Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline

Automatic identification of clinically important Aspergillus species by artificial intelligence-based image recognition: proof-of-concept study

While morphological examination is the most widely used for Aspergillus identification in clinical laboratories, PCR-sequencing and MALDI-TOF MS are emerging technologies in more financially-competent laboratories. However, mycological expertise, molecular biologists and/or expensive equipment are needed for these. Recently, artificial intelligence (AI), especially image recognition, is being increasingly employed in medicine for fast and automated disease diagnosis. We explored the potential utility of AI in identifying Aspergillus species. In this proof-of-concept study, using 2813, 2814 and 1240 images from four clinically important Aspergillus species for training, validation and testing, respectively; the performances and accuracies of automatic Aspergillus identification using colonial images by three different convolutional neural networks were evaluated. Results demonstrated that ResNet-18 outperformed Inception-v3 and DenseNet-121 and is the best algorithm of choice because it made the fewest misidentifications (n = 8) and possessed the highest testing accuracy (99.35%). Images showing more unique morphological features were more accurately identified. AI-based image recognition using colonial images is a promising technology for Aspergillus identification. Given its short turn-around-time, minimal demand of expertise, low reagent/equipment costs and user-friendliness, it has the potential to serve as a routine laboratory diagnostic tool after the database is further expanded.

Population Pharmacokinetics of Isavuconazole in Hematologic Patients: Implications for Model-Informed Precision Dosing

BACKGROUND

Isavuconazole is a broad-spectrum antifungal agent used for treating invasive fungal infections (IFIs). Its pharmacokinetics may be impacted in hematologic patients due to concomitant clinical and therapeutic factors potentially affecting drug exposure. The aim of this study was to develop a population pharmacokinetic (popPK) model of isavuconazole in adult hematologic patients to support model-informed precision dosing.

MATERIALS AND METHOD

Prospective, non-controlled study performed in adult hematologic patients receiving isavuconazole for IFIs and followed up by a therapeutic drug monitoring (TDM) program. Isavuconazole plasma concentrations were quantified using an ultra-high-performance liquid chromatography (UPLC) with UV detector. A popPK model was developed using NONMEM v.7.5.0. Simulations were based on the final model to evaluate the differences across physiological variables with impact on drug exposure.

RESULTS

A one-compartment model with first-order absorption and elimination described adequately 121 isavuconazole concentrations from 52 patients. Body surface area (BSA) and serum albumin (ALB) significantly influenced drug clearance. The final popPK model showed good precision, robustness, and predictive performance, supporting its use for individualized isavuconazole dosing in this population.

CONCLUSIONS

BSA and serum ALB were identified as covariates influencing isavuconazole clearance in adult hematologic patients. Further studies are needed to better characterize the absorption of isavuconazole and implications on dosage recommendations, especially for higher proposed doses.

Invasive pulmonary aspergillosis often misdiagnosed as lung cancer: A case report

RATIONALE

The incidence of epidemiological pulmonary aspergillosis (PA) is increasing worldwide. Diagnosis of PA is challenging because of the nonspecificity of its clinical manifestations and imaging characteristics. PA has a high mortality rate, making early diagnosis and treatment critical.

PATIENT CONCERNS

A 67-year-old female patient was admitted to the hospital with a half-month history of cough, blood-tinged sputum, and a sore throat. The patient had no history of chronic diseases, such as hypertension, coronary heart disease, or diabetes. The patient had a family history of cancer.

DIAGNOSES

The patient was diagnosed with invasive pulmonary aspergillosis (IPA).

INTERVENTIONS

After the diagnosis of IPA, the patient underwent antifungal treatment with oral voriconazole.

OUTCOMES

After treatment, the patient's symptoms improved, and a follow-up chest computed tomography scan showed a reduction in the area of inflammation.

LESSONS

Immunocompetent individuals may develop IPA. The clinical and imaging manifestations of IPA vary, which makes misdiagnosis possible. When necessary, a pathological biopsy can be performed to confirm the diagnosis.

Duration of systemic antifungal therapy for patients with invasive fungal diseases: A reassessment

Invasive fungal diseases are associated with significant morbidity and mortality, especially among immunocompromised patients, and often prompt for rapid and aggressive treatment aiming cure. Due to the expanding magnitude of patients burdened by chronic immunosuppression and affected by fungal diseases, the diversity of clinical settings has risen. This often results in prolonged therapy (induction, consolidation and maintenance) associated with potentially severe side effects, and clinicians face the challenging decisions of when and how to stop anti-fungal therapy. Adequate duration of therapy is poorly defined, hampered by the lack of dedicated trials to the question, the heterogeneity of cases (type of fungal pathogen, localization of infection, underlying host conditions) and various confounding factors that may influence the clinical response (e.g. persistence vs recovery of immunosuppression, impact of surgery). In this review, we aim to evaluate the existing data underlying the guidelines and recommendations of treatment duration for the most frequent invasive fungal diseases (cryptococcal meningitis, Pneumocystis pneumonia, invasive aspergillosis, invasive candidiasis and mucormycosis), as well as specific localizations of deep-seated diseases (osteo-articular or central nervous system diseases and endocarditis) and emerging considerations and strategies.

The impact of the bedside check of medication appropriateness (BED-CMA) at the hematology ward: a mixed-methods study

BACKGROUND

Hematology patients have complex medication regimens and rapidly changing organ function, rendering them susceptible to medication errors. Health information technology can facilitate the detection of inappropriate prescriptions and assist healthcare professionals in enhancing patient safety.

AIM

To evaluate the impact of a pharmacist-oriented clinical decision support system, called Bedside Check of Medication Appropriateness (BED-CMA), on inappropriate prescribing at the hematology ward, and to qualitatively assess its impact on the organization of bedside clinical pharmacy practice.

METHOD

A mixed-methods study was conducted at the semi-critical 15-bed hematology ward of UZ Leuven between 2020 and 2023. A pre-post study was performed to evaluate the impact of BED-CMA on residual potentially inappropriate prescriptions (PIPs), defined as those that persisted for at least 24 h after their initial identification. A time trend analysis was performed to identify any potential pre-existing patterns. The BED-CMA intervention consisted of embedding 19 clinical rules into the hospital information system. The pre-intervention cohort received usual clinical pharmacy services. Post-intervention, clinical pharmacists used BED-CMA alerts in addition to standard practices. A focus group discussion with clinical pharmacists assessed the impact on the organization of bedside clinical pharmacy practice.

RESULTS

Pre-intervention, 70% (48/69) of initial PIPs remained residual PIPs, which decreased to 20% (13/66) post-intervention (odds ratio 0.11 (95% confidence interval 0.05-0.22, P < .0.0001)). There was no evidence for a pre-existing time trend (P = .0.52). Pharmacists reported improved workflow efficiency through enhanced patient prioritization and prompt identification of PIPs.

CONCLUSION

BED-CMA significantly reduced residual PIPs by streamlining clinical pharmacy practice at a hematology ward.

Predictive nomogram for early detection of invasive fungal disease deterioration --- a 10-year retrospective cohort study

BACKGROUND

Invasive fungal disease (IFD) is characterized by its capacity to rapidly escalate to life-threatening conditions, even when patients are hospitalized. However, the precise prognostic significance of baseline clinical characteristics related to the progression outcome of IFD remains elusive.

METHODS

A retrospective cohort study spanning a duration of 10 years was conducted at two prominent tertiary teaching hospitals in Southern China. Patients with proven IFD were queried and divided into serious and non-serious groups based on the disease deterioration. To establish robust predictive models, patients from the first hospital were randomly assigned to either a training set or an internal validation set, while patients from the second hospital constituted an external test set. To analyze the potential predictors of IFD deterioration and identify independent predictors, the study employed the least absolute shrinkage and selection operator (LASSO) method in conjunction with binary logistic regressions. Based on the outcomes of this analysis, a predictive nomogram was constructed. The performance of the developed model was thoroughly evaluated using the training set, internal validation set, and external test set.

RESULTS

A total of 480 cases from the first hospital and 256 cases from the second hospital were included in the study. Among the 480 patients, 81 cases (16.9%) experienced deterioration, and out of those, 45 (55.6%) cases resulted in mortality. Seven independent predictors were identified and utilized to construct a predictive nomogram. The nomogram exhibited excellent predictive performance in all three sets: the training set, internal validation set, and external test set. The area under the receiver operating characteristic curve (AUC) for the training set was 0.88, for the internal validation set was 0.91, and for the external test set was 0.90. The Hosmer-Lemeshow test and Brier score indicated a high goodness of fit for the model. Furthermore, the calibration curve demonstrated a strong agreement between the predicted outcomes from the nomogram and the actual observations. Additionally, the decision curve analysis exhibited that the nomogram provided significant clinical net benefits in predicting IFD deterioration.

CONCLUSIONS

The study successfully identified seven independent predictors and developed a predictive nomogram for early assessment of the likelihood of IFD deterioration.

Successful Management of Spondylodiscitis Caused by Aspergillus nidulans: A Case Report and Literature Review

We report a case of spondylodiscitis caused by Aspergillus nidulans (SCAN). A. nidulans is a saprophytic fungus and emerging pathogen responsible for a variety of infections, although it is rarely implicated in osteoarticular infections. The patient was a 59-year-old immunocompromised patient with a history of lymphoma and splenectomy. Following diagnosis, the patient was promptly and effectively treated with voriconazole. A literature review underlines the distinctive features of the few case reports of SCAN, as well as the original features of the present case report.

Survey of current national and international guidance to reduce risk of aspergillosis in hospitals

Aspergillus spp. are most commonly associated with disease in the severely immunocompromised host and those with chronic chest disease. The scope of patients at risk is expanding, including intensive care (inclusive of severe viral pneumonia), trauma, burns and major surgery. As exposure or colonization is a prerequisite to Aspergillus-related disease, this has prompted a global review of preventative measures recommended in healthcare establishments. This global review includes 75 documents from 24 countries, categorized into clinical, infection prevention and control, and building-related guidance for prevention of invasive aspergillosis (IA). We overview the IA incubation period and different acceptable levels of airborne Aspergilli in protected environments (PEs), including critical care and operating rooms. Few documents cover all aspects of prevention, prophylaxis, avoidance, preventative measures and monitoring (environmental and clinical). A multi-disciplinary approach is required to identify and minimize the multiple risks and ensure adequate preventative measures. Most building-related guidance addresses construction and internal hospital alterations, but we also review the importance of good management of the healthcare environment (including ventilation systems) and uncertainties of environmental monitoring. We highlight the differences in standards recommended for protective patient environments including the critical care environment. The large capital investment required for PEs is often limited to patient groups most at risk. Single document comprehensive guidance is lacking, and many countries provide no guidance. Reduction in healthcare-associated acquisition of invasive aspergillosis during vulnerable inpatient episodes requires heightened awareness of patients at risk, careful risk assessment and attentive maintenance of the general hospital environment.

Voriconazole in the treatment of pediatric patients with hematologic malignancies and invasive fungal infections: a real-world study

PURPOSE

To evaluate the factors influencing voriconazole (VRC) administration, clinical efficacy, and safety in children with hematological malignancies (HM) and invasive fungal infection (IFD).

METHODS

This is a single-center, retrospective real-world study conducted between July 2018 and December 2023. Univariate and multivariate logistic regression analysis were used to analyze the affecting factors.

RESULTS

A total of 167 patients were included in this study. Among them, 13.77% (23/167) of children under 2 years old received off-label use of VRC, with an initial maintenance dose higher than that of other groups (P < 0.001). There were 8 cases (4.79%) of cured, 148 cases (88.62%) of improved, and 11 cases (6.59%) of ineffective. Thirty-eight cases experienced adverse drug reactions (ADR), with a highest incidence (10.2%) of hepatotoxicity. The concomitant proton pump inhibitors (PPIs), days of central venous catheterization and coagulopathy were independent influencing factors of ADR. Sixty-six patients underwent therapeutic drug monitoring (TDM), which increased the probability of achieving the target plasma trough concentration (Cmin). Among children < 2 years old underwent TDM, 88.89% (8/9) achieved therapeutic concentration, and the probability was higher than that of the older groups. Days of VRC treatment had a positive but not statistically significant effect on achievement of target Cmin. Hypoalbuminemia and days of antimicrobials treatment were independent influencing factors of Cmin distribution.

CONCLUSION

Attention to the off-label use of VRC in children < 2 years old, hypoalbuminemia and coagulopathy correction, potential drug interactions with VRC, and ADR monitoring is crucial for clinical efficacy and safety.

Features of Invasive Aspergillosis Caused by Aspergillus flavus, France, 2012-2018

Invasive aspergillosis (IA) caused by Aspergillus flavus remains poorly described. We retrospectively analyzed 54 cases of IA caused by A. flavus reported in France during 2012-2018. Among cases, underlying IA risk factors were malignancy, solid organ transplantation, and diabetes. Most (87%, 47/54) infections were localized, of which 33 were pleuropulmonary and 13 were ear-nose-throat (ENT) infection sites. Malignancy (70% [23/33]) and solid organ transplantation (21% [7/33]) were the main risk factors in localized pulmonary infections, and diabetes mellitus was associated with localized ENT involvement (61.5%, [8/13]). Fungal co-infections were frequent in pulmonary (36%, 12/33) but not ENT IA (0 cases). Antifungal monotherapy was prescribed in 45/50 (90%) cases, mainly voriconazole (67%, 30/45). All-cause 30-day case-fatality rates were 39.2% and 90-day rates were 47.1%, and rates varied according to risk factor, IA site, and fungal co-infections. Clinicians should remain vigilant for A. flavus and consider it in the differential diagnosis for IA.

Evaluation of the clinical characteristics and survival outcomes of invasive pulmonary aspergillosis patients

Background

Invasive pulmonary aspergillosis (IPA) is a severe infectious disease caused by Aspergillus spp. It is associated with high mortality, particularly in immunocompromised patients, as well as in those with COVID-19 pneumonia or critically ill individuals in intensive care units (ICUs). Accurate clinical diagnosis remains a significant challenge, often resulting in missed diagnoses.

Methods

This study evaluated IPA inpatients diagnosed through mycological evidence and clinical criteria over 12 months. Inclusion criteria required at least one positive mycological result, including a positive culture from bronchoalveolar lavage fluid (BALF) or high-quality sputum, or a positive galactomannan antigen (GM) test.

Results

A total of 216 patients were diagnosed with IPA, with a mortality rate of 68.5%. Hematologic malignancies were the primary underlying condition in 33.8% of cases. Voriconazole or posaconazole was used in 45% (98/216) of patients overall, but only 26% (32/121) of non-hematologic malignancy patients received these treatments. The 28-day survival rate for patients treated with Voriconazole/Posaconazole was 0.776 ± 0.038, compared to 0.421 ± 0.043 for untreated patients. Median survival was 130 days (95% CI, 35.3-224.7) for treated patients vs. 20 days (95% CI, 15.8-24.2) for untreated patients (p < 0.001). Biomarkers for IPA diagnosis demonstrated high diagnostic value, with area under the curve (AUC) values for GM, G, PCT, IL-6, WBC, NEU%, and D-dimer of 0.953, 0.983, 1.000, 0.999, 0.961, 0.996, and 1.000, respectively. GM levels >0.5 pg/ml had a positive predictive value of 52.9% (27/51), while positive mycological culture had a predictive value of 46.5% (33/71). Multivariable regression analysis identified several significant factors associated with in-hospital mortality: IPA (OR 7.509, 95% CI 4.227-13.339, p < 0.001), Voriconazole/Posaconazole treatment (OR 0.124, 95% CI 0.063-0.242, p < 0.001), ICU hospitalization (OR 5.280, 95% CI 1.549-18.002, p = 0.008), hematologic malignancy (OR 0.316, 95% CI 0.174-0.573, p < 0.001), and NEU% ≥87.25% (OR 3.409, 95% CI 1.455-7.990, p = 0.005).

Conclusion

Non-hematologic malignancy patients with IPA were frequently undertreated with antifungal therapy. A comprehensive diagnostic approach using biomarkers, CT, mycological evidence is crucial. Key risk factors for mortality include lack of Voriconazole/Posaconazole treatment, IPA diagnosis, ICU admission, non-hematologic malignancies, and elevated NEU%.

Development and validation of a clinical risk score nomogram for predicting voriconazole trough concentration above 5 mg/L: a retrospective cohort study

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.

Doubling of triazole resistance rates in invasive aspergillosis over a 10-year period, Belgium, 1 April 2022 to 31 March 2023

BackgroundDutch national treatment guidelines for fungal infections have been adapted based on surveillance findings of triazole resistance rates >10% in Aspergillus species isolates. In Belgium, nationwide resistance data have not been collected since 2011.AimOur objective was to evaluate changes in antifungal susceptibility among Aspergillus species isolates from patients with invasive aspergillosis.MethodsLaboratories across Belgium were invited to send all clinically relevant Aspergillus species isolates from patients diagnosed with invasive aspergillosis, collected between April 2022 and March 2023, to the National Reference Centre for Mycosis at UZ Leuven for identification and antifungal susceptibility testing.ResultsOverall, 29 clinical laboratories contributed 309 isolates from 297 patients. Median patient age was 66 years (range: 6 months-96 years). Among isolates, 61% (189/309) were from male patients. At species level, Aspergillus fumigatus isolates predominated (278/309, 90%), with a 9.7% (27/278) triazole resistance rate, compared to the 4.6% rate found in 2011. Of 27 resistant isolates, successful Cyp51A sequencing of 26 showed 20 with the TR34/L98H resistance mechanism. Across the country, local A. fumigatus triazole resistance rates varied. Among provinces in the Flanders region, Antwerp had the highest resistance rate (15.4%: 10/65; p = 0.082), Flemish Brabant (6/48) also had a rate >10%, while Limburg (2/46) had the lowest rate.ConclusionsGeographical differences in A. fumigatus triazole resistance rates stress the importance of implementing broad prospective surveillance initiatives, not limited to one region or one hospital. In Belgium, triazole resistance rates have doubled over 10 years, nearly attaining the 10% threshold, warranting re-evaluation of local empirical antifungal treatment regimen decisions.

Updated recommendations for the management of hepatitis B, C, and E virus infections in patients with haematological malignancies and those undergoing haematopoietic cell transplantation: recommendations from the 9th European Conference on Infections in Leukaemia (ECIL-9)

Viral hepatitis remains a global health challenge and immune status affects outcomes. In patients with haematological malignancies, including haematopoietic stem-cell transplantation recipients, viral hepatitis can be life-threatening due to the direct effects of the virus or the need to modify or delay chemotherapy. Additionally, haematopoietic stem-cell donors with past or current viral hepatitis infections might transmit the virus to recipients. The growing recognition of hepatitis E virus (HEV), advances in haematological therapies, and the availability of direct-acting antivirals for hepatitis C virus (HCV), led the 2022 9th European Conference on Infections in Leukaemia (ECIL-9) to update the 2013 ECIL-5 guidelines on viral hepatitis. The ECIL organising committee convened a panel of 13 impartial international experts (all authors of this Review) in viral hepatitis, both within and outside the fields of haematological malignancies and immunosuppression. The ECIL-9 panel conducted a review of the literature on hepatitis B virus (HBV), HCV, and HEV, grading the evidence based on the European Society for Clinical Microbiology and Infectious Diseases system. The panel identified key clinical questions and outcomes and built on the recommendations established during ECIL-5. A consensus conference was held in Sofia Antipolis, France, from Sept 15-17, 2022, bringing together 49 experts from 19 countries. The ECIL-9 panel presented the proposed recommendations, which were revised following expert discussions. A final consensus on updated guidelines was reached in a second plenary session. The updated ECIL-9 guidelines provide evidence-based recommendations on the prevention, screening, treatment, and long-term surveillance of viral hepatitis in patients with haematological malignancies and haematopoietic cell transplantation recipients.

Role of liposomal amphotericin B in intensive care unit: an expert opinion paper

INTRODUCTION

Invasive fungal infections (IFI) are frequent in patients admitted to the intensive care unit (ICU). The use of first-line antifungals like triazoles or echinocandins may be limited by the global spread of multi-drug resistance species, drug-drug interactions, low organ penetration, and some safety concerns in case of multi-organ failure. Liposomal amphotericin B (L-AmB) is a polyene drug with a broad activity against mold and yeast and an acceptable safety profile. To outline the role of L-AmB in the treatment of IFI in critically ill patients, a panel of experts was invited to draw up an expert opinion paper on the appropriate place in therapy of L-AmB in different clinical scenarios of patients admitted to ICU.

METHODS

A multidisciplinary group of 16 specialists in infectious disease, microbiology, pharmacology, and intensive care elaborated an expert opinion document through a multi-step approach: (1) the scientific panel defined the items and wrote the statements on the management of IFI in ICU, (2) a survey was submitted to an external panel to express agreement or disagreement on the statements, and (3) the panel reviewed the survey and implemented the final document.

RESULTS

The final document included 35 statements that focused on epidemiology and microbiological rationale of the use of systemic L-AmB in critically ill patients and its potential role in specific clinical scenarios in the ICU.

CONCLUSION

Systemic L-AmB may represent an appropriate therapeutic choice for IFI in ICU patients with different underlying conditions, especially when the use of first-line agents is undermined. This expert opinion paper may provide a useful guide for clinicians.

Isavuconazole as an optimal treatment option for multiple pathogens induced severe pneumonia in immunocompromised hosts: a case series report

Background

Treating severe pneumonia caused by multiple pathogens in immunocompromised hosts (ICHs) presents significant challenges. Isavuconazole (ISA), a next-generation triazole antifungal agent, has shown promise in managing fungal infections. However, clinical evidence regarding its efficacy in cases of complex infections involving multiple pathogens in ICHs remains limited.

Case presentation

This study describes a case series of three ICHs diagnosed with severe pneumonia, including invasive aspergillosis (IA). All three patients received ISA-based personalized antimicrobial regimens. Alleviation of symptoms was observed in all patients following antimicrobial treatment, with notable absorption of pulmonary lesions and no significant hepatorenal toxic side effects, with no recurrence observed.

Conclusion

ICHs are highly susceptible to fungal infections, and the severity of their condition can escalate dramatically, with a significant risk of mortality, when severe pneumonia caused by multiple pathogens occurs concurrently. A stepwise treatment strategy, which balances the use between immunosuppressant and effective antimicrobial treatment, is crucial. The selection of appropriate drugs should account for potential adverse drug reactions (ADRs). In this case series, ISA exhibited robust efficacy in treating IA with minimal ADRs. Therefore, ISA represents a valuable option for managing severe pneumonia in ICHs, particularly in the context of IA and co-infections caused by multiple pathogens.

Metamizole induces voriconazole metabolism and results in subtherapeutic voriconazole concentrations

AIMS

Voriconazole is extensively metabolized via cytochrome P450 (CYP) enzymes, predominantly CYP2C19 and CYP3A4. Drugs influencing the activity or expression of CYP enzymes can cause clinically relevant changes in the metabolism and voriconazole exposure. Metamizole is known to induce CYP3A4 and CYP2C19. This study aimed to investigate the pharmacokinetic drug-drug interaction between metamizole and voriconazole.

METHODS

In this single-centre retrospective observational cohort study, we compared voriconazole serum trough concentrations before, during and after metamizole treatment.

RESULTS

In the 9 included patients, the median voriconazole trough concentration decreased by 71% during metamizole treatment (P = .028) compared to before start of metamizole. The concentration/dose ratio similarly decreased by 81% during metamizole treatment (P = .018). Additionally, the metabolic ratio (voriconazole-n-oxide/voriconazole) increased from 0.9 to 2.4 (P = .028) during metamizole treatment. Subtherapeutic voriconazole trough concentrations were more frequent when combined with metamizole (before 14%, during 70%, after 17%).

CONCLUSIONS

Metamizole increases voriconazole metabolism and decreases voriconazole trough concentrations, probably through a CYP3A4 and CYP2C19 inducing effect. It is recommended to avoid concurrent use of metamizole and voriconazole or to closely monitor voriconazole trough concentrations during metamizole treatment and up to 2 weeks after discontinuation of metamizole.

Combinations of posaconazole and tacrolimus are effective against infections with azole-resistant Aspergillus fumigatus

Background

Solid organ transplant recipients on immunosuppressants such as tacrolimus are at increased risk of developing pulmonary aspergillosis, a severe to deadly complication with limited treatment options, especially against azole-resistant strains. This study investigates the antifungal interaction between posaconazole and tacrolimus, prompted by a case where a liver transplant recipient on tacrolimus experienced unexpected eradication of chronic Aspergillus fumigatus colonization following posaconazole prophylaxis.

Methods

We compared the combined antifungal activity of posaconazole and tacrolimus against azole-sensitive and resistant A. fumigatus in vitro against planktonic isolates and biofilm formation and in vivo in Galleria mellonella larvae, to evaluate the potential benefit over posaconazole monotherapy.

Results

The posaconazole-tacrolimus combination demonstrated a 4-fold increase in efficacy against azole-resistant isolates and a 30-fold increase against an azole-sensitive strain, in contrast to voriconazole. Moreover, this combination enhanced antifungal activity by 4- to 15-fold against biofilm formation of azole-sensitive strains, though no synergy was observed against azole-resistant biofilms. In vivo studies in Galleria mellonella confirmed a 2- to 7-fold decrease in fungal burden of both azole-sensitive and azole-resistant strains when combining posaconazole with tacrolimus, relative to posaconazole alone.

Conclusion

In vitro and in vivo findings confirm that posaconazole may offer therapeutic benefits for treating A. fumigatus infections in patients receiving tacrolimus. These results warrant further confirmation in mice and exploration of their clinical implications.

Risk stratification and impact of donor type on breakthrough invasive fungal infections in haematopoietic cell transplant with post-transplant cyclophosphamide and mould-active prophylaxis

Incidence of breakthrough proven-probable invasive fungal infections (b-PP-IFIs) in allogeneic haematopoietic cell transplant recipients (allo-HCT-r) receiving mould-active prophylaxis (MAP) and post-transplant cyclophosphamide (PT-Cy) is largely unknown. Retrospective study on allo-HCT-r, classified at high-risk for IFIs whether ≥1 of the following conditions was met: 1] active disease; 2] cord-blood; 3] previous transplant; 4] acute graft-versus-host-disease (a-GVHD) grade≥3; 5] mismatched-related or unrelated donor with neutropenia before transplant or grade-2 a-GVHD or Cytomegalovirus infection. Objectives were to estimate cumulative incidence function (CIF) of b-PP-IFIs, evaluate infection-related mortality (IRM) and predictive factors of b-PP-IFIs. Overall, 473 allo-HCT-r (n = 286 posaconazole, n = 187 voriconazole) were analysed: 64.7% were at high-risk, 81.6% received PT-Cy. Fifteen b-PP-IFIs occurred: 14/306 in high-risk, 1/167 in non-high-risk group. CIF of b-PP-IFIs in high-risk group was 2.0% (95%CI = 0.8-4.1%) at 30-day and 5.1% (95%CI = 2.9-8.2%) at 1-year post-transplant. The 1-year CIF of IRM was higher in allo-HCT-r with b-PP-IFIs compared to those without [46.7% (95%CI = 19.6-70%) vs. 8.2% (95%CI = 5.3-9.2%), Gray's test: p < 0.001]. In allo-HCT-r receiving PT-Cy, neutropenia before transplant [sHR 7.54 (95%CI = 1.81-31.43)] and chronic myeloproliferative disorders versus AML/MDS [sHR 7.72 (95%CI = 1.68-35.42)] increased risk of b-PP-IFIs, while donor type did not. MAP effectively prevented IFIs. PT-Cy conferred a comparable risk of b-PP-IFIs in matched compared to mismatched-transplants.

Galactomannan detection in sputum samples of patients with chronic obstructive pulmonary disease: A promising marker for diagnosis of chronic pulmonary aspergillosis?

BACKGROUND AND PURPOSE

Diagnosing chronic pulmonary aspergillosis (CPA) is challenging due to nonspecific symptoms, variable radiological findings, and limited mycological evidences. While galactomannan (GM) testing has been validated in serum and bronchoalveolar lavage fluid (BAL) for invasive pulmonary aspergillosis (IPA), its usefulness in sputum samples for CPA remains unclear. This study aimed to determine an appropriate GM cut-off level in sputum samples and its performance in diagnosis of CPA.

MATERIALS AND METHODS

The diagnostic performance of sputum GM was evaluated in patients with COPD suspected of having CPA referred to the two reference centers for pulmonary diseases in Iran, and compared against established diagnostic criteria, including Aspergillus culture and IgG antibody tests. The sensitivity, specificity and positive and negative predictive value for sputum GM test were calculated. The optimal cut-off for sputum GM was determined by receiver operating characteristic (ROC).

RESULTS

Of 196 COPD patients, 189 were analyzed for sputum GM. Sputum GM demonstrated an area under the receiver operating characteristic curve (AUC) of 0.83 (with 95 % confidence intervals (CI) of 0.748 - 0.913 and a p-value < 0.001). The optimal cut-off value for the sputum GM index was 1.44. The sensitivity and specificity were found to be 83.3 % and 74.2 % respectively. The median (IQR) levels of sputum GM index were significantly higher in CPA patients compared to non-CPA patients. (Pv <0.001).

CONCLUSIONS

Overall, our findings suggest that sputum GM is a valuable tool in the diagnosis of CPA; however, further prospective validation is warranted to increase its clinical utility.

Challenges in the diagnosis and treatment of chronic pulmonary aspergillosis in Japan

Chronic pulmonary aspergillosis (CPA) is a refractory infectious disease that occurs in patients with mildly compromised immunity or an underlying pulmonary disease. The mortality rate associated with pulmonary aspergillosis has also increased. In the diagnosis and management of CPA, numerous challenges persist. The Aspergillus IgG antibody test is a highly accurate adjunctive diagnostic method for CPA that has been approved in Japan since 2024. However, the diagnostic accuracy for non-fumigatus species is not as high as that for Aspergillus fumigatus. The development of an auxiliary diagnostic method for non-fumigatus CPA is a pressing concern. Azole-resistant strains, related species, and challenges in long-term therapy are significant issues. Currently, most azole-resistant strains in Japan are patient-route strains that harbor CYP51A mutations. Although the prevalence of azole-resistant strains transmitted via environmental routes remains limited, ongoing surveillance and monitoring are essential. Furthermore, the lack of health insurance coverage for drug susceptibility testing is another critical issue. The recommended treatment duration for CPA is a minimum of 6-12 months; however, maintaining long-term therapy is challenging because of the higher incidence of adverse events associated with antifungal agents than with other antimicrobial medications. Additionally, CPA co-infection in patients with non-tuberculosis mycobacteria has recently become a concern owing to poor prognosis and drug-drug interactions between antifungal and antimycobacterial agents. Therefore, the development of treatment agents with improved safety profiles and fewer drug-drug interactions is highly desirable.

Observational study of the recent efficacy and economy of itraconazole vs. voriconazole in perioperative pulmonary aspergillosis

Background

Antifungal therapy is a common treatment option for pulmonary aspergillosis, but its use to prevent recurrence and relieve symptoms in patients with pulmonary aspergillosis remains controversial. This study aimed to explore the short-term efficacy and cost of itraconazole vs. voriconazole in the treatment of pulmonary aspergillosis during the perioperative period.

Methods

We retrospectively collected the clinical data of 55 patients with pulmonary aspergillosis who underwent surgery and received itraconazole or voriconazole as antifungal therapy between January 1, 2016, and October 31, 2022, at the Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical University. We analyzed the effects of different antifungal therapies on the incidence of adverse events, short-term efficacy, and cost-effectiveness of pulmonary aspergillosis treatment.

Results

Except for the younger average age of patients in the itraconazole group, there were no significant differences in baseline characteristics such as sex, BMI, underlying lung disease, accompanying symptoms, and lesion location between the voriconazole and itraconazole groups. There was no significant difference in the incidence of adverse events or short-term efficacy, including recovery, symptom improvement, and recurrence rates, during the administration of the antifungal regimens between the two groups. Regarding economic cost efficiency, there was no significant difference in the median hospitalization costs between the two groups. However, despite the longer antifungal treatment duration in the itraconazole group, the cost of itraconazole was significantly lower than that of voriconazole.

Conclusion

Both itraconazole and voriconazole effectively prevented the recurrence of pulmonary aspergillosis. They are similar in terms of the incidence of adverse events and short-term efficacy; however, itraconazole is more economical.

Real World Posaconazole Pharmacokinetic Data in Paediatric Stem Cell Transplant Recipients

Background: Invasive fungal disease is a significant cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant (alloHSCT) recipients. Posaconazole, a broad-spectrum triazole, is widely used as prophylaxis. Methods: We conducted a monocentric, retrospective study to present real-world data on posaconazole trough levels in paediatric alloHSCT patients. The main objective was to determine the required daily dose of posaconazole in paediatric patients. We analysed factors influencing posaconazole levels, and the association between posaconazole levels and breakthrough fungal infection. Results: Among 102 allogeneic HSCT recipients, we measured posaconazole plasma concentrations in 548 blood samples. The required daily doses to reach a target range of 0.7-2.0 mg/L were 15.22 (suspension), 7.52 (tablet), and 7.84 mg/kg (intravenous). Patients aged < 13 years needed higher doses to achieve the target range. The presence of enteral symptoms during prophylaxis was associated with lower plasma concentrations (p < 0.001), while co-administration of proton pump inhibitors did not (p = 0.09). Eight breakthrough infections occurred; low levels of posaconazole (<0.7 mg/L) were observed in five out of eight cases. The Cox regression model showed that higher mean plasma concentrations decreased the hazard of breakthrough infections. Conclusions: The tablet and intravenous formulations of posaconazole outperformed the suspension in terms of predictability. Our analyses on breakthrough infections and posaconazole plasma levels suggest an exposure-response relationship.

Antifungal Resistance in Non-fumigatus Aspergillus Species

This review provides an in-depth exploration of antifungal resistance in non-fumigatus Aspergillus species, mainly focusing on acquired resistance. The available data have been compiled and sometimes re-analysed. It highlights the increasing prevalence of resistance in non-fumigatus species belonging to Flavi, Terrei, Nigri, and Nidulantes Aspergillus sections, offering a detailed analysis of resistance detection methods and the global distribution of resistant strains. The review also thoroughly examines the molecular mechanisms behind resistance and raises key unresolved issues, such as the factors contributing to resistance selection and the clinical implications of in vitro resistance. Additionally, it addresses the challenges of treating infections caused by resistant Aspergillus species and cryptic species and discusses current and future strategies relying on combination therapy and newly developed antifungals. The conclusion emphasises the need for further research into resistance mechanisms and alternative treatments to address the rising threat of antifungal resistance in Aspergillus species.

2024 update of the AGIHO guideline on diagnosis and empirical treatment of fever of unknown origin (FUO) in adult neutropenic patients with solid tumours and hematological malignancies

Febrile Neutropenia is an emergency in the treatment of cancer patients. It requires prompt and evidence-based clinical and antimicrobial management. The implementation of standard operating procedures (SOP) across hospitals and outpatient cancer departments can improve the outcome of FN patients by reducing FN-related morbidity and mortality and by the continuation of cancer treatment. This guideline describes an evidence-based approach to risk stratification, epidemiology, diagnosis, and treatment. It is provided by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and is an update of the 2017 version. Emerging aspects in epidemiology, diagnostic procedures, risk stratification, first-line antimicrobial treatment, empiric antifungal treatment and the duration of antimicrobial treatment are discussed and rated on evidence-based strength of recommendation and quality of evidence as described by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). By this, the aim of this guideline is to provide evidence-based recommendations on the management of febrile neutropenia in cancer patients for the practicing clinician.

Comparative Analysis of Chemiluminescence Immunoassay (CLIA)-Based Tests in the Diagnosis of Invasive Aspergillosis in Patients With Hematologic Malignancies

BACKGROUND AND AIM

Rapid chemiluminescence immunoassays (CLIA) have emerged as a promising alternative to traditional serological methods for the diagnosis of invasive aspergillosis (IA). The aim of this study was to compare the diagnostic performance of rapid CLIA tests in IA.

METHODS

Patient group consisted of 17 patients who were diagnosed with probable IA according to EORTC/MSG criteria. Patients without invasive fungal infection (IFI) were defined as the control group, whereas healthy volunteers were also included. A total of 93 serum samples were used in this study. Platelia Aspergillus Ag test and Dynamiker Aspergillus Ag Kit, CLIA tests Aspergillus Galactomannan Detection Kit and Fungus (1-3) ꞵ-D-Glucan Detection Kit, were used. Specificity, sensitivity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. Receiver operating characteristic (ROC) curve was used to evaluate the overall diagnostic performance of CLIA tests comparing FDA-approved GM ELISA test.

RESULTS

The sensitivity of the CLIA galactomannan (CLIA GM) test was 70.6%, specificity 92.1%, PPV 66.7% and NPV 93.3% (p < 0.001), while the sensitivity of the CLIA beta-glucan (CLIA BDG) test was 88.2%, specificity 81.6%, PPV 51.7% and NPV 96.9% (p < 0.001). Using the PlateliaTM Aspergillus Ag Test as the reference method, the areas under the curve (AUC) of the ROC curve were 0.878 for CLIA BDG and 0.869 for CLIA GM.

CONCLUSIONS

CLIA-based tests were evaluated as being rapid diagnostic tests for IA since their NPVs were found to be very high. Integrating CLIA into clinical practice may significantly improve diagnostic efficiency and patient outcomes.

Elevating fungal care: bridging Brazil's healthcare practices to global standards

Brazil faces unique challenges in managing invasive fungal infections (IFIs) due to diverse ecosystems, a rural workforce, and prevalent health conditions. In Europe, IFIs are primarily associated with transplantation, intensive care, and chronic diseases. Inspired by initiatives in the Caribbean and Latin America in 2019, efforts to map global diagnostic and treatment resources expanded to Africa, Europe, and Asia/Pacific. This study conducts a comparative analysis, mainly drawing data from Brazil and Europe, to investigate IFI epidemiology and management. Data were collected through online surveys distributed to Brazilian and European institutions, with collaborations from scientific organizations. Surveys covered institutional profiles, IFI diagnoses, accessibility to diagnostic techniques, and antifungal drugs. A comparative survey involving 96 Brazilian and 388 European institutions revealed variations in the perception and practices related to fungal pathogens. Differences in ranking and prevalence were observed, along with variations in diagnostic procedures, fluorescence dye usage, culture practices, antifungal medication availability, and technological approaches. Europe exhibited higher utilization rates for molecular diagnostic approaches, including PCR tests, and therapeutic drug monitoring (TDM) was more widespread in Europe compared with Brazil, indicating substantial differences in understanding and managing fungal infections. Customized IFI management is crucial, considering regional differences and addressing technological gaps like underutilized PCR. The study advocates for increased international collaboration, targeted training, and enhanced resources to foster a unified global approach in preventing, diagnosing, and treating IFI.

IMPORTANCE

This work is significant as it highlights the unique challenges Brazil faces in managing invasive fungal infections (IFIs) due to its diverse ecosystems and public health landscape. By comparing Brazil's situation with Europe-where IFIs are mainly linked to transplantation and intensive care-this study identifies key disparities in diagnostic and treatment practices. The findings reveal substantial differences in the availability and use of molecular diagnostics, antifungal drugs, and therapeutic drug monitoring, with Europe demonstrating more advanced practices. By mapping these variations, the study underscores the importance of tailored approaches to IFI management that consider regional differences and technological gaps. Ultimately, it calls for enhanced international collaboration, targeted training, and resource allocation to improve IFI outcomes globally, particularly in regions with limited access to advanced diagnostic tools and treatments.

Appraisal of guidelines and variations in recommendations on drug therapy for invasive aspergillosis prevention and treatment

Background

In recent years, many guidelines related to aspergillosis have been published worldwide. However, no studies have applied assessment tools to systematically evaluate the quality of these guidelines.

Objectives

This study aimed to assess the quality of clinical practice guidelines and compared their recommendations related to drug therapy for the prevention and treatment of invasive aspergillosis.

Methods

Electronic databases, guideline development organizations, and professional society websites were searched to identify clinical practice guidelines for invasive aspergillosis published between 1 January 2013, and 12 September 2023. The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. Recommendations for the drug prevention and treatment of invasive aspergillosis were extracted and descriptively analyzed.

Results

Among the 18 included clinical practice guidelines, the median scores and interquartile range for each AGREE II domain were: scope and purpose, 76.39% (69.1%, 80.21%); stakeholder involvement, 59.72% (50.35%, 67.02%); rigor of development, 64.58% (44.4%, 72.27%); clarity and presentation, 81.25% (68.06%, 91.32%); applicability, 41.67% (36.46%, 47.92%); and editorial independence, 76.05% (50%, 87.5%). Voriconazole and isavuconazole are recommended as first-line therapy for invasive aspergillosis currently. Posaconazole remains the first choice for invasive aspergillosis prophylaxis in patients with hematological malignancies.

Conclusion

The development processes and reporting of invasive aspergillosis -related clinical practice guidelines varied and their quality requires improvement. The guideline recommendations have changed since the approval of isavuconazole.

Cardiac arrhythmias of BCR-ABL inhibitors with or without triazole antifungal agents: A real-world pharmacovigilance study based on the food and drug administration adverse event reporting system database

Objectives

Breakpoint Cluster Region (BCR)-Abelson tyrosine kinase (ABL) inhibitors are widely used in the treatment of blood cancers, particularly chronic myelogenous leukemia and are often combined with triazole antifungal agents to prevent fungal infections. However, the cardiac arrhythmia risks associated with BCR-ABL inhibitors in combination with triazole antifungal agents in real-world settings remain poorly understood. To address this gap, we conducted a pharmacovigilance study to evaluate and compare the cardiac arrhythmia profiles of BCR-ABL inhibitors when used with and without triazole antifungal agents in clinical practice.

Methods

A disproportionality analysis was performed using the Food and Drug Administration Adverse Event Reporting System database (2004Q1-2024Q2). To identify potential signals of cardiac arrhythmias associated with BCR-ABL inhibitors, with or without triazole antifungal agents, we calculated reporting odds ratios and 95% confidence intervals. Comparisons were made between BCR-ABL inhibitor monotherapy and all other drugs in the Food and Drug Administration Adverse Event Reporting System database, as well as between BCR-ABL inhibitors combined with triazole antifungal agents and BCR-ABL inhibitor monotherapy. Additionally, the Weibull shape parameter test was also used to evaluate time-to-onset.

Results

From 2004Q1 to 2024Q2, the Food and Drug Administration Adverse Event Reporting System database reported 21,433,114 cases, including 2666 and 68 cases of cardiac arrhythmias linked to BCR-ABL inhibitor monotherapy and its combination with triazole antifungal agents, respectively. The reporting odds ratios and their 95% confidence intervals for BCR-ABL inhibitor monotherapy, asciminib, nilotinib, and ponatinib were 1.31 (1.27-1.36), 2.11 (1.45-3.06), 2.66 (2.53-2.80), and 1.18 (1.05-1.33), respectively. Dasatinib plus triazole antifungal agents (reporting odds ratio: 2.98, 95% CI: 1.93-4.60) and ponatinib plus triazole antifungal agents (reporting odds ratio: 1.53, 95% CI: 1.08-2.16) were associated with a higher disproportionality of cardiac arrhythmias than BCR-ABL inhibitor monotherapy. The median time-to-onset was longer with monotherapy than with BCR-ABL inhibitors plus triazole antifungal agents (2.63 vs. 0.34 months, p < 0.001), both indicating an early failure type.

Conclusions

BCR-ABL inhibitors plus triazole antifungal agents increase the risk of cardiac arrhythmia, particularly in the early stages of treatment, with the risk decreasing over time.

Impact of current clinical guidelines on the management of invasive fungal disease

Isavuconazole is a new broad-spectrum antifungal triazole with a better safety profile in terms of drug-drug interactions, adverse effects, and tolerance compared to other azoles. Increasing evidence supports the usefulness of isavuconazole in the treatment of invasive fungal diseases. In this review, we aim to analyze the influence of this new evidence on the main clinical guidelines. We reviewed the most recent consensus guidelines issued by the major infectious diseases societies worldwide, focusing on the novelties regarding the recommendations for the use of isavuconazole in different invasive fungal infections and management strategies. Isavuconazole has been included as first-line therapy for invasive aspergillosis, with slight differences in preference for voriconazole or isavuconazole depending on the clinical scenario. In mucormycosis, isavuconazole is considered an alternative first-line therapy to liposomal amphotericin B, especially in those patients with underlying renal impairment. Additionally, the use of isavuconazole is suggested in salvage scenario for both conditions, and the combination with other mold-active drugs is considered. The guidelines report the promising results obtained with the use of this drug for treating mycoses caused by other molds and rare yeasts, as well as endemic mycoses, but since solid evidence is still lacking, the recommendations in this area are generally weak. Isavuconazole is a suitable therapeutic option for invasive fungal infections, offering efficacy against a range of pathogens, including Aspergillus and fungi within the order Mucorales. Its safety profile and its favorable drug interaction profile make it a valuable alternative to traditional agents like voriconazole or liposomal amphotericin B in certain scenarios. However, continued research is essential to better understand its role in combination therapies and to assess its effectiveness against other fungal species.

Fungal Pericarditis-A Systematic Review of 101 Cases

Fungal pericarditis is a rare disease but its incidence has risen in parallel with the global increase in invasive fungal infections. This systematic review analyzes data from previously reported cases of fungal pericarditis to provide an improved understanding of the etiology, clinical presentation, management, and outcomes of this rare disease. We reviewed Medline and Scopus databases from 1 January 1990 to 29 January 2024 for case reports that documented the isolation of a fungal pathogen from pericardial fluid or tissue. Of the 2330 articles screened, 101 cases met the inclusion criteria. Patients with fungal pericarditis and the involvement of at least one other organ-usually the lungs, brain, or kidney-had worse outcomes than patients with isolated pericardial disease. Immunosuppression was reported in 50% of cases and was associated with worse outcomes in adults. Patients who presented with chest pain, received adequate empiric antifungal therapy, and underwent pericardiocentesis and pericardiectomy had improved survival. The most common isolated pathogens were Candida spp., followed by Aspergillus spp. and Mucor spp., with the latter two linked to worse outcomes. Only 35% of patients received empiric antifungal medications before the causative pathogen was identified, and mortality was associated with a delay in appropriate therapy. Immunosuppression, disseminated disease, and presence of shock/multiorgan failure were additional risk factors associated with death. Fungal pericarditis carries a mortality rate of up to 50%, with nearly half of patients being immunocompromised. Clinicians frequently do not consider fungal pericarditis in the differential diagnoses, which leads to delays in treatment and poorer outcomes. Further prospective multicenter studies are urgently needed to better understand the epidemiology, improve diagnostic testing and management, and decrease unacceptably high mortality in patients with fungal pericarditis.

Lateral-flow device for the diagnosis of invasive aspergillosis: a systematic review and diagnostic meta-analysis

BACKGROUND

Early diagnosis of invasive aspergillosis (IA) can significantly enhance patient survival rates; however, accurately diagnosing IA remains a formidable challenge. Lateral flow device (LFD), as a non-invasive detection method, have been extensively investigated in numerous clinical studies. The objective of this study was to elucidate the diagnostic accuracy of LFD in detecting IA through a meta-analysis.

METHODS

The PubMed, Embase, and Web of Science database were searched to obtain clinical studies on the diagnosis of IA by LFD. A random-effects meta-analysis with a bivariate hierarchical model was used, the estimates and 95% confidence intervals (CI) were used to present pooled sensitivity, specificity, and summary receiver operating characteristic curves (SROC).

RESULTS

Twenty-five cohort or case-control studies were included. The pooled sensitivity of LFD in the diagnosis of IA was 0.67 (95% CI: 0.57-0.75), specificity was 0.90 (95% CI: 0.85-0.93), diagnostic odds ratio was 15.70 (95% CI: 9.69-25.44), the area under the SROC curve (AUC) was 0.87 (95% CI: 0.82-0.93). Subgroup analysis showed that the sensitivity of bronchoalveolar lavage fluid specimen was higher than serum specimen (0.72, 95% CI: 0.67-0.78 vs. 0.49, 95% CI: 0.41-0.56), bronchoalveolar lavage fluid specimens also have higher diagnostic accuracy (AUC = 0.89).

CONCLUSIONS

LFD is an effective technique for the detection of IA infection, but attention should be paid to the influence of specimen source on the accuracy of this technique.

Mitral Valve Aspergillus Endocarditis With Aortal Embolization in an Immunocompetent Patient

Aspergillus endocarditis is a rare condition. The clinical presentation is often atypical and insidious, resulting in delayed diagnosis and challenges in management. We report a case of native mitral valve Aspergillus endocarditis in an immunocompetent patient, with rare aortal embolization, who was managed in a multidisciplinary approach. Evidence for Aspergillus endocarditis is limited, and prospective data are unlikely to be available because of the low incidence of the disease. This case report adds great value to the current published case series to provide experience for clinicians when tackling similar conditions. Aspergillus endocarditis is rare but fatal. Cardiac surgery improves early survival, but long-term outcomes remain dismal. An endocarditis team with a multimodality approach is paramount to manage this difficult-to-treat disease.

Refractory versus resistant invasive aspergillosis

Despite notable progress, the management of invasive aspergillosis (IA) remains challenging and treatment failures are common. The final patient outcome is subject to multiple factors including the host (the severity of the underlying conditions), the fungus (the virulence and susceptibility pattern of the Aspergillus species involved), and the therapy (the timing related to severity of infection and choice of therapy-dose, efficacy, cidal versus static, toxicity and interaction). Consequently, assessment of failure is complex yet crucial in order to ensure appropriate management. Refractoriness in absence of drug resistance may reflect severity of the underlying disease/infection at the time of initiation of therapy prolonging time to response. It may also reflect a suboptimal antifungal drug exposure due to poor compliance, inappropriate dosing or increased drug metabolism, or it may reflect 'pseudo' failure due to worsening of imaging due to recovery of neutrophils. Refractoriness may also be related to inherent drug resistance in various Aspergillus species or acquired resistance in a normally susceptible species. The latter scenario is mostly encountered in A. fumigatus, where azole resistance is increasing and includes azole-naive patients due to resistance related to azole fungicide use in agriculture and horticulture. Although diagnostics and resistance detection have been greatly improved, the time to resistance reporting is often still suboptimal, which calls for close assessment and potentially management changes even before the susceptibility is known. In this article we address the various definitions and approaches to assessment and management of clinical refractoriness/failure in the setting of proven and probable IA.

Clinical aspects and recent advances in fungal diseases impacting human health

Fungal diseases are of growing clinical concern in human medicine as the result of changes in the epidemiology, diversity in clinical presentation, emergence of new pathogens, difficulties in diagnosis and increasing resistance to antifungals of current available classes. There is a need for high disease awareness among the public and healthcare physicians, improvement in diagnostic methods and the development of drugs from new therapeutic classes with an improved resistance profile. In this article, we will explore some key aspects of fungal diseases in humans and provide a general overview of this important topic.

Clinical insights into invasive aspergillosis among immunosuppressed patients: A single-centre experience from Argentina

BACKGROUND

Invasive aspergillosis poses a significant threat to immunocompromised individuals. Diagnostic criteria incorporating biomarkers and imaging have improved diagnosis, and treatment options have expanded. However, in Argentina, diverse patient demographics and environmental factors add complexity to managing this infection.

AIMS

This study aims to explore the epidemiology, diagnostic methods, and treatment of invasive aspergillosis in an Argentine hospital setting.

METHODS

We collected data from patients with suspected invasive aspergillosis at a tertiary care hospital in Central-Northern Argentina. Variables included demographics, underlying conditions, diagnostic criteria, treatment, and outcomes.

RESULTS

With a median age of 44.5 years and a 51% of male patients, our institution conducted invasive aspergillosis screenings on 192 patients, many of whom were battling malignancies (90%). One third of them had the infection set as probable or possible. Imaging (31%) and positive microbiological results (16%) were examples of diagnostic evidence. With an overall mortality rate of 15%, half of the patients got antifungal treatment for a median of seven days. Mortality among the diagnosed patients was 22%. Patients without stem-cell transplantation had a high death rate (31%), although this difference was not statistically significant; in patients having pulmonary nodules (15%) the death rate was not statistically significant either. There were no discernible variations in mortality according to the type of treatment received.

CONCLUSIONS

Our study reveals that invasive aspergillosis remains a significant issue in high-risk patients, and has a notable mortality rate, particularly among those patients with pulmonary nodules. Computed tomography provides a high diagnostic yield.

Pentraxin-3 as a novel prognostic biomarker in non-neutropenic invasive pulmonary aspergillosis patients

The incidence of invasive pulmonary aspergillosis (IPA) in non-neutropenic patients is increasing. This study aimed to evaluate the clinical outcomes and risk factors for mortality in non-neutropenic IPA patients. We conducted a prospective, multicenter study from August 2020 to February 2024, enrolling 565 patients with suspected IPA. The study cohort comprised 195 IPA (non-neutropenic) cases and 370 non-IPA cases. Peripheral blood and bronchoalveolar lavage fluid (BALF) specimens were collected to measure pentraxin-3 (PTX3) levels. Additionally, demographic data, clinical characteristics, and antifungal therapy of each patient were recorded. We analyzed factors associated with 30- and 90-day mortality. IPA patients exhibited higher mortality rates compared to non-IPA patients, with 30-day rates of 26.15% versus 8.38% (P < 0.001) and 90-day rates of 34.36% versus 13.24% (P < 0.001). Higher plasma and BALF PTX3 levels were associated with poor prognosis in IPA patients. ROC curve analysis identified optimal PTX3 thresholds of 4.29 ng/mL in BALF (sensitivity, 67.1%; specificity, 81.4%) and 7.11 ng/mL in plasma (sensitivity, 73.4%; specificity, 82.8%) for predicting mortality. Multivariate Cox regression analysis confirmed PTX3 levels in plasma (hazard ratio [HR] 3.87, 95%CI [1.87-8.00], P＜0.001) and BALF (HR 2.40 [1.19-4.84], P = 0.014) were independent prognostic factors for IPA mortality. Additionally, positive galactomannan test results in both BALF and plasma were initially correlated with increased mortality in IPA patients. However, after adjusting for potential confounding factors, this correlation no longer remained statistically significant. In conclusion, PTX3 is a promising prognostic biomarker of mortality in IPA patients.IMPORTANCEStudies have confirmed the value of pentraxin-3 (PTX3) in the diagnosis of invasive pulmonary aspergillosis (IPA), yet its prognostic significance in IPA remains unclear. This study found that in non-neutropenic IPA patients, plasma and bronchoalveolar lavage fluid (BALF) levels of PTX3 are independently associated with poor outcomes. Furthermore, the optimal cutoff values of PTX3 for predicting a poor prognosis of IPA are 4.29 ng/mL in BALF and 7.11 ng/mL in plasma. These findings could help us better manage IPA in non-neutropenic patients, potentially enhancing the prognosis of patients with this condition.

Beyond Conventional Antifungals: Combating Resistance Through Novel Therapeutic Pathways

The rising burden of fungal infections presents a significant challenge to global healthcare, particularly with increasing antifungal resistance limiting treatment efficacy. Early detection and timely intervention remain critical, yet fungal pathogens employ diverse mechanisms to evade host immunity and develop resistance, undermining existing therapeutic options. Limited antifungal options and rising resistance necessitate novel treatment strategies. This review provides a comprehensive overview of conventional antifungal agents, their mechanisms of action, and emerging resistance pathways. Furthermore, it highlights recently approved and investigational antifungal compounds while evaluating innovative approaches such as nanotechnology, drug repurposing, and immunotherapy. Addressing antifungal resistance requires a multifaceted strategy that integrates novel therapeutics, enhanced diagnostic tools, and future research efforts to develop sustainable and effective treatment solutions.

Isavuconazole off-label use as an empirical treatment of invasive fungal infections

Given its good tolerance and broad-spectrum, isavuconazole is increasingly used off-label as an empirical therapy of invasive fungal infections. We retrospectively reviewed isavuconazole empirical treatment during a 12-month period in four hospitals. During isavuconazole treatment (n=27), none of the patients had a mycological evidence for fungal infection, but 19% (5/27) developed liver test abnormalities without leading to isavuconazole discontinuation. Isavuconazole could be considered as an off-label empirical therapy only if patients cannot receive caspofungin or liposomal amphotericin B.

Fungal β-Glucans: Biological Properties, Immunomodulatory Effects, Diagnostic and Therapeutic Applications

Research from the past to the present has shown that natural ingredients in the human daily diet play a crucial role in preventing various diseases. One well-known compound is β-glucan, a natural polysaccharide found in the cell walls of many fungi, yeasts, and some microorganisms, as well as in plants such as barley and wheat. β-glucans are widely recognized for their ability to lower cholesterol and blood glucose levels, thereby reducing the risk of cardiovascular disease and diabetes. In addition to their effects on lipid levels and glucose metabolism, these molecules exhibit antioxidant properties by eliminating reactive oxygen species. As a result, they help lower the risk of conditions such as atherosclerosis, cardiovascular disease, neurological disorders, diabetes, and cancer. Furthermore, β-glucans have been reported to possess immune-boosting and antitumor effects. By binding to specific receptors on the surface of immune cells, they stimulate immune activity. Additionally, β-glucans belong to a group of probiotics that promote the growth and activity of beneficial gut microbiota, preventing the proliferation of harmful pathogens. They play a vital role in maintaining gastrointestinal health, reducing inflammation, and lowering the risk of colon cancer. Further research on the health benefits of β-glucans may be key to improving overall well-being and preventing many chronic non-communicable diseases such as diabetes, high cholesterol, obesity, cardiovascular disease, and cancer.

Invasive Aspergillosis in the Current Era

Despite significant advances, aspergillosis remains a critical health concern, with an evolving epidemiology and expanding populations of at-risk patients. Historically, fewer than 10 Aspergillus species were considered clinically significant. However, advancements in diagnostic technologies, such as DNA sequencing and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, have identified previously unrecognized "cryptic" Aspergillus species. This clinical review highlights the current epidemiology, risk factors, pathogenesis, clinical presentation, diagnosis, and invasive aspergillosis (IA) treatment. Diagnosing IA necessitates a multifaceted approach, integrating clinical evaluation, imaging studies, microbiological culture, serologic tests, and advanced molecular techniques.

Immune Phenotypes in Patients With Invasive Mould Infection Support the Use of PD-1 Inhibition as Potential Treatment Option

BACKGROUND

Invasive mould infections (IMI) cause substantial morbidity and mortality in populations at risk. Novel treatment approaches are urgently needed. Targeting immune checkpoints may reverse hyporesponsiveness of the innate and adaptive immune systems.

METHODS

In this prospective, observational study, we investigated immune checkpoint expression levels on immune cells in patients with invasive aspergillosis (IA; n = 25) and mucormycosis (MU; n = 7). Healthy controls (HC; n = 5) and patients with matched haematological diseases but without IMI served as control populations (CP; n = 10). Multicolour flow cytometry analysis was used to compare immune cell subsets and the expression of immune-regulatory molecules in peripheral blood mononuclear cells (PBMCs).

RESULTS

Lymphocyte subsets and immune phenotypes in PBMCs were similar between patients with IMI and haematological CP, except for regulatory T cells, which were increased in PBMCs of patients with IA and MU compared to HCs. In IA and MU, PBMCs showed increased expression of immune checkpoint molecules compared to healthy controls and matched haematological CP, with this effect being more pronounced in IA than in MU. We found heterogeneous, disease-, molecule-, and patient-specific expression patterns of immune checkpoint molecules. For example, PD-1 expression was highest in MU PBMCs, followed by IA PBMCs, while HC PBMCs showed lower expression levels. Overall mortality in our patient population was 44.0% (IPA) and 80.0% (MU).

CONCLUSIONS

We report an immune phenotype consistent with T-cell exhaustion in IMI, indicating potential contributions from haematological treatment, underlying disease, and infection. However, the primary underlying cause remains unclear and requires further investigation. A marker that was notably higher in IMI patients was PD-1, and treatment approaches specifically targeting this molecule may be promising.

Molecular Diagnostics for Invasive Molds: From Lab to Bedside

This review highlights the current state of molecular diagnostic modalities to detect invasive fungal infections, with a focus on molds in immunocompromised children and adults. Molecular diagnostics may also be utilized to detect antifungal drug resistance. Although both pathogen-specific and pathogen-agnostic assays may be beneficial in more rapidly identifying fungal infection with less invasive sampling in high-risk populations, the clinical implementation and interpretation of these tests must consider several important factors, including anatomic site and type of specimen, host characteristics, use of antifungal prophylaxis, and timing of specimen collection.

Invasive aspergillosis leading to fatal cerebral hemorrhage: a case report and comprehensive literature review

Aspergillus fumigatus significantly threatens immunocompromised individuals by causing potentially fatal diseases, primarily invasive aspergillosis (IA). IA, mostly affecting the lungs, can disseminate to other organs, including the central nervous system (CNS), leading to high mortality rates. We present the case of an 84-year-old immunocompetent male with a history of significant comorbidities, who developed a lethal subarachnoid and tetraventricular hemorrhage. Initial symptoms included paroxysmal neuralgic pain and ophthalmic manifestations. Despite diagnostic efforts, the infection was confirmed only after a positive Aspergillus galactomannan antigen test on cerebrospinal fluid, post-mortem microbiological culture, and mass spectrometry (MS) authentication. The patient exhibited rapid deterioration and succumbed due to the erosion of a mycotic cerebral aneurysm of the left internal carotid artery. Diagnosing IA, particularly isolated CNS IA in immunocompetent patients, is challenging due to its nonspecific symptoms and difficulty detecting the pathogen in standard diagnostic tests. This article emphasizes the pivotal role of pathological examination to obtain a definitive diagnosis, assess fungal infiltration of brain vessels, and thus clarify the accurate source of fatal brain hemorrhages.

Follow-up of Surgical and Nonsurgical Patients With Pulmonary Aspergillosis: A Real-World Study

Objective

In the real clinical world, both surgery and medication are used to treat pulmonary aspergillosis (PA), but the prognosis of different treatments is unclear. The purpose of this study was to investigate the diagnosis and treatment, follow-up results and prognostic factors of PA patients in the real world, so as to deepen our understanding of PA and improve the prognosis of PA patients.

Materials and Methods

Eligible patients with pathologically diagnosed PA (n = 125) were retrospectively enrolled and followed up. Further comparisons and subgroup analyses were performed between patients receiving surgical and nonsurgical treatments. Univariate and multivariate logistic regression analyses were used to investigate the factors associated with treatment failure.

Results

A total of 125 patients with PA were included in the study. Of these, 49 (39.2%) received surgical treatment (25 of whom also received postoperative antifungal therapy), while 76 (60.8%) received antifungal therapy alone. The median age was 59 years (46.5-67 years). Compared with the nonsurgical group, the surgical group had lower inflammatory cell counts and less inflammatory response, and higher hemoglobin and albumin levels. Multivariate logistic regression analysis showed that white blood cell (WBC) levels >9.5×109/L and C-reactive protein (CRP) levels >8 mg/L were independent predictors linked to treatment failure.

Conclusion

PA patients with severe inflammation and poor general health are usually treated with antifungal drugs only. Risk factors including elevated WBC levels and high CRP levels can help identify PA patients who may have a less favorable response to treatment at an early stage. It should be noted that increasing the dose and duration of antifungal therapy may improve patient prognosis.

Antifungal Policy and Practice Across Five Countries: A Qualitative Review

The burden of invasive fungal infections (IFIs) is increasing worldwide. National, regional, and local policies on IFI management should respond to the changing landscape. We assessed antifungal policies from five countries of varying size, IFI burden, and geography: the Netherlands, Italy, South Korea, China, and India. These countries were selected as a representative sample reflecting different types of economic and health systems that patients and providers access worldwide. This assessment focused on a comprehensive range of antifungal policy elements, including recognition and prioritization, awareness and education, prevention and monitoring, diagnosis and coordinated care, access to appropriate treatment, and diagnostic and treatment innovation. Although countries in this analysis all have some form of policy for IFI management, we have identified substantial gaps, including low prioritization of IFI diagnostics, omission of fungal pathogens from antimicrobial resistance policies, and a general lack of awareness and healthcare professional (HCP) training on IFI management. The gaps identified are intended to inform HCPs and policy- and decision-makers about aspects to consider in reducing the IFI burden for patients and health systems while demonstrating responsible antifungal stewardship.

Invasive fungal infections in patients with liver disease: immunological and clinical considerations for the intensive care unit

Patients with liver disease in the intensive care unit (ICU) face a unique susceptibility to infection due to the complex immune dysfunction resulting from hepatic failure. Bacterial infections are commonly present in these patients upon arrival to the hospital, often being the primary reason for ICU admission. In contrast, invasive fungal infections (IFIs) afflict a smaller percentage of patients and are usually discovered in the course of the ICU stay. IFI diagnosis in the ICU, particularly in patients with liver disease, is often delayed or overlooked, contributing to the extremely high ICU mortality associated with IFI in these patients despite the availability of effective (and largely safe) antifungal therapy. Thus, to improve outcomes, it is crucial for intensive care clinicians to be vigilant for IFIs in patients with liver disease. This review aims to contribute to the intensive care literature in this regard. We begin with an overview of normal antifungal immunity followed by a summary of how it may become compromised in the setting of hepatic dysfunction. Next, a general discussion of IFIs in liver disease is presented and then the three most relevant fungal pathogens, namely Candida, Aspergillus, and Cryptococcus, are individually examined. This review concludes by highlighting key knowledge and practice gaps that require attention by the scientific and clinical communities in the coming years.