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Lee WC, Chang CC, Ho MC, Lin CM, Leu SW, Lin CK, Fang YH, Huang SY, Lin YC, Chuang MC, Yang TM, Hung MS, Chou YL, Tsai YH, Hsieh MJ. Invasive pulmonary aspergillosis among patients with severe community-acquired pneumonia and influenza in ICUs: a retrospective cohort study. Pneumonia (Nathan) 2024; 16:10. [PMID: 38790032 PMCID: PMC11127357 DOI: 10.1186/s41479-024-00129-9] [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: 11/30/2023] [Accepted: 03/06/2024] [Indexed: 05/26/2024] Open
Abstract
RATIONALE The prevalence, clinical characteristics, and outcomes of invasive pulmonary aspergillosis in patients with severe community-acquired pneumonia (CAP) in intensive care units remain underestimated because of the lack of a disease-recognition scheme and the inadequacy of diagnostic tests. OBJECTIVES To identify the prevalence, risk factors, and outcomes of severe CAP complicated with invasive pulmonary aspergillosis (IPA) in intensive care units (ICUs). METHODS We conducted a retrospective cohort study including recruited 311 ICU-hospitalized patients with severe CAP without influenza or with influenza. Bronchoalveolar lavage fluid (BALF) samples were from all patients and subjected to mycological testing. Patients were categorized as having proven or probable Aspergillus infection using a modified form of the AspICU algorithm comprising clinical, radiological, and mycological criteria. MEASUREMENTS AND MAIN RESULTS Of the 252 patients with severe CAP and 59 influenza patients evaluated, 24 met the diagnostic criteria for proven or probable Aspergillus infection in the CAP group and 9 patients in the influenza group, giving estimated prevalence values of 9.5% and 15.3%, respectively. COPD and the use of inhaled corticosteroids were independent risk factors for IPA. IPA in patients with severe CAP was significantly associated with the duration of mechanical support, the length of ICU stay, and the 28-day mortality. CONCLUSIONS An aggressive diagnostic approach for IPA patients with severe CAP and not only influenza or COVID-19 should be pursued. Further randomized controlled trials need to evaluate the timing, safety, and efficacy of antifungal therapy in reducing IPA incidence and improving clinical outcomes.
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Affiliation(s)
- Wei-Chun Lee
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Che-Chia Chang
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Meng-Chin Ho
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Chieh-Mo Lin
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Shaw-Woei Leu
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Medical Foundation, Linkou Chang-Gung Memorial Hospital, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (ROC)
| | - Chin-Kuo Lin
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Yu-Hung Fang
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Shu-Yi Huang
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Yu-Ching Lin
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Min-Chun Chuang
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Tsung-Ming Yang
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Ming-Szu Hung
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Yen-Li Chou
- Department of Pulmonary and Critical Care Medicine, Chiayi Chang-Gung Memorial Hospital, Chang-Gung Medical Foundation, Chiayi, Taiwan
| | - Ying-Huang Tsai
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Medical Foundation, Linkou Chang-Gung Memorial Hospital, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (ROC)
- Department of Respiratory Therapy, School of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Meng-Jer Hsieh
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Medical Foundation, Linkou Chang-Gung Memorial Hospital, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (ROC).
- Department of Respiratory Therapy, School of Medicine, Chang-Gung University, Taoyuan, Taiwan.
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Cattaneo D, Torre A, Schiuma M, Civati A, Casalini G, Gori A, Antinori S, Gervasoni C. Management of Polypharmacy and Potential Drug-Drug Interactions in Patients with Pulmonary Aspergillosis: A 2-Year Study of a Multidisciplinary Outpatient Clinic. J Fungi (Basel) 2024; 10:107. [PMID: 38392779 PMCID: PMC10889795 DOI: 10.3390/jof10020107] [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: 12/18/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/24/2024] Open
Abstract
Pulmonary aspergillosis mainly affects elderly patients, patients with pulmonary complications, patients with hematological malignancies, organ transplant recipients, or critically ill patients. Co-morbidities may result in a high rate of polypharmacy and a high risk of potential drug-drug interaction (pDDI)-related antifungal azoles, which are perpetrators of several pharmacokinetic- and pharmacodynamic-driven pDDIs. Here, we report the results of the first 2-year study of an outpatient clinic focusing on the management of therapies in patients with pulmonary aspergillosis. All patients who underwent an outpatient visit from May 2021 to May 2023 were included in this retrospective analysis. A total of 34 patients who were given an azole as an antifungal treatment (53% voriconazole, 41% isavuconazole, and 6% itraconazole) were included. Overall, 172 pDDIs were identified and classified as red- (8%), orange- (74%), or yellow-flag (18%) combinations. We suggested handling polypharmacy in those patients using specific diagnostic and pharmacologic interventions. As expected, red-flag pDDIs involved mainly voriconazole as a perpetrator (71%). However, nearly 30% of red-flag pDDIs were not related to antifungal therapy. These findings highlight the importance of conducting an overall assessment of the pharmacologic burden and the key role played by a multidisciplinary team for the optimization of therapies in patients with pulmonary aspergillosis.
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Affiliation(s)
- Dario Cattaneo
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli-Sacco University Hospital, 20154 Milan, Italy
| | - Alessandro Torre
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Marco Schiuma
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Aurora Civati
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Giacomo Casalini
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Andrea Gori
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Spinello Antinori
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
| | - Cristina Gervasoni
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco University Hospital, 20157 Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli-Sacco University Hospital, 20154 Milan, Italy
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Osman H, Shaik AN, Nguyen PL, Cantor Z, Kaafarani M, Soubani AO. The Clinical Significance of Aspergillus Detected in Lower-Respiratory-Tract Samples of Critically Ill COVID-19-Positive Patients. Adv Respir Med 2023; 91:337-349. [PMID: 37736973 PMCID: PMC10514834 DOI: 10.3390/arm91050027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/23/2023]
Abstract
Objective: Critically ill patients with acute respiratory distress syndrome (ARDS) due to viral infection are at risk for secondary complications, including invasive aspergillosis. Our study aimed to characterize the clinical significance and outcome of Aspergillus species isolated from lower-respiratory-tract samples of critically ill OVID-19 patients at a single center. Design: We conducted a retrospective cohort study to evaluate the characteristics of patients with COVID-19 and aspergillus isolated from the lower respiratory tract and to identify predictors of outcomes in this population. Setting: The setting was a single-center hospital system within the metropolitan Detroit region. Results: The prevalence of Aspergillus isolated in hospitalized COVID-19 patients was 1.18% (30/2461 patients), and it was 4.6% in critically ill ICU patients with COVID-19. Probable COVID-19-associated invasive pulmonary aspergillosis (CAPA) was found in 21 critically ill patients, and 9 cases were classified as colonization. The in-hospital mortality of critically ill patients with CAPA and those with aspergillus colonization were high but not significantly different (76% vs. 67%, p = 1.00). Furthermore, the in-hospital mortality for ICU patients with or without Aspergillus isolated was not significantly different 73.3% vs. 64.5%, respectively (OR 1.53, CI 0.64-4.06, p = 0.43). In patients in whom Aspergillus was isolated, antifungal therapy (p = 0.035, OR 12.3, CI 1.74-252); vasopressors (0.016, OR 10.6, CI 1.75-81.8); and a higher mSOFA score (p = 0.043, OR 1.29 CI 1.03-1.72) were associated with a worse outcome. In a multivariable model adjusting for other significant variables, FiO2 was the only variable associated with in-hospital mortality in patients in whom Aspergillus was isolated (OR 1.07, 95% CI 1.01-1.27). Conclusions: The isolation of Aspergillus from lower-respiratory-tract samples of critically ill patients with COVID-19 is associated with high mortality. It is important to have a low threshold for superimposed infections such as CAPA in critically ill patients with COVID-19.
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Affiliation(s)
- Heba Osman
- Department of Medicine and Pediatrics, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Asra N. Shaik
- Department of Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Paul L. Nguyen
- Department of Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Zachary Cantor
- Department of Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Mirna Kaafarani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R-3 Hudson, Detroit, MI 48201, USA
| | - Ayman O. Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R-3 Hudson, Detroit, MI 48201, USA
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Kanaujia R, Singh S, Rudramurthy SM. Aspergillosis: an Update on Clinical Spectrum, Diagnostic Schemes, and Management. CURRENT FUNGAL INFECTION REPORTS 2023; 17:1-12. [PMID: 37360858 PMCID: PMC10157594 DOI: 10.1007/s12281-023-00461-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review This review gives an overview of the diseases caused by Aspergillus, including a description of the species involved and the infected clinical systems. We provide insight into the various diagnostic methods available for diagnosing aspergillosis, particularly invasive aspergillosis (IA), including the role of radiology, bronchoscopy, culture, and non-culture-based microbiological methods. We also discuss the available diagnostic algorithms for the different disease conditions. This review also summarizes the main aspects of managing infections due to Aspergillus spp., such as antifungal resistance, choice of antifungals, therapeutic drug monitoring, and new antifungal alternatives. Recent Findings The risk factors for this infection continue to evolve with the development of many biological agents that target the immune system and the increase of viral illnesses such as coronavirus disease. Due to the limitations of present mycological test methods, establishing a fast diagnosis is frequently difficult, and reports of developing antifungal resistance further complicate the management of aspergillosis. Many commercial assays, like AsperGenius®, MycAssay Aspergillus®, and MycoGENIE®, have the advantage of better species-level identification and concomitant resistance-associated mutations. Fosmanogepix, ibrexafungerp, rezafungin, and olorofim are newer antifungal agents in the pipeline exhibiting remarkable activity against Aspergillus spp. Summary The fungus Aspergillus is found ubiquitously around the world and can cause various infections, from harmless saprophytic colonization to severe IA. Understanding the diagnostic criteria to be used in different patient groups and the local epidemiological data and antifungal susceptibility profile is critical for optimal patient management.
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Affiliation(s)
- Rimjhim Kanaujia
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research PGIMER, Chandigarh, India
| | - Shreya Singh
- Department of Microbiology, Dr B R Ambedkar State Institute of Medical Sciences (AIMS), Mohali, Punjab India
| | - Shivaprakash M. Rudramurthy
- Mycology Division, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research PGIMER, Chandigarh, India
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The Comparative Evaluation of the Fujifilm Wako β-Glucan Assay and Fungitell Assay for Diagnosing Invasive Fungal Disease. J Fungi (Basel) 2022; 9:jof9010006. [PMID: 36675827 PMCID: PMC9861801 DOI: 10.3390/jof9010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/03/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Serum 1,3-β-d-glucan(BDG) is a broad fungal biomarker for invasive fungal disease (IFD). More data is still required to support the Fujifilm Wako assay as a valuable alternative to the widely used Fungitell assay. We included archived serum samples from 157 individuals (97 cases; 33-IA, 64-IC, and 60 controls) for the comparative performance evaluation of the Fungitell assay and the Fujifilm Wako assay for IFD diagnosis. The BDG value was significantly higher in patients with IFD vs. controls (70.79 pg/mL vs. 3.03 pg/mL, p: 0.0002). An area under the curve (AUC) for the IFD, IC, and IA diagnosis was 0.895, 0.910, and 0.866, respectively, for the Fujifilm Wako assay. Based on the highest Youden’s index (0.667), a cutoff of 5 pg/mL was selected as the optimum for the Fujifilm Wako assay with good sensitivity (79.4%), specificity (88.3%) and agreement (84.7%, Cohen’s k:0.691) with the Fungitell assay. The mean run-time of the Fujifilm Wako assay was 70.12 min, and real-time observation allowed earlier time to result in Fujifilm Wako vs. Fungitell assay (37 vs. 120 min, p: < 0.0001). Thus, our findings support the diagnostic value of the Fujifilm Wako assay for the diagnosis of IFD. However, there is still a need to validate diagnostic protocols to optimize their use in multi-centre studies with different patient groups.
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Aspergillus Tracheobronchitis With Airway Obstruction. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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Wuniqiemu T, Nabijan M, Cui J, Teng F, Lv Z, Wei Y, Dong J. Serum galactomannan level for the diagnosis of invasive pulmonary aspergillosis in hospitalized patients with chronic obstructive pulmonary disease (COPD): Meta-analysis. TRADITIONAL MEDICINE AND MODERN MEDICINE 2021. [DOI: 10.1142/s2575900020300027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The serum galactomannan (GM) assay is used to diagnose invasive pulmonary aspergillosis (IPA). We conducted a meta-analysis to assess the overall accuracy of the serum GM test for detecting IPA in critically ill COPD patients. Methods: The web of science, Pubmed, Embase, China National Knowledge Infrastructure, WanFang, Weipu (VIP) Science China databases were searched for all the eligible studies, including randomized controlled trials and prospective studies up to February 2019. We selected and assessed articles that reported diagnostic data related to serum GM for diagnosis of invasive fungal disease in hospitalized COPD patients. Additionally, pooled sensitivity (SEN), specificity (SPE), true positive (TP), false positive (FP), true negative (TN), false negative (FN) were estimated for summarizing overall test performance. Results: Of 1104 articles screened, 14 studies were involved in the meta-analysis with 1127 patients in the COPD serum sample. The pooled serum GM assay results with cutoff value of 0.5 were as follows: DOR: 15 (95% CI, 6–38), sensitivity: 0.57 (95% CI, 0.37–0.75), specificity: 0.92 (95%,CI, 0.85–0.96), and the SROC was 0.89 (95% CI, 0.86–0.91). When the cutoff value was 1, the results were as follows: DOR: 33 (95% CI, 15–70), sensitivity: 0.57 (95% CI, 0.39–0.73), specificity: 0.96 (95% CI, 0.93–0.98), and SROC was 0.95 (95% CI, 0.92–0.96). Conclusion: Serum GM can be used to assist in diagnosis of IPA in critically ill COPD patients. When cutoff value was set as 1, serum GM had better diagnostic value compared to those with cutoff of 0.5.
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Affiliation(s)
- Tulake Wuniqiemu
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, P. R. China
| | - Mohammadtursun Nabijan
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, P. R. China
- Institutes of Integrative Medicine, Fudan University, Shanghai, P. R. China
| | - Jie Cui
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, P. R. China
- Institutes of Integrative Medicine, Fudan University, Shanghai, P. R. China
| | - Fangzhou Teng
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, P. R. China
- Institutes of Integrative Medicine, Fudan University, Shanghai, P. R. China
| | - Zexi Lv
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, P. R. China
- Institutes of Integrative Medicine, Fudan University, Shanghai, P. R. China
| | - Ying Wei
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, P. R. China
- Institutes of Integrative Medicine, Fudan University, Shanghai, P. R. China
| | - Jingcheng Dong
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, P. R. China
- Institutes of Integrative Medicine, Fudan University, Shanghai, P. R. China
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Respiratory Mycoses in COPD and Bronchiectasis. Mycopathologia 2021; 186:623-638. [PMID: 33709335 DOI: 10.1007/s11046-021-00539-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/22/2021] [Indexed: 02/07/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) and bronchiectasis represent chronic airway diseases associated with significant morbidity and mortality. Bacteria and viruses are commonly implicated in acute exacerbations; however the significance of fungi in these airways remains poorly defined. While COPD and bronchiectasis remain recognized risk factors for the occurrence of Aspergillus-associated disease including chronic and invasive aspergillosis, underlying mechanisms that lead to the progression from colonization to invasive disease remain uncertain. Nonetheless, advances in molecular technologies have improved our detection, identification and understanding of resident fungi characterizing these airways. Mycobiome sequencing has revealed the complex varied and myriad profile of airway fungi in COPD and bronchiectasis, including their association with disease presentation, progression, and mortality. In this review, we outline the emerging evidence for the clinical importance of fungi in COPD and bronchiectasis, available diagnostic modalities, mycobiome sequencing approaches and association with clinical outcomes.
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Th17 cells are involved in mouse chronic obstructive pulmonary disease complicated with invasive pulmonary aspergillosis. Chin Med J (Engl) 2020; 134:555-563. [PMID: 33323817 PMCID: PMC7929714 DOI: 10.1097/cm9.0000000000001183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The incidence of chronic obstructive pulmonary disease (COPD) complicated with invasive pulmonary aspergillosis (IPA) has increased in the last two decades. The mechanism underpinning susceptibility to and high mortality of COPD complicated with IPA is unclear, and the role of T helper cells 17 (Th17 cells) in the compound disease remains unknown. Therefore, this study aimed to assess the function of Th17 cells in COPD combined with IPA. METHODS COPD, IPA, and COPD+IPA mouse models were established in male wild type C57/BL6 mice. The amounts of Th17 cells and retinoic acid-related orphan receptors γt (RORγt) were tested by flow cytometry. Then, serum interleukin (IL)-17 and IL-23 levels were detected by enzyme-linked immunosorbent assay (ELISA) in the control, COPD, IPA and COPD+IPA groups. In addition, COPD+IPA was induced in IL-17 knockout (KO) mice, for determining the role of Th17 cells in COPD+IPA. RESULTS Compared with the COPD group, the COPD+IPA group showed higher amounts of blood RORγt ([35.09 ± 16.12]% vs. [17.92 ± 4.91]%, P = 0.02) and serum IL-17 (17.96 ± 9.59 pg/mL vs. 8.05 ± 4.44 pg/mL, P = 0.02), but blood ([5.18 ± 1.09]% vs. [4.15 ± 0.87]%, P = 0.28) and lung levels of Th17 cells ([1.98 ± 0.83]% vs. [2.03 ± 0.98]%, P = 0.91), lung levels of RORγt ([9.58 ± 6.93]% vs. [9.63 ± 5.98]%, P = 0.49) and serum IL-23 (51.55 ± 27.82 pg/mL vs. 68.70 ± 15.20 pg/mL, P = 0.15) showed no significant differences. Compared with the IPA group, the COPD+IPA group displayed lower amounts of blood ([5.18 ± 1.09]% vs. [9.21 ± 3.56]%, P = 0.01) and lung Th17 cells ([1.98 ± 0.83]% vs. [6.29 ± 1.11]%, P = 0.01) and serum IL-23 (51.55 ± 27.82 pg/mL vs. 154.90 ± 64.60 pg/mL, P = 0.01) and IL-17 (17.96 ± 9.59 pg/mL vs. 39.81 ± 22.37 pg/mL, P = 0.02), while comparable blood ([35.09 ± 16.12]% vs. [29.86 ± 15.42]%, P = 0.25) and lung levels of RORγt ([9.58 ± 6.93]% vs. [15.10 ± 2.95]%, P = 0.18) were found in these two groups. Finally, Aspergillus load in IL-17 KO COPD+IPA mice was almost 2 times that of COPD+IPA mice (1,851,687.69 ± 944,480.43 vs. 892,958.10 ± 686,808.80, t = 2.32, P = 0.02). CONCLUSION These findings indicate that Th17 cells might be involved in the pathogenesis of COPD combined with IPA, with IL-17 likely playing an antifungal role.
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10
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Kunadharaju R, Sethi S. Treatment of Acute Exacerbations in Chronic Obstructive Pulmonary Disease. Clin Chest Med 2020; 41:439-451. [PMID: 32800197 DOI: 10.1016/j.ccm.2020.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Management of a chronic obstructive pulmonary disease (COPD) exacerbation begins with an accurate diagnosis. Although more than 80% of exacerbations are managed on an outpatient basis, hospitalization is all too common and associated with considerable health care costs and mortality. Irrespective of the site of treatment, the treatment modalities are the same. Noninvasive ventilation has greatly decreased the mortality in exacerbations that require ventilatory support. Across the range of exacerbation severity, treatment failure and relapses are frequent, and should be carefully evaluated. New therapeutic options to address infection and inflammation in COPD are needed to improve the outcome of exacerbations.
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Affiliation(s)
- Rajesh Kunadharaju
- Division of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Sanjay Sethi
- Division of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; Clinical and Translational Research Center, Room 6045A, 875 Ellicott Street, Buffalo, NY 14203, USA.
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11
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Youssif SF, Hassan EA, Moharram AM, Farhan MA, Badary DM, Hasan AAA. Is bronchoscopic view a reliable method in diagnosis of tracheobronchial aspergillosis in critically ill non-neutropenic patients? CLINICAL RESPIRATORY JOURNAL 2020; 14:956-964. [PMID: 32568453 DOI: 10.1111/crj.13229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 05/27/2020] [Accepted: 06/11/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pulmonary aspergillosis is the main respiratory fungal infection however; its diagnosis is missed or delayed in critically ill non-neutropenic patients. Despite the utility of fiberoptic bronchoscopy for the evaluation of tracheobronchial aspergillosis (TBA) in immunocompromised patients has been extensively studied, however its utility in critically ill non-neutropenic patients is underestimated. OBJECTIVES To assess the bronchoscopic changes suspected TBA relative to the microbiological and histopathological aspects in critically ill non-neutropenic patients admitted to respiratory intensive care unit (RICU). METHODS We prospectively studied 139 critically ill non-neutropenic patients admitted to RICU and had a clinical suspicion of broncho-pulmonary Aspergillus infection. Those patients were subjected to clinical and bronchoscopic assessment for the evaluation of suspected TBA. Microbiological culture of bronchoalveolar lavage (BAL) and histopathological examination of tracheobronchial biopsies were done. RESULTS Bronchoscopic changes suspected TBA were found in 48.2% of patients (67/139), where Aspergillus infection was confirmed microbiologically in 59.7% (40/67) and histopathologically in 56.7% (38/67). Of these changes, whitish plaques ± ulcers, pseudomembrane and/or sticky secretion with hyperemic mucosa were detected in 68.7%, 26.9% and 16.4% respectively. These changes were mostly seen in the main bronchi (54/67; 80.6%). The sensitivity, specificity, positive, negative predictive values and overall accuracy of these bronchoscopic changes as compared with BAL fluid results were 83.3%, 70.3%, 53.2%, 91.2% and 74.1% respectively. CONCLUSIONS Bronchoscopy could be a reliable procedure for TBA diagnosis in critically ill non-neutropenic patients. Whitish plaques ± ulcers were the prominent bronchoscopic changes with reasonable diagnostic accuracy for prediction of TBA.
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Affiliation(s)
| | - Elham Ahmed Hassan
- Faculty of Medicine, Department of Gastroenterology and Tropical Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Mohamed Moharram
- Faculty of Science, Department of Botany and Microbiology, Assiut University, Assiut, Egypt
| | | | - Dalia M Badary
- Department of Pathology, Assiut University, Assiut, Egypt
| | - Ali Adel Azeem Hasan
- Faculty of Medicine, Department of Chest Diseases, Assiut University, Assiut, Egypt
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Bulpa P, Duplaquet F, Dimopoulos G, Vogelaers D, Blot S. Invasive Pulmonary Aspergillosis in Chronic Obstructive Pulmonary Disease Exacerbations. Semin Respir Crit Care Med 2020; 41:851-861. [PMID: 32599634 DOI: 10.1055/s-0040-1702210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Nowadays, reports in the literature support that patients with severe chronic obstructive pulmonary disease (COPD) are at higher risk to develop invasive pulmonary aspergillosis (IPA). However, the interpretation of Aspergillus-positive cultures from the airways in critically ill COPD is still a challenge. Indeed, as the patient could be merely colonized, tissue samples are required to ascertain IPA diagnosis but they are rarely obtained before death. Consequently, diagnosis is often only suspected on the basis of a combination of three elements: clinical characteristics, radiological images (mostly thoracic CT scan), and microbiological, and occasionally serological, results. To facilitate the analysis of these data, several algorithms have been developed, and the best effectiveness has been demonstrated by the Clinical algorithm. This is of importance as IPA prognosis in these patients remains presently very poor and using such an algorithm could promote prompter diagnosis, early initiation of treatment, and subsequently improved outcome.While the most classical presentation of IPA in critically ill COPD patients features a combination of obstructive respiratory failure, antibiotic-resistant pneumonia, recent or chronic corticosteroid therapy, and positive Aspergillus cultures from the lower respiratory tract, the present article will also address less typical presentations and discuss the most appropriate treatments which could alter prognosis.
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Affiliation(s)
- Pierre Bulpa
- Department of Intensive Care Unit, Mont-Godinne University Hospital, CHU UCL Namur, Namur, Belgium
| | - Fabrice Duplaquet
- Department of Pneumology, Mont-Godinne University Hospital, CHU UCL Namur, Namur, Belgium
| | - George Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, Haidari, Greece
| | - Dirk Vogelaers
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
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13
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Factores clínicos asociados a enfermedad pulmonar por Aspergillus spp. en pacientes con enfermedad pulmonar obstructiva crónica. Enferm Infecc Microbiol Clin 2020; 38:4-10. [DOI: 10.1016/j.eimc.2019.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/15/2019] [Accepted: 06/20/2019] [Indexed: 11/24/2022]
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Sakaguchi K, Koga Y, Yagi T, Nakahara T, Todani M, Fujita M, Tsuruta R. Severe Fever with Thrombocytopenia Syndrome Complicated with Pseudomembranous Aspergillus Tracheobronchitis in a Patient without Apparent Risk Factors for Invasive Aspergillosis. Intern Med 2019; 58:3589-3592. [PMID: 31366803 PMCID: PMC6949450 DOI: 10.2169/internalmedicine.3257-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Severe fever with thrombocytopenia syndrome (SFTS) is a tick-borne infectious disease. A 91-year-old woman was admitted to our intensive-care unit with SFTS, and she developed dyspnea with wheezes 5 days after admission. Bronchoscopy showed scattered white mold in her central airway. An airway tissue biopsy and culture of bronchial lavage fluid revealed fungal hyphae in the necrotic tissue, confirmed as Aspergillus fumigatus. She was thus diagnosed with pseudomembranous aspergillus tracheobronchitis. She had no common risk factors for invasive aspergillosis (IA). Patients with SFTS, even those without apparent risk factors for IA, may be at risk of developing IA.
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Affiliation(s)
- Kento Sakaguchi
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
- Department of Emergency and Critical Care Medicine, Yamagata University Faculty of Medicine, Japan
| | - Yasutaka Koga
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Takeshi Yagi
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Takashi Nakahara
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Masaki Todani
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Motoki Fujita
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Japan
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15
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Collateral Development of Invasive Pulmonary Aspergillosis (IPA) in Chronic Obstructive Pulmonary Disease (COPD) Patients. Fungal Biol 2019. [DOI: 10.1007/978-3-030-18586-2_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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16
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Workum JD, de Jong SW, Gresnigt MS, Becker KL, Pickkers P, van de Veerdonk FL, Heijdra YF, Kolwijck E. Microbiological and immunological characteristics of a lethal pulmonary Aspergillus niger infection in a non-neutropenic patient. Med Mycol Case Rep 2018; 21:4-7. [PMID: 29984147 PMCID: PMC6026298 DOI: 10.1016/j.mmcr.2018.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/18/2018] [Accepted: 03/01/2018] [Indexed: 12/15/2022] Open
Abstract
Invasive pulmonary aspergillosis is increasingly described in non-neutropenic patients, such as patients with COPD receiving corticosteroids and the critically ill. Here, we present a case of a lethal pulmonary Aspergillus niger infection in a COPD patient. Immunological tests showed an impaired innate and adaptive immune response to Aspergillus. A history of COPD, unresponsiveness to antibiotics and especially a suggestive CT-scan should trigger the clinician to consider diseases caused by Aspergillus.
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Affiliation(s)
- Jessica D Workum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suzanne W de Jong
- Department of Pulmonology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark S Gresnigt
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Katharina L Becker
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne F Heijdra
- Department of Pulmonology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva Kolwijck
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
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Lass-Flörl C, Cuenca-Estrella M. Changes in the epidemiological landscape of invasive mould infections and disease. J Antimicrob Chemother 2017; 72:i5-i11. [PMID: 28355462 DOI: 10.1093/jac/dkx028] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Although a wide variety of pathogens are associated with invasive mould diseases, Aspergillus spp. have historically been one of the most common causative organisms. Most invasive mould infections are caused by members of the Aspergillus fumigatus species complex and an emerging issue is the occurrence of azole resistance in A. fumigatus, with resistance to amphotericin B documented in other Aspergillus spp. The epidemiology of invasive fungal disease has shifted in recent years as non-A. fumigatus Aspergillus spp. and other moulds have become progressively more important, although there are no consolidated data on the prevalence of less common species of moulds. The incidence of mucormycosis may have been underestimated, which is a potential concern since species belonging to the order Mucorales are more resistant to antifungal agents than Aspergillus spp. All species of Mucorales are unaffected by voriconazole and most show moderate resistance in vitro to echinocandins. Fusarium spp. may be the second most common nosocomial fungal pathogen after Aspergillus in some tertiary hospitals, and show a susceptibility profile marked by a higher level of resistance than that of Aspergillus spp. Recently, Scedosporium aurantiacum has been reported as an emerging opportunistic pathogen, against which voriconazole is the most active antifungal agent. Other mould species can infect humans, although invasive fungal disease occurs less frequently. Since uncommon mould species exhibit individual susceptibility profiles and require tailored clinical management, accurate classification at species level of the aetiological agent in any invasive fungal disease should be regarded as the standard of care.
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Affiliation(s)
- Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstraße 41, 6020 Innsbruck, Austria
| | - Manuel Cuenca-Estrella
- Department of Mycology, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Ctra. Majadahonda-Pozuelo Km 2, Majadahonda, Madrid, Spain
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Huang L, He H, Jin J, Zhan Q. Is Bulpa criteria suitable for the diagnosis of probable invasive pulmonary Aspergillosis in critically ill patients with chronic obstructive pulmonary disease? A comparative study with EORTC/ MSG and ICU criteria. BMC Infect Dis 2017; 17:209. [PMID: 28292284 PMCID: PMC5351185 DOI: 10.1186/s12879-017-2307-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/07/2017] [Indexed: 01/11/2023] Open
Abstract
Background Three diagnostic criteria have been proposed used for invasive pulmonary aspergillosis (IPA) diagnosis, namely EORTC/ MSG criteria, Bulpa criteria and intensive care unit (ICU) criteria. The Bulpa criteria were proposed to diagnose IPA in chronic obstructive pulmonary disease (COPD) patients specially. Our aim is to verify that whether the Bulpa criteria are the most suitable for diagnosing probable IPA in critically ill COPD patients compared with the other two criteria. Methods We included critically ill COPD patients admitted to the ICU from April 2006 to August 2013. Patients were classified into four populations: population one (n1 = 59) comprised all included patients; population two (n2 = 24) comprised patients with positive mycological findings (both positive cultures and positive serologic tests); population three (n3 = 18) comprised patients with positive lower respiratory tracts (LRTs) isolation; and population four (n4 = 5) comprised proven IPA patients with histopathology. Patients in four groups were diagnosed as probable IPA using three criteria respectively, and the “diagnostic rate” of each criteria were compared with each other. Then, the reasons for differences in “diagnostic rate” were analyzed in population two. Finally, the modified Bulpa criteria were proposed. Results Bulpa criteria yielded the highest “diagnostic rate” of probable IPA followed by the ICU criteria, while the EORTC/ MSG criteria provided the lowest rates in four populations (the “diagnostic rate” of probable IPA was 33.9%, 16.9% and 6.8% in population one, p = 0.001; 83.3%, 41.7% and 16.7% in population two, p < 0.001; 100%, 55.6% and 22.2% in population three, p < 0.001; 100%, 60% and 20% in population four, p = 0.036). The reasons for the highest “diagnostic rate” by Bulpa criteria were its less strict requirements regarding the doses/courses of steroid use and typical computed tomography (CT) findings. Finally, the modified Bulpa criteria for probable IPA were proposed for critically ill COPD patients admitted to ICU, mainly involving revised interpretations of microbiological findings. Conclusions Among the existing three criteria, the Bulpa criteria are the most suitable for diagnosing probable IPA in critically ill COPD patients admitted to ICU. A modified criteria maybe proposed for better diagnosis,and its clinical validity need to be verified in future studies. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2307-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Linna Huang
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Hangyong He
- Beijing Institute of Respiratory Medicine, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jingjing Jin
- Beijing Institute of Respiratory Medicine, Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Critical Care Medicine, Children's Hospital affiliated with the Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China. .,, No.2 Yinghua East Road, Chaoyang District, Beijing, 100029, China.
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Xu H, Wu Y, Li L, Yuan W, Zhang D, Yan Q, Guo Z, Huang W. MiR-344b-1-3p targets TLR2 and negatively regulates TLR2 signaling pathway. Int J Chron Obstruct Pulmon Dis 2017; 12:627-638. [PMID: 28243080 PMCID: PMC5317246 DOI: 10.2147/copd.s120415] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives COPD is an abnormal inflammatory response characterized by decreased expression of TLR2 in patients, which is suggested to induce invasive pulmonary aspergillosis (IPA). MicroRNAs (miRNAs) have been shown to play important roles in the pathogenesis of human respiratory system disorders. Therefore, the aim of this study was to identify the miRNAs involved in the regulation of TLR2 signaling in COPD. Materials and methods miRNA microarray analysis was performed to screen for the dysregulated miRNAs in alveolar macrophages (AMs) isolated from COPD rats. The interaction between these miRNAs and TLR2 gene was predicted using miRBase and validated using dual luciferase assay. Based on the analysis, a novel miR-344b-1-3p was identified as a novel modulator of TLR2 gene. Then, the mechanism through which miR-344b-1-3p regulated TLR2 expression was explored using cigarette smoke extract (CSE)-pretreated NR8383 cells. Moreover, by subjecting CSE-pretreated NR8383 cells to Pam3CSK4, the effect of miR-344b-1-3p on NF-κB activity and other important mediators of COPD, including IRAK-1, ERK, TNF-α, IL-1β, and MIP-2, was also assessed. Results COPD rat model was successfully induced by smoke inhalation. Among the 11 upregulated miRNAs in AMs from COPD rats, miR-344b-1-3p was predicted to be a novel miRNA targeting TLR2 gene. In the CSE pretreated NR8383 cells exposed to Pam3CSK4, miR-344b-1-3p inhibition increased the expression levels of TLR2, TNF-α, and IL-1β and decreased the expression levels of MIP-2. In addition, the phosphorylation of IRAK-1, IκBα, and IRK was augmented by miR-344b-1-3p inhibition. Conclusion Findings outlined in this study suggest that miR-344b-1-3p was an effective modulator of TLR2 gene, which can be employed as a promising therapeutic and preventive target of IPA in COPD patients.
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Affiliation(s)
- Hong Xu
- Department of Respiratory Medicine; Guangdong Provincial Key Laboratory of Geriatric Infection and Organ Function Support; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support
| | - Yuting Wu
- Guangdong Provincial Key Laboratory of Geriatric Infection and Organ Function Support; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support; Department of Geriatric Respiratory Medicine, General Hospital of Guangzhou Command of PLA, Guangzhou, Guangdong, People's Republic of China
| | - Li Li
- Department of Respiratory Medicine; Guangdong Provincial Key Laboratory of Geriatric Infection and Organ Function Support; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support
| | - Weifeng Yuan
- Department of Respiratory Medicine; Guangdong Provincial Key Laboratory of Geriatric Infection and Organ Function Support; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support
| | - Deming Zhang
- Guangdong Provincial Key Laboratory of Geriatric Infection and Organ Function Support; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support; Department of Geriatric Respiratory Medicine, General Hospital of Guangzhou Command of PLA, Guangzhou, Guangdong, People's Republic of China
| | - Qitao Yan
- Guangdong Provincial Key Laboratory of Geriatric Infection and Organ Function Support; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support
| | - Zhenhui Guo
- Guangdong Provincial Key Laboratory of Geriatric Infection and Organ Function Support; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support
| | - Wenjie Huang
- Department of Respiratory Medicine; Guangdong Provincial Key Laboratory of Geriatric Infection and Organ Function Support; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support
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20
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Pegorie M, Denning DW, Welfare W. Estimating the burden of invasive and serious fungal disease in the United Kingdom. J Infect 2017; 74:60-71. [DOI: 10.1016/j.jinf.2016.10.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 10/17/2016] [Accepted: 10/18/2016] [Indexed: 01/07/2023]
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21
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Shahi M, Ayatollahi Mousavi SA, Nabili M, Aliyali M, Khodavaisy S, Badali H. Aspergillus colonization in patients with chronic obstructive pulmonary disease. Curr Med Mycol 2015; 1:45-51. [PMID: 28680996 PMCID: PMC5490329 DOI: 10.18869/acadpub.cmm.1.3.45] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background and Purpose: Chronic obstructive pulmonary disease (COPD) has been recognized as a risk factor for invasive aspergillosis. Airway colonization by Aspergillus species is a common feature of chronic pulmonary diseases. Nowadays, the incidence of COPD has increased in critically ill patients. The aim of the present study was to isolate and identify Aspergillus colonies in the respiratory tract of COPD patients. Materials and Methods: This study was performed on 50 COPD patients, who were aged above 18 years, and were in intensive care units of three hospitals in Sari, Iran, for at least six days. All the samples obtained from sputum, bronchoalveolar lavage, and tracheal aspirates were cultured for fungi each week. According to the conventional techniques, Aspergillus isolates were initially based on growth and standard morphological characteristics. To confirm the identification of grown Aspergillus, the partial beta-tubulin gene was sequenced using specific primers. Results: A total of 50 patients, who met our inclusion criteria, were enrolled in the study during 2012-14. The results showed that 27 (54%) and 23 (46%) of the participants were male and female, respectively. The majority of the patients developed dyspnea followed by hemoptysis, chest pain, and high fever. Corticosteroids and broad-spectrum antibacterial agents were administered to 75% and 80% of the patients, respectively. Based on the conventional and molecular approaches, A. fumigatus (seven cases; 43.7%), A. flavus (five cases; 31.2%), A. niger (one case; 6.2%), A. terreus (one case; 6.2%), A. orezea (one case; 6.2%), and A. tubingensis (one case; 6.2%) were recovered. Conclusion: Recovery of Aspergillus species from the respiratory tract of COPD patients with pneumonia indicates two possibilities: either colonization or invasive aspergillosis.
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Affiliation(s)
- M Shahi
- Department of Medical Mycology and Parasitology, Faculty of Medicine, Tropical and Infectious Diseases Center, Kerman University of Medical Sciences, Kerman, Iran
| | - S A Ayatollahi Mousavi
- Department of Medical Mycology and Parasitology, Faculty of Medicine, Tropical and Infectious Diseases Center, Kerman University of Medical Sciences, Kerman, Iran
| | - M Nabili
- Students Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - M Aliyali
- Pulmonary and Critical Care Division, Mazandaran University of Medical Sciences, Sari, Iran
| | - S Khodavaisy
- Department of Medical Parasitology and Mycology, Kurdistan University of Medical Sciences, Sanandaj, Iran.,Department of Medical Parasitology and Mycology, Tehran University of Medical Sciences, Tehran, Iran
| | - H Badali
- Invasive Fungi Research Center (IFRC), Department of Medical Mycology and Parasitology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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Taccone FS, Van den Abeele AM, Bulpa P, Misset B, Meersseman W, Cardoso T, Paiva JA, Blasco-Navalpotro M, De Laere E, Dimopoulos G, Rello J, Vogelaers D, Blot SI. Epidemiology of invasive aspergillosis in critically ill patients: clinical presentation, underlying conditions, and outcomes. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:7. [PMID: 25928694 PMCID: PMC4344741 DOI: 10.1186/s13054-014-0722-7] [Citation(s) in RCA: 255] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 12/15/2014] [Indexed: 12/20/2022]
Abstract
Introduction Invasive aspergillosis (IA) is a fungal infection that particularly affects immunocompromised hosts. Recently, several studies have indicated a high incidence of IA in intensive care unit (ICU) patients. However, few data are available on the epidemiology and outcome of patients with IA in this setting. Methods An observational study including all patients with a positive Aspergillus culture during ICU stay was performed in 30 ICUs in 8 countries. Cases were classified as proven IA, putative IA or Aspergillus colonization according to recently validated criteria. Demographic, microbiologic and diagnostic data were collected. Outcome was recorded 12 weeks after Aspergillus isolation. Results A total of 563 patients were included, of whom 266 were colonized (47%), 203 had putative IA (36%) and 94 had proven IA (17%). The lung was the most frequent site of infection (94%), and Aspergillus fumigatus the most commonly isolated species (92%). Patients with IA had higher incidences of cancer and organ transplantation than those with colonization. Compared with other patients, they were more frequently diagnosed with sepsis on ICU admission and more frequently received vasopressors and renal replacement therapy (RRT) during the ICU stay. Mortality was 38% among colonized patients, 67% in those with putative IA and 79% in those with proven IA (P < 0.001). Independent risk factors for death among patients with IA included older age, history of bone marrow transplantation, and mechanical ventilation, RRT and higher Sequential Organ Failure Assessment score at diagnosis. Conclusions IA among critically ill patients is associated with high mortality. Patients diagnosed with proven or putative IA had greater severity of illness and more frequently needed organ support than those with Aspergillus spp colonization.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070, Brussels, Belgium.
| | | | - Pierre Bulpa
- Department of Intensive Care Mont-Godinne University Hospital, Catholic University of Louvain, Avenue G.Thérasse 1, 5530, Yvoir, Belgium.
| | - Benoit Misset
- Department of Intensive Care Foundation Hospital Saint-Joseph, Paris-Descartes University, 185 Rue Raymond Losserand, 75014, Paris, France.
| | - Wouter Meersseman
- Medical Intensive Care Unit, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Teresa Cardoso
- Department of Intensive Care, Santo Antonio Hospital, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.
| | - José-Artur Paiva
- Department of Emergency and Intensive Care, Hospital Centre S. Joao and University of Porto Medical School Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Miguel Blasco-Navalpotro
- Department of Intensive Care, University Hospital Severo Ochoa, Avenida de Orellana, s/n 28911, Leganés, Madrid, Spain.
| | - Emmanuel De Laere
- Department of Microbiology, General Hospital Delta, Brugsesteenweg 90, 8800, Roeselare, Belgium.
| | - George Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, University of Athens Medical School, 1 Rimini Street, Haidari, 124 62, Athens, Greece.
| | - Jordi Rello
- Hospital Universitari Vall d'Hebron, Vall D'Hebron, Institute of Research, CIBERES, Autonomous University of Barcelona, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
| | - Dirk Vogelaers
- Department of Internal Medicine Faculty of Medicine & Health Science, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Stijn I Blot
- Department of Internal Medicine Faculty of Medicine & Health Science, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium. .,Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Butterfield Street, Herston (Brisbane), 4006, Queensland, Australia.
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23
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Prattes J, Flick H, Prüller F, Koidl C, Raggam RB, Palfner M, Eigl S, Buzina W, Zollner-Schwetz I, Thornton CR, Krause R, Hoenigl M. Novel tests for diagnosis of invasive aspergillosis in patients with underlying respiratory diseases. Am J Respir Crit Care Med 2014; 190:922-9. [PMID: 25203869 DOI: 10.1164/rccm.201407-1275oc] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Invasive pulmonary aspergillosis has been increasingly reported in nonneutropenic patients, including those with underlying respiratory diseases. OBJECTIVES We compared the diagnostic performances of galactomannan, 1,3-β-D-glucan, and Aspergillus-specific lateral-flow device tests with that of conventional culture by using bronchoalveolar lavage fluid samples from patients with underlying respiratory diseases. METHODS We analyzed 268 bronchoalveolar lavage samples from 221 patients with underlying respiratory diseases (and without hematologic malignancy or previous solid organ transplantation) that were collected for routine microbiological workup between February 2012 and May 2014 at the University Hospital of Graz, Austria. Invasive pulmonary aspergillosis was defined according to European Organization of Research and Treatment of Cancer/Mycoses Study Group criteria modified for patients with respiratory diseases. MEASUREMENTS AND MAIN RESULTS Thirty-one patients (14%) had probable or proven, 25 possible, and the remaining 165 patients no invasive pulmonary aspergillosis. Probable/proven aspergillosis was associated with a significantly higher (P = 0.034) 30-day mortality rate of 32%. Sensitivities, specificities, and diagnostic odd ratios differed markedly between galactomannan (cut-off 0.5: optical density index, 0.97, 0.81, 124.4; cut-off 1.0: 0.97, 0.93, 422.1; cut-off 3.0: 0.61, 0.99, 109.8), β-D-glucan (cut-off 80 pg/ml: 0.90, 0.42, 6.57; cut-off 200 pg/ml: 0.70, 0.61, 3.7), lateral-flow device tests (0.77, 0.92, 41.8), and mycological culture (0.29, 0.97, 14). CONCLUSIONS Probable or proven invasive pulmonary aspergillosis was diagnosed in 14% of our study population and associated with significantly higher 30-day mortality rates. Although the performance of β-D-glucan was limited by low specificity and that of mycological culture by low sensitivity, the Aspergillus lateral-flow device seems to be a promising alternative to galactomannan testing, which remains the diagnostic gold standard for aspergillosis. Clinical trial registered with www.clinicaltrials.gov (NCT 02058316).
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Barberán J, Mensa J. [Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease]. Rev Iberoam Micol 2014; 31:237-41. [PMID: 25481431 DOI: 10.1016/j.riam.2014.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) is a common infection in immunocompromised patients with hematological malignancies or allogenic stem cell transplantation, and is less frequent in the context of chronic obstructive pulmonary disease (COPD). Mucociliary activity impairment, immunosuppression due to the inhibition of alveolar macrophages and neutrophils by steroids, and receiving broad-spectrum antibiotics, play a role in the development of IPA in COPD patients. Colonized patients or those with IPA are older, with severe CODP stage (GOLD≥III), and have a higher number of comorbidities. The mortality rate is high due to the fact that having a definitive diagnosis of IPA in COPD patients is often difficult. The main clinical and radiological signs of IPA in these types of patients are non-specific, and tissue samples for definitive diagnosis are often difficult to obtain. The poor prognosis of IPA in COPD patients could perhaps be improved by faster diagnosis and prompt initiation of antifungal treatment. Some tools, such as scales and algorithms based on risk factors of IPA, may be useful for its early diagnosis in these patients.
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Affiliation(s)
- José Barberán
- Servicio de Medicina Interna, Hospital Universitario Montepríncipe, Universidad San Pablo-CEU, Madrid, España.
| | - José Mensa
- Servicio de Enfermedades Infecciosas, Hospital Clínic, Barcelona, España
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Bassetti M, Righi E, De Pascale G, De Gaudio R, Giarratano A, Mazzei T, Morace G, Petrosillo N, Stefani S, Antonelli M. How to manage aspergillosis in non-neutropenic intensive care unit patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:458. [PMID: 25167934 PMCID: PMC4220091 DOI: 10.1186/s13054-014-0458-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Invasive aspergillosis has been mainly reported among immunocompromised patients during prolonged periods of neutropenia. Recently, however, non-neutropenic patients in the ICU population have shown an increasing risk profile for aspergillosis. Associations with chronic obstructive pulmonary disease and corticosteroid therapy have been frequently documented in this cohort. Difficulties in achieving a timely diagnosis of aspergillosis in non-neutropenic patients is related to the non-specificity of symptoms and to lower yields with microbiological tests compared to neutropenic patients. Since high mortality rates are typical of invasive aspergillosis in critically ill patients, a high level of suspicion and prompt initiation of adequate antifungal treatment are mandatory. Epidemiology, risk factors, diagnostic algorithms, and different approaches in antifungal therapy for invasive aspergillosis in non-neutropenic patients are reviewed.
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Abstract
Invasive fungal infections have increase worldwide and represent a threat for immunocompromised patients including HIV-infected, recipients of solid organ and stem cell transplants, and patients receiving immunosuppressive therapies. High mortality rates and difficulties in early diagnosis characterize pulmonary fungal infections. Invasive pulmonary aspergillosis has been reviewed focussing on therapeutic management. Although new compounds have become available in the past years (i.e., amphotericin B lipid formulations, last-generation azoles, and echinocandines), new diagnostic tools and careful therapeutic management are mandatory to assure an early appropriate targeted treatment that represents the key factor for a successful conservative approach in respiratory fungal infections.
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Aspergillus in the lower respiratory tract of immunocompetent critically ill patients. J Infect 2014; 69:284-92. [PMID: 24924557 DOI: 10.1016/j.jinf.2014.04.010] [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] [Received: 11/10/2013] [Revised: 04/05/2014] [Accepted: 04/08/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To shed light on the meaning of Aspergillus-positive lower-respiratory-tract samples in non immunocompromized critically ill patients. METHODS Multicentre matched case-control (1:5) study. We used prospectively collected data to identify risk factors for Aspergillus-positive specimens, as well as outcomes in Aspergillus-positive patients. RESULTS 66 cases (5 with definite invasive pulmonary aspergillosis (IPA), 18 with probable IPA, and 43 colonisations) were matched to 330 controls. In the multivariate conditional logistic model, independent risk factors for at least one Aspergillus-positive respiratory-tract specimen were worse SAPSII at admission [OR, 1.10; 95%CI, 1.00-1.21], ARDS [OR, 2.64; 95%CI, 1.29-5.40]; long-term steroid therapy [OR, 4.77; 95%CI, 1.49-15.23]; steroid therapy started in the ICU [OR, 11.03; 95%CI, 4.40-27.67]; and bacterial infection [OR, 2.73; 95%CI, 1.37-5.42]. The risk of death, compared to the controls, was not higher in the cases overall [HR, 0.66; 95%CI, 0.41-1.08; p = 0.1] or in the subgroups with definite IPA [HR, 1.60; 95%CI, 0.43-5.94; p = 0.48], probable IPA [HR, 0.84; 95%CI, 0.28-2.50; p = 0.76], or colonisation [HR, 0.58; 95%CI, 0.33-1.02; p = 0.06]. In cases who received antifungal therapy, mortality was not lower than in untreated cases [HR, 0.67; 95%CI, 0.36-1.24; p = 0.20]. CONCLUSIONS In critically ill immunocompetent patients, risk factors for presence of Aspergillus in lower respiratory tract specimens are steroid therapy (either chronic or initiated in the ICU), ARDS, and high severity of the acute illness. Prospective studies are warranted to further examine these risk factors and to investigate immune functions as well as the impact of antifungal therapy on patient outcomes.
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Álvarez Lerma F, Olaechea Astigarraga P, Palomar Martínez M, Rodríguez Carvajal M, Machado Casas JF, Jiménez Quintana MM, Esteve Urbano F, Ballesteros Herráez JC, Zavala Zegarra E. [Respiratory infections caused by Aspergillus spp. in critically ill patients admitted to the intensive care units]. Med Intensiva 2014; 39:149-59. [PMID: 24713089 DOI: 10.1016/j.medin.2014.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 02/03/2014] [Accepted: 02/11/2014] [Indexed: 11/18/2022]
Abstract
UNLABELLED The presence of respiratory fungal infection in the critically ill patient is associated with high morbidity and mortality. OBJECTIVES To assess the incidence of respiratory infection caused by Aspergillus spp. independently of the origin of infection in patients admitted to Spanish ICUs, as well as to describe the rates, characteristics, outcomes and prognostic factors in patients with this type of infection. MATERIAL AND METHODS An observational, retrospective, open-label and multicenter study was carried out in a cohort of patients with respiratory infection caused by Aspergillus spp. admitted to Spanish ICUs between 2006 and 2012 (months of April, May and June), and included in the ENVIN-HELICS registry (108,244 patients and 825,797 days of ICU stay). Variables independently related to in-hospital mortality were identified by multiple logistic regression analysis. RESULTS A total of 267 patients from 79 of the 198 participating ICUs were included (2.46 cases per 1000 ICU patients and 3.23 episodes per 10,000 days of ICU stay). From a clinical point of view, infections were classified as ventilator-associated pneumonia in 93 cases (34.8%), pneumonia unrelated to mechanical ventilation in 120 cases (44.9%), and tracheobronchitis in 54 cases (20.2%). The study population included older patients (mean 64.8±17.1 years), with a high severity level (APACHE II score 22.03±7.7), clinical diseases (64.8%) and prolonged hospital stay before the identification of Aspergillus spp. (median 11 days), transferred to the ICU mainly from hospital wards (58.1%) and with high ICU (57.3%) and hospital (59.6%) mortality rates, exhibiting important differences depending on the type of infection involved. Independent mortality risk factors were previous admission to a hospital ward (OR=7.08, 95%CI: 3.18-15.76), a history of immunosuppression (OR=2.52, 95%CI: 1.24-5.13) and severe sepsis or septic shock (OR=8.91, 95%CI: 4.24-18.76). CONCLUSIONS Respiratory infections caused by Aspergillus spp. in critically ill patients admitted to the ICU in Spain are infrequent, and affect a very selected group of patients, characterized by high mortality and conditioned by non-modifiable risk factors.
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Affiliation(s)
- F Álvarez Lerma
- Servicio de Medicina Intensiva, Hospital del Mar, Parc de Salut Mar, Barcelona, España.
| | | | - M Palomar Martínez
- Servicio de Medicina Intensiva, Hospital Arnau de Vilanova, Lleida, España
| | - M Rodríguez Carvajal
- Servicio de Medicina Intensiva, Hospital General de Huelva Juan Ramón Jiménez, Huelva, España
| | - J F Machado Casas
- Servicio de Medicina Intensiva, Complejo Hospitalario de Jaén, Jaén, España
| | - M M Jiménez Quintana
- Unidad de Cuidados Intensivos, Hospital Médico-Quirúrgico Virgen de las Nieves, Granada, España
| | - F Esteve Urbano
- Servicio de Medicina Intensiva, Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | | | - E Zavala Zegarra
- Unidad de Cuidados Intensivos Quirúrgica, Hospital Clinic i Provincial, IDIBAPS, Barcelona, España
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Host biomarkers of invasive pulmonary aspergillosis to monitor therapeutic response. Antimicrob Agents Chemother 2014; 58:3373-8. [PMID: 24687510 DOI: 10.1128/aac.02482-14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) is a life-threatening disease of immunocompromised patients that requires aggressive therapy. Detection of the disease and monitoring of the therapeutic response during IPA are complex, and current molecular diagnostics are not suitably robust. Here, we explored proteomic profiles of bronchoalveolar lavage fluid (BALF) specimens from a persistently neutropenic rabbit model of IPA. Three experimental arms, uninfected control animals, infected untreated animals, and animals infected and treated with ravuconazole/amphotericin B, were studied. Total proteins were evaluated by two-dimensional (2D) gel electrophoresis, followed by matrix-assisted laser desorption ionization-time of flight/time of flight (MALDI-TOF/TOF) mass spectrometry (MS) and quantified by enzyme-linked immunosorbent assay (ELISA). Host-derived proteins haptoglobin (Hp), C-reactive protein (CRP), and annexin A1 (Anx A1) were prominently found in BALF during the IPA infection and showed significant changes in response to antifungal therapy (P < 0.0001). In serum, differences in Hp (P = 0.0001) between infected and treated rabbits were observed. Preliminary in vitro studies revealed that Aspergillus fumigatus-secreted proteases may contribute to the cleavage of Anx A1 during IPA. In summary, host protein biomarkers Hp, CRP, and Anx A1 may have value in monitoring therapeutic response to antifungal agents in IPA patients with confirmed disease.
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He H, Jiang S, Zhang L, Sun B, Li F, Zhan Q, Wang C. Aspergillus tracheobronchitis in critically ill patients with chronic obstructive pulmonary diseases. Mycoses 2014; 57:473-82. [PMID: 24673772 DOI: 10.1111/myc.12185] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/20/2014] [Accepted: 02/23/2014] [Indexed: 12/27/2022]
Abstract
Aspergillus tracheobronchitis (ATB) is considered as an unusual form of invasive aspergillosis and has a fatal outcome. There is little current information on several aspects of chronic obstructive pulmonary diseases (COPD) complicated by ATB, the frequency of which is expected to increase in the coming years. In a prospective study of invasive bronchial-pulmonary aspergillosis (IBPA) in a critically ill COPD population, three proven cases of ATB were identified. The three new cases, combined with eight previously reported cases of COPD with ATB over a 30-year period (1983-2013), were analysed. Among 153 critically ill COPD patients admitted to the ICU, eight cases were complicated by ATB [23.5% of IBPA (8 of 34); and 5.2% of COPD (8 of 153)], and three cases were finally diagnosed as proven ATB by histopathological findings. Among the three new cases reported and the eight published cases, the overall mortality rate was 72.7% (8 of 11 cases), with a median of 11.5 days (range, 7-27 days) between admission to death. The mortality rate was significantly higher in patients with invasive pulmonary aspergillosis (IPA) [100% (8 of 8 patients)] than in patients without parenchyma invasion [0% (0 of 3 patient), P = 0.006]. Seven patients (77.8%) received systemic corticosteroid therapy and three patients (33.3%) inhaled corticosteroids before diagnosis with ATB. Dyspnoea resistant to corticosteroids (77.8%) was the most frequent symptom. The radiological manifestations progressed rapidly in three patients (75%) who had normal chest X-rays (CXRs) at admission. Pseudomembranous lesions were the most frequent form (54.5%) observed by bronchoscopy. Aspergillus fumigatus was the most frequently isolated pathogen (40%). ATB is an uncommon cause of exacerbation in approximately 5% of critically ill COPD patients admitted to the ICU, and may progress rapidly to IPA with a high mortality rate. Dyspnoea resistant to corticosteroids and appropriate antibiotics with a negative CXR should raise the suspicion of ATB. Early diagnosis of ATB is based on bronchoscopic examination and proven diagnosis maybe safely established with a bronchial mucous biopsy.
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Affiliation(s)
- Hangyong He
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Institute of Respiratory Medicine, Beijing, China
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Huerta A, Soler N, Esperatti M, Guerrero M, Menendez R, Gimeno A, Zalacaín R, Mir N, Aguado JM, Torres A. Importance of Aspergillus spp. isolation in Acute exacerbations of severe COPD: prevalence, factors and follow-up: the FUNGI-COPD study. Respir Res 2014; 15:17. [PMID: 24517318 PMCID: PMC3996133 DOI: 10.1186/1465-9921-15-17] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 12/27/2013] [Indexed: 11/17/2022] Open
Abstract
Background Acute exacerbations of COPD (AECOPD) are often associated with infectious agents, some of which may be non-usual, including Aspergillus spp. However, the importance of Aspergillus spp. in the clinical management of AECOPD still remains unclear. Objectives The aims of the study were to analyze the prevalence and risk factors associated with Aspergillus spp. isolation in AECOPD, and to investigate the associated clinical outcomes during a 1-year follow-up period. Methods Patients presenting with an AECOPD requiring hospitalization were prospectively included from four hospitals across Spain. Clinical, radiological and microbiological data were collected at admission and during the follow-up period (1, 6 and 12 months after discharge), and re-admissions and mortality data collected during the follow-up. Results A total of 240 patients with severe AECOPD were included. Valid sputum samples were obtained in 144 (58%) patients, and in this group, the prevalence of Aspergillus spp. isolation was 16.6% on admission and 14.1% at one-year follow-up. Multivariate logistic-regression showed that AECOPD in the previous year (OR 12.35; 95% CI, 1.9-29.1; p < 0.001), concurrent isolation of pathogenic bacteria (OR 3.64; 95% CI 1.65-9.45, p = 0.001) and concomitant isolation of Pseudomonas aeruginosa (OR 2.80; 95% IC, 1.81-11.42; p = 0.001) were the main risk factors for Aspergillus spp. isolation. Conclusions The main risk factors for Aspergillus spp. isolation were AECOPD in the previous year and concomitant isolation of Pseudomonas aeruginosa. However, although Aspergillus spp. is often isolated in sputum samples from patients with AECOPD, the pathogenic and clinical significance remains unclear.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Antoni Torres
- Department of Pneumology, Institute of Thorax (ICT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, University of Barcelona (UB), CIBER de Enfermedades Respiratorias (CIBERES 06/06/0028), Villarroel 170, 08037 Barcelona, Spain.
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Bajwa S, Kulshrestha A. Fungal infections in intensive care unit: challenges in diagnosis and management. Ann Med Health Sci Res 2013; 3:238-44. [PMID: 23919197 PMCID: PMC3728870 DOI: 10.4103/2141-9248.113669] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Infections have almost become an inseparable part of the intensive care units throughout the globe in spite of numerous advancements in diagnostic and therapeutic interventions. With advances in critical care medicine and introduction of broad-spectrum antibiotics, the incidence of invasive fungal infections in intensive care is on the rise, especially in patients with immunosuppression. The aim of this review is to collect recent information about various types of invasive fungal infections prevalent in the intensive care unit, the problems in their diagnosis and recent trends in their management. A thorough literature search was made in PubMed and Google using the following keywords for our search: Invasive fungal infection, antifungal therapy in intensive care unit, candidiasis. The major fungi implicated worldwide are Candida and Aspergillus spp., followed by Cryptococcus, Histoplasma, etc., in endemic areas. These produce a wide variety of infections that are difficult to diagnose as most of the diagnosing tests are non-specific and the culture takes a long time. An early suspicion of fungal infection with institution of appropriate antifungal therapy is mandatory for a positive outcome and to prevent development of invasive fungal infection.
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Affiliation(s)
- Sj Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
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Strauß R. [Pulmonary and other aspergilloses in patients in the intensive care unit]. Mycoses 2013; 55 Suppl 2:25-9. [PMID: 22519629 DOI: 10.1111/j.1439-0507.2012.02180.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Richard Strauß
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Erlangen, Deutschland.
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Álvarez-Lerma F, Rey-Pérez A. [Pulmonary aspergillosis in a non-immunocompromised critically ill patient]. Rev Iberoam Micol 2013; 29:90-2. [PMID: 22463784 DOI: 10.1016/j.riam.2012.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In non-immunocompromised patients admitted to intensive care departments or units (ICU), it is difficult to establish a definitive diagnosis of pulmonary aspergillosis because the signs and symptoms of this infectious disease are non-specific, and serological techniques are not very specific as well. For this reason, a diagnosis of possible pulmonary aspergillosis is initially established, and the starting of the treatment is controversial. CASE REPORT An immunocompetent subject had a work-related accident after a fall, which resulted in multiple injuries (head, thorax, lower extremities). The patient required mechanical ventilation since admission. On the second week of ICU admission, he showed a clinical presentation of respiratory infection with fever, purulent secretions, bilateral pulmonary infiltrates and repeated isolation of Mucor and Aspergillus fumigatus in bronchial secretions and pharyngeal swabs. The patient was treated with amphotericin B lipid complex and voriconazole with an excellent clinical and radiological outcome. CONCLUSIONS Combined treatment of antifungal agents, in this case amphotericin B lipid complex and voriconazole, is a therapeutic possibility to be considered in patients who failed to respond to initial antifungal monotherapy.
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Wessolossky M, Welch VL, Sen A, Babu TM, Luke DR. Invasive Aspergillus infections in hospitalized patients with chronic lung disease. Infect Drug Resist 2013; 6:33-9. [PMID: 23761976 PMCID: PMC3674018 DOI: 10.2147/idr.s43069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Although invasive pulmonary aspergillosis (IPA) is more prevalent in immunocompromised patients, critical care clinicians need to be aware of the occurrence of IPA in the nontraditional host, such as a patient with chronic lung disease. The purpose of this study was to describe the IPA patient with chronic lung disease and compare the data with that of immunocompromised patients. METHODS The records of 351 patients with Aspergillus were evaluated in this single-center, retrospective study for evidence and outcomes of IPA. The outcomes of 57 patients with chronic lung disease and 56 immunocompromised patients were compared. Patients with chronic lung disease were defined by one of the following descriptive terms: emphysema, asthma, idiopathic lung disease, bronchitis, bronchiectasis, sarcoid, or pulmonary leukostasis. RESULTS Baseline demographics were similar between the two groups. Patients with chronic lung disease were primarily defined by emphysema (61%) and asthma (18%), and immunocompromised patients primarily had malignancies (27%) and bone marrow transplants (14%). A higher proportion of patients with chronic lung disease had a diagnosis of IPA by bronchoalveolar lavage versus the immunocompromised group (P < 0.03). The major risk factors for IPA were found to be steroid use in the chronic lung disease group and neutropenia and prior surgical procedures in the immunocompromised group. Overall, 53% and 69% of chronic lung disease and immunocompromised patients were cured (P = 0.14); 55% of chronic lung patients and 47% of immunocompromised patients survived one month (P = 0.75). CONCLUSION Nontraditional patients with IPA, such as those with chronic lung disease, have outcomes and mortality similar to that in the more traditional immunocompromised population.
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Affiliation(s)
- Mireya Wessolossky
- Division of Infectious Diseases, University of Massachusetts Medical School, Worcester, MA, USA
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36
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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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Barton RC, Hobson RP, McLoughlin H, Morris A, Datta B. Assessment of the significance of respiratory culture of Aspergillus in the non-neutropenic patient. A critique of published diagnostic criteria. Eur J Clin Microbiol Infect Dis 2013; 32:923-8. [DOI: 10.1007/s10096-013-1827-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/14/2013] [Indexed: 10/27/2022]
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Yazıcıoğlu Moçin O, Karakurt Z, Aksoy F, Güngör G, Partal M, Adıgüzel N, Acartürk E, Batı Kutlu S, Baran R, Erdem H. Bronchoscopy as an indicator of tracheobronchial fungal infection in non-neutropenic intensive-care unit patients. Clin Microbiol Infect 2013; 19:E136-41. [PMID: 23331540 DOI: 10.1111/1469-0691.12112] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 09/26/2012] [Accepted: 11/14/2012] [Indexed: 11/26/2022]
Abstract
We aimed to establish that a bronchoscopic view can be as reliable as microbiology, and support an empirical tracheobronchial fungal infection (TBFI) treatment decision. We retrospectively studied 95 respiratory failure patients with suspected TBFI admitted to the intensive-care unit (ICU) in 2008 with sticky secretions, hyperaemic mucosa, and whitish plaques on bronchoscopic view. Patients not suspected of having TBFI were chosen as a control group (n = 151). Broncheoalveolar lavage (BAL) fluid was cultured, and biopsy samples were taken from the lesions. Biopsy samples positive for fungi were defined as 'proven', only BAL-positive (+ fungi) cases were 'probable TBFI', and BAL-negative (- fungi) cases were 'possible TBFI'. BAL (+ fungi) and BAL (- fungi) in the control group were defined as 'colonization' and 'no TBFI', respectively. The sensitivity, specificity and positive and negative predictive values of BAL (+ fungi) were 85.1% (63/74), 81.4% (140/172), 66.3% (63/95), and 92.7% (140/151), respectively. Biopsies were performed in 78 of 95 patients, and 28 were proven TBFI with fungal elements, and 100% were BAL (+ fungi). Probable TBFI was seen in 30 of 95 patients with BAL (+ fungi), and possible TBFI (BAL(- fungi)) in 25 of 95. Among the 95 patients, microbiology revealed fungi (90.5% Candida species; 9.5% Aspergillus) in 63 (66.3%). In the controls, the colonization and no TBFI rates were 11 of 151 and 140 of 151, respectively. Observing sticky secretions, hyperaemic mucosa and whitish plaques by bronchoscopy is faster than and may be as reliable as microbiology for diagnosing TBFI. These findings are relevant for empirical antifungal therapy in suspected TBFI patients in the ICU.
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Affiliation(s)
- O Yazıcıoğlu Moçin
- Pulmonology and Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
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Wauters J, Baar I, Meersseman P, Meersseman W, Dams K, De Paep R, Lagrou K, Wilmer A, Jorens P, Hermans G. Invasive pulmonary aspergillosis is a frequent complication of critically ill H1N1 patients: a retrospective study. Intensive Care Med 2012; 38:1761-8. [PMID: 22895826 PMCID: PMC7079899 DOI: 10.1007/s00134-012-2673-2] [Citation(s) in RCA: 193] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 07/03/2012] [Indexed: 12/31/2022]
Abstract
PURPOSE Despite their controversial role, corticosteroids (CS) are frequently administered to patients with H1N1 virus infection with severe respiratory failure secondary to viral pneumonia. We hypothesized that invasive pulmonary aspergillosis (IPA) is a frequent complication in critically ill patients with H1N1 virus infection and that CS may contribute to this complication. METHODS We retrospectively selected all adult patients with confirmed H1N1 virus infection admitted to the intensive care unit (ICU) of two tertiary care hospitals from September 2009 to March 2011. Differences in baseline factors, risk factors, and outcome parameters were studied between patients with and without IPA. RESULTS Of 40 critically ill patients with confirmed H1N1, 9 (23 %) developed IPA 3 days after ICU admission. Five patients had proven and four had probable IPA. Significantly more IPA patients received CS within 7 days before ICU admission (78 versus 23 %, p = 0.002). IPA patients also received significantly higher doses of CS before ICU admission [hydrocortisone equivalent 800 (360-2,635) versus 0 (0-0) mg, p = 0.005]. On multivariate analysis, use of CS before ICU admission was independently associated with IPA [odds ratio (OR) 14.4 (2.0-101.6), p = 0.007]. CONCLUSIONS IPA was diagnosed in 23 % of critically ill patients with H1N1 virus infection after a median of 3 days after ICU admission. Our data suggest that use of CS 7 days before ICU admission is an independent risk factor for fungal superinfection. These findings may have consequences for clinical practice as they point out the need for increased awareness of IPA, especially in those critically ill H1N1 patients already receiving CS.
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Affiliation(s)
- Joost Wauters
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.
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40
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Shi LN, Li FQ, Lu JF, Kong XX, Wang SQ, Huang M, Shao HF, Shao SH. Antibody specific to thioredoxin reductase as a new biomarker for serodiagnosis of invasive aspergillosis in non-neutropenic patients. Clin Chim Acta 2012; 413:938-43. [DOI: 10.1016/j.cca.2012.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 02/09/2012] [Accepted: 02/11/2012] [Indexed: 10/28/2022]
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Blot SI, Taccone FS, Van den Abeele AM, Bulpa P, Meersseman W, Brusselaers N, Dimopoulos G, Paiva JA, Misset B, Rello J, Vandewoude K, Vogelaers D. A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients. Am J Respir Crit Care Med 2012; 186:56-64. [PMID: 22517788 DOI: 10.1164/rccm.201111-1978oc] [Citation(s) in RCA: 444] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The clinical relevance of Aspergillus-positive endotracheal aspirates in critically ill patients is difficult to assess. OBJECTIVES We externally validate a clinical algorithm to discriminate Aspergillus colonization from putative invasive pulmonary aspergillosis in this patient group. METHODS We performed a multicenter (n = 30) observational study including critically ill patients with one or more Aspergillus-positive endotracheal aspirate cultures (n = 524). The diagnostic accuracy of this algorithm was evaluated using 115 patients with histopathologic data, considered the gold standard. Subsequently, the diagnostic workout of the algorithm was compared on the total cohort (n = 524), with the categorization based on the diagnostic criteria of the European Organization for the Research and Treatment of Cancer/Mycoses Study Group. MEASUREMENTS AND MAIN RESULTS Among 115 histopathology-controlled patients, 79 had proven aspergillosis. The algorithm judged 86 of 115 cases to have putative aspergillosis. This diagnosis was confirmed in 72 and rejected in 14 patients. The algorithm judged 29 patients to have Aspergillus colonization. This was confirmed in 22 and rejected in 7 patients. The algorithm had a specificity of 61% and a sensitivity of 92%. The positive and negative predictive values were 61 and 92%, respectively. In the total cohort (n = 524), 79 patients had proven invasive pulmonary aspergillosis (15.1%). According to the European Organization for the Research and Treatment of Cancer/Mycoses Study Group criteria, 32 patients had probable aspergillosis (6.1%) and 413 patients were not classifiable (78.8%). The algorithm judged 199 patients to have putative aspergillosis (38.0%) and 246 to have Aspergillus colonization (46.9%). CONCLUSIONS The algorithm demonstrated favorable operating characteristics to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients.
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Affiliation(s)
- Stijn I Blot
- General Internal Medicine and Infectious Diseases, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium.
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Abstract
Invasive aspergillosis has been classically associated with certain risk factors: cytotoxic chemotherapy, prolonged neutropenia, corticosteroids, transplantation, AIDS. However, the literature is growing that this mycosis, particularly pulmonary aspergillosis, can be seen in patients lacking these factors. Many of the latter patients are in the intensive care unit. Other associated conditions include influenza, nonfungal pneumonia, chronic obstructive lung disease, immaturity, sepsis, liver failure, alcoholism, chronic granulomatous disease and surgery. Certain focal sites, such as sinusitis or cerebral aspergillosis, have additional risk factors. This emphasizes the potential importance of a positive culture for Aspergillus in the critically ill, the need for awareness about possible aspergillosis in patients lacking the classical risk factors, and readiness to proceed with appropriate diagnostic maneuvers.
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Affiliation(s)
- David A Stevens
- Department of Medicine, Santa Clara Valley Medical Center, 751 So. Bascom Ave., San Jose, CA 95128-2699, USA.
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Shi LN, Li FQ, Huang M, Lu JF, Kong XX, Wang SQ, Shao HF. Immunoproteomics based identification of thioredoxin reductase GliT and novel Aspergillus fumigatus antigens for serologic diagnosis of invasive aspergillosis. BMC Microbiol 2012; 12:11. [PMID: 22251604 PMCID: PMC3398318 DOI: 10.1186/1471-2180-12-11] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 01/18/2012] [Indexed: 01/14/2023] Open
Abstract
Background There has been a rising incidence of invasive aspergillosis (IA) in critically ill patients, even in the absence of an apparent predisposing immunodeficiency. The diagnosis of IA is difficult because clinical signs are not sensitive and specific, and serum galactomannan has relatively low sensitivity in this group of patients. Therefore, more prompt and accurate disease markers for early diagnosis are needed. To establish disease markers demands a thorough knowledge of fungal antigens which may be detected in the serum or other body fluids of patients. Herein we report novel immunodominant antigens identified from extracellular proteins of Aspergillus fumigatus. Results Extracellular proteins of A. fumigatus were separated by two-dimensional electrophoresis (2-DE) and probed with the sera from critically ill patients with proven IA. The immunoreactive protein spots were identified by MALDI-TOF mass spectrometry (MALDI-TOF -MS). Forty spots from 2DE gels were detected and 17 different proteins were identified as immunogenic in humans. Function annotation revealed that most of these proteins were metabolic enzymes involved in carbohydrate, fatty acid, amino acid, and energy metabolism. One of the proteins, thioredoxin reductase GliT (TR), which showed the best immunoactivity, was analyzed further for secretory signals, protein localization, and homology. The results indicated that TR is a secretory protein with a signal sequence exhibiting a high probability for secretion. Furthermore, TR did not match any human proteins, and had low homology with most other fungi. The recombinant TR was recognized by the sera of all proven IA patients with different underlying diseases in this study. Conclusions The immunoreactive proteins identified in this study may be helpful for the diagnosis of IA in critically ill patients. Our results indicate that TR and other immunodominant antigens have potential as biomarkers for the serologic diagnosis of invasive aspergillosis.
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Affiliation(s)
- Li-ning Shi
- Laboratory of Molecular Biology, Institute of Medical Laboratory Sciences, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing 210002, PR China
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Xu H, Li L, Huang WJ, Wang LX, Li WF, Yuan WF. Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease: a case control study from China. Clin Microbiol Infect 2011; 18:403-8. [PMID: 22023558 DOI: 10.1111/j.1469-0691.2011.03503.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with severe chronic obstructive pulmonary disease (COPD) are at higher risk of developing invasive pulmonary aspergillosis (IPA). However, there are limited data for this disease. To evaluate risk factors and the clinical characteristics of IPA in COPD patients, we conducted a hospital-based, retrospective case-control study of 30 COPD patients with IPA and 60 COPD control patients without IPA. Patients in the case group were significantly more likely to have concurrent co-morbidities than controls. Of the IPA patients, 65.4% had worsening radiological findings vs. 11.4% in the control group (p<0.001). IPA in COPD was associated with a higher proportion of mechanical ventilation (43.3% vs. 5%; p<0.001), a longer hospital stay duration (45.8±39.1 days vs. 18.4±11.8 days; p<0.001), and higher mortality (43.3% vs. 11.4%; p<0.001). Systemic use of steroids in the stable phase, treatment with three or more antibiotics during hospitalization and antibiotic treatment longer than 10 days were independent risk factors associated with IPA. COPD patients with obvious dyspnoea, antibiotic-resistant lower respiratory tract infection and repeated detection of Aspergillus in sputum should be considered for the possibility of IPA.
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Affiliation(s)
- H Xu
- Respiratory Medicine Clinical Laboratory, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
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He H, Ding L, Chang S, Li F, Zhan Q. Value of consecutive galactomannan determinations for the diagnosis and prognosis of invasive pulmonary aspergillosis in critically ill chronic obstructive pulmonary disease. Med Mycol 2011; 49:345-51. [DOI: 10.3109/13693786.2010.521523] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ruiz-Camps I, Aguado J, Almirante B, Bouza E, Ferrer-Barbera C, Len O, Lopez-Cerero L, Rodríguez-Tudela J, Ruiz M, Solé A, Vallejo C, Vazquez L, Zaragoza R, Cuenca-Estrella M. Guidelines for the prevention of invasive mould diseases caused by filamentous fungi by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). Clin Microbiol Infect 2011; 17 Suppl 2:1-24. [DOI: 10.1111/j.1469-0691.2011.03477.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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He H, Ding L, Li F, Zhan Q. Clinical features of invasive bronchial-pulmonary aspergillosis in critically ill patients with chronic obstructive respiratory diseases: a prospective study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R5. [PMID: 21211008 PMCID: PMC3222032 DOI: 10.1186/cc9402] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 11/30/2010] [Accepted: 01/06/2011] [Indexed: 11/10/2022]
Abstract
Introduction Critically ill patients with chronic obstructive respiratory diseases (CORD) who require intensive care unit (ICU) admission are at particular risk for invasive bronchial-pulmonary aspergillosis (IBPA). The purpose of this study is to investigate clinical features for rapid recognition of IBPA in critically ill patients with CORD. Methods We included 55 consecutive CORD patients in a respiratory ICU in a prospective, single-center, cohort study. In this study, IBPA combined two entities: ATB and IPA. Results Thirteen of 55 patients were diagnosed with IBPA. Before ICU admission, three variables were independent predictors of IBPA with statistical significance: more than three kinds of antibiotics used before the ICU admission, accumulated doses of corticosteroids (>350 mg) received before the ICU admission, and APACHE II scores >18 (OR, 1.208; P = 0.022; OR, 8.661; P = 0.038; and OR, 19.488; P = 0.008, respectively). After ICU admission, more IBPA patients had a high fever (>38.5°C) (46.2% versus 11.9%; P = 0.021), wheeze without exertion (84.6% versus 50.0%; P = 0.027), dry rales (84.6% versus 40.4%; P = 0.005), higher white blood cell counts (21 × 109/L versus 9.4 × 109/L; P = 0.012), lower mean arterial pressures (77.9 mm Hg versus 90.5 mm Hg; P = 0.019), and serum creatinine clearances (36.2 ml/min versus 68.8 ml/min; P < 0.001), and liver-function and coagulation abnormalities. Bronchospasm, sputum ropiness, and plaque formation were more common for IBPA patients during bronchoscopy (66.7% versus 14.3%; P = 0.082; 18% versus 0; P = 0.169; and 73% versus 13%; P = 0.003, respectively). More IBPA patients had nodules and patchiness on chest radiograph on day 1 of admission, which rapidly progressed to consolidation on day 7. IBPA mortality was higher than that of non-IBPA patients (69.2% versus 16.7%; P = 0.001). Conclusions IBPA may be suspected in critically ill CORD patients with respiratory failure and clinical and bronchoscopic manifestations of severe infection, bronchospasm, and rapid progression of radiologic lesions that are irresponsive to steroids and antibiotics. To avoid misdiagnosis and establish the microbiologic etiology, early bronchoscopy and tight radiologic follow-up should be performed.
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Affiliation(s)
- Hangyong He
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang South Road, Beijing 100020, PR China
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Patel DA, Gao X, Stephens JM, Forshag MS, Tarallo M. US hospital database analysis of invasive aspergillosis in the chronic obstructive pulmonary disease non-traditional host. J Med Econ 2011; 14:227-37. [PMID: 21385144 DOI: 10.3111/13696998.2011.564246] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Invasive aspergillosis (IA) is reported increasingly in non-traditional hosts, typically patients with chronic obstructive pulmonary disease (COPD). Objectives were to describe the excess burden of IA in COPD, including mortality, resource utilization, and costs, as well as to examine the impact of initial antifungal selection on clinical and economic outcomes. METHODS This retrospective cohort study used national data from 2005 to 2008, from the Premier Perspective hospital database. IA was identified using proxy ICD-9 codes based on published algorithms. The COPD + IA patient cohort was analyzed using descriptive statistics. Excess resource utilization was analyzed by matching cases (COPD + IA) and controls (COPD patients without aspergillosis) on demographic and clinical variables. Multivariate analyses were used to assess the impact of initial antifungal drug selection on outcomes in COPD + IA. RESULTS In total, 475 COPD + IA patients were identified (mean age 69 years, 50% male, 76% Caucasian). COPD + IA cases had significantly higher costs, length of stay, intensive care unit (ICU) stay, and mortality compared to COPD controls (all p < 0.01). On average, antifungal therapy was initiated on hospital day 6, with mean length of therapy 15 days, and one-third of patients were in the ICU when antifungal treatment was initiated. Most commonly used antifungals were voriconazole, fluconazole, and caspofungin. Patients receiving fluconazole as the initial antifungal, an agent inactive against moulds, had almost two times greater mortality (p = 0.016), two additional hospital days (p = 0.002), and 25% greater costs (p = 0.007), compared to patients receiving voriconazole first-line. Findings were consistent in sub-analyses including ICU patients. LIMITATIONS 'Invasive' form of aspergillosis was identified using proxy ICD-9 codes based on published literature. Additional limitations stem from the study's non-randomized, retrospective design that is typical with any database analyses. CONCLUSIONS COPD + IA patients had significantly higher mortality, resource utilization, and costs versus COPD controls. Treatment with an agent active against Aspergillus was associated with better survival and reduced economic burden, therefore this potential etiology of pneumonia should be considered when contemplating antifungal therapy in COPD patients.
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Garbino J, Fluckiger U, Elzi L, Imhof A, Bille J, Zimmerli S. Survey of aspergillosis in non-neutropenic patients in Swiss teaching hospitals. Clin Microbiol Infect 2010; 17:1366-71. [PMID: 20950331 DOI: 10.1111/j.1469-0691.2010.03402.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Invasive aspergillosis (IA) is a live-threatening opportunistic infection that is best described in haematological patients with prolonged neutropenia or graft-versus-host disease. Data on IA in non-neutropenic patients are limited. The aim of this study was to establish the incidence, disease manifestations and outcome of IA in non-neutropenic patients diagnosed in five Swiss university hospitals during a 2-year period. Case identification was based on a comprehensive screening of hospital records. All cases of proven and probable IA were retrospectively analysed. Sixty-seven patients were analysed (median age 60 years; 76% male). Sixty-three per cent of cases were invasive pulmonary aspergillosis (IPA), and 17% of these were disseminated aspergillosis. The incidence of IPA was 1.2/10 000 admissions. Six of ten cases of extrapulmonary IA affected the brain. There were six cases of invasive rhinosinusitis, six cases of chronic pulmonary aspergillosis, and cases three of subacute pulmonary aspergillosis. The most frequent underlying condition of IA was corticosteroid treatment (57%), followed by chronic lung disease (48%), and intensive-care unit stays (43%). In 38% of patients with IPA, the diagnosis was established at autopsy. Old age was the only risk factor for post-mortem diagnosis, whereas previous solid organ transplantation and chronic lung disease were associated with lower odds of post-mortem diagnosis. The mortality rate was 57%.
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Affiliation(s)
- J Garbino
- Infectious Diseases, University Hospitals Geneva, Geneva, Switzerland.
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