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Poth JM, Schmandt M, Schewe JC, Lehmann F, Kreyer S, Kohistani Z, Bakhtiary F, Hischebeth G, Putensen C, Weller J, Ehrentraut SF. Prevalence and prognostic relevance of invasive fungal disease during veno-arterial ECMO: A retrospective single-center study. J Crit Care 2024; 83:154831. [PMID: 38797056 DOI: 10.1016/j.jcrc.2024.154831] [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: 03/21/2024] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE To assess the prevalence and relevance of invasive fungal disease (IFD) during veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO). METHODS Retrospective analysis from January 2013 to November 2023 of adult V-A ECMO cases at a German University Hospital. Parameters relating to IFD, demographics, length of stay (LoS), days on ECMO and mechanical ventilation, prognostic scores and survival were assessed. Multivariable logistic regression analyses with IFD and death as dependent variables were performed. Outcome was assessed after propensity score matching IFD-patients to non-IFD-controls. RESULTS 421 patients received V-A ECMO. 392 patients with full electronic datasets were included. The prevalence of IFD, invasive candidiasis and probable invasive pulmonary aspergillosis was 4.6%, 3.8% and 1.0%. Severity of acute disease, pre-existing moderate-to-severe renal disease and continuous kidney replacement therapy were predictive of IFD. In-hospital mortality (94% (17/18) compared to 67% (252/374) in non-IFD patients (p = 0.0156)) was predicted by female sex, SOFA score at admission, SAVE score and IFD (for IFD: OR: 8.31; CI: 1.60-153.18; p: 0.044). There was no difference in outcome after matching IFD-cases to non-IFD-controls. CONCLUSIONS IFD are detected in about one in 20 patients on V-A ECMO, indicating mortality >90%. However, IFD do not contribute to prognosis in this population.
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Affiliation(s)
- Jens M Poth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Mathias Schmandt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Rostock, 18057 Rostock, Germany
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Zaki Kohistani
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, 53127 Bonn, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, 53127 Bonn, Germany
| | - Gunnar Hischebeth
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, 53127 Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Johannes Weller
- Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan F Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany.
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Teoh PJ, McGuire E, Borman AM, Gorton R, Wilson AJ, Merrion C, Gant V. Invasive Trichoderma longibrachiatum infection in a neutropaenic patient. Med Mycol Case Rep 2024; 45:100656. [PMID: 39026576 PMCID: PMC11255095 DOI: 10.1016/j.mmcr.2024.100656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/02/2024] [Accepted: 06/08/2024] [Indexed: 07/20/2024] Open
Abstract
Invasive fungal infection is a life-threatening complication of chemotherapy and neutropaenia in the haematology population. Trichoderma species rarely cause human disease but have been reported to cause invasive infection in the immunosuppressed. We present a case of invasive Trichoderma longibrachiatum pulmonary infection with fatal outcome in a neutropaenic patient with acute myeloid leukaemia. 2012 Elsevier Ltd. All rights reserved.
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Affiliation(s)
- Penelope J. Teoh
- Hospital for Tropical Diseases, University College London Hospital NHS Foundation Trust, Capper Street, London, WC1E 6JB, United Kingdom
| | - Emma McGuire
- Hospital for Tropical Diseases, University College London Hospital NHS Foundation Trust, Capper Street, London, WC1E 6JB, United Kingdom
| | - Andrew M. Borman
- UKHSA National Mycology Reference Laboratory, Bristol, BS10 5NB, UK and Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, EX4 4QD, United Kingdom
| | - Rebecca Gorton
- Department of Infection Sciences, Health Services Laboratories, 1 Mabledon Pl, London, WC1H 9AX, United Kingdom
| | - Andrew J. Wilson
- University College London Hospital NHS Foundation Trust, University College Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom
| | - Chloe Merrion
- University College London Hospital NHS Foundation Trust, University College Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom
| | - Vanya Gant
- University College London Hospital NHS Foundation Trust, University College Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom
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3
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Park SY, Ardura MI, Zhang SX. Diagnostic limitations and challenges in current clinical guidelines and potential application of metagenomic sequencing to manage pulmonary invasive fungal infections in patients with haematological malignancies. Clin Microbiol Infect 2024; 30:1139-1146. [PMID: 38460819 DOI: 10.1016/j.cmi.2024.03.003] [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: 07/28/2023] [Revised: 02/24/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Pulmonary invasive fungal infections (pIFI) disproportionately affect patients with haematological malignancies (HM). Establishing a rapid and accurate diagnosis of pIFI is challenging. Multiple guidelines recommend diagnostic testing of invasive fungal infections but lack consensus and may contribute to inconsistent diagnostic approaches. OBJECTIVE To identify key diagnostic challenges and review metagenomic sequencing data. SOURCES PubMed, professional consortium, and scientific society websites search to identify relevant, published, evidence-based clinical guidelines within the past 5 years. PubMed searchs for papers describing clinically relevant novel diagnostic technologies. CONTENT Current guidelines for patients with HM and suspected pIFI recommend chest computed tomography imaging and specimen testing with microscopic examination (including calcofluor white stain, histopathology, cytopathology, etc.), Aspergillus galactomannan, β-D-glucan, PCR, and culture, each with certain limitations. Emerging real-world data support the adjunctive use of metagenomic sequencing-based tests for the timely diagnosis of pIFI. IMPLICATIONS High-quality evidence from robust clinical trials is needed to determine whether guidelines should be updated to include novel diagnostic technologies. Trials should ask whether the combination of powerful novel diagnostics, such as pathogen-agnostic metagenomic sequencing technologies in conjunction with conventional testing can optimize the diagnostic yield for all potential pIFI pathogens that impact the health of patients with HM.
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Affiliation(s)
| | - Monica I Ardura
- Section of Infectious Diseases & Host Defense Program, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sean X Zhang
- Medical Mycology Laboratory, Johns Hopkins Hospital, Baltimore, MD, USA; Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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Taynton T, Allsup D, Barlow G. How can we optimize antifungal use and stewardship in the treatment of acute leukemia? Expert Rev Hematol 2024; 17:581-593. [PMID: 39037307 DOI: 10.1080/17474086.2024.2383401] [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: 04/26/2024] [Accepted: 07/18/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION The global need for antifungal stewardship is driven by spreading antimicrobial and antifungal resistance. Triazoles are the only oral and relatively well-tolerated class of antifungal medications, and usage is associated with acquired resistance and species replacement with intrinsically resistant organisms. On a per-patient basis, hematology patients are the largest inpatient consumers of antifungal drugs, but are also the most vulnerable to invasive fungal disease. AREAS COVERED In this review we discuss available and forthcoming antifungal drugs, antifungal prophylaxis and empiric antifungal therapy, and how a screening based and diagnostic-driven approach may be used to reduce antifungal consumption. Finally, we discuss components of an antifungal stewardship program, interventions that can be employed, and how impact can be measured. The search methodology consisted of searching PubMed for journal articles using the term antifungal stewardship plus program, intervention, performance measure or outcome before 1 January 2024. EXPERT OPINION Initial focus should be on implementing effective antifungal stewardship programs by developing and implementing local guidelines and using interventions, such as post-prescription review and feedback, which are known to be effective. Technologies such as microbiome analysis and machine learning may allow the development of truly individualized risk-factor-based approaches to antifungal stewardship in the future.
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Affiliation(s)
- Thomas Taynton
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Centre for Biomedical Research, Hull York Medical School, Hull, UK
| | - David Allsup
- Biomedical Institute for Multimorbidity, Hull York Medical School, Hull, UK
- Queen's Centre for Oncology and Haematology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Gavin Barlow
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
- York Biomedical Research Institute and Hull York Medical School, University of York, York, UK
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Machado M, Fortún J, Muñoz P. Invasive aspergillosis: A comprehensive review. Med Clin (Barc) 2024; 163:189-198. [PMID: 38714471 DOI: 10.1016/j.medcli.2024.01.045] [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: 11/30/2023] [Revised: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 05/09/2024]
Abstract
Invasive aspergillosis (IA) is a severe fungal infection caused by Aspergillus species, particularly Aspergillus fumigatus, although new species, sometimes resistant to antifungals are becoming more common. IA predominantly affects immunocompromised patients, such as those with haematological malignancies, solid organ transplant recipients, and critically ill patients. However, new at-risk populations have emerged in recent years, such as IA associated with severe viral infections. Advanced diagnostic methods are crucial, especially considering the rising concern of antifungal resistance. Early detection is critical for successful treatment, typically involving antifungal medications like voriconazole or amphotericin B, but new antifungals are arriving to complete the therapeutic strategies. Despite advancements, mortality rates remain high, underscoring the importance of timely interventions and ongoing research. Healthcare providers should maintain a high index of suspicion, especially in immunocompromised patients and other new risk factors that are arising, to promptly diagnose and manage invasive aspergillosis.
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Affiliation(s)
- Marina Machado
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Universidad de Alcalá, Escuela de Doctorado, Alcalá de Henares, Spain.
| | - Jesús Fortún
- Infectious Diseases Department, Hospital Ramón y Cajal, Madrid, Spain; Universidad de Alcalá, Escuela de Doctorado, Alcalá de Henares, Spain; IRYCIS: Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER de Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, Faculty of Medicine, Universidad Complutense de Madrid, Spain
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Yun J, Wang Z, Liu W. Voriconazole-induced central nervous system toxicity: a pharmacovigilance study based on FDA adverse event reporting system (FAERS) database. Expert Opin Drug Saf 2024:1-8. [PMID: 39129467 DOI: 10.1080/14740338.2024.2391492] [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: 06/09/2024] [Revised: 07/30/2024] [Accepted: 08/07/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND This study aims to evaluate the relationship between voriconazole (VRC) and central nervous system (CNS) toxicity based on the real world data. RESEARCH DESIGN AND METHODS The reports of FAERS from January 2004 to March 2022 were included in our study. The CNS toxicity events were identified by using Medical Dictionary for Regulatory Activities terms. Reporting odds ratios corresponding to 95% confidence intervals were employed to quantify the signals of VRC-associated CNS events. RESULTS The overall RORs (95%CI) for psychiatric disorders, nervous system disorders, and eye disorders were 1.84 (1.70, 2.00), 1.09 (1.01, 1.18), and 3.84 (3.48, 4.23), respectively (p < 0.05). The median time to the CNS events of VRC was 1(IQR 0-5) day. Top six signals were macular opacity, chloropsia, scintillating scotoma, toxic optic neuropathy, corneal bleeding, and dyschromatopsia, all of them grouped as eye disorders. Compared with itraconazole, fluconazole, posaconazole, and isavuconazole, VRC shows significant relationship and higher incidence rate of psychiatric disorders, nervous system disorders, and eye disorders, respectively (p < 0.05). CONCLUSIONS VRC was significantly associated with the CNS toxicity. Dosing adjustment, model-based individualized treatment project, and the therapeutic drug monitoring-guided individualized medication regime could be good strategies for efficacy improvement and the adverse events of reducing of VRC.
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Affiliation(s)
- Juping Yun
- Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Zihe Wang
- Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Wei Liu
- Beijing You'an Hospital, Capital Medical University, Beijing, China
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7
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Dong L, Zhuang X, Yang T, Yan K, Cai Y. A Physiologically Based Pharmacokinetic Model of Voriconazole in Human CNS -- Integrating Time-Dependent Inhibition of CYP3A4, Genetic Polymorphisms of CYP2C19 and Possible Transporter Mechanisms. Int J Antimicrob Agents 2024:107310. [PMID: 39168418 DOI: 10.1016/j.ijantimicag.2024.107310] [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: 03/04/2024] [Revised: 07/26/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
AIMS Voriconazole is a classical antifungal drug that is often used to treat CNS fungal infections due to its permeability through the BBB. However, its clinical use remains challenging because of its narrow therapeutic window and wide inter-individual variability. In this study, we proposed an optimized and validated PBPK model by integrating in vitro, in vivo and clinical data to simulate the distribution and PK process of voriconazole in the CNS, providing guidance for clinical individualized treatment. METHODS The model structure was optimized and tissue-to-plasma partition coefficients were obtained through animal experiments. Using the allometric relationships, the distribution of voriconazole in the human CNS was predicted. The model integrated factors affecting inter-individual variation and drug interactions of voriconazole-polymorphisms in the CYP2C19 gene and auto-inhibition and then was validated using real clinical data. RESULTS The overall AFE value showing model predicted differences was 1.1420 in the healthy population; and in the first prediction of plasma and CSF in actual clinical patients, 89.5% of the values were within the 2-fold error interval, indicating good predictive performance of the model. The bioavailability of voriconazole varied at different doses (39%-86%), and the optimized model conformed to this pattern (46%-83%). CONCLUSION Combined with the relevant pharmacodynamic indexes, the PBPK model provides a feasible way for precise medication in patients with CNS infection and improve the treatment effect and prognosis.
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Affiliation(s)
- Liuhan Dong
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing 100853, China; State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
| | - Xiaomei Zhuang
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
| | - Tianli Yang
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing 100853, China
| | - Kaicheng Yan
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing 100853, China
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing 100853, China.
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8
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Cheng L, You X, Wang X, Yu M, Jia C. The Role of Plasma Trough Concentration of Voriconazole and Voriconazole N-Oxide in Its Hepatotoxicity in Adult Patients. Drug Des Devel Ther 2024; 18:3617-3628. [PMID: 39156484 PMCID: PMC11330242 DOI: 10.2147/dddt.s475706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 08/09/2024] [Indexed: 08/20/2024] Open
Abstract
Objective Hepatotoxicity is an important cause of early withdrawal of voriconazole (VCZ). The role of the plasma trough concentration of VCZ (C0) in hepatotoxicity is confusion. VCZ N-oxide is the primary metabolite of VCZ in plasma. We investigated the role of VCZ C0 and plasma trough concentration of VCZ N-oxide (CN) in hepatotoxicity in adult patients. Materials and Methods This was a prospective study. VCZ C0 and CN were measured using liquid chromatography-tandem mass spectrometry. Results In total, 601 VCZ C0 and CN from 376 adult patients were included. The percentage of grade 1 or higher adverse events for ALP, ALT, AST, γ-GT, and TBIL were 35.4%, 21.0%, 30.1%, 56.2%, and 22.2%, respectively. Compared with younger adult patients, elderly patients (≥65 years) had a higher rate of grade 1 or higher adverse events of ALP. In the multivariate analysis, VCZ C0 was a risk factor for grade 1 or higher adverse events of AST in elderly patients and TBIL in younger adult patients, and VCZ CN was a risk factor for grade 1 or higher adverse events of ALT, AST, and TBIL. Results of the receiver operating characteristic curve analysis indicated that when the VCZ C0 was higher than 4.0 μg/mL, or the VCZ CN was lower than 1.7 μg/mL, the incidence of grade 1 or higher adverse events of AST and TBIL increased. Conclusion VCZ C0 and CN were associated with liver function-related adverse events. Measurement of VCZ CN should be considered for VCZ therapeutic drug monitoring.
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Affiliation(s)
- Lin Cheng
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Xi You
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Xiaowen Wang
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Mingjie Yu
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
| | - Changsheng Jia
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University, Chongqing, People’s Republic of China
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Panagopoulou P, Roilides E. An update on pharmacotherapy for fungal infections in allogeneic stem cell transplant recipients. Expert Opin Pharmacother 2024. [PMID: 39096057 DOI: 10.1080/14656566.2024.2387686] [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: 05/18/2024] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Invasive fungal diseases (IFD) constitute a major cause of morbidity and mortality in hematopoietic stem cell transplantation (HSCT) recipients. AREAS COVERED We describe epidemiology, causes and risk factors of IFD in allogeneic HSCT discussing prophylaxis and treatment in various HSCT phases. We present the most recent studies on this thematic area, including novel data on currently available antifungals, i.e. formulations, dosing, safety, efficacy and therapeutic drug monitoring. Finally, we present the most recent relevant recommendations published. Literature search included PubMed, Scopus and clinicaltrials.gov between January 2014-April 2024. EXPERT OPINION The antifungal agents employed for prophylaxis and therapy should be predicated on local epidemiology of IFD. Fluconazole prophylaxis remains a first-line choice before engraftment when the main pathogen is Candida spp. After engraftment prophylaxis should be with mold-active agents (i.e. triazoles). For candidiasis echinocandins are suggested as first-line treatment, whereas aspergillosis responds well to mold-active azoles and liposomal amphotericin B (L-AmB). For mucormycosis treatment of choice includes L-AmB and isavuconazole. Choice between fever-driven and diagnostics-driven strategies remains equivocal. Open research topics remain: 1) optimization of tools to ensure prompt and accurate IFD diagnosis to avoid unnecessary exposure to antifungals, drug interactions and cost; 2) refinement of treatment for resistant/refractory strains.
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Affiliation(s)
- Paraskevi Panagopoulou
- Pediatric Hematology & Oncology, 4th Department of Pediatrics, Aristotle University School of Medicine and Papageorgiou General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University School of Medicine and Hippokration General Hospital, Thessaloniki, Greece
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10
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Ergün M, Jansen AME, Hilbrands LB, de Kort E, Kunst H, Reijers MHE, Schouten JA, Verweij PE, Brüggemann RJM. Isavuconazole as prophylaxis and therapy for invasive fungal diseases: a real-life observational study. J Antimicrob Chemother 2024; 79:1801-1810. [PMID: 38935893 PMCID: PMC11290874 DOI: 10.1093/jac/dkae139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/10/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Isavuconazole is a relatively new antifungal agent indicated for the management of various invasive fungal diseases (IFDs), including invasive aspergillosis. Information on real-world experience with isavuconazole is scarce. This retrospective observational study aimed to describe the usage of isavuconazole in clinical practice with an in-depth evaluation of individual isavuconazole exposure. METHODS Patients treated with isavuconazole were evaluated based on retrospective data, including therapeutic drug monitoring (TDM) data and efficacy and safety data. Additionally, we calculated the individual isavuconazole exposure described by the average AUC24 over the first 7 days of treatment by means of non-linear mixed-effects modelling and compared this with the currently desired lower target AUC of 60 mg·h/L. RESULTS Ninety-nine patients treated with isavuconazole were evaluated. In our real-life cohort, isavuconazole was often deployed off-label in patients with non-classical host factors and infections with non-Aspergillus and non-Mucorales species. Isavuconazole was most often chosen for its safety profile, even after prior triazole treatment with manifestations of toxicity. TDM and subsequent dosage adjustments were frequently performed. The individual average AUC24 over 7 days was above 60 mg·h/L in 29 out of 77 (37.7%) patients. CONCLUSIONS This overview provides practical insights that can aid clinicians in the management of their patients with IFD. Our study shows that isavuconazole was used in a diverse patient population and was well tolerated overall. Individual isavuconazole exposure reflected by the average AUC24 over the first 7 days of treatment was generally low and variable. Dosage adjustments following TDM were frequently performed. Our experience shows that isavuconazole is a feasible alternative after prior azole treatment.
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Affiliation(s)
- Mehmet Ergün
- Radboudumc—CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anouk M E Jansen
- Radboudumc—CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elizabeth de Kort
- Radboudumc—CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henricus Kunst
- Department of Otorhinolaryngology, Dutch Academic Alliance Skull Base Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Otorhinolaryngology, Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Monique H E Reijers
- Radboudumc—CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pulmonology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul E Verweij
- Radboudumc—CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J M Brüggemann
- Radboudumc—CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
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Fumarola B, Signorini L, Lorenzotti S, Lanza P, Saccani B, Van Hauwermeiren E, Mulè A, Piva S, Rota M, Zuccalà F, Rasulo FA, Filippini M, Bertazzoli A, Del Fabro G, Matteelli A. Use of nebulized liposomal amphotericin B and posaconazole as antifungal prophylaxis in patients with severe SARS-CoV2 infection in intensive care unit. Infection 2024; 52:1459-1468. [PMID: 38530518 PMCID: PMC11289071 DOI: 10.1007/s15010-024-02234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/12/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE COVID-19 associated pulmonary aspergillosis (CAPA) is common and linked with high fatality rates. To assess the impact on the incidence and outcome of CAPA of an antifungal prophylaxis (AFP) we compared two cohorts of COVID-19 patients admitted to intensive care units (ICU) in Brescia, Italy, from January to August 2021. METHODS The study cohort included all mechanically ventilated patients observed between April 2021 and August 2021 with SARS-CoV-2-pneumonia, who received AFP with oral posaconazole (200 mg every 6 h) and nebulized liposomal amphotericin B (50 mg every 2 weeks) from ICU admission to 7 days after discharge or, if applicable, until tracheostomy removal. The control cohort included COVID-19 patients admitted to the same ICU between January and March 2021 who did not receive any AFP. Subjects with CAPA at ICU admission were excluded. RESULTS We included 270 patients, of whom 64 (23.7%) received AFP. In patients in the study group, CAPA-related mortality was significantly reduced (29% vs. 48% p = 0.04), as well as the incidence of CAPA (3.1% vs 12.1%, p = 0.03). Patients who developed CAPA were older (mean of 70-y-old vs 63-y-old, p < 0.001). One subject discontinued posaconazole due to an adverse reaction. Among the 46 patients who received it, only one patient reached an effective plasma concentration of posaconazole. CONCLUSION AFP was associated with reduced incidence and mortality from CAPA and was well tolerated in patients with severe COVID-19. Posaconazole concentrations below the efficacy threshold in almost all patients may be attributable to drug interactions and prompt further studies to define its clinical significance.
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Affiliation(s)
| | - Liana Signorini
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | | | - Paola Lanza
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | - Barbara Saccani
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | | | - Alice Mulè
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Medicine, University of Brescia, Brescia, Italy
| | - Simone Piva
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Matteo Rota
- Department of Molecular and Translational Medicine, Università degli Studi di Brescia, Brescia, Italy
| | - Francesco Zuccalà
- Department of Anesthesia and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Francesco Antonio Rasulo
- Intensive Care and Anesthesiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and Spedali Civili Hospital, Brescia, Italy
| | - Matteo Filippini
- Intensive Care and Anesthesiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and Spedali Civili Hospital, Brescia, Italy
| | - Alberto Bertazzoli
- Department of Anesthesia and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Giovanni Del Fabro
- Department of Infectious Diseases, ASFO "Santa Maria Degli Angeli" Hospital of Pordenone, Pordenone, Italy
| | - Alberto Matteelli
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Medicine, University of Brescia, Brescia, Italy
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12
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Marianna C, Matteo B, Alfonso P, Francesca F, Luisa V, Francesco M, Claudia B, Maria Ilaria DP, Maria Chiara T, Chiara C, Marco P, Valentina B, Nicola F, Anna C, Katia P, Marta S, Anna Rita L, Maurizio S, Alessandro B, Livio P. Revision of antifungal strategies definitions for invasive fungal infections (proven/probable/possible) in 461 patients with haematological malignancies (REDEFI-SEIFEM). Mycoses 2024; 67:e13781. [PMID: 39148202 DOI: 10.1111/myc.13781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 07/23/2024] [Accepted: 07/28/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Invasive fungal infections (IFI) are a relevant cause of morbidity and mortality among patients with haematological neoplasms (HMs). Since 2002, a classification of IFI based on host factors, clinical and radiological features and mycological tests was published for research purpose. OBJECTIVES These criteria are widely used in clinical practice to identify patients at risk for IFI. The aim of the study was to evaluate the clinical applicability of EORTC/MSG 2008 criteria for the diagnosis of IFI in daily practice. PATIENTS/METHODS This multicentre, non-interventional, observational, prospective study gathered all consecutive inpatients with HMs in which an intravenous antifungal treatment was started. Exclusion criteria were a previous or concomitant transplant procedure, outpatient status and oral antifungal therapy. EORTC/MSG 2008 criteria were used to classify patients at the beginning of antifungal therapy and at 30 days. An independent board reviewed the classification of IFI given by local clinicians at T0 and T30. RESULTS The highest percentage of agreement was found for possible IFI (96%), while a lower agreement was reported for proven IFI (74%), and the highest variability was observed for probable IFI (56%). At T30, the board re-evaluation confirmed a strict agreement for possible IFI only (98%). Among 306 patients classified as possible, 156 (51%) patients showed non-typical radiological findings and 45 (15%) patients presented host factors only. CONCLUSIONS In real life, the EORTC/MSG criteria can be applicable only for possible IFI. As non-typical radiological findings are reported in possible IFI, introducing a new IFI category should be considered.
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Affiliation(s)
- Criscuolo Marianna
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bonanni Matteo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Farina Francesca
- Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Verga Luisa
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Marchesi Francesco
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Basilico Claudia
- UO di Ematologia, Ospedale di Circolo - Fondazione Macchi, ASST Settelaghi, Varese, Italy
| | | | - Tisi Maria Chiara
- Hematology Unit, San Bortolo Hospital, AULSS 8 Berica, Vicenza, Italy
| | - Cattaneo Chiara
- Hematology Division, ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Picardi Marco
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Bonuomo Valentina
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Fracchiolla Nicola
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Candoni Anna
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Perruccio Katia
- Pediatric Oncology Hematology, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - Stanzani Marta
- Hematopoietic Stem Cell Transplantation and Cellular Therapy, Hematology Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Larici Anna Rita
- Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Diagnostica per Immagini e Radioterapia Oncologica-Advanced Radiology Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sanguinetti Maurizio
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Busca Alessandro
- Department of Hematology and Stem Cell Transplant Unit, Azienda Ospedaliera Universitaria Citta' della Salute e della Scienza, Torino, Italy
| | - Pagano Livio
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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Pantić N, Barać A, Mano V, Dedeić-Ljubović A, Malkodanski I, Jaksić O, Gkentzi D, Mitrović M, Munteanu O, Šišević D, Stojanoski Z, Popescu O, Todorović J, Cornely OA, Salmanton-García J. Mapping the path to excellence: Evaluation of the diagnostic and treatment tools for invasive fungal infections in the balkans. J Infect Public Health 2024; 17:102493. [PMID: 38970927 DOI: 10.1016/j.jiph.2024.102493] [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: 03/21/2024] [Revised: 06/11/2024] [Accepted: 06/30/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND In the Balkans, rising concerns about invasive fungal infections over the past decade stem from various factors. Primarily, there has been a notable uptick in immunocompromised individuals, including those with chronic illnesses like immunological and hematological diseases. Thus, it is essential to assess the region's laboratory capabilities and the availability of antifungals. This evaluation is vital for gauging the preparedness to diagnose and treat fungal infections effectively, thus minimizing their public health impact. METHODS Data were collected via an online questionnaire targeting healthcare professionals specializing in relevant fields across diverse healthcare settings in Balkan countries. The survey covered various aspects, including diagnostic methods, imaging techniques, and available antifungal armamentarium. RESULTS Responses were obtained from 50 institutions across the Balkans. While conventional diagnostic methods like microscopy (96 %) and culture (100 %) diagnostics were widely available, access to newer diagnostic tools such as molecular assays (61 %) were limited, often relying on outsourced services. Imaging modalities like ultrasound (100 %) and CT scans (93 %) were universally accessible. A variety of antifungal drugs were available, including amphotericin B formulations (80 %), echinocandins (79 %), and triazoles (100 %). However, access to newer agents like posaconazole (62 %) and isavuconazole (45 %) was inconsistent. Therapeutic drug monitoring (53 %) services were also limited. CONCLUSION The study underscores the need for equitable access to diagnostic facilities and antifungal treatments across healthcare settings in the Balkan geographic region. Improving access to molecular diagnostic tools and essential antifungal drugs, as well as implementing therapeutic drug monitoring, would optimize the management of fungal infections in the region.
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Affiliation(s)
- Nikola Pantić
- Clinic for Hematology, University Clinical Centre of Serbia, Belgrade, Serbia.
| | - Aleksandra Barać
- Faculty of Medicine, University of Belgrade, Hospital for Infectious and Tropical Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Vasilika Mano
- Laboratory of Microbiology, University Medical Center of Tirana "Mother Teresa", Tirana, Albania
| | - Amela Dedeić-Ljubović
- Department of Clinical Microbiology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Ivan Malkodanski
- St. Marina University Hospital, Medical University, Pleven, Bulgaria
| | - Ozren Jaksić
- Division of Hematology, Department of Medicine, University Hospital Dubrava, Medical School University of Zagreb, Zagreb, Croatia
| | - Despoina Gkentzi
- Department of Paediatrics, University of Patras, University General Hospital of Patras, Patras, Greece
| | - Mirjana Mitrović
- Clinic for Hematology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Oxana Munteanu
- Division of Pneumology and Allergology, Department of Internal Medicine, State University of Medicine and Pharmacy "Nicolae Testemițanu", Medpark International Hospital, Chișinău, Moldova
| | | | - Zlate Stojanoski
- University Hematology Clinic, Medical Faculty, Ss. Cyril and Methodius University, Skopje, North Macedonia
| | - Oana Popescu
- National Institute of Pneumology Marius Nasta, Bucharest, Romania
| | | | - Oliver A Cornely
- Faculty of Medicine and University Hospital Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany; Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Jon Salmanton-García
- Faculty of Medicine and University Hospital Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany; Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.
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14
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Zhou J, Xu B, Zheng Y, Huang H, Wei Z, Chen S, Huang W, Liu M, Zhang Y, Wu X. Optimization of oral isavuconazole dose for population in special physiological or pathological state: a physiologically based pharmacokinetics model-informed precision dosing. J Antimicrob Chemother 2024:dkae240. [PMID: 39086118 DOI: 10.1093/jac/dkae240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 06/27/2024] [Indexed: 08/02/2024] Open
Abstract
OBJECTIVE To recommend precision dosing and improve therapeutic efficacy against invasive fungal disease, a physiologically based pharmacokinetic model (PBPK) of oral isavuconazole (ISA) was established and used to explore its disposition across populations in different physiological and pathological states. METHODS Twenty-five pharmacokinetic (PK) studies of oral ISA were identified through a systematic search of PubMed. Concentration-time data were extracted using WebPlotDigitizer. Physiochemical parameters were obtained from published literature and DrugBank. Model development and simulation used the Simcyp population-based simulator, and visual predictive check and predictive error were used for the model evaluation. Probability of target attainment and the cumulative fraction of response analyses were performed for dose optimization. RESULTS The developed PBPK model was successfully validated in different populations. Most predicted concentration-time points aligned with the observed data, with acceptable predictive errors for the critical parameters. We predicted the PK profiles and parameters of ISA in a population with severe hepatic impairment (HI), a population with obesity and paediatric patients aged 1 to less than 6 years old. The probability of target attainment and cumulative fraction of response analyses indicated that the population with severe HI should have half the maintenance dose. The population with obesity and population with severe HI should have a loading dose of 300 mg every 8 h for 2 days. For paediatric patients aged 1 to less than 6 years old, a weight-based dosing regimen (5.38 mg/kg) of ISA was suggested. CONCLUSION The predicted value aligns with observations, suggesting ISA's potential predictability in PK profiles for other populations. The recommended dosing regimens increase our understanding of the use of ISA in special populations.
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Affiliation(s)
- Jianxing Zhou
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Baohua Xu
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - You Zheng
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Huiping Huang
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Zipeng Wei
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Shengyang Chen
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Wei Huang
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Maobai Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yifan Zhang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Xuemei Wu
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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15
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Cai X, Sun C, Zhong H, Cai Y, Cao M, Wang L, Sun W, Tao Y, Ma G, Huang B, Yan S, Zhong J, Wang J, Lu Y, Guan Y, Song M, Wang Y, Li Y, Su X. The value of metagenomic next-generation sequencing with different nucleic acid extracting methods of cell-free DNA or whole-cell DNA in the diagnosis of non-neutropenic pulmonary aspergillosis. Front Cell Infect Microbiol 2024; 14:1398190. [PMID: 39135636 PMCID: PMC11317373 DOI: 10.3389/fcimb.2024.1398190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024] Open
Abstract
Purpose Metagenomic next-generation sequencing(mNGS) is a novel molecular diagnostic technique. For nucleic acid extraction methods, both whole-cell DNA (wcDNA) and cell-free DNA (cfDNA) are widely applied with the sample of bronchoalveolar lavage fluid (BALF). We aim to evaluate the clinical value of mNGS with cfDNA and mNGS with wcDNA for the detection of BALF pathogens in non-neutropenic pulmonary aspergillosis. Methods mNGS with BALF-cfDNA, BALF-wcDNA and conventional microbiological tests (CMTs) were performed in suspected non-neutropenic pulmonary aspergillosis. The diagnostic value of different assays for pulmonary aspergillosis was compared. Results BALF-mNGS (cfDNA, wcDNA) outperformed CMTs in terms of microorganisms detection. Receiver operating characteristic (ROC) analysis indicated BALF-mNGS (cfDNA, wcDNA) was superior to culture and BALF-GM. Combination diagnosis of either positive for BALF-mNGS (cfDNA, wcDNA) or CMTs is more sensitive than CMTs alone in the diagnosis of pulmonary aspergillosis (BALF-cfDNA+CMTs/BALF-wcDNA+CMTs vs. CMTs: ROC analysis: 0.813 vs.0.66, P=0.0142/0.796 vs.0.66, P=0.0244; Sensitivity: 89.47% vs. 47.37%, P=0.008/84.21% vs. 47.37%, P=0.016). BALF-cfDNA showed a significantly greater reads per million (RPM) than BALF-wcDNA. The area under the ROC curve (AUC) for RPM of Aspergillus detected by BALF-cfDNA, used to predict "True positive" pulmonary aspergillosis patients, was 0.779, with a cut-off value greater than 4.5. Conclusion We propose that the incorporation of BALF-mNGS (cfDNA, wcDNA) with CMTs improves diagnostic precision in the identification of non-neutropenic pulmonary aspergillosis when compared to CMTs alone. BALF-cfDNA outperforms BALF-wcDNA in clinical value.
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Affiliation(s)
- Xiaomin Cai
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Chao Sun
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Huanhuan Zhong
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, China
| | - Yuchen Cai
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Min Cao
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Li Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Wenkui Sun
- Department of Respiratory and Critical Care Medicine, Jiangsu Province Hospital, The First Affiliated of Nanjing Medical University, Nanjing, China
| | - Yujian Tao
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Guoer Ma
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Baoju Huang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Shengmei Yan
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jinjin Zhong
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jiamei Wang
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yajie Lu
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yuanlin Guan
- Department of Research and Development, Hugobiotech Co., Ltd., Beijing, China
| | - Mengyue Song
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, China
| | - Yujie Wang
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yuanyuan Li
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xin Su
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
- Department of Respiratory and Critical Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Nemoto H, Hino M, Aoki T, Yamashita Y, Okunushi T, Nagasawa K, Ishiwada N, Watanabe A, Yamazaki S, Hamada H. Effectiveness of isavuconazole in invasive cerebral aspergillosis during hematopoietic stem cell transplantation in a pediatric patient with myelodysplastic syndrome: A case report. J Infect Chemother 2024:S1341-321X(24)00202-2. [PMID: 39047812 DOI: 10.1016/j.jiac.2024.07.018] [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: 04/11/2024] [Revised: 07/04/2024] [Accepted: 07/21/2024] [Indexed: 07/27/2024]
Abstract
Pediatric myelodysplasia syndrome is often characterized by hypoplastic bone marrow morphology and predisposition to infection. Invasive aspergillosis during hematopoietic stem cell transplantation poses a significant threat and often requires voriconazole (VRCZ) therapy. However, difficulties in achieving appropriate VRCZ blood levels due to drug interactions have prompted the exploration of alternative treatments, such as isavuconazole (ISCZ). We present the case of a 4-year-old boy with myelodysplasia syndrome who developed multiple abscesses, including a brain abscess caused by Aspergillus fumigatus, and was successfully treated with ISCZ. Despite initial treatment with liposomal amphotericin B and VRCZ, the patient's condition deteriorated. Transitioning to ISCZ treatment resulted in significant clinical improvement, resolution of the abscesses, and reduced antigen levels. Although ISCZ induced hepatic enzyme elevation, supportive care improved without discontinuation of treatment. This case highlights the potential of ISCZ in cases of pediatric invasive aspergillosis where traditional therapies fail, underscoring the need for further research and formulation development to optimize its use in this population. As more cases accumulate, ISCZ may become a promising option for treating severe invasive aspergillosis in pediatric patients undergoing hematopoietic stem cell transplantation.
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Affiliation(s)
- Hajime Nemoto
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
| | - Moeko Hino
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan.
| | - Takahiro Aoki
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
| | | | - Tomoko Okunushi
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
| | - Koo Nagasawa
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
| | - Naruhiko Ishiwada
- Department of Infectious Diseases, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Akira Watanabe
- Division of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Shingo Yamazaki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Hiromichi Hamada
- Department of Pediatrics, Chiba University Hospital, Chiba, Japan
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Boutin CA, Durocher F, Beauchemin S, Ziegler D, Abou Chakra CN, Dufresne SF. Breakthrough Invasive Fungal Infections in Patients With High-Risk Hematological Disorders Receiving Voriconazole and Posaconazole Prophylaxis: A Systematic Review. Clin Infect Dis 2024; 79:151-160. [PMID: 38752732 PMCID: PMC11259221 DOI: 10.1093/cid/ciae203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Primary antifungal prophylaxis with mold-active azoles is used to prevent invasive fungal infections in patients with high-risk hematological disorders; however, breakthrough infections occur, and the reasons for treatment failure are still not fully understood. To help inform clinical decisions, we sought to define microbiological, clinical, and pharmacological characteristics of proven and probable breakthrough invasive fungal infections (bIFIs) in patients with high-risk hematological disorders receiving voriconazole or posaconazole prophylaxis. METHODS We performed a systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search strategy was last conducted on 19 April 2023. RESULTS We assessed 5293 studies for eligibility, and 300 were selected for data extraction. These studies described 1076 cases of bIFIs occurring under voriconazole (42.5%) or posaconazole (57.5%). The most commonly found pathogens were Aspergillus (40%), Mucorales (20%), Candida (18%), and Fusarium (9%) species. Mucorales were more frequent among voriconazole-emerging cases, whereas Aspergillus and Fusarium were more prevalent among posaconazole-emerging cases. Definitive, putative, or probable antifungal resistance was found in 31% of cases. Therapeutic drug monitoring showed subtherapeutic azole concentration in 32 of 90 (36%) cases. Infection-related mortality was reported in 117 cases and reached 35%. CONCLUSIONS In our systemic review, the most common bIFIs were aspergillosis, mucormycosis, candidiasis, and fusariosis. Antifungal resistance explains only a minority of cases. Subtherapeutic prophylaxis was frequent but rarely reported. Prospective studies are needed to better understand these infections and to establish optimal management.
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Affiliation(s)
- Catherine-Audrey Boutin
- Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, Centre hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Florence Durocher
- Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | | | - Daniela Ziegler
- Direction de l’enseignement et de l’Académie, Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | | | - Simon Frédéric Dufresne
- Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre de Recherche de l’Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
- Division of Infectious Diseases and Clinical Microbiology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Est-de-l’Île-de-Montréal, Montréal, Québec, Canada
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18
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Sedik S, Boyer J, Egger M, Dichtl K, Prattes J, Prüller F, Hoenigl M. Comparative Analysis of the Clarus Aspergillus Galactomannan Enzyme Immunoassay Prototype for the Diagnosis of Invasive Pulmonary Aspergillosis in Bronchoalveolar Lavage Fluid. Mycopathologia 2024; 189:67. [PMID: 39023825 PMCID: PMC11258175 DOI: 10.1007/s11046-024-00876-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/04/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Galactomannan (GM) testing using Platelia Aspergillus enzyme immunoassay (Platelia AGM) from bronchoalveolar lavage fluid (BALF) aids in early diagnosis of invasive pulmonary aspergillosis (IPA). Globally, only a minority of laboratories have the capability to perform on-site GM testing, necessitating accessible and affordable alternatives. Hence, we conducted a comparative evaluation of the new clarus Aspergillus GM enzyme immunoassay prototype (clarus AGM prototype) with Platelia AGM using BALF samples. METHODS This is a single-center, prospective, cross-sectional study, where Platelia AGM testing was routinely performed followed by clarus AGM prototype testing in those with true positive or true negative AGM test results according to the 2020 EORTC/MSG and the 2024 FUNDICU consensus definitions. Descriptive statistics, ROC curve analysis, and Spearman's correlation analysis were used to evaluate analytical performance of the clarus AGM prototype assay. RESULTS This study enrolled 259 adult patients, of which 53 (20%) were classified as probable IPA, while 206 did not fulfill IPA-criteria. Spearman's correlation analysis revealed a strong correlation between the two assays (rho = 0.727, p < 0.001). The clarus AGM prototype had a sensitivity of 96% (51/53) and a specificity of 74% (153/206) for differentiating probable versus no IPA when using the manufacturer recommended cut-off. ROC curve analysis showed an AUC of 0.936 (95% CI 0.901-0.971) for the clarus AGM prototype, while the Platelia AGM yielded an AUC of 0.918 (95% CI 0.876-0.959). CONCLUSIONS Clarus AGM prototype demonstrated a strong correlation and promising test performance, comparable to Platelia AGM, rendering it a viable alternative in patients at risk of IPA.
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Affiliation(s)
- Sarah Sedik
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Auenbruggerplatz 15, 8036, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
| | - Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Auenbruggerplatz 15, 8036, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
| | - Matthias Egger
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Auenbruggerplatz 15, 8036, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
| | - Karl Dichtl
- Diagnostic and Research Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Graz, Austria
| | - Juergen Prattes
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Auenbruggerplatz 15, 8036, Graz, Austria.
- Translational Mycology, Medical University of Graz, Graz, Austria.
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Auenbruggerplatz 15, 8036, Graz, Austria.
- Translational Mycology, Medical University of Graz, Graz, Austria.
- BioTechMed-Graz, Graz, Austria.
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19
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Wang H, Yu D, Chen X, Zhou Y, Qian X, Liu D, Wang L, Tang Y, Wang M. Performance of rapid on-site evaluation of touch imprints of bronchoscopic biopsies or lung tissue biopsies for the diagnosis of invasive pulmonary filamentous fungi infections in non-neutropenic patients. J Clin Microbiol 2024; 62:e0047924. [PMID: 38856218 PMCID: PMC11250116 DOI: 10.1128/jcm.00479-24] [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: 04/03/2024] [Accepted: 05/13/2024] [Indexed: 06/11/2024] Open
Abstract
The diagnosis of invasive pulmonary fungal disease depends on histopathology and mycological culture; there are few studies on touch imprints of bronchoscopic biopsies or lung tissue biopsies for the diagnosis of pulmonary filamentous fungi infections. The purpose of the present study was to explore the detection accuracy of rapid on-site evaluation of touch imprints of bronchoscopic biopsies or lung tissue biopsies for the filamentous fungi, and it aims to provide a basis for initiating antifungal therapy before obtaining microbiological evidence. We retrospectively analyzed the diagnosis and treatment of 44 non-neutropenic patients with invasive pulmonary filamentous fungi confirmed by glactomannan assay, histopathology, and culture from February 2017 to December 2023. The diagnostic positive rate and sensitivity of rapid on-site evaluation for these filamentous fungi identification, including diagnostic turnaround time, were calculated. Compared with the final diagnosis, the sensitivity of rapid on-site evaluation was 81.8%, and the sensitivity of histopathology, culture of bronchoalveolar lavage fluid, and glactomannan assay of bronchoalveolar lavage fluid was 86.4%, 52.3%, and 68.2%, respectively. The average turnaround time of detecting filamentous fungi by rapid on-site evaluation was 0.17 ± 0.03 hours, which was significantly faster than histopathology, glactomannan assay, and mycological culture. A total of 29 (76.3%) patients received earlier antifungal therapy based on ROSE diagnosis and demonstrated clinical improvement. Rapid on-site evaluation showed good sensitivity and accuracy that can be comparable to histopathology in identification of pulmonary filamentous fungi. Importantly, it contributed to the triage of biopsies for further microbial culture or molecular detection based on the preliminary diagnosis, and the decision on early antifungal therapy before microbiological evidence is available.
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Affiliation(s)
- Hansheng Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Dan Yu
- Department of Pathology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xiao Chen
- Department of Laboratory, Shiyan Maternal and Child Health Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Yanhui Zhou
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xin Qian
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Dan Liu
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Lei Wang
- Department of Laboratory, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Yijun Tang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Meifang Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
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20
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Castro-Fuentes CA, Frías-De-León MG, González-Villaseñor MDC, Duarte-Escalante E, Valencia-Ledezma OE, Martínez-Gamboa A, Meraz-Ríos B, Reyes-Montes MDR. Evaluation of Primers OPF-01, P54, and 1253 to Identify A. fumigatus, A. flavus, and A. niger from Polymorphic Patterns Obtained by RAPD-PCR. Pathogens 2024; 13:574. [PMID: 39057801 PMCID: PMC11280055 DOI: 10.3390/pathogens13070574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/06/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
We evaluated the specificity of the primers OPF-01, P54, and 1253 to identify A. fumigatus, A. flavus, and A. niger, respectively, with the RAPD-PCR method. Eighty-two isolates belonging to the sections Fumigati, Flavi, and Nigri were used. The isolates were identified by phenotypic (macro- and micromorphology) and genotypic (partial sequences of the BenA gene) methods. The RAPD-PCR method was used to obtain polymorphic patterns with the primers OPF-01, P54, and 1253. The specificity of the polymorphic patterns of the isolates of each species was evaluated through the UPGMA clustering method and logistic regression model. All isolates of the genus Aspergillus were identified at the section level by macro- and micromorphology showing the typical morphology of the sections Fumigati, Flavi, and Nigri, and the species were identified by the construction of the phylogeny of the partial sequence of the BenA gene. The patterns' polymorphic strains obtained with the primers OPF-01, P54, and 1253 for the isolates of A. fumigatus, A. flavus, and A niger, respectively, showed the same polymorphic pattern as the reference strains for each species. To verify the specificity of the primers, they were tested with other species from the sections Fumigati, Flavi and Nigri. The results support that the primers OPF-01, P54, and 1253 generate polymorphic patterns by RAPD-PCR species specific to A. fumigatus, A. flavus, and A. niger, respectively.
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Affiliation(s)
- Carlos Alberto Castro-Fuentes
- Posgrado en Ciencias Biológicas, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico;
- Unidad de Investigación, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-Bienestar. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Mexico City 01020, Mexico;
| | - María Guadalupe Frías-De-León
- Unidad de Investigación Biomédica, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-Bienestar. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Mexico City 01020, Mexico;
| | | | - Esperanza Duarte-Escalante
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Avenida Universidad 3000, Ciudad Universitaria, Coyoacán, Mexico City 04510, Mexico; (E.D.-E.); (B.M.-R.)
| | - Omar Esteban Valencia-Ledezma
- Unidad de Investigación, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-Bienestar. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Mexico City 01020, Mexico;
| | - Areli Martínez-Gamboa
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc. 16, Tlalpan, Mexico City 14080, Mexico;
| | - Beatriz Meraz-Ríos
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Avenida Universidad 3000, Ciudad Universitaria, Coyoacán, Mexico City 04510, Mexico; (E.D.-E.); (B.M.-R.)
| | - María del Rocío Reyes-Montes
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, Avenida Universidad 3000, Ciudad Universitaria, Coyoacán, Mexico City 04510, Mexico; (E.D.-E.); (B.M.-R.)
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21
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Xie M, Jiang M, Xu J, Zhu Y, Kong L. Development and validation of a clinical risk score nomogram for predicting voriconazole trough concentration above 5 mg/L: a retrospective cohort study. J Chemother 2024:1-9. [PMID: 38978301 DOI: 10.1080/1120009x.2024.2376453] [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: 03/29/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024]
Abstract
The therapeutic range of voriconazole (VRC) is narrow, this study aimed to explore factors influencing VRC plasma concentrations > 5 mg/L and to construct a clinical risk score nomogram prediction model. Clinical data from 221 patients with VRC prophylaxis and treatment were retrospectively analyzed. The patients were randomly divided into a training cohort and a validation cohort at a 7:3 ratio. Univariate and binary logistic regression analysis was used to select independent risk factors for VRC plasma concentration above the high limit (5 mg/L). Four indicators including age, weight, CYP2C19 genotype, and albumin were selected to construct the nomogram prediction model. The area under the curve values of the training cohort and the validation cohort were 0.841 and 0.802, respectively. The decision curve analysis suggests that the nomogram model had good clinical applicability. In conclusion, the nomogram provides a reference for early screening and intervention in a high-risk population.
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Affiliation(s)
- Mengyuan Xie
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
- School of Pharmacy, Bengbu Medical University, Bengbu, China
| | - Manxue Jiang
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
- School of Pharmacy, Bengbu Medical University, Bengbu, China
| | - Jian Xu
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
- School of Pharmacy, Bengbu Medical University, Bengbu, China
| | - Yulin Zhu
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
- School of Pharmacy, Bengbu Medical University, Bengbu, China
| | - Lingti Kong
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
- School of Pharmacy, Bengbu Medical University, Bengbu, China
- Institute of Emergency and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
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22
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Jaafari A, Mansour S, Lebrun L, Kaefer K, Attou R. A Rare Case of Invasive Thyroid Aspergillosis Revealed on 18F-FDG-PET/CT. Diagnostics (Basel) 2024; 14:1451. [PMID: 39001341 PMCID: PMC11240972 DOI: 10.3390/diagnostics14131451] [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: 06/07/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024] Open
Abstract
Invasive aspergillosis (IA) represents a common form of fungal infection caused by various species of Aspergillus that most frequently affect immunocompromised patients. Typically, this disease occurs preferentially in high-risk groups including patients infected with the human immunodeficiency virus (HIV), patients with leukemia, patients with autoimmune diseases, and organ transplant patients undergoing medical immunosuppression. Considered the second most common cause of opportunistic fungal infection in humans after Candida albicans, this pathogen predominantly affects the lungs, but it may also spread by a hematogenous route to various organs and have a heterogeneous presentation. Owing to its high iodine levels, high perfusion, and enclosed capsule, the thyroid gland is considered to have a lower susceptibility to microbial invasion, and it is fairly uncommon to find associated infectious nodules. In metabolic imaging, 18F-FDG-PET/CT has become increasingly useful for detecting a wide range of infectious and inflammatory diseases and is already the gold standard for certain indications. According to the literature, no studies of hypermetabolic nodular thyroid aspergillosis on 18F-FDG-PET/CT confirmed on histology have yet been reported. Here, we report the first case of a patient with a heterogeneous presentation of IA and the presence of a hypermetabolic nodule in the thyroid with a surprising result.
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Affiliation(s)
- Ayoub Jaafari
- Nuclear Medicine Department, H.U.B Hospital, 1070 Brussel, Belgium
| | - Sohaïb Mansour
- Internal Medicine Department, C.H.U Brugmann, 1020 Brussel, Belgium
| | - Laetitia Lebrun
- Anatomopathological Department, H.U.B Hospital, 1070 Brussel, Belgium
| | - Keitiane Kaefer
- Intensive Care Unit Department, C.H.U Brugmann, 1020 Brussel, Belgium
| | - Rachid Attou
- Intensive Care Unit Department, C.H.U Brugmann, 1020 Brussel, Belgium
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23
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Hosseinikargar N, Zarrinfar H, Seyedi SJ, Mojtahedi SS. Inappropriate treatment of pulmonary aspergillosis caused by Aspergillus flavus in susceptible pediatric patients: a case series. J Med Case Rep 2024; 18:301. [PMID: 38951939 PMCID: PMC11218340 DOI: 10.1186/s13256-024-04599-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 05/15/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Pulmonary aspergillosis is a prevalent opportunistic fungal infection that can lead to mortality in pediatric patients with underlying immunosuppression. Appropriate and timely treatment of pulmonary aspergillosis can play a crucial role in reducing mortality among children admitted with suspected infections. CASE PRESENTATION The present study reports three cases of inappropriate treatment of pulmonary aspergillosis caused by Aspergillus flavus in two Iranian pediatric patients under investigation and one Afghan patient. Unfortunately, two of them died. The cases involved patients aged 9, 1.5, and 3 years. They had been diagnosed with pulmonary disorders, presenting nonspecific clinical signs and radiographic images suggestive of pneumonia. The identification of A. flavus was confirmed through DNA sequencing of the calmodulin (CaM) region. CONCLUSION A. flavus was the most prevalent cause of pulmonary aspergillosis in pediatric patients. Early diagnosis and accurate antifungal treatment of pulmonary aspergillosis could be crucial in reducing the mortality rate and also have significant potential for preventing other complications among children. Moreover, antifungal prophylaxis seems to be essential for enhancing survival in these patients.
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Affiliation(s)
| | - Hossein Zarrinfar
- Allergy Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
- Sinus and Surgical Endoscopic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Seyed Javad Seyedi
- Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyedeh Sabereh Mojtahedi
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Parasitology and Mycology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Laboratory Sciences, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
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24
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Garnacho-Montero J, Barrero-García I, León-Moya C. Fungal infections in immunocompromised critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2024; 4:299-306. [PMID: 39035612 PMCID: PMC11258510 DOI: 10.1016/j.jointm.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 07/23/2024]
Abstract
Diverse pathogenic fungi can produce severe infections in immunocompromised patients, thereby justifying intensive care unit (ICU) admissions. In some cases, the infections can develop in immunocompromised patients who were previously admitted to the ICU. Aspergillus spp., Pneumocystis jirovecii, Candida spp., and Mucorales are the fungi that are most frequently involved in these infections. Diagnosis continues to be challenging because symptoms and signs are unspecific. Herein, we provide an in-depth review about the diagnosis, with emphasis on recent advances, and treatment of these invasive fungal infections in the ICU setting.
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Affiliation(s)
- José Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Irene Barrero-García
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Cristina León-Moya
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
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25
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Cancela Costa A, Kritikos A, Glampedakis E, Da Silva Pereira Clara J, Schaller F, Mercier T, Strasser R, Balmpouzis Z, Koutsokera A, Manuel O, Buclin T, Decosterd LA, Lamoth F. Antifungal drug penetration in soft tissue abscesses: a comparative analysis. J Antimicrob Chemother 2024; 79:1668-1672. [PMID: 38785349 PMCID: PMC11215542 DOI: 10.1093/jac/dkae162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Invasive fungal infections (IFIs) are severe and difficult-to-treat infections affecting immunocompromised patients. Antifungal drug penetration at the site of infection is critical for outcome and may be difficult to achieve. Data about antifungal drug distribution in infected human tissues under real circumstances of IFI are scarce. METHODS Multiple samples were obtained from soft tissue abscesses of a lung transplant patient with Candida albicans invasive candidiasis who underwent recurrent procedures of drainage, while receiving different consecutive courses of antifungal therapy [itraconazole (ITC), fluconazole, caspofungin]. Antifungal drug concentrations were measured simultaneously at the site of infection (surrounding inflammatory tissue and fluid content of the abscess) and in plasma for calculation of the tissue/plasma ratio (R). The concentration within the infected tissue was interpreted as appropriate if it was equal or superior to the MIC of the causal pathogen. RESULTS A total of 30 tissue samples were collected for measurements of ITC (n = 12), fluconazole (n = 17) and caspofungin (n = 1). Variable concentrations were observed in the surrounding tissue of the lesions with median R of 2.79 (range 0.51-15.9) for ITC and 0.94 (0.21-1.37) for fluconazole. Concentrations ranges within the fluid content of the abscesses were 0.39-1.83 for ITC, 0.66-1.02 for fluconazole and 0.23 (single value) for caspofungin. The pharmacodynamic target (tissue concentration ≥ MIC) was achieved in all samples for all three antifungal drugs. CONCLUSIONS This unique dataset of antifungal drug penetration in infected human soft tissue abscesses suggests that ITC, fluconazole and caspofungin could achieve appropriate concentrations in soft tissue abscesses.
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Affiliation(s)
- Alicia Cancela Costa
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonios Kritikos
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emmanouil Glampedakis
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jorge Da Silva Pereira Clara
- Service and Laboratory of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabian Schaller
- Service and Laboratory of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thomas Mercier
- Service and Laboratory of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Roland Strasser
- Department of Orthopedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Zisis Balmpouzis
- Division of Pulmonary Medicine, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Angela Koutsokera
- Division of Pulmonary Medicine, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Oriol Manuel
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Buclin
- Service and Laboratory of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent Arthur Decosterd
- Service and Laboratory of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Frederic Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Microbiology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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26
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Elkayal O, Mertens B, Wauters J, Debaveye Y, Rijnders B, Verweij PE, Brüggemann RJ, Spriet I, Dreesen E. Dosing of IV posaconazole to treat critically ill patients with invasive pulmonary aspergillosis: a population pharmacokinetics modelling and simulation study. J Antimicrob Chemother 2024; 79:1645-1656. [PMID: 38828958 DOI: 10.1093/jac/dkae160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Posaconazole is used for the prophylaxis and treatment of invasive fungal infections in critically ill patients. Standard dosing was shown to result in adequate attainment of the prophylaxis Cmin target (0.7 mg/L) but not of the treatment Cmin target (1.0 mg/L). OBJECTIVES To provide an optimized posaconazole dosing regimen for IV treatment of patients with invasive pulmonary aspergillosis in the ICU. METHODS A population pharmacokinetics (popPK) model was developed using data from the POSA-FLU PK substudy (NCT03378479). Monte Carlo simulations were performed to assess treatment Cmin and AUC0-24 PTA. PTA ≥90% was deemed clinically acceptable. PopPK modelling and simulation were performed using NONMEM 7.5. RESULTS Thirty-one patients with intensive PK sampling were included in the PK substudy, contributing 532 posaconazole plasma concentrations. The popPK of IV posaconazole was best described by a two-compartment model with linear elimination. Interindividual variability was estimated on clearance and volume of distribution in central and peripheral compartments. Posaconazole peripheral volume of distribution increased with bodyweight. An optimized loading regimen of 300 mg q12h and 300 mg q8h in the first two treatment days achieved acceptable PTA by Day 3 in patients <100 kg and ≥100 kg, respectively. A maintenance regimen of 400 mg q24h ensured ≥90% Cmin PTA, whereas the standard 300 mg q24h was sufficient to achieve the AUC0-24 target throughout 14 days, irrespective of bodyweight. CONCLUSIONS We have defined a convenient, optimized IV posaconazole dosing regimen that was predicted to attain the treatment target in critically ill patients with invasive aspergillosis.
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Affiliation(s)
- Omar Elkayal
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Beatrijs Mertens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, UZ Leuven, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, UZ Leuven, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bart Rijnders
- Department of Internal Medicine, Section of Infectious Diseases and Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology and Radboudumc, CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy and Radboud Institute for Medical Innovation, Radboud University Medical Center, Nijmegen and Radboudumc, CWZ Center of Expertise for Mycology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, UZ Leuven, Leuven, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Gerard R, Gabriel F, Accoceberry I, Imbert S, Ducassou S, Angoso M, Jubert C. Is there still a place for serum galactomannan in the diagnosis of invasive aspergillosis in children at high risk and under antifungal prophylaxis? Mycoses 2024; 67:e13764. [PMID: 38970226 DOI: 10.1111/myc.13764] [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: 01/25/2024] [Revised: 06/21/2024] [Accepted: 06/27/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND The performance of serum galactomannan (GM) for the diagnosis of invasive aspergillosis (IA) has been studied mainly in adults. Paediatric data are scarce and based on small and heterogeneous cohorts. OBJECTIVE To evaluate the performance of serum GM for the diagnosis of IA in a paediatric oncologic population at high risk of IA and to clarify the impact of antifungal prophylaxis on this test. METHODS We performed a retrospective study from January 2014 to December 2020 in the paediatric oncologic haematologic department of the University Hospital of Bordeaux. The diagnosis of IA was made using the recommendations of the EORTC and the MSGERC. RESULTS Among the 329 periods at high risk of IA in 222 patients, the prevalence of IA was 1.8% (3 proven and 3 probable IA). In the total population, the sensitivity, and the positive predictive value (PPV) were respectively 50% and 17.6%. Under antifungal prophylaxis, the sensitivity and PPV dropped, respectively, to 33.3% and 14.3%. In this group, the post-test probability of IA was 2% for a negative serum GM and only 14%. CONCLUSION In this large cohort of children at high risk of IA, the incidence of IA is low and the diagnostic performance of GM is poor, especially in the case of mould-active prophylaxis. Screening should be targeted rather than systematic and should be reserved for patients at highest risk for IA without mould-active prophylaxis. Combination with other tests such as Aspergillus PCR would increase the accuracy of GM in screening setting.
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Affiliation(s)
- Rémy Gerard
- Pediatric Hematology Oncology Unit, Children Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Frédéric Gabriel
- Laboratory of Parasitology-Mycology, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Isabelle Accoceberry
- Laboratory of Parasitology-Mycology, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Sébastien Imbert
- Laboratory of Parasitology-Mycology, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Stéphane Ducassou
- Pediatric Hematology Oncology Unit, Children Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Marie Angoso
- Pediatric Hematology Oncology Unit, Children Hospital, Bordeaux University Hospital, Bordeaux, France
| | - Charlotte Jubert
- Pediatric Hematology Oncology Unit, Children Hospital, Bordeaux University Hospital, Bordeaux, France
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Flett L, Abdelatif R, Baz SA, Brady S, Corbacho B, Common K, Cowling A, Fairhurst C, Fitzmaurice E, Gandhi S, Hilton A, Hope W, Howard A, Laycock J, Lillie P, Mitchell G, Parker A, Peel M, Sheard L, Sneddon J, Taynton T, Tharmanathan P, Torgerson D, Wang HI, Allsup D, Barlow G. Biomarker Driven Antifungal Stewardship (BioDriveAFS) in acute leukaemia-a multi-centre randomised controlled trial to assess clinical and cost effectiveness: a study protocol for a randomised controlled trial. Trials 2024; 25:427. [PMID: 38943201 PMCID: PMC11214238 DOI: 10.1186/s13063-024-08272-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/19/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Acute leukaemias (AL) are life-threatening blood cancers that can be potentially cured with treatment involving myelosuppressive, multiagent, intensive chemotherapy (IC). However, such treatment is associated with a risk of serious infection, in particular invasive fungal infection (IFI) associated with prolonged neutropenia. Current practice guidelines recommend primary antifungal (AF) prophylaxis to be administered to high-risk patients to reduce IFI incidence. AFs are also used empirically to manage prolonged neutropenic fever. Current strategies lead to substantial overuse of AFs. Galactomannan (GM) and β-D-glucan (BG) biomarkers are also used to diagnose IFI. Combining both biomarkers may enhance the predictability of IFI compared to administering each test alone. Currently, no large-scale randomised controlled trial (RCT) has directly compared a biomarker-based diagnostic screening strategy without AF prophylaxis to AF prophylaxis (without systematic biomarker testing). METHODS BioDriveAFS is a multicentre, parallel, two-arm RCT of 404 participants from UK NHS Haematology departments. Participants will be allocated on a 1:1 basis to receive either a biomarker-based antifungal stewardship (AFS) strategy, or a prophylactic AF strategy, which includes existing standard of care (SoC). The co-primary outcomes will be AF exposure in the 12-month post randomisation and the patient-reported EQ-5D-5L measured at 12-month post randomisation. Secondary outcomes will include total AF exposure, probable/proven IFI, survival (all-cause mortality and IFI mortality), IFI treatment outcome, AF-associated adverse effects/events/complications, resource use, episodes of neutropenic fever requiring hospital admission or outpatient management, AF resistance in fungi (non-invasive and invasive) and a Desirability of Outcome Ranking. The trial will have an internal pilot phase during the first 9 months. A mixed methods process evaluation will be integrated in parallel to the internal pilot phase and full trial, aiming to robustly assess how the intervention is delivered. Cost-effectiveness analysis will also be performed. DISCUSSION The BioDriveAFS trial aims to further the knowledge of strategies that will safely optimise AF use through comparison of the clinical and cost-effectiveness of a biomarker-led diagnostic strategy versus prophylactic AF to prevent and manage IFI within acute leukaemia. The evidence generated from the study will help inform global clinical practice and approaches within antifungal stewardship. TRIAL REGISTRATION ISRCTN11633399. Registered 24/06/2022.
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Affiliation(s)
- Lydia Flett
- Department of Health Sciences, University of York, York, UK.
| | | | | | - Samantha Brady
- Department of Health Sciences, University of York, York, UK
| | - Belén Corbacho
- Department of Health Sciences, University of York, York, UK
| | - Kate Common
- Patient and Public Involvement, University of York, York, UK
| | - Abbie Cowling
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Andrea Hilton
- Faculty of Health Sciences, University of Hull, Hull, UK
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Alex Howard
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Joanne Laycock
- Department of Health Sciences, University of York, York, UK
| | | | - Gemma Mitchell
- Institute for Social Marketing and Health, University of Stirling, Stirling, UK
| | - Adwoa Parker
- Department of Health Sciences, University of York, York, UK
| | - Mary Peel
- Patient and Public Involvement, University of York, York, UK
| | - Laura Sheard
- Department of Health Sciences, University of York, York, UK
| | | | | | | | | | - Han-I Wang
- Department of Health Sciences, University of York, York, UK
| | - David Allsup
- Biomedical Institute for Multimorbidity, Hull York Medical School, University of Hull, Hull, UK
| | - Gavin Barlow
- Department of Experimental Medicine & Biomedicine, Hull York Medical School, University of York, York, UK
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Huang J, Chen Y, Zhong M, Tan R. Case report: dose-dependent interaction between dexamethasone and voriconazole in severely ill patients with non-Hodgkin's lymphoma being treated for invasive pulmonary aspergillosis. Front Pharmacol 2024; 15:1403966. [PMID: 38994198 PMCID: PMC11236688 DOI: 10.3389/fphar.2024.1403966] [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: 03/21/2024] [Accepted: 05/30/2024] [Indexed: 07/13/2024] Open
Abstract
Background Voriconazole is primarily metabolized by CYP2C19 and CYP3A4. Drug interactions that affect this pathway can alter its plasma exposures, resulting in untargeted voriconazole concentrations. Case summary In this case report, we describe the case of a 64-year-old man who was treated for non-Hodgkin's lymphoma with continuous glucocorticoids co-administrated with voriconazole against invasive pulmonary aspergillosis. A decrease in trough concentration (Cmin) of voriconazole was observed and related with co-administration of dexamethasone in the patient carrying the CYP2C19 *1*2 genotype: voriconazole Cmin/dose ratios of 0.018 (0.1 mg L-1/5.7 mg kg-1 day-1), 0.18 (1 mg L-1/5.7 mg kg-1 day-1), and 0.23 (2 mg L-1/8.6 mg kg-1 day-1) at dexamethasone doses of 20, 12.5, and 2.5 mg, respectively. Sub-therapeutic voriconazole Cmin was associated with high- and moderate-dose dexamethasone (20 and 12.5 mg), leading to failure of antifungal treatment. Conclusion The extent of voriconazole-dexamethasone interaction was determined by the dose of dexamethasone and associated with the CYP2C19 *1*2 genotype. Therapeutic drug monitoring of voriconazole is necessary to avoid clinically relevant interactions for optimal antifungal therapy.
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Affiliation(s)
- Jingjing Huang
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ming Zhong
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruoming Tan
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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30
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Petrikkos L, Kourti M, Stathi A, Antoniadi K, Ampatzidou M, Stefanaki K, Zachariadou L, Iosifidis E, Roilides E, Polychronopoulou S. Successful Treatment of Disseminated Fusariosis in a 15-Month-Old Boy With Refractory Acute Lymphoblastic Leukemia Using High-Dose Voriconazole. Pediatr Infect Dis J 2024:00006454-990000000-00914. [PMID: 38916910 DOI: 10.1097/inf.0000000000004451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
BACKGROUND Infections due to rare molds, such as Fusarium spp., cause severe and difficult-to-control diseases with increasing frequency. Data on fusariosis in children and on the use of voriconazole (VCZ), considered a drug of choice, are scarce in infants and children <2 years of age. CASE PRESENTATION We present the first, to our knowledge, pediatric case of disseminated mycosis due to Fusarium musae in a 15-month-old boy with relapsed/refractory acute lymphoblastic leukemia, diagnostics and outcome. Herein, at this severely immunocompromised patient, after prompt diagnosis, disseminated fusariosis was successfully treated with high-dose VCZ at a final dose of 15 mg/kg of body weight twice a day. This occurred by achieving adequate drug exposures as determined by drug susceptibility testing and followed by therapeutic drug monitoring without observed toxicity. CONCLUSIONS Appropriate diagnostic approach and timely administration of optimal antifungal therapy with VCZ were important for the successful treatment of disseminated fusariosis. Therapeutic drug monitoring, especially in <2-year-old children, is necessary to achieve sufficient drug exposure for optimal therapeutic response without toxicity.
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Affiliation(s)
- Loizos Petrikkos
- From the Department of Pediatric Hematology-Oncology (T.A.O.), "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Maria Kourti
- Infectious Diseases Unit, Third Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Angeliki Stathi
- Department of Microbiology, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Kondilia Antoniadi
- From the Department of Pediatric Hematology-Oncology (T.A.O.), "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Mirella Ampatzidou
- From the Department of Pediatric Hematology-Oncology (T.A.O.), "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Kalliopi Stefanaki
- Department of Pathology, "Aghia Sophia" Children's Hospital, Athens, Greece
| | | | - Elias Iosifidis
- Infectious Diseases Unit, Third Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, Third Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece
| | - Sophia Polychronopoulou
- From the Department of Pediatric Hematology-Oncology (T.A.O.), "Aghia Sophia" Children's Hospital, Athens, Greece
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31
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Portillo V, Neofytos D. An Update on Breakthrough Invasive Mold Infections. Mycopathologia 2024; 189:56. [PMID: 38869662 PMCID: PMC11176211 DOI: 10.1007/s11046-024-00864-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/21/2024] [Indexed: 06/14/2024]
Abstract
The incidence of breakthrough mold infections (bIMI) has been increasing, due to routine administration of broad-spectrum antifungal prophylaxis and an increasing pool of high-risk patient populations, with fungi more challenging to treat, resulting in a sustained high mortality, despite progress in diagnostic and therapeutic options. Pharmacokinetics of antifungal drugs, fungal, and host, including genetic, factors play a role in the emergence of bIMI. Suggested therapeutic approaches have included change of antifungal class treatment, with amphotericin-B products predominating as first-line empirical treatment and switching from one broad-spectrum azole to another remaining the most frequently used treatment modalities. Future perspectives include determining individual susceptibility to IMI to tailor prophylaxis and treatment strategies, improved diagnostic tests, and the introduction of new antifungal agents that may reduce morbidity and mortality caused by bIMI.
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Affiliation(s)
- Vera Portillo
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
- Internal Medecine, Ensemble Hospitalier de la Côte, Hôpital de Moges, Chemin de la Crêt 2, Morges, Vaud, Switzerland.
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
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Hoenigl M, Arastehfar A, Arendrup MC, Brüggemann R, Carvalho A, Chiller T, Chen S, Egger M, Feys S, Gangneux JP, Gold JAW, Groll AH, Heylen J, Jenks JD, Krause R, Lagrou K, Lamoth F, Prattes J, Sedik S, Wauters J, Wiederhold NP, Thompson GR. Novel antifungals and treatment approaches to tackle resistance and improve outcomes of invasive fungal disease. Clin Microbiol Rev 2024; 37:e0007423. [PMID: 38602408 PMCID: PMC11237431 DOI: 10.1128/cmr.00074-23] [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] [Indexed: 04/12/2024] Open
Abstract
SUMMARYFungal infections are on the rise, driven by a growing population at risk and climate change. Currently available antifungals include only five classes, and their utility and efficacy in antifungal treatment are limited by one or more of innate or acquired resistance in some fungi, poor penetration into "sequestered" sites, and agent-specific side effect which require frequent patient reassessment and monitoring. Agents with novel mechanisms, favorable pharmacokinetic (PK) profiles including good oral bioavailability, and fungicidal mechanism(s) are urgently needed. Here, we provide a comprehensive review of novel antifungal agents, with both improved known mechanisms of actions and new antifungal classes, currently in clinical development for treating invasive yeast, mold (filamentous fungi), Pneumocystis jirovecii infections, and dimorphic fungi (endemic mycoses). We further focus on inhaled antifungals and the role of immunotherapy in tackling fungal infections, and the specific PK/pharmacodynamic profiles, tissue distributions as well as drug-drug interactions of novel antifungals. Finally, we review antifungal resistance mechanisms, the role of use of antifungal pesticides in agriculture as drivers of drug resistance, and detail detection methods for antifungal resistance.
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Affiliation(s)
- Martin Hoenigl
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Amir Arastehfar
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Roger Brüggemann
- Department of Pharmacy and Radboudumc Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc-CWZ Center of Expertise in Mycology, Nijmegen, The Netherlands
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW South Wales Health Pathology, Westmead Hospital, Westmead, Australia
- The University of Sydney, Sydney, Australia
| | - Matthias Egger
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Simon Feys
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Jean-Pierre Gangneux
- Centre National de Référence des Mycoses et Antifongiques LA-AspC Aspergilloses chroniques, European Excellence Center for Medical Mycology (ECMM EC), Centre hospitalier Universitaire de Rennes, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) UMR_S 1085, Rennes, France
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andreas H. Groll
- Department of Pediatric Hematology/Oncology and Infectious Disease Research Program, Center for Bone Marrow Transplantation, University Children’s Hospital, Muenster, Germany
| | - Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Jeffrey D. Jenks
- Department of Public Health, Durham County, Durham, North Carolina, USA
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Robert Krause
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Frédéric Lamoth
- Department of Laboratory Medicine and Pathology, Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Medicine, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Juergen Prattes
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Sarah Sedik
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Nathan P. Wiederhold
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - George R. Thompson
- Department of Internal Medicine, Division of Infectious Diseases University of California-Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
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Koulenti D, Paramythiotou E, Almyroudi MP, Karvouniaris M, Markou N, Paranos P, Routsi C, Meletiadis J, Blot S. Severe mold fungal infections in critically ill patients with COVID-19. Future Microbiol 2024; 19:825-840. [PMID: 38700287 PMCID: PMC11290760 DOI: 10.2217/fmb-2023-0261] [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: 11/21/2023] [Accepted: 02/20/2024] [Indexed: 05/05/2024] Open
Abstract
The SARS-CoV-2 pandemic put an unprecedented strain on modern societies and healthcare systems. A significantly higher incidence of invasive fungal co-infections was noted compared with the pre-COVID-19 era, adding new diagnostic and therapeutic challenges in the critical care setting. In the current narrative review, we focus on invasive mold infections caused by Aspergillus and Mucor species in critically ill COVID-19 patients. We discuss up-to-date information on the incidence, pathogenesis, diagnosis and treatment of these mold-COVID-19 co-infections, as well as recommendations on preventive and prophylactic interventions. Traditional risk factors were often not recognized in COVID-19-associated aspergillosis and mucormycosis, highlighting the role of other determinant risk factors. The associated patient outcomes were worse compared with COVID-19 patients without mold co-infection.
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Affiliation(s)
- Despoina Koulenti
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Maria Panagiota Almyroudi
- Emergency Department, Attikon University Hospital, National & Kapodistrian University of Athens, Greece
| | | | - Nikolaos Markou
- Intensive Care Unit of Latseio Burns Centre, Thriasio General Hospital of Elefsina, Greece
| | - Paschalis Paranos
- Clinical Microbiology Laboratory, Attikon University Hospital, National & Kapodistrian Uni-versity of Athens, Greece
| | - Christina Routsi
- First Department of Intensive Care, School of Medicine, National & Kapodistrian University of Athens, Evangelismos General Hospital, Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, National & Kapodistrian Uni-versity of Athens, Greece
| | - Stijn Blot
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium
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Kwon M, Gómez-Centurión I, Oarbeascoa G, Torres M, Martinez AP, Suarez-Lledó M, Chinea A, Cascón MJP, Vazquez L, Espigado I, Izquierdo I, Parody R, Cadenas IG, Calbacho M, Sierra PG, Heras I, Yañez L, Torrent A, Bautista G, Gonzalez S, Roldan E, Vallejo JC, Bailen R, Borrero A, Lopez-Jiménez J, Casas MAC, Solano C. Real-World Experience with Isavuconazole in Allogeneic Stem Cell Transplantation in Spain. Transplant Cell Ther 2024:S2666-6367(24)00467-6. [PMID: 38871055 DOI: 10.1016/j.jtct.2024.06.009] [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: 05/22/2024] [Accepted: 06/05/2024] [Indexed: 06/15/2024]
Abstract
Invasive fungal infections (IFI) pose a significant complication after hematopoietic stem cell transplantation (HSCT). Isavuconazole (ISV) is a new generation azole with a favourable adverse effect and interaction profile approved for the treatment of invasive aspergillosis and mucormycosis. We analyzed the indications, effectiveness, adverse event profile and drug interaction management of ISV in the real-world setting in adults who received allogeneic-HSCT (allo-HSCT) within the Spanish Group of HSCT and Cell Therapy (GETH-TC). We conducted a multicenter retrospective study of all consecutive adult allo-HSCT recipients (≥18 years) who received ISV either for IFI treatment or prophylaxis, from December 2017 to August 2021, in 20 centers within the Spanish Group of Hematopoietic Stem Cell Transplantation and Cell Therapy (GETH-TC). A total of 166 adult allografted patients who received ISV from 2017 to 2021 were included. Median age was 48 years with 43% females. In 81 (49%) patients, ISV was used for treatment of IFI, and in 85 (51%) for prophylaxis. Median duration of ISV administration for IFI treatment was 57 days (range 31-126) and 86 days (range 33-196) for prophylaxis. Most frequent indication for treatment was invasive aspergillosis (78%), followed by mucormycosis (6%). Therapeutic success (45%) was the most frequent reason for ISV withdrawal. In the prophylaxis group, the resolution of IFI risk factors was the most frequent reason for withdrawal (62%). Six (7%) breakthrough IFI were reported. The majority of patients (80%) presented pharmacologic interactions. Twenty-one patients (13%) reported adverse events related to ISV, mainly liver biochemistry abnormalities, which led to ISV withdrawal in 7 patients (4%). ISV was effective and well tolerated for IFI treatment and prophylaxis, with a manageable interaction profile.
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Affiliation(s)
- Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañon, Madrid, Spain; Department of Hematology, Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain.
| | - Ignacio Gómez-Centurión
- Department of Hematology, Hospital General Universitario Gregorio Marañon, Madrid, Spain; Department of Hematology, Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain
| | - Gillen Oarbeascoa
- Department of Hematology, Hospital General Universitario Gregorio Marañon, Madrid, Spain; Department of Hematology, Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain
| | - Melissa Torres
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | | | - Maria Suarez-Lledó
- Department of Hematology, Hospital Clinic Institute of Hematology & Oncology, Barcelona, Spain
| | - Anabelle Chinea
- Department of Hematology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | | | - Lourdes Vazquez
- Department of Hematology, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Ildefonso Espigado
- Department of Hematology, Department of Medicine, University of Seville, HUV Macarena-HUV Rocío, IBiS/CSIC, Sevilla, Spain
| | - Isabel Izquierdo
- Department of Hematology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Rocio Parody
- Department of Hematology, Institut Català Oncologia-Hospital Duran i Reynals, Barcelona, Spain
| | - Irene Garcia Cadenas
- Department of Hematology, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Maria Calbacho
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pedro Gonzalez Sierra
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Inmaculada Heras
- Department of Hematology, Hospital Universitario Morales Meseguer, Murcia, Spain
| | - Lucrecia Yañez
- Department of Hematology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Anna Torrent
- Department of Hematology, Institut Català d'oncologia, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Guiomar Bautista
- Department of Hematology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Soledad Gonzalez
- Department of Hematology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Elisa Roldan
- Department of Hematology, Vall d'Hebron Instituto de Oncología, Barcelona, Spain
| | | | - Rebeca Bailen
- Department of Hematology, Hospital General Universitario Gregorio Marañon, Madrid, Spain; Department of Hematology, Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain
| | - Asunción Borrero
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | | | | | - Carlos Solano
- Department of Hematology, Hospital Clínico Universitario de Valencia, Valencia, Spain
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Prisusanti RD, Suhariyono US, Mahdi C. Response to "Prevalence, Risk Factors, and Mortality of Invasive Pulmonary Aspergillosis in Patients with Anti-MDA5 + Dermatomyositis: A Retrospective Study in China" [Letter]. J Inflamm Res 2024; 17:3653-3654. [PMID: 38855166 PMCID: PMC11162640 DOI: 10.2147/jir.s479288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/29/2024] [Indexed: 06/11/2024] Open
Affiliation(s)
- Retno Dewi Prisusanti
- Medical Record and Health Information Department, ITSK RS DR Soepraoen Malang, Kota Malang, Jawa Timur, Indonesia
| | - Untung Slamet Suhariyono
- Medical Record and Health Information Department, ITSK RS DR Soepraoen Malang, Kota Malang, Jawa Timur, Indonesia
| | - Chanif Mahdi
- Medical Record and Health Information Department, ITSK RS DR Soepraoen Malang, Kota Malang, Jawa Timur, Indonesia
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Lewis R, Niazi-Ali S, McIvor A, Kanj SS, Maertens J, Bassetti M, Levine D, Groll AH, Denning DW. Triazole antifungal drug interactions-practical considerations for excellent prescribing. J Antimicrob Chemother 2024; 79:1203-1217. [PMID: 38629250 DOI: 10.1093/jac/dkae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Systemic antifungal therapy is critical for reducing the mortality from many invasive and chronic fungal infections. Triazole antifungals are the most frequently prescribed antifungals but require attention to dosing and drug interactions. Nearly 600 severe drug-drug interactions and over 1100 moderate interactions requiring dose modifications are described or anticipated with systemic antifungal agents (see https://www.aspergillus.org.uk/antifungal-drug-interactions/). In this article, we address the common and less common, but serious, drug interactions observed in clinical practice with triazole antifungals, including a group of drugs that cannot be prescribed with all or most triazole antifungals (ivabradine, ranolazine, eplerenone, fentanyl, apomorphine, quetiapine, bedaquiline, rifampicin, rifabutin, sirolimus, phenytoin and carbamazepine). We highlight interactions with drugs used in children and new agents introduced for the treatment of haematological malignancies or graft versus host disease (midostaurin, ibrutinib, ruxolitinib and venetoclax). We also summarize the multiple interactions between oral and inhaled corticosteroids and triazole antifungals, and the strategies needed to optimize the therapeutic benefits of triazole antifungal therapy while minimizing potential harm to patients.
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Affiliation(s)
- Russell Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Saarah Niazi-Ali
- Antifungal Database Consultancy Pharmacist, Fungal Infection Trust, PO Box 482, Macclesfield, Cheshire SK10 9AR, UK
| | - Andrew McIvor
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine and Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, Department of Haematology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Matteo Bassetti
- Department of Health Sciences, Infectious Diseases Clinic, University of Genoa and Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Deborah Levine
- Lung Transplant Program, Division of Pulmonary Critical Care and Allergy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital, Albert-Schweitzer-Campus 1, Building A1, Münster, 48149, Germany
| | - David W Denning
- Manchester Fungal Infection Group, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
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Boyer J, Sedik S, Egger M, Dichtl K, Prattes J, Kriegl L, Krause R, Prüller F, Hoenigl M. Performance of the clarus Aspergillus galactomannan enzyme immunoassay prototype for the diagnosis of invasive pulmonary aspergillosis in serum. Mycoses 2024; 67:e13756. [PMID: 38886163 DOI: 10.1111/myc.13756] [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: 05/07/2024] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Serum galactomannan (GM) testing is essential for diagnosing invasive aspergillosis (IA), particularly in immunocompromised individuals. The global lack of on-site GM testing capacities necessitates cost-effective alternatives, such as .the clarus Aspergillus GM enzyme immunoassay prototype (clarus AGM prototype). METHODS This single-centre, cross-sectional study compared the diagnostic performance of the clarus AGM prototype (IMMY, Norman, Oklahoma) with the serological gold standard (=Platelia AGM assay; Bio-Rad, Marnes-la-Cocquette, France). IA was classified according to modified 2020 EORTC/MSG consensus and 2024 FUNDICU criteria. In total, 300 prospectively (May-Dec 2023) and retrospectively (2012-2015) collected samples were included. RESULTS Among 300 samples from 232 patients, 49 (16%) were classified as proven (n = 1) or probable IA (n = 48). In non-IA cases (n = 250), one patient was classified as possible IA. With the manufacturer recommended cut-off of ≥0.2, sensitivity and specificity of the clarus AGM prototype were 27% (13/49; 95% confidence interval [CI]: 15%-41%) and 99% (248/250; 95% CI: 97%-100%), respectively, while sensitivity and specificity were 78% and 79% when using the optimised Youden's cut-off of 0.0045 ODI. ROC curve analysis demonstrated an area under the curve (AUC) of 0.829 (95% CI: 0.760-0.898) for the clarus AGM prototype in distinguishing between proven/probable IA and non-IA. The AUC for the Platelia AGM was 0.951 (95% CI: 0.909-994). Spearman's correlation analysis showed a weak correlation between the two assays (0.382; p < .001). CONCLUSIONS The weak correlation between the clarus AGM prototype and Platelia AGM highlights the need for further investigation into the clinical performance of the clarus AGM prototype, giving the different antigen epitopes addressed.
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Affiliation(s)
- Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
| | - Sarah Sedik
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
| | - Matthias Egger
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
| | - Karl Dichtl
- Diagnostic and Research Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Graz, Austria
| | - Juergen Prattes
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
| | - Lisa Kriegl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- Translational Mycology, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
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Vergidis P, Sendi P, Alkhateeb HB, Nguyen MH. How do I manage refractory invasive pulmonary aspergillosis. Clin Microbiol Infect 2024; 30:755-761. [PMID: 38286175 DOI: 10.1016/j.cmi.2024.01.015] [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: 08/11/2023] [Revised: 11/06/2023] [Accepted: 01/20/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Invasive aspergillosis is associated with significant morbidity and mortality in patients with haematologic malignancies and haematopoietic cell transplant recipients. The prognosis is worse among patients who have failed primary antifungal treatment. OBJECTIVES We aim to provide guidance on the diagnosis and management of refractory invasive pulmonary aspergillosis. SOURCES Using PubMed, we performed a review of original articles, meta-analyses, and systematic reviews. CONTENT We discuss the diagnostic criteria for invasive pulmonary aspergillosis and the evidence on the treatment of primary infection. We outline our diagnostic approach to refractory disease. We propose a treatment algorithm for refractory disease and discuss the role of experimental antifungal agents. IMPLICATIONS For patients with worsening disease while on antifungal therapy, a thorough diagnostic evaluation is required to confirm the diagnosis of aspergillosis and exclude another concomitant infection. Treatment should be individualized. Current options include switching to another triazole, transitioning to a lipid formulation of amphotericin B, or using combination antifungal therapy.
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Affiliation(s)
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | | | - M Hong Nguyen
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
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Dinh A, Savoy JM, Kontoyiannis DP, Takahashi K, Issa GC, Kantarjian HM, DiNardo CD, Rausch CR. Ivosidenib significantly reduces triazole levels in patients with acute myeloid leukemia and myelodysplastic syndrome. Cancer 2024; 130:1964-1971. [PMID: 38340331 DOI: 10.1002/cncr.35251] [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: 09/13/2023] [Revised: 11/20/2023] [Accepted: 01/12/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Ivosidenib is primarily metabolized by CYP3A4; however, it induces CYP450 isozymes, including CYP3A4 and CYP2C9, whereas it inhibits drug transporters, including P-glycoprotein. Patients with acute myeloid leukemia are at risk of invasive fungal infections, and therefore posaconazole and voriconazole are commonly used in this population. Voriconazole is a substrate of CYP2C9, CYP2C19, and CYP3A4; therefore, concomitant ivosidenib may result in decreased serum concentrations. Although posaconazole is a substrate of P-glycoprotein, it is metabolized primarily via UDP glucuronidation; thus, the impact of ivosidenib on posaconazole exposure is unknown. METHODS Patients treated with ivosidenib and concomitant triazole with at least one serum trough level were included. Subtherapeutic levels were defined as posaconazole <700 ng/mL and voriconazole <1.0 µg/mL. The incidences of breakthrough invasive fungal infections and QTc prolongation were identified at least 5 days after initiation of ivosidenib with concomitant triazole. RESULTS Seventy-eight serum triazole levels from 31 patients receiving ivosidenib-containing therapy and concomitant triazole were evaluated. Of the 78 concomitant levels, 47 (60%) were subtherapeutic (posaconazole: n = 20 of 43 [47%]; voriconazole: n = 27 of 35 [77%]). Compared to levels drawn while patients were off ivosidenib, median triazole serum levels during concomitant ivosidenib were significantly reduced. There was no apparent increase in incidence of grade 3 QTc prolongation with concomitant azole antifungal and ivosidenib 500 mg daily. CONCLUSIONS This study demonstrated that concomitant ivosidenib significantly reduced posaconazole and voriconazole levels. Voriconazole should be avoided, empiric high-dose posaconazole (>300 mg/day) may be considered, and therapeutic drug monitoring is recommended in all patients receiving concomitant ivosidenib.
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Affiliation(s)
- Ashley Dinh
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - J Michael Savoy
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Caitlin R Rausch
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Luong ML, Nakamachi Y, Silveira FP, Morrissey CO, Danziger-Isakov L, Verschuuren EAM, Wolfe CR, Hadjiliadis D, Chambers DC, Patel JK, Dellgren G, So M, Verleden GM, Blumberg EA, Vos R, Perch M, Holm AM, Mueller NJ, Chaparro C, Husain S. Management of infectious disease syndromes in thoracic organ transplants and mechanical circulatory device recipients: a Delphi panel. Transpl Infect Dis 2024; 26:e14251. [PMID: 38351512 DOI: 10.1111/tid.14251] [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: 10/03/2023] [Revised: 12/23/2023] [Accepted: 01/25/2024] [Indexed: 06/19/2024]
Abstract
PURPOSE Antimicrobial misuse contributes to antimicrobial resistance in thoracic transplant (TTx) and mechanical circulatory support (MCS) recipients. This study uses a modified Delphi method to define the expected appropriate antimicrobial prescribing for the common clinical scenarios encountered in TTx and MCS recipients. METHODS An online questionnaire on managing 10 common infectious disease syndromes was submitted to a multidisciplinary Delphi panel of 25 experts from various disciplines. Consensus was predefined as 80% agreement for each question. Questions where consensus was not achieved were discussed during live virtual live sessions adapted by an independent process expert. RESULTS An online survey of 62 questions related to 10 infectious disease syndromes was submitted to the Delphi panel. In the first round of the online questionnaire, consensus on antimicrobial management was reached by 6.5% (4/62). In Round 2 online live discussion, the remaining 58 questions were discussed among the Delphi Panel members using a virtual meeting platform. Consensus was reached among 62% (36/58) of questions. Agreement was not reached regarding the antimicrobial management of the following six clinical syndromes: (1) Burkholderia cepacia pneumonia (duration of therapy); (2) Mycobacterium abscessus (intra-operative antimicrobials); (3) invasive aspergillosis (treatment of culture-negative but positive BAL galactomannan) (duration of therapy); (4) respiratory syncytial virus (duration of antiviral therapy); (5) left ventricular assist device deep infection (initial empirical antimicrobial coverage) and (6) CMV (duration of secondary prophylaxis). CONCLUSION This Delphi panel developed consensus-based recommendations for 10 infectious clinical syndromes seen in TTx and MCS recipients.
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Affiliation(s)
- Me-Linh Luong
- Department of Medicine, Division of Infectious Diseases, CHUM, Montreal, Quebec, Canada
| | | | - Fernanda P Silveira
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh and UPMC, Pittsburgh, Pennsylvania, USA
| | - Catherine O Morrissey
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Erik A M Verschuuren
- Department of Pulmonary diseases and tuberculosis, University Medical Center Groningen, Groningen, The Netherlands
| | - Cameron R Wolfe
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Denis Hadjiliadis
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel C Chambers
- Queensland Lung Transplant Program, The Prince Charles Hospital, Brisbane, Australia
| | - Jignesh K Patel
- Department of Medicine, Division of Cardiology, Cedars Sinai Heart Institute, Los Angeles, California, USA
| | - Goran Dellgren
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Miranda So
- University Health Network, Toronto, Ontario, Canada
| | - Geert M Verleden
- Department of Medicine, Division of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Emily A Blumberg
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robin Vos
- Department of Medicine, Division of Respiratory Diseases, University Hospital Gasthuisberg, Leuven, Belgium
| | - Michael Perch
- Department of Cardiology, Section for Lung transplantation, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Are M Holm
- Department of Medicine, Division of Respirology, Oslo University Hospital, Oslo, Norway
| | - Nicholas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Cecilia Chaparro
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Department of Medicine, Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
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Yang S, Wan F, Zhang M, Lin H, Hu L, Zhou Z, Wang D, Zhou A, Ni L, Guo J, Wu W. In Vitro Activitiy of Rezafungin in Comparison with Anidulafungin and Caspofungin against Invasive Fungal Isolates (2017 to 2022) in China. J Fungi (Basel) 2024; 10:397. [PMID: 38921383 PMCID: PMC11204387 DOI: 10.3390/jof10060397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/09/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
The efficacy of different echinocandins is assessed by evaluating the in vitro activity of a novel antifungal, rezafungin, against invasive fungal isolates in comparison with anidulafungin and caspofungin. Using the broth microdilution (BMD) method, the susceptibility of 1000 clinical Candida isolates (including 400 C. albicans, 200 C. glabrata, 200 C. parapsilosis, 150 C. tropicalis and 50 C. krusei) and 150 Aspergillus isolates (100 A. fumigatus and 50 A. flavus) from the Eastern China Invasive Fungi Infection Group (ECIFIG) was tested for the antifungals including anidulafungin, rezafungin, caspofungin and fluconazole. The echinocandins showed strong activity against C. albicans that was maintained against fluconazole-resistant isolates. The GM MIC (geometric mean minimum inhibitory concentration) value of rezafungin was found to be comparable to that of anidulafungin or caspofungin against the five tested common Candida species. C. tropicalis exhibited higher resistance rates (about 8.67-40.67% in different antifungals) than the other four Candida species. Through the sequencing of FKS genes, we searched for mutations in echinocandin-resistant C. tropicalis isolates and found that all displayed alterations in FKS1 S654P. The determined MEC (minimal effective concentration) values against A. fumigatus and A. flavus for rezafungin (0.116 μg/mL, 0.110 μg/mL) are comparable to those of caspofungin (0.122 μg/mL, 0.142 μg/mL) but higher than for anidulafungin (0.064 μg/mL, 0.059 μg/mL). Thus, the in vitro activity of rezafungin appears comparable to anidulafungin and caspofungin against most common Candida and Aspergillus species. Rezafungin showed higher susceptibility rates against C. glabrata. Rezafungin indicates its potent activity for potential clinical application.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Jian Guo
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, 1800 Yuntai Road, Pudong New District, Shanghai 200123, China; (S.Y.); (F.W.); (M.Z.); (H.L.); (L.H.); (Z.Z.); (D.W.); (A.Z.); (L.N.)
| | - Wenjuan Wu
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, 1800 Yuntai Road, Pudong New District, Shanghai 200123, China; (S.Y.); (F.W.); (M.Z.); (H.L.); (L.H.); (Z.Z.); (D.W.); (A.Z.); (L.N.)
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Fernández-Ruiz M, Gioia F, Bodro M, Gutiérrez Martín I, Sabé N, Rodriguez-Álvarez R, Corbella L, López-Viñau T, Valerio M, Illaro A, Salto-Alejandre S, Cordero E, Arnaiz de Las Revillas F, Fariñas MC, Muñoz P, Vidal E, Carratalà J, Goikoetxea J, Ramos-Martínez A, Moreno A, Martín-Dávila P, Fortún J, Aguado JM. Isavuconazole Versus Voriconazole as the First-line Therapy for Solid Organ Transplant Recipients With Invasive Aspergillosis: Comparative Analysis of 2 Multicenter Cohort Studies. Transplantation 2024:00007890-990000000-00775. [PMID: 38773846 DOI: 10.1097/tp.0000000000005082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
BACKGROUND Isavuconazole (ISA) and voriconazole (VORI) are recommended as the first-line treatment for invasive aspergillosis (IA). Despite theoretical advantages of ISA, both triazole agents have not been compared in solid organ transplant recipients. METHODS We performed a post hoc analysis of 2 retrospective multicenter cohorts of solid organ transplant recipients with invasive fungal disease (the SOTIS [Solid Organ Transplantation and ISavuconazole] and DiasperSOT [DIagnosis of ASPERgillosis in Solid Organ Transplantation] studies). We selected adult patients with proven/probable IA that were treated for ≥48 h with ISA (n = 57) or VORI (n = 77) as first-line therapy, either in monotherapy or combination regimen. The primary outcome was the rate of clinical response at 12 wk from the initiation of therapy. Secondary outcomes comprised 12-wk all-cause and IA-attributable mortality and the rates of treatment-emergent adverse events and premature treatment discontinuation. RESULTS Both groups were comparable in their demographics and major clinical and treatment-related variables. There were no differences in the rate of 12-wk clinical response between the ISA and VORI groups (59.6% versus 59.7%, respectively; odds ratio [OR], 0.99; 95% confidence interval [CI], 0.49-2.00). This result was confirmed after propensity score adjustment (OR, 0.81; 95% CI, 0.32-2.05) and matching (OR, 0.79; 95% CI, 0.31-2.04). All-cause and IA-attributable mortality were also similar. Patients in the ISA group were less likely to experience treatment-emergent adverse events (17.5% versus 37.7%; P = 0.011) and premature treatment discontinuation (8.8% versus 23.4%; P = 0.027). CONCLUSIONS Front-line treatment with ISA for posttransplant IA led to similar clinical outcomes than VORI, with better tolerability and higher treatment completion.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Francesca Gioia
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Marta Bodro
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Isabel Gutiérrez Martín
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahona, Spain
| | - Núria Sabé
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Laura Corbella
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Teresa López-Viñau
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Pharmacy, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Aitziber Illaro
- Department of Pharmacy, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Sonsoles Salto-Alejandre
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen del Rocío, Institute of Biomedicine of Seville, Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Elisa Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen del Rocío, Institute of Biomedicine of Seville, Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Francisco Arnaiz de Las Revillas
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - María Carmen Fariñas
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
- Department of Medicine, School of Medicine, Universidad de Cantabria, Santander, Spain
| | - Patricia Muñoz
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Elisa Vidal
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- Department of Medicine, School of Medicine, University of Córdoba, Córdoba, Spain
| | - Jordi Carratalà
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Josune Goikoetxea
- Unit of Infectious Diseases, Hospital Universitario de Cruces, Baracaldo, Spain
| | - Antonio Ramos-Martínez
- Unit of Infectious Diseases, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
- Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Asunción Moreno
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Pilar Martín-Dávila
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Jesús Fortún
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad de Alcalá, Alcalá de Henares, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Zhang H, Wang Y, Diao R, Huo X, Zhao Q. The practice and evaluation of antifungal stewardship programs at a tertiary first-class hospital in China. BMC Infect Dis 2024; 24:506. [PMID: 38773459 PMCID: PMC11106957 DOI: 10.1186/s12879-024-09405-x] [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: 02/18/2024] [Accepted: 05/15/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND The sharp increase in fungal infections, insufficient diagnostic and treatment capabilities for fungal infections, poor prognosis of patients with fungal infections as well as the increasing drug resistance of fungi are serious clinical problems. It is necessary to explore the implementation and evaluation methods of antifungal stewardship (AFS) to promote the standardized use of antifungal drugs. METHODS The AFS programme was implemented at a tertiary first-class hospital in China using a plan-do-check-act (PDCA) quality management tool. A baseline investigation was carried out to determine the utilization of antifungal drugs in pilot hospitals, analyse the existing problems and causes, and propose corresponding solutions. The AFS programme was proposed and implemented beginning in 2021, and included various aspects, such as team building, establishment of regulations, information construction, prescription review and professional training. The management effectiveness was recorded from multiple perspectives, such as the consumption of antifungal drugs, the microbial inspection rate of clinical specimens, and the proportion of rational prescriptions. The PDCA management concept was used for continuous improvement to achieve closed-loop management. RESULTS In the first year after the implementation of the AFS programme, the consumption cost, use intensity and utilization rate of antifungal drugs decreased significantly (P < 0.01). The proportion of rational antifungal drug prescriptions markedly increased, with the proportion of prescriptions with indications increasing from 86.4% in 2019 to 97.0% in 2022, and the proportion of prescriptions with appropriate usage and dosage increased from 51.9 to 87.1%. In addition, after the implementation of the AFS programme, physicians' awareness of the need to complete microbial examinations improved, and the number of fungal cultures and serological examinations increased substantially. Statistics from drug susceptibility tests revealed a decrease in the resistance rate of Candida to fluconazole. CONCLUSION This study indicated that the combination of AFS and the PDCA cycle could effectively reduce antifungal consumption and promote the rational use of antifungal drugs, providing a reference for other health care systems to reduce the overuse of antifungal drugs and delay the progression of fungal resistance.
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Affiliation(s)
- Huiyuan Zhang
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Yinglin Wang
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Ruigang Diao
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Xuechen Huo
- Department of Hepatobiliary Surgery, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China.
| | - Quan Zhao
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China.
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Chen X, Lin S, Jin Q, Zhang L, Jiang W, Lu X, Wang G, Ge Y. Prevalence, Risk Factors, and Mortality of Invasive Pulmonary Aspergillosis in Patients with Anti-MDA5+ Dermatomyositis: A Retrospective Study in China. J Inflamm Res 2024; 17:3247-3257. [PMID: 38800596 PMCID: PMC11122320 DOI: 10.2147/jir.s460702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
Objective To investigate the prevalence, risk factors and prognosis of invasive pulmonary aspergillosis (IPA) in patients with anti-melanoma differentiation-associated gene 5 positive dermatomyositis (anti-MDA5+ DM). Methods A retrospective analysis was conducted in anti-MDA5+ DM patients diagnosed between January 2016 and March 2023. Patients with lower respiratory tract specimens were categorized into IPA+ and IPA- groups based on the presence of IPA and their clinical characteristics and prognoses then compared. Results Of the 415 patients diagnosed with anti-MDA5+ DM, 28 cases had IPA (prevalence rate of 6.7%) with Aspergillus fumigatus being the most common species. The patients were categorized into IPA+ (n=28) and IPA- (n=98) groups, with no significant age or gender-related differences (P>0.05). The IPA+ group had a lower lymphocyte count, particularly the CD4+ T-cell count, and reduced serum albumin and higher serum ferritin levels (P all<0.05). An elevated bronchoalveolar lavage fluid (BALF) galactomannan level was found to be the sole independent risk factor for the occurrence of IPA (adjusted OR=2.191, P=0.029) with a cut-off value of 0.585 and area under the curve of 0.779. The mortality rate in the IPA+ group was 25%. Compared to survivors, non-survivors in this group exhibited a higher incidence of rapidly progressive interstitial lung disease, lower lymphocyte counts, and increased co-infection with Pneumocystis jirovecii (P all<0.05). Conclusion IPA was not rare in patients with anti-MDA5+ DM, with elevated BALF galactomannan levels being an independent risk factor for IPA occurrence. Clinicians must exercise vigilance to identify patients exhibiting the aforementioned risk factors.
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Affiliation(s)
- Xixia Chen
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, People’s Republic of China
| | - Sang Lin
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Qiwen Jin
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, People’s Republic of China
| | - Lu Zhang
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Wei Jiang
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Xin Lu
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Guochun Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, People’s Republic of China
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Yongpeng Ge
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, People’s Republic of China
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Zhou YB, Rezaei-Matehkolaei A, Meijer M, Kraak B, Gerrits van den Ende B, Hagen F, Afzalzadeh S, Kiasat N, Takesh A, Hoseinnejad A, Houbraken J. Aspergillus hubkae, a Novel Species Isolated from a Patient with Probable Invasive Pulmonary Aspergillosis. Mycopathologia 2024; 189:44. [PMID: 38734862 DOI: 10.1007/s11046-024-00848-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/17/2024] [Indexed: 05/13/2024]
Abstract
A 50-year-old man, previously diagnosed with pulmonary tuberculosis and lung cavities, presented with symptoms including fever, shortness of breath, and cough. A pulmonary CT scan revealed multiple cavities, consolidation and tree-in-bud in the upper lungs. Further investigation through direct examination of bronchoalveolar lavage fluid showed septate hyphae with dichotomous acute branching. Subsequent isolation and morphological analysis identified the fungus as belonging to Aspergillus section Nigri. The patient was diagnosed with probable invasive pulmonary aspergillosis and successfully treated with a three-month oral voriconazole therapy. Phylogenetic analysis based on partial β-tubulin, calmodulin and RNA polymerase second largest subunit sequences revealed that the isolate represents a putative new species related to Aspergillus brasiliensis, and is named Aspergillus hubkae here. Antifungal susceptibility testing demonstrated that the isolate is resistant to itraconazole but susceptible to voriconazole. This phenotypic and genetic characterization of A. hubkae, along with the associated case report, will serve as a valuable resource for future diagnoses of infections caused by this species. It will also contribute to more precise and effective patient management strategies in similar clinical scenarios.
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Affiliation(s)
- Ya Bin Zhou
- Department of Dermatology, Beijing Children's Hospital, Capital Medical University, National Key Discipline of Pediatrics, Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, Beijing, China
- Westerdijk Fungal Biodiversity Institute, Uppsalalaan 8, 3584 CT, Utrecht, The Netherlands
| | - Ali Rezaei-Matehkolaei
- Department of Medical Mycology, School of Medicine, Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Martin Meijer
- Westerdijk Fungal Biodiversity Institute, Uppsalalaan 8, 3584 CT, Utrecht, The Netherlands
| | - Bart Kraak
- Westerdijk Fungal Biodiversity Institute, Uppsalalaan 8, 3584 CT, Utrecht, The Netherlands
| | | | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Uppsalalaan 8, 3584 CT, Utrecht, The Netherlands
- Institute for Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sara Afzalzadeh
- Department of Infectious Diseases, Razi Teaching Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Neda Kiasat
- Department of Medical Mycology, School of Medicine, Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ameneh Takesh
- Department of Medical Mycology, School of Medicine, Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Akbar Hoseinnejad
- Department of Medical Mycology, School of Medicine, Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Jos Houbraken
- Westerdijk Fungal Biodiversity Institute, Uppsalalaan 8, 3584 CT, Utrecht, The Netherlands.
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Hoenigl M, Enoch DA, Wichmann D, Wyncoll D, Cortegiani A. Exploring European Consensus About the Remaining Treatment Challenges and Subsequent Opportunities to Improve the Management of Invasive Fungal Infection (IFI) in the Intensive Care Unit. Mycopathologia 2024; 189:41. [PMID: 38704761 PMCID: PMC11070387 DOI: 10.1007/s11046-024-00852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 04/12/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND The global prevalence of invasive fungal infections (IFI) is increasing, particularly within Intensive Care Units (ICU), where Candida spp. and Aspergillus spp. represent the most important pathogens. Diagnosis and management of IFIs becomes progressively challenging, with increasing antifungal resistance and the emergence of rare fungal species. Through a consensus survey focused on assessing current views on how IFI should be managed, the aim of this project was to identify challenges around diagnosing and managing IFIs in the ICU. The current status in different countries and perceived challenges to date amongst a multidisciplinary cohort of healthcare professionals involved in the care of IFI in the ICU was assessed. METHODS Using a modified Delphi approach, an expert panel developed 44 Likert-scale statements across 6 key domains concerning patient screening and minimal standards for diagnosis of IFIs in ICU; initiation and termination of antifungal treatments and how to minimise their side effects and insights for future research on this topic. These were used to develop an online survey which was distributed on a convenience sampling basis utilising the subscriber list held by an independent provider (M3 Global). This survey was distributed to intensivists, infectious disease specialists, microbiologists and antimicrobial/ICU pharmacists within the UK, Germany, Spain, France and Italy. The threshold for consensus was set at 75%. RESULTS A total of 335 responses were received during the five-month collection period. From these, 29/44 (66%) statements attained very high agreement (≥ 90%), 11/44 (25%) high agreement (< 90% and ≥ 75%), and 4/44 (9%) did not meet threshold for consensus (< 75%). CONCLUSION The results outline the need for physicians to be aware of the local incidence of IFI and the associated rate of azole resistance in their ICUs. Where high clinical suspicion exists, treatment should start immediately and prior to receiving the results from any diagnostic test. Beta-D-glucan testing should be available to all ICU centres, with results available within 48 h to inform the cessation of empirical antifungal therapy. These consensus statements and proposed measures may guide future areas for further research to optimise the management of IFIs in the ICU.
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Affiliation(s)
- Martin Hoenigl
- Division of Infectious Diseases, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
- BioTechMed-Graz, Graz, Austria.
- ECMM Excellence Center for Medical Mycology, Translational Medical Mycology Research Unit, Medical University of Graz, Graz, Austria.
| | - David A Enoch
- Clinical Microbiology & Public Health Laboratory, UK Health Security Agency, Cambridge University Hospital NHS Foundation Trust, Addenbrookes Hospital, Cambridge, UK
| | - Dominic Wichmann
- Department of Intensive Care Medicine, University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
| | - Duncan Wyncoll
- Department of Intensive Care, Guy's and St Thomas' Hospital, London, UK
| | - Andrea Cortegiani
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
- Department of Anesthesia Intensive Care and Emergency, University Hospital Policlinico 'Paolo Giaccone, Palermo, Italy
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Şensoy L, Atilla A, Güllü YT, Gür Vural D, Turgut M, Esen Ş, Tanyel E. Evaluation of interleukin-8 levels in the diagnosis of invasive pulmonary aspergillosis in patients with haematological malignancies. Med Mycol 2024; 62:myae036. [PMID: 38592958 DOI: 10.1093/mmy/myae036] [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: 12/06/2023] [Revised: 03/05/2024] [Accepted: 04/08/2024] [Indexed: 04/11/2024] Open
Abstract
This study aimed to determine the level of interleukin (IL)-8 in diagnosing of invasive pulmonary aspergillosis (IPA). We conducted this study with 50 controls and 25 IPA patients with haematological malignancies. Demographic data, haematological diagnoses, chemotherapy regimen, galactomannan level, fungal culture, and computed tomography findings of the patients were evaluated prospectively. IL-8 levels were studied with the ELISA method. The mean age of patients in the case group was 60.84 ± 15.38 years, while that of the controls was 58.38 ± 16.64 years. Of the patients, 2/25 were classified as having 'proven', 13/25 as 'probable', and 10/25 as 'possible' invasive aspergillosis (IA). Serum IL-8 levels were found to be significantly higher in the case group compared to the controls. There was a negative correlation between serum IL-8 levels and neutrophil counts and a positive correlation with the duration of neutropenia. A significant cutoff value for serum IL-8 parameter in detecting IPA disease was obtained as ≥274 ng/l; sensitivity was 72%; specificity was 64%; PPV was 50%; and NPV was 82%. In the subgroup analysis, there was no significant difference in serum IL-8 levels between the case group and the patients in the neutropenic control group, while a significant difference was found in with the patients in the non-neutropenic control group. Serum IL-8 levels in neutropenic patients who develop IPA are not adequate in terms of both the diagnosis of the disease and predicting mortality. New, easily applicable methods with high sensitivity and specificity in diagnosing IPA are still needed.
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Affiliation(s)
- Levent Şensoy
- Department of Clinical Microbiology and Infectious Diseases, Fatsa Government Hospital, Ordu 52400, Türkiye
| | - Aynur Atilla
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Medicine, Ondokuz Mayis University, Samsun 55100, Türkiye
| | - Yusuf Taha Güllü
- Department of Pulmonary Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun 55100, Türkiye
| | - Demet Gür Vural
- Department of Medical Microbiology, Faculty of Medicine, Ondokuz Mayis University, Samsun 55100, Türkiye
| | - Mehmet Turgut
- Department of Hematology, Faculty of Medicine, Ondokuz Mayis University, Samsun 55100, Türkiye
| | - Şaban Esen
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Medicine, Ondokuz Mayis University, Samsun 55100, Türkiye
| | - Esra Tanyel
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Medicine, Ondokuz Mayis University, Samsun 55100, Türkiye
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Muehlberg L, Pabst T, Largiadèr C, Aebi Y, Hayoz M, Muehlethaler K, Zimmerli S, Hirzel C. Evaluation of Posaconazole Serum Concentrations Achieved With Delayed-release Tablets and Oral Suspension in Patients Undergoing Intensive Chemotherapy for Acute Myeloid Leukemia and Myelodysplastic Syndrome. Open Forum Infect Dis 2024; 11:ofae263. [PMID: 38798896 PMCID: PMC11127630 DOI: 10.1093/ofid/ofae263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024] Open
Abstract
Data on posaconazole serum levels of patients on prophylaxis with delayed-release tablets or oral suspension during intensive chemotherapy for acute myeloid leukemia and myelodysplastic syndrome are scarce. In this analysis, the proportion of patients with acute myeloid leukemia/myelodysplastic syndrome achieving posaconazole target concentrations with delayed-release tablets was higher than with oral suspension.
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Affiliation(s)
- Leonora Muehlberg
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Carlo Largiadèr
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Yolanda Aebi
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Michael Hayoz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Konrad Muehlethaler
- Department of Clinical Microbiology, Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Stefan Zimmerli
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Cédric Hirzel
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Mikulska M, Oltolini C, Zappulo E, Bartoletti M, Frustaci AM, Visentin A, Vitale C, Mauro FR. Prevention and management of infectious complications in patients with chronic lymphocytic leukemia (CLL) treated with BTK and BCL-2 inhibitors, focus on current guidelines. Blood Rev 2024; 65:101180. [PMID: 38331696 DOI: 10.1016/j.blre.2024.101180] [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: 12/08/2023] [Revised: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024]
Abstract
CLL is associated with an increased risk of infectious complications. Treatment with BTK or BCL-2 inhibitors does not seem to increase significantly the risk of opportunistic infections, but the role of combination therapies including BTK and/or BCL-2 inhibitors remains to be established. Various infectious complications can be successfully prevented with appropriate risk management strategies. In this paper we reviewed the international guidelines on prevention and management of infectious complications in patients with CLL treated with BTK or BCL-2 inhibitors. Universal pharmacological anti-herpes, antibacterial or antifungal prophylaxis is not warranted. Reactivation of HBV should be prevented in HBsAg-positive subjects. For HBsAg-negative/HBcAb-positive patients recommendations differ, but in case of combination treatment should follow those for other, particularly anti-CD20, agent. Immunization should be provided preferably before the onset of treatment. Immunoglobulin therapy has favourable impact on morbidity but not mortality in patients with hypogammaglobulinemia and severe or recurrent infections. Lack of high-quality data and heterogeneity of patients or protocols included in the studies might explain differences among the main guidelines. Better data collection is warranted.
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Affiliation(s)
- Malgorzata Mikulska
- Infectious Diseases Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | | | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele Milan, Italy; Infectious Disease Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Turin, Italy
| | - Francesca R Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
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Kato H, Umemura T, Hagihara M, Shiota A, Asai N, Hamada Y, Mikamo H, Iwamoto T. Development of a therapeutic drug-monitoring algorithm for outpatients receiving voriconazole: A multicentre retrospective study. Br J Clin Pharmacol 2024; 90:1222-1230. [PMID: 38320604 DOI: 10.1111/bcp.16004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/08/2024] Open
Abstract
AIMS Although therapeutic drug monitoring (TDM) of voriconazole is performed in outpatients to prevent treatment failure and toxicity, whether TDM should be performed in all or only selected patients remains controversial. This study evaluated the association between voriconazole trough concentrations and clinical events. METHODS We investigated the aggravation of clinical symptoms, incidence of hepatotoxicity and visual disturbances, change in co-medications and interaction between voriconazole and co-medications in outpatients receiving voriconazole between 2017 and 2021 in three facilities. Abnormal trough concentrations were defined as <1.0 mg/L (low group) and >4.0 mg/L (high group). RESULTS A total of 141 outpatients (578 concentration measurements) met the inclusion criteria (treatment, 37 patients, 131 values; prophylaxis, 104 patients, 447 values). The percentages of patients with abnormal concentrations were 29.0% and 31.5% in the treatment and prophylaxis groups, respectively. Abnormal concentrations showed 50% of the concentrations at the first measurement in both therapies. Aggravation of clinical symptoms was most frequently observed in the low treatment group (18.2%). Adverse events were most common in the high group for both therapies (treatment, hepatotoxicity 6.3%, visual disturbance 18.8%; prophylaxis, hepatotoxicity 27.9%). No differences were found in changes to co-medications and drug interactions. In the prophylaxis group, prescription duration in the presence of clinical events tended to be longer than in their absence (47.4 ± 23.4 days vs 39.7 ± 21.9 days, P = .1132). CONCLUSIONS We developed an algorithm based on clinical events for appropriate implementation of TDM in outpatients. However, future interventions based on this algorithm should be validated.
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Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu, Mie, Japan
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takumi Umemura
- Department of Pharmacy, Tosei General Hospital, Seto, Aichi, Japan
| | - Mao Hagihara
- Department of Molecular Epidemiology and Biomedical Sciences, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Arifumi Shiota
- Department of Pharmacy, Aichi Medical University Hospital, Nagakute, Aichi, Japan
| | - Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Kochi Medical School Hospital, Nankoku, Kochi, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Tsu, Mie, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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