancies, the incidence of probable/proven IFI was 3% (molds 2.3%, yeasts 0.5%, mixed infections 0.2%). Eight patients developed a yeast infection documented by blood cultures in seven cases and by the microscopic observation of Candida spp. in the vitreum after vitrectomy in one case. Among molds we diagnosed three proven infections by histologic evidence of Aspergillus spp. (n = 2) and Mucor (n = 1) in the lung and 28 probable mycoses. Three mixed infections from both molds and yeasts were also observed. Twenty-two cases showed positivity of galactomannan antigen in the serum (n = 16), in bronchoalveolar lavage (BAL) fluid (n = 4) or in both (n = 2). Cultures were positive in 11 cases. The overall rate of response to therapy was 64%. Fungal-attributable mortality rate was 17%, with a significant difference between molds and yeasts (16% vs. 25%, p = 0.03). At univariate analysis, the only risk factors related to mortality were severe and prolonged neutropenia (p = 0.003) and age (p = 0.03). Among molds, the rapid start of antifungals was probably partially responsible, together with new drugs, for the reduction of mortality, despite the severe immunosuppression of these patients.
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Lanternier F, Cypowyj S, Picard C, Bustamante J, Lortholary O, Casanova JL, Puel A. Primary immunodeficiencies underlying fungal infections. Curr Opin Pediatr 2013; 25:736-47. [PMID: 24240293 PMCID: PMC4098727 DOI: 10.1097/mop.0000000000000031] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW We review the primary immunodeficiencies (PIDs) underlying an increasing variety of superficial and invasive fungal infections. We also stress that the occurrence of such fungal infections should lead physicians to search for the corresponding single-gene inborn errors of immunity. Finally, we suggest that other fungal infections may also result from hitherto unknown inborn errors of immunity, at least in some patients with no known risk factors. RECENT FINDINGS An increasing number of PIDs are being shown to underlie fungal infectious diseases in children and young adults. Inborn errors of the phagocyte NADPH oxidase complex (chronic granulomatous disease), severe congenital neutropenia (SCN) and leukocyte adhesion deficiency type I confer a predisposition to invasive aspergillosis and candidiasis. More rarely, inborn errors of interferon-γ immunity underlie endemic mycoses. Inborn errors of interleukin-17 immunity have recently been shown to underlie chronic mucocutaneous candidiasis (CMC), while inborn errors of caspase recruitment domain-containing protein 9 (CARD9) immunity underlie deep dermatophytosis and invasive candidiasis. SUMMARY CMC, invasive candidiasis, invasive aspergillosis, deep dermatophytosis, pneumocystosis, and endemic mycoses can all be caused by PIDs. Each type of infection is highly suggestive of a specific type of PID. In the absence of overt risk factors, single-gene inborn errors of immunity should be sought in children and young adults with these and other fungal diseases.
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MESH Headings
- Adolescent
- Adult
- Aspergillosis/genetics
- Aspergillosis/immunology
- Autoantibodies
- Candidiasis, Chronic Mucocutaneous/genetics
- Candidiasis, Chronic Mucocutaneous/immunology
- Child
- Child, Preschool
- Disease Susceptibility
- Female
- Genetic Diseases, Inborn/genetics
- Genetic Diseases, Inborn/immunology
- Humans
- Immunity, Cellular/genetics
- Immunologic Deficiency Syndromes/complications
- Immunologic Deficiency Syndromes/genetics
- Immunologic Deficiency Syndromes/immunology
- Infant
- Infant, Newborn
- Interleukin-17/immunology
- Male
- Mycoses/genetics
- Mycoses/immunology
- Pneumonia, Pneumocystis/genetics
- Pneumonia, Pneumocystis/immunology
- Risk Factors
- T-Lymphocytes, Helper-Inducer/immunology
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Affiliation(s)
- Fanny Lanternier
- aLaboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U980 Necker Medical School, Imagine Institute and Paris Descartes University, Sorbonne Paris Cité bInfectious Diseases and Tropical Medicine Unit, Necker-Enfants Malades Hospital, AP-HP and Paris Descartes University cPasteur Institute, National Reference Center of Invasive Mycoses and Antifungals, Paris, France dSt Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, New York, USA eStudy Center for Immunodeficiency fPediatric Hematology-Immunology Unit, Necker Enfants-Malades Hospital, AP-HP, and Paris Descartes University, Sorbonne Paris Cité, Paris, France
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221
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Mikulska M, Novelli A, Aversa F, Cesaro S, de Rosa FG, Girmenia C, Micozzi A, Sanguinetti M, Viscoli C. Voriconazole in clinical practice. J Chemother 2013; 24:311-27. [DOI: 10.1179/1973947812y.0000000051] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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222
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Montagna MT, Lovero G, Coretti C, Martinelli D, Delia M, De Giglio O, Caira M, Puntillo F, D'Antonio D, Venditti M, Sambri V, Di Bernardo F, Barbui A, Lo Cascio G, Concia E, Mikulska M, Viscoli C, Maximova N, Candoni A, Oliveri S, Lombardi G, Pitzurra L, Sanguinetti M, Masciari R, Santantonio T, Andreoni S, Barchiesi F, Pecile P, Farina C, Viale P, Specchia G, Caggiano G, Pagano L. SIMIFF study: Italian fungal registry of mold infections in hematological and non-hematological patients. Infection 2013; 42:141-51. [PMID: 24150958 PMCID: PMC3906525 DOI: 10.1007/s15010-013-0539-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 09/24/2013] [Indexed: 11/29/2022]
Abstract
Purpose We compared the risk factors, the diagnostic tools and the outcome of filamentous fungal infections (FFIs) in hematological patients (HAEs) and non-hematological patients (non-HAEs). Methods Prospective surveillance (2009–2011) of proven and probable FFIs was implemented in 23 Italian hospitals. Results Out of 232 FFIs, 113 occurred in HAEs and 119 in non-HAEs. The most frequent infection was invasive aspergillosis (76.1 % for HAEs, 56.3 % for non-HAEs), and the localization was principally pulmonary (83.2 % for HAEs, 74.8 % for non-HAEs). Neutropenia was a risk factor for 89.4 % HAEs; the main underlying condition was corticosteroid treatment (52.9 %) for non-HAEs. The distribution of proven and probable FFIs was different in the two groups: proven FFIs occurred more frequently in non-HAEs, whereas probable FFIs were correlated with the HAEs. The sensitivity of the galactomannan assay was higher for HAEs than for non-HAEs (95.3 vs. 48.1 %). The overall mortality rate was 44.2 % among the HAEs and 35.3 % among the non-HAEs. The etiology influenced the patient outcomes: mucormycosis was associated with a high mortality rate (57.1 % for HAEs, 77.8 % for non-HAEs). Conclusions The epidemiological and clinical data for FFIs were not identical in the HAEs and non-HAEs. The differences should be considered to improve the management of FFIs according to the patients’ setting.
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Affiliation(s)
- M T Montagna
- Hygiene Section, Department of Biomedical Science and Human Oncology, University of Bari, Piazza Giulio Cesare 11, 70124, Bari, Italy,
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223
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Nabili M, Shokohi T, Janbabaie G, Hashemi-Soteh MB, Ali-Moghaddam K, Aghili SR. Detection of invasive aspergillosis in bone marrow transplant recipients using real-time PCR. J Glob Infect Dis 2013; 5:68-75. [PMID: 23853434 PMCID: PMC3703213 DOI: 10.4103/0974-777x.112296] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: The invasive aspergillosis (IA) is a serious opportunistic infection caused by various species of Aspergillus in immunocompromised individuals. Basically, rapid and early diagnosis prevents IA progression. In this study we performed a Real Time PCR/ Fluorescence Resonance Energy Transfer (FRET) for diagnosis of IA in hematologic malignancies and bone marrow transplant recipients. Materials and Methods: Sixty two patients with hematologic malignancies and marrow transplant recipients were evaluated for IA in Sari and Tehran from 2009 to 2010. The primer and hybridization probe were designed to amplify the specific sequence of 18S rRNA genes using Light Cycler system and FRET. Galactomannan (GM) assay was performed on serums which obtained from selected patients using the Platelia Aspergillus kit. Results: According to the criteria defined by the European Organization for Research and Treatment of Cancer and Mycoses Study Group (EORTC/MSG) for IA, 18 (29%) patients out of 62 patients were stratified into probable and possible groups. The female-to-male ratio was 1:2; the mean age of the patients was 36 years. The most common malignancies in these patients were acute lymphoblastic leukemia (38.9%). The minimum detection limit was 10 conidia (101 CFU/ml) equivalents (100 fg) per PCR reaction. GM assay was positive in 20.9% and real-time PCR probe set assay were positive in 17.7% patients who had clinical signs and host factor according to the mentioned criteria. Conclusion: Using the Real-Time PCR/FRET assay in whole blood specimens seems to be a promising method for diagnosis of IA, especially when used in combination with the GM detection test.
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Affiliation(s)
- Mojtaba Nabili
- Department of Parasitology and Mycology, Invasive Fungi Research Center, Sari, Iran ; Social Security Organization, Golestan, Iran
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224
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Invasive pulmonary aspergillosis in critically ill immunocompetent patients. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0686-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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225
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Méheust D, Le Cann P, Reboux G, Millon L, Gangneux JP. Indoor fungal contamination: health risks and measurement methods in hospitals, homes and workplaces. Crit Rev Microbiol 2013; 40:248-60. [PMID: 23586944 DOI: 10.3109/1040841x.2013.777687] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Indoor fungal contamination has been associated with a wide range of adverse health effects, including infectious diseases, toxic effects and allergies. The diversity of fungi contributes to the complex role that they play in indoor environments and human diseases. Molds have a major impact on public health, and can cause different consequences in hospitals, homes and workplaces. This review presents the methods used to assess fungal contamination in these various environments, and discusses advantages and disadvantages for each method in consideration with different health risks. Air, dust and surface sampling strategies are compared, as well as the limits of various methods are used to detect and quantify fungal particles and fungal compounds. In addition to conventional microscopic and culture approaches, more recent chemical, immunoassay and polymerase chain reaction (PCR)-based methods are described. This article also identifies common needs for future multidisciplinary research and development projects in this field, with specific interests on viable fungi and fungal fragment detections. The determination of fungal load and the detection of species in environmental samples greatly depend on the strategy of sampling and analysis. Quantitative PCR was found useful to identify associations between specific fungi and common diseases. The next-generation sequencing methods may afford new perspectives in this area.
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226
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Does the current treatment of invasive fungal infection need to be reviewed? Enferm Infecc Microbiol Clin 2013; 32:523-8. [PMID: 23587702 DOI: 10.1016/j.eimc.2013.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 02/17/2013] [Indexed: 11/24/2022]
Abstract
Invasive fungal infections (IFIs) are becoming more frequent due to the increasing number of patients at risk. Over the last decade, their prognosis has improved with the diagnostic and therapeutic advances, including new antifungals. In the two years, from 2007 to 2009, antifungal consumption increased by 27%, 67 times more than antibacterial consumption, albeit with great differences between hospitals. The scientific evidence of the indications for antifungal prophylaxis and targeted antifungal therapy is strong; however, it is weak for empirical antifungal therapy, which is the most common indication. Antifungals are not harmless, since they are associated with a wide range of adverse effects and drug interactions, favor the development of resistance, contribute to other fungal superinfections and cause significant healthcare spending. Therefore, the question arises whether this extraordinary increase in consumption is justified, whether the use of antifungals is optimal, or whether it is necessary to reconsider the current treatment of IFIs instead.
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227
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Ullmann AJ, Akova M, Herbrecht R, Viscoli C, Arendrup MC, Arikan-Akdagli S, Bassetti M, Bille J, Calandra T, Castagnola E, Cornely OA, Donnelly JP, Garbino J, Groll AH, Hope WW, Jensen HE, Kullberg BJ, Lass-Flörl C, Lortholary O, Meersseman W, Petrikkos G, Richardson MD, Roilides E, Verweij PE, Cuenca-Estrella M. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: adults with haematological malignancies and after haematopoietic stem cell transplantation (HCT). Clin Microbiol Infect 2013; 18 Suppl 7:53-67. [PMID: 23137137 DOI: 10.1111/1469-0691.12041] [Citation(s) in RCA: 233] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Fungal diseases still play a major role in morbidity and mortality in patients with haematological malignancies, including those undergoing haematopoietic stem cell transplantation. Although Aspergillus and other filamentous fungal diseases remain a major concern, Candida infections are still a major cause of mortality. This part of the ESCMID guidelines focuses on this patient population and reviews pertaining to prophylaxis, empirical/pre-emptive and targeted therapy of Candida diseases. Anti-Candida prophylaxis is only recommended for patients receiving allogeneic stem cell transplantation. The authors recognize that the recommendations would have most likely been different if the purpose would have been prevention of all fungal infections (e.g. aspergillosis). In targeted treatment of candidaemia, recommendations for treatment are available for all echinocandins, that is anidulafungin (AI), caspofungin (AI) and micafungin (AI), although a warning for resistance is expressed. Liposomal amphotericin B received a BI recommendation due to higher number of reported adverse events in the trials. Amphotericin B deoxycholate should not be used (DII); and fluconazole was rated CI because of a change in epidemiology in some areas in Europe. Removal of central venous catheters is recommended during candidaemia but if catheter retention is a clinical necessity, treatment with an echinocandin is an option (CII(t) ). In chronic disseminated candidiasis therapy, recommendations are liposomal amphotericin B for 8 weeks (AIII), fluconazole for >3 months or other azoles (BIII). Granulocyte transfusions are only an option in desperate cases of patients with Candida disease and neutropenia (CIII).
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Affiliation(s)
- A J Ullmann
- Department of Internal Medicine II, Julius-Maximilians-University, Würzburg, Germany.
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Lelièvre L, Groh M, Angebault C, Maherault AC, Didier E, Bougnoux ME. Azole resistant Aspergillus fumigatus: an emerging problem. Med Mal Infect 2013; 43:139-45. [PMID: 23562488 DOI: 10.1016/j.medmal.2013.02.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 01/21/2013] [Accepted: 02/20/2013] [Indexed: 11/25/2022]
Abstract
Azole resistance has appeared recently in Aspergillus fumigatus and increased dangerously in the last decade. The main resistance mechanism is a point mutation of CYP51A, the gene encoding 14α-sterol demethylase, the target enzyme of azole antifungal drugs. This mutation can induce resistance to itraconazole alone or multi-azole resistance. CYP51A mutation can occur in two cases. The first usually concerns patients receiving long-term azole therapy, most of the time for chronic aspergillosis, and involves a wide range of mutations. The second is due to the use of azole fungicides in agriculture. The latter favors a single mutagenesis event: a substitution of leucine for histidine at codon 98 and the tandem repeat of a 34-base pair tandem sequence in the CYP51A gene promoter region. This confers cross-resistance to all azole antifungal drugs. This emerging and environmentally linked issue is of growing concern for the management of antifungal therapy. This mechanism of resistance was first described in the Netherlands and is now reported worldwide. It may have become the leading mechanism of azole resistance in A. fumigatus. Azoles are major agents for the treatment of aspergillosis, and the only oral antifungals. Infection with antifungal-resistant strains is correlated with treatment failure. This emerging phenomenon stresses the urgent need for new preventive strategies (controlled use of antifungals and azole prophylaxis), new diagnostic strategies (early detection of resistance), and new therapeutic strategies in the management of A. fumigatus infections.
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Affiliation(s)
- L Lelièvre
- Unité de bactériologie, service de microbiologie, hôpital Necker-Enfants-Malades, Assistance publique-Hôpitaux de Paris, rue Vaugirard, 75015 Paris, France.
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Rogers TR, Morton CO, Springer J, Conneally E, Heinz W, Kenny C, Frost S, Einsele H, Loeffler J. Combined real-time PCR and galactomannan surveillance improves diagnosis of invasive aspergillosis in high risk patients with haematological malignancies. Br J Haematol 2013; 161:517-24. [DOI: 10.1111/bjh.12285] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 01/25/2013] [Indexed: 10/27/2022]
Affiliation(s)
- Thomas R. Rogers
- Department of Clinical Microbiology; Trinity College Dublin & St James's Hospital; Dublin Ireland
| | - Charles Oliver Morton
- Department of Clinical Microbiology; Trinity College Dublin & St James's Hospital; Dublin Ireland
| | - Jan Springer
- Department for Internal Medicine II; University of Wuerzburg Medical Centre; Wuerzburg Germany
| | - Eibhlin Conneally
- Department of Haematology; Trinity College Dublin & St James's Hospital; Dublin Ireland
| | - Werner Heinz
- Department for Internal Medicine II; University of Wuerzburg Medical Centre; Wuerzburg Germany
| | - Claire Kenny
- Department of Clinical Microbiology; Trinity College Dublin & St James's Hospital; Dublin Ireland
| | - Susanna Frost
- Department of Clinical Microbiology; Trinity College Dublin & St James's Hospital; Dublin Ireland
| | - Hermann Einsele
- Department for Internal Medicine II; University of Wuerzburg Medical Centre; Wuerzburg Germany
| | - Juergen Loeffler
- Department for Internal Medicine II; University of Wuerzburg Medical Centre; Wuerzburg Germany
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230
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Méheust D, Le Cann P, Gangneux JP. Rapid quantification of viable fungi in hospital environments: analysis of air and surface samples using solid-phase cytometry. J Hosp Infect 2013; 83:122-6. [DOI: 10.1016/j.jhin.2012.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 10/14/2012] [Indexed: 11/24/2022]
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231
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Invasive aspergillosis in patients with hematological malignancies in the Czech and Slovak republics: Fungal InfectioN Database (FIND) analysis, 2005–2009. Int J Infect Dis 2013; 17:e101-9. [DOI: 10.1016/j.ijid.2012.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 08/21/2012] [Accepted: 09/02/2012] [Indexed: 10/27/2022] Open
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232
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Kauffmann-Lacroix C, Arvier M, Charron M, Rodier MH, Vassault A. [Detection of Aspergillus antigen galactomannan using ELISA method: validation of the performances of the method for accreditation]. J Mycol Med 2013; 23:33-9. [PMID: 23375860 DOI: 10.1016/j.mycmed.2012.12.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 12/13/2012] [Accepted: 12/17/2012] [Indexed: 10/27/2022]
Abstract
Diagnosis of invasive aspergillosis for patients with high risk of infection is based on the monitoring of Aspergillus antigenemia assessed by the detection of galactomannan in serum by a sandwich-type ELISA (Biorad(®)). The validation of the method was displayed according to the guide COFRAC SH GTA 04. The internal quality control system settled, involves two quality control samples made of pools of sera (negative and positive). The repeatability of the measurements, as estimated by the coefficients of variation (CV), obtained by two different technicians was found from 9 to 13.7% for the positive control. The CV of the negative control, for which the provider indicates it is not useful in the analytical process, was found from 7.1 to 30%. In our experience it could be an indicator of environmental contamination. The evaluation of the intermediary fidelity was 15.7% for the positive control and 22.5% for the negative one. In the lack of reference material (International Standard) and recommendation from scientific societies, performances obtained will be discussed according to the results reported in the technical form of the supplier and those obtained by 39 laboratories participating in the only available external quality assessment program organized in France by ProBioQual(®) where the CV of reproducibility are 44.7% of unit (mean index 0.131) for the negative control and 18% (mean index 1.089) for the positive one in 2011.
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Affiliation(s)
- C Kauffmann-Lacroix
- Service de Parasitologie et Mycologie Médicale, CHU de Poitiers, 2 rue de la Milétrie, 86021 Poitiers cedex, France.
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233
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Barton RC. Laboratory diagnosis of invasive aspergillosis: from diagnosis to prediction of outcome. SCIENTIFICA 2013; 2013:459405. [PMID: 24278780 PMCID: PMC3820361 DOI: 10.1155/2013/459405] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/14/2012] [Indexed: 06/02/2023]
Abstract
Invasive aspergillosis (IA), an infection caused by fungi in the genus Aspergillus, is seen in patients with immunological deficits, particularly acute leukaemia and stem cell transplantation, and has been associated with high rates of mortality in previous years. Diagnosing IA has long been problematic owing to the inability to culture the main causal agent A. fumigatus from blood. Microscopic examination and culture of respiratory tract specimens have lacked sensitivity, and biopsy tissue for histopathological examination is rarely obtainable. Thus, for many years there has been a great interest in nonculture-based techniques such as the detection of galactomannan, β -D-glucan, and DNA by PCR-based methods. Recent meta-analyses suggest that these approaches have broadly similar performance parameters in terms of sensitivity and specificity to diagnose IA. Improvements have been made in our understanding of the limitations of antigen assays and the standardisation of PCR-based DNA detection. Thus, in more recent years, the debate has focussed on how these assays can be incorporated into diagnostic strategies to maximise improvements in outcome whilst limiting unnecessary use of antifungal therapy. Furthermore, there is a current interest in applying these tests to monitor the effectiveness of therapy after diagnosis and predict clinical outcomes. The search for improved markers for the early and sensitive diagnosis of IA continues to be a challenge.
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Affiliation(s)
- Richard C. Barton
- Mycology Reference Centre, Department of Microbiology, Leeds Teaching Hospitals Trust, Leeds LS1 3EX, UK
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234
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Morrissey CO. Advancing the Field: Evidence for New Management Strategies in Invasive Fungal Infections. CURRENT FUNGAL INFECTION REPORTS 2013; 7:51-58. [PMID: 23420637 PMCID: PMC3568482 DOI: 10.1007/s12281-012-0128-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Invasive fungal infections (IFI) are a significant cause of morbidity and mortality in the immunocompromised. The traditional diagnostic methods of culture and histological examination lack sensitivity and often only make a diagnosis late when the fungal burden is high, reducing the chances of cure even with the availability of new more potent and less toxic antifungal agents. New non-culture-based serological and PCR assays have been developed. These appear more sensitive and are able to make an earlier diagnosis as compared with traditional diagnostic methods. Early diagnosis is central to reducing IFI-related morbidity and mortality. This review describes the diagnostic potential of the new serological and PCR assays and outlines how these assays have been incorporated into algorithms to improve the management of IFI.
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Affiliation(s)
- C. Orla Morrissey
- Infectious Diseases Unit, Alfred Health, Level 2, Burnet Building, 85 Commercial Road, Melbourne, Victoria 3004 Australia
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Australia
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235
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Gavaldà J, Meije Y, Len Ó, Pahissa A. Infección fúngica invasora en el trasplante de órgano sólido. Enferm Infecc Microbiol Clin 2012; 30:645-53. [DOI: 10.1016/j.eimc.2012.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 09/05/2012] [Accepted: 09/06/2012] [Indexed: 11/27/2022]
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236
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Seven-year surveillance of nosocomial invasive aspergillosis in a French University Hospital. J Infect 2012; 65:559-67. [DOI: 10.1016/j.jinf.2012.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 07/19/2012] [Accepted: 08/08/2012] [Indexed: 11/24/2022]
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237
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Abstract
Infectious complications have been known to be a major cause of morbidity and mortality in Chronic Lymphocytic Leukemia (CLL) patients who are prone to infections because of both the humoral immunodepression inherent to the hematologic disease and to the immunosuppression related to the therapy. The majority of infections in CLL patients treated with alkilating agents is of bacterial origin. The immunodeficiency and natural infectious history of alkylator-resistant, corticosteroid-treated patients appears to have changed with the administration of purine analogs, which has been complicated by very severe and unusual infections and also more viral infections due to sustained reduction of CD4-positive T lymphocytes. The subsequent introduction of monoclonal antibodies in therapies, in particular alemtuzumab, further increased the immunodepression, increasing also infections which appeared more often in patients with recurrent neutropenia due to chemotherapy cycles.Epidemiological data regarding fungal infections in lymphoproliferative disorders are scarce. Italian SEIFEM group in a retrospective multicentre study regarding CLL patients reported an incidence of mycoses 0.5%; however, chronic lymphoproliferative disorders emerged as second haematological underlying disease after acute leukemia in a French study on aspergillosis; in particular CLL with aspergillosis accounted for a third of these chronic lymphoproliferative diseases presenting mould infection.
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238
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Vallejo Llamas JC, Ruiz-Camps I. Infección fúngica invasora en los pacientes hematológicos. Enferm Infecc Microbiol Clin 2012; 30:572-9. [DOI: 10.1016/j.eimc.2012.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 08/02/2012] [Accepted: 08/02/2012] [Indexed: 11/29/2022]
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239
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Hadrich I, Makni F, Neji S, Cheikhrouhou F, Bellaaj H, Elloumi M, Ayadi A, Ranque S. Amphotericin Bin vitroresistance is associated with fatalAspergillus flavusinfection. Med Mycol 2012; 50:829-34. [DOI: 10.3109/13693786.2012.684154] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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240
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Steinbach WJ, Marr KA, Anaissie EJ, Azie N, Quan SP, Meier-Kriesche HU, Apewokin S, Horn DL. Clinical epidemiology of 960 patients with invasive aspergillosis from the PATH Alliance registry. J Infect 2012; 65:453-64. [DOI: 10.1016/j.jinf.2012.08.003] [Citation(s) in RCA: 211] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 08/02/2012] [Accepted: 08/07/2012] [Indexed: 01/23/2023]
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241
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Invasive aspergillosis in a renal transplant recipient successfully treated with interferon-gamma. Case Rep Transplant 2012; 2012:493758. [PMID: 23259133 PMCID: PMC3504275 DOI: 10.1155/2012/493758] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 08/27/2012] [Indexed: 12/04/2022] Open
Abstract
Invasive aspergillosis is a serious complication of solid organ transplantation. An early diagnosis is hampered by the lack of reliable serum markers and, even if appropriately diagnosed and treated with current antifungal agents, has a high mortality rate. We report a case of invasive pulmonary and cerebral aspergillosis in a renal transplant patient treated with IFN-γ in conjunction with combination anti-fungal therapy for six weeks in whom complete resolution of the fungal infection was achieved. Renal function remained intact throughout the treatment period. Surveillance CT scans of the chest and head showed resolution of prior disease but revealed a new left upper lobe mass four months after completion of treatment with IFN-γ. Biopsy of the lesion was positive for primary lung adenocarcinoma, for which she underwent left upper lobe resection. The pathology report confirmed clear surgical margins and lymph nodes and no evidence of fungal hyphae. IFN-γ should be considered early in the management of invasive aspergillosis in renal transplant patients. To date, allograft rejection has not been encountered.
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242
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Leleu C, Menotti J, Meneceur P, Choukri F, Sulahian A, Garin YJF, Derouin F. Efficacy of liposomal amphotericin B for prophylaxis of acute or reactivation models of invasive pulmonary aspergillosis. Mycoses 2012; 56:241-9. [DOI: 10.1111/myc.12011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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243
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Wang DY, Hadj-Henni L, Thierry S, Arné P, Chermette R, Botterel F, Hadrich I, Makni F, Ayadi A, Ranque S, Huang WY, Guillot J. Simple and highly discriminatory VNTR-based multiplex PCR for tracing sources of Aspergillus flavus isolates. PLoS One 2012; 7:e44204. [PMID: 23028503 PMCID: PMC3444452 DOI: 10.1371/journal.pone.0044204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 07/30/2012] [Indexed: 11/26/2022] Open
Abstract
Aspergillus flavus is second only to A. fumigatus in causing invasive aspergillosis and it is the major agent responsible for fungal sinusitis, keratitis and endophthalmitis in many countries in the Middle East, Africa and Southeast Asia. Despite the growing challenge due to A. flavus, data on the molecular epidemiology of this fungus remain scarce. The objective of the present study was to develop a new typing method based on the detection of VNTR (Variable number tandem repeat) markers. Eight VNTR markers located on 6 different chromosomes (1, 2, 3, 5, 7 and 8) of A. flavus were selected, combined by pairs for multiplex amplifications and tested on 30 unrelated isolates and six reference strains. The Simpson index for individual markers ranged from 0.398 to 0.818. A combined loci index calculated with all the markers yielded an index of 0.998. The MLVA (Multiple Locus VNTR Analysis) technique proved to be specific and reproducible. In a second time, a total of 55 isolates from Chinese avian farms and from a Tunisian hospital have been evaluated. One major cluster of genotypes could be defined by using the graphing algorithm termed Minimum Spanning Tree. This cluster comprised most of the isolates collected in an avian farm in southern China. The MLVA technique should be considered as an excellent and cost-effective typing method that could be used in many laboratories without the need for sophisticated equipment.
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Affiliation(s)
- Dong Ying Wang
- Parasitology Department, College of Animal Science and Technology, Guangxi University, Nanning, China
- ANSES, Laboratoire de Santé Animale, UMR BIPAR, Maisons-Alfort, France
| | - Leila Hadj-Henni
- ANSES, Laboratoire de Santé Animale, UMR BIPAR, Maisons-Alfort, France
| | - Simon Thierry
- ANSES, Laboratoire de Santé Animale, UMR BIPAR, Maisons-Alfort, France
| | - Pascal Arné
- ENVA, Laboratoire de Santé Animale, UMR BIPAR, Maisons-Alfort, France
| | - René Chermette
- ENVA, Laboratoire de Santé Animale, UMR BIPAR, Maisons-Alfort, France
| | | | - Inès Hadrich
- Laboratoire de Biologie Moléculaire Parasitaire et Fongique, Faculté de Médecine de Sfax, Sfax, Tunisia
| | - Fattouma Makni
- Laboratoire de Biologie Moléculaire Parasitaire et Fongique, Faculté de Médecine de Sfax, Sfax, Tunisia
| | - Ali Ayadi
- Laboratoire de Biologie Moléculaire Parasitaire et Fongique, Faculté de Médecine de Sfax, Sfax, Tunisia
| | - Stéphane Ranque
- Aix-Marseille Université, UMR MD3, Marseille, France
- APHM, Timone, Laboratoire de Parasitologie-Mycologie, Marseille, France
| | - Wei Yi Huang
- Parasitology Department, College of Animal Science and Technology, Guangxi University, Nanning, China
| | - Jacques Guillot
- ENVA, Laboratoire de Santé Animale, UMR BIPAR, Maisons-Alfort, France
- * E-mail:
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244
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Herbrecht R, Caillot D, Cordonnier C, Auvrignon A, Thiebaut A, Brethon B, Michallet M, Mahlaoui N, Bertrand Y, Preziosi P, Ruiz F, Gorin NC, Gangneux JP. Indications and outcomes of antifungal therapy in French patients with haematological conditions or recipients of haematopoietic stem cell transplantation. J Antimicrob Chemother 2012; 67:2731-8. [DOI: 10.1093/jac/dks266] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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245
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246
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In vitro combination of anidulafungin and voriconazole against intrinsically azole-susceptible and -resistant Aspergillus spp. Antimicrob Agents Chemother 2012; 56:4500-3. [PMID: 22615296 DOI: 10.1128/aac.00045-12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In vitro interaction of anidulafungin with voriconazole was tested by a microdilution broth checkerboard technique and an agar diffusion method against 30 Aspergillus clinical isolates belonging to five different species. By using a complete inhibition endpoint, indifferent interactions were observed for 97% of the isolates by the checkerboard technique (FIC index from 0.5 to 2) and for 100% of the isolates by the agar diffusion method (variation of -2 to +1 log(2) dilutions).
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247
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Sifuentes-Osornio J, Corzo-León DE, Ponce-de-León LA. Epidemiology of Invasive Fungal Infections in Latin America. CURRENT FUNGAL INFECTION REPORTS 2012; 6:23-34. [PMID: 22363832 PMCID: PMC3277824 DOI: 10.1007/s12281-011-0081-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The pathogenic role of invasive fungal infections (IFIs) has increased during the past two decades in Latin America and worldwide, and the number of patients at risk has risen dramatically. Working habits and leisure activities have also been a focus of attention by public health officials, as endemic mycoses have provoked a number of outbreaks. An extensive search of medical literature from Latin America suggests that the incidence of IFIs from both endemic and opportunistic fungi has increased. The increase in endemic mycoses is probably related to population changes (migration, tourism, and increased population growth), whereas the increase in opportunistic mycoses may be associated with the greater number of people at risk. In both cases, the early and appropriate use of diagnostic procedures has improved diagnosis and outcome.
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Affiliation(s)
- Jose Sifuentes-Osornio
- Laboratory of Microbiology, Salvador Zubiran National Institute of Medical Science and Nutrition, 15 Vasco de Quiroga, sección XVI, Tlalpan, México City, ZC 14000 Mexico
| | - Dora E. Corzo-León
- Infectious Diseases, Salvador Zubiran National Institute of Medical Science and Nutrition, México City, Mexico
| | - L. Alfredo Ponce-de-León
- Laboratory of Microbiology, Salvador Zubiran National Institute of Medical Science and Nutrition, 15 Vasco de Quiroga, sección XVI, Tlalpan, México City, ZC 14000 Mexico
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248
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Salmeron G, Porcher R, Bergeron A, Robin M, Peffault de Latour R, Ferry C, Rocha V, Petropoulou A, Xhaard A, Lacroix C, Sulahian A, Socié G, Ribaud P. Persistent poor long-term prognosis of allogeneic hematopoietic stem cell transplant recipients surviving invasive aspergillosis. Haematologica 2012; 97:1357-63. [PMID: 22371177 DOI: 10.3324/haematol.2011.058255] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Voriconazole treatment increases early survival of allogeneic hematopoietic stem cell transplant recipients with invasive aspergillosis. We investigated whether this survival advantage translates into an increased long-term survival. DESIGN AND METHODS This retrospective study involved all patients with an invasive aspergillosis diagnosis transplanted between September 1997 and December 2008, at the Saint-Louis Hospital, Paris, France. The primary end point was survival up to 36 months. Survival analysis before and after 12 weeks, as well as cumulative incidence analysis in a competing risk framework, were used to assess the effect of voriconazole treatment and other factors on mortality. RESULTS Among 87 patients, 42 received first-line voriconazole and 45 received another antifungal agent. Median survival time was 2.6 months and survival rate at 36 months was 18%. Overall, there was a significant difference in the survival rates of the two groups. Specifically, there was a dramatic difference in survival rates up to ten months post-aspergillosis diagnosis but no significant difference after this time. Over the first 36 months as a whole, no significant difference in survival rate was observed between the two groups. First-line voriconazole significantly reduced aspergillosis-attributable mortality. However, first-line voriconazole patients experienced a significantly higher probability of death from a non-aspergillosis-attributable cause. CONCLUSIONS Although the prognosis for invasive aspergillosis after stem cell transplantation has dramatically improved with the use of voriconazole, this major advance in care does not translate into increased long-term survival for these severely immunocompromised patients.
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Affiliation(s)
- Géraldine Salmeron
- Assistance Publique-Hôpitaux de Paris, Service d’Hématologie-Greffe, Hôpital Saint-Louis, Paris, France
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249
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Chronic Granulomatous Disease in an Adult Recognized by an Invasive Aspergillosis. Am J Med Sci 2012; 343:174-176. [DOI: 10.1097/maj.0b013e31823484de] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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250
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Wintenberger C. [Invasive aspergillosis: new tools for a targeted medical management]. Med Mal Infect 2011; 41:679-83. [PMID: 22137038 DOI: 10.1016/j.medmal.2011.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- C Wintenberger
- Service de maladies infectieuses et tropicales, CHU de Grenoble, France.
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