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Sachdeva M, Malik M, Pradhan P, Kaur K, Dogra S, Mathew JL. Systematic review on efficacy and safety of empirical versus pre-emptive antifungal therapy among children with febrile neutropenia reveals paucity of data. Mycoses 2024; 67:e13722. [PMID: 38606896 DOI: 10.1111/myc.13722] [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: 01/06/2024] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Two approaches are used to manage invasive fungal disease (IFD) in febrile neutropenic patients viz. empirical therapy (without attempting to confirm the diagnosis), or pre-emptive therapy (after screening tests for IFD). OBJECTIVE This systematic review was undertaken to compare these approaches in children. METHODS We searched PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, CINAHL, Clinical Trial Registries and grey literature, for randomized controlled trials (RCT) comparing empirical versus pre-emptive antifungal therapy in children with FN suspected to have IFD. We used the Cochrane Risk of bias 2 tool for quality assessment, and evaluated the certainty of evidence using the GRADE approach. RESULTS We identified 7989 citations. Stepwise screening identified only one relevant RCT that administered empirical (n = 73) or pre-emptive (n = 76) antifungal therapy. There were no significant differences in all-cause mortality (RR 1.56, 95% CI: 0.46, 5.31), IFD mortality (RR 1.04, 95% CI:0.15, 7.20) and other clinically important outcomes such as duration of fever, duration of hospitalization and proportion requiring ICU admission. There were no safety data reported. The number of days of antifungal therapy was significantly lower in the pre-emptive therapy arm. The certainty of evidence for all outcomes was 'moderate'. CONCLUSIONS This systematic review highlighted the paucity of data, comparing empirical versus pre-emptive antifungal therapy in children with febrile neutropenia having suspected invasive fungal disease. Data from a single included trial suggests that both approaches may be comparable in research settings. Robust trials are warranted to address the gap in existing knowledge about the optimal approach in clinical practice.
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Affiliation(s)
- Meenakshi Sachdeva
- Advanced Centre for Evidence Based Child Health, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Meenakshi Malik
- Advanced Centre for Evidence Based Child Health, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pranita Pradhan
- Advanced Centre for Evidence Based Child Health, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kulbir Kaur
- Advanced Centre for Evidence Based Child Health, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sarita Dogra
- Advanced Centre for Evidence Based Child Health, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Joseph L Mathew
- Advanced Centre for Evidence Based Child Health, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Heylen J, Vanbiervliet Y, Maertens J, Rijnders B, Wauters J. Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment. Semin Respir Crit Care Med 2024; 45:69-87. [PMID: 38211628 DOI: 10.1055/s-0043-1777769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Among all clinical manifestations of pulmonary aspergillosis, invasive pulmonary aspergillosis (IPA) is the most acute presentation. IPA is caused by Aspergillus hyphae invading the pulmonary tissue, causing either tracheobronchitis and/or bronchopneumonia. The degree of fungal invasion into the respiratory tissue can be seen as a spectrum, going from colonization to deep tissue penetration with angio-invasion, and largely depends on the host's immune status. Patients with prolonged, severe neutropenia and patients with graft-versus-host disease are at particularly high risk. However, IPA also occurs in other groups of immunocompromised and nonimmunocompromised patients, like solid organ transplant recipients or critically ill patients with severe viral disease. While a diagnosis of proven IPA is challenging and often warranted by safety and feasibility, physicians must rely on a combination of clinical, radiological, and mycological features to assess the likelihood for the presence of IPA. Triazoles are the first-choice regimen, and the choice of the drug should be made on an individual basis. Adjunctive therapy such as immunomodulatory treatment should also be taken into account. Despite an improving and evolving diagnostic and therapeutic armamentarium, the burden and mortality of IPA still remains high. This review aims to give a comprehensive and didactic overview of the current knowledge and best practices regarding the epidemiology, clinical presentation, diagnosis, and treatment of acute IPA.
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Affiliation(s)
- Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yuri Vanbiervliet
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Sprute R, Nacov JA, Neofytos D, Oliverio M, Prattes J, Reinhold I, Cornely OA, Stemler J. Antifungal prophylaxis and pre-emptive therapy: When and how? Mol Aspects Med 2023; 92:101190. [PMID: 37207579 DOI: 10.1016/j.mam.2023.101190] [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: 01/07/2023] [Revised: 04/22/2023] [Accepted: 05/05/2023] [Indexed: 05/21/2023]
Abstract
The growing pool of critically ill or immunocompromised patients leads to a constant increase of life-threatening invasive infections by fungi such as Aspergillus spp., Candida spp. and Pneumocystis jirovecii. In response to this, prophylactic and pre-emptive antifungal treatment strategies have been developed and implemented for high-risk patient populations. The benefit by risk reduction needs to be carefully weighed against potential harm caused by prolonged exposure against antifungal agents. This includes adverse effects and development of resistance as well as costs for the healthcare system. In this review, we summarise evidence and discuss advantages and downsides of antifungal prophylaxis and pre-emptive treatment in the setting of malignancies such as acute leukaemia, haematopoietic stem cell transplantation, CAR-T cell therapy, and solid organ transplant. We also address preventive strategies in patients after abdominal surgery and with viral pneumonia as well as individuals with inherited immunodeficiencies. Notable progress has been made in haematology research, where strong recommendations regarding antifungal prophylaxis and pre-emptive treatment are backed by data from randomized controlled trials, whereas other critical areas still lack high-quality evidence. In these areas, paucity of definitive data translates into centre-specific strategies that are based on interpretation of available data, local expertise, and epidemiology. The development of novel immunomodulating anticancer drugs, high-end intensive care treatment and the development of new antifungals with new modes of action, adverse effects and routes of administration will have implications on future prophylactic and pre-emptive approaches.
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Affiliation(s)
- Rosanne Sprute
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, 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), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Julia A Nacov
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, 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), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Dionysios Neofytos
- Division of Infectious Diseases, Transplant Infectious Disease Service, University Hospital of Geneva, Geneva, Switzerland
| | - Matteo Oliverio
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Juergen Prattes
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, 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), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Medical University of Graz, Department of Internal Medicine, Division of Infectious Disease, Excellence Center for Medical Mycology (ECMM), Graz, Austria
| | - Ilana Reinhold
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Zurich, Switzerland
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, 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), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Jannik Stemler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, 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), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.
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Bochennek K, Hogardt M, Lehrnbecher T. Immune signatures, testing, and management of febrile neutropenia in pediatric cancer patients. Expert Rev Clin Immunol 2023; 19:267-277. [PMID: 36635981 DOI: 10.1080/1744666x.2023.2168646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Infectious complications, particularly invasive bacterial and fungal infections, are still a major cause of morbidity in pediatric cancer patients and are associated with significant mortality. Over the last few years, there has been much effort in defining risk groups to tailor antimicrobial therapy, and in establishing pediatric-specific guidelines for antimicrobial strategies. AREAS COVERED This review provides a critical overview of defining risk groups for infection, diagnostic work-up, antimicrobial prophylaxis, empirical therapy, and treatment of established infections. EXPERT OPINION To date, no generalizable risk prediction model has been established for pediatric cancer patients. There is growing interest in defining the impact of the individual genetic background on infectious complications. New diagnostic tools have been developed over the last few years, but they need to be validated in pediatric cancer patients. International, pediatric-specific guidelines for antimicrobial prophylaxis, empirical therapy, and treatment of established infections have recently been published and will harmonize antimicrobial strategies in the future.
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Affiliation(s)
- Konrad Bochennek
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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Fisher BT. Fungal diagnostic testing and therapy: navigating the neutropenic period in children with high-risk leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:361-367. [PMID: 34889439 PMCID: PMC8791115 DOI: 10.1182/hematology.2021000267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Children, adolescents, and young adults receiving intensive chemotherapy for acute myeloid leukemia or high-risk or relapsed acute lymphoblastic leukemia sustain prolonged periods of neutropenia that predispose them to invasive fungal disease (IFD). For many decades the standard of care for these patients was to initiate empirical antifungal therapy after a period of prolonged fever and neutropenia. Recent publications have yielded important evidence on the utility of different diagnostic and therapeutic approaches aimed at reducing the impact of IFD among these patients during these vulnerable periods. This case-based review highlights and interprets the published data to provide context for the IFD diagnostic and therapeutic recommendations proposed in multiple published guidelines. Personalized approaches are offered at points where evidence is lacking. Time points where specific knowledge gaps exist are identified along the clinical trajectory of the prolonged neutropenic period to illustrate areas for future investigation.
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Affiliation(s)
- Brian T. Fisher
- Correspondence Brian T. Fisher, Division of Infectious Diseases, Children's Hospital of Philadelphia, Roberts Pediatric Research Center, 2716 South Str, Rm 10-362, Philadelphia, PA 19146; e-mail:
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8th European Conference on Infections in Leukaemia: 2020 guidelines for the diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or post-haematopoietic cell transplantation. Lancet Oncol 2021; 22:e254-e269. [PMID: 33811813 DOI: 10.1016/s1470-2045(20)30723-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/24/2022]
Abstract
Paediatric patients with cancer and those undergoing allogeneic haematopoietic cell transplantation have an increased susceptibility to invasive fungal diseases. In addition to differences in underlying conditions and comorbidities relative to adults, invasive fungal diseases in infants, children, and adolescents are unique in terms of their epidemiology, the validity of current diagnostic methods, the pharmacology and dosing of antifungal agents, and the absence of phase 3 clinical trials to provide data to guide evidence-based interventions. To re-examine the state of knowledge and to further improve invasive fungal disease diagnosis, prevention, and management, the 8th European Conference on Infections in Leukaemia (ECIL-8) reconvened a Paediatric Group to review the literature and to formulate updated recommendations according to the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and European Confederation of Medical Mycology (ECMM) grading system, which are summarised in this Review.
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Clinical feature, image findings and outcome of hepatosplenic candidiasis in patients with acute myeloid leukemia. Biomed J 2020; 44:S252-S257. [PMID: 35292266 PMCID: PMC9068564 DOI: 10.1016/j.bj.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 11/08/2020] [Accepted: 11/10/2020] [Indexed: 11/26/2022] Open
Abstract
Background Patients with acute myeloid leukemia (AML) are at risk of hepatosplenic candidiasis (HSC). HSC is often associated with prolonged fever and difficulty in definitive clinical diagnosis. We aimed to explore the incidence, clinical features, image findings and outcomes of HSC among patients with AML in a tertiary hospital, Taiwan. Methods We did a chart review of patient data in our institute from 2009 to 2012. The diagnosis of HSC was based on risk factors, febrile symptoms and image findings. Results Two hundred and ninety-two patients with AML were analyzed. In total, 1051 chemotherapy sessions were administered. Eleven patients (4 males and 7 females) experienced HSC (incidence 3.8%, 95% conference interval 2.11–6.72%). Among those with HSC, the median age was 62. Eight patients developed HSC following induction or re-induction chemotherapies. Three developed HSC following consolidation chemotherapies. The median duration of severe neutropenia was 25 days (range 10–142). In all patients with HSC, multiple hypodense lesions were found in the involved organs by computed tomography scans. Lesions consistent with HSC could be identified by ultrasound in 5 out of 6 patients. Other than liver and spleen, lung was frequently (7 cases) and kidney occasionally (3 cases) involved. Four patients died within 90 days. Prolonged neutropenia was associated with mortality. Conclusion HSC occurred more often during induction or re-induction periods. Lungs are commonly involved and pleural effusion was frequently seen in CT scans. Pleural effusion may suggest more serious infections but its clinical relevance should be investigated in large-scale studies. Prolonged neutropenia is the only prognostic factor. Prophylaxis should be considered. In the absence of prophylaxis, we advise early image studies and prompt antifungal treatment in patients at risk for HSC.
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Yamashita C, Takesue Y, Matsumoto K, Ikegame K, Enoki Y, Uchino M, Miyazaki T, Izumikawa K, Takada T, Okinaka K, Ueda T, Miyazaki Y, Mayumi T. Echinocandins versus non-echinocandins for empirical antifungal therapy in patients with hematological disease with febrile neutropenia: A systematic review and meta-analysis. J Infect Chemother 2020; 26:596-603. [PMID: 32171659 DOI: 10.1016/j.jiac.2020.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/16/2020] [Accepted: 01/28/2020] [Indexed: 01/05/2023]
Abstract
Empirical antifungal therapy is recommended in high-risk patients who have persistent febrile neutropenia (FN) despite broad-spectrum antibiotic therapy. Based on high-quality evidence, most guidelines recommend caspofungin. The aim of this study was to clarify whether echinocandins, including micafungin, are associated with improved clinical outcomes in patients with persistent FN. We conducted a meta-analysis of randomized controlled trials (RCTs) of empirical therapy with echinocandins and non-echinocandins for FN in patients with hematological disease. The primary outcome was all-cause mortality within 7 days after completion of therapy. Secondary outcomes included treatment success, and discontinuation of therapy because of adverse events. For subgroup analysis, we compared RCTs of echinocandins with liposomal amphotericin B. Six RCTs (four that evaluated caspofungin and two that evaluated micafungin) were included in the meta-analysis. Mortality and adverse events in echinocandin-treated patients were significantly lower than in those treated with non-echinocandins [risk ratio (RR) 0.70, 95% confidence interval (CI) 0.49-0.99; RR 0.48, 95% CI 0.33-0.71, respectively]. There was no significant difference in treatment success (RR 1.09, 95% CI 0.87-1.36). Mortality and adverse events in echinocandin-treated patients were significantly lower than in those treated with liposomal amphotericin B (RR 0.68, 95% CI 0.46-0.99; RR 0.53, 95% CI 0.37-0.74, respectively). In conclusion, patients with persistent FN treated with echinocandins had decreased risk of death and adverse events. Both caspofungin and micafungin may be recommended as first-line empirical antifungal therapy in these patients. However, the small number of enrolled patients and the lack of RCTs involving pediatric patients should be considered when using micafungin.
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Affiliation(s)
- Chizuru Yamashita
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Nagoya, Japan
| | - Yoshio Takesue
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Infection Control and Prevention, Hyogo College of Medicine, Hyogo, Japan.
| | - Kazuaki Matsumoto
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Kazuhiro Ikegame
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Hematology, Hyogo College of Medicine, Hyogo, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Motoi Uchino
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Hyogo, Japan
| | - Taiga Miyazaki
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Izumikawa
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tohru Takada
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Infection Control and Prevention, Fukuoka University Hospital, Fukuoka, Japan
| | - Keiji Okinaka
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Hematology, National Cancer Center Hospital East, Japan
| | - Takashi Ueda
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Infection Control and Prevention, Hyogo College of Medicine, Hyogo, Japan
| | - Yoshitsugu Miyazaki
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan
| | - Toshihiko Mayumi
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Emergency Department, University of Occupational and Environmental Health, Fukuoka, Japan
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López-Sánchez C, Valcárcel D, Gómez V, López-Jiménez J, Serrano D, Rubio V, Solano C, Vázquez L, Ruiz I. Use of micafungin as antifungal prophylaxis in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) in Spain (GETH-MIC). REVISTA ESPANOLA DE QUIMIOTERAPIA 2020; 33:110-115. [PMID: 32056418 PMCID: PMC7111230 DOI: 10.37201/req/094.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction The fungal infections remain an important problem in the allogeneic stem cell trasnsplantation (allo-SCT) setting and thus, anti-fungal prophylaxis is commonly used. The antifungal drug should offer activity, at least against Candida and Aspergillus spp., a good safety profile and low probability interactions. Micafungin could theoretically fulfill these requisites. The aim of the study was to describe the experience with micafungin as primary prophylaxis in patients undergoing allo-SCT in a cohort of Spanish centres, and to evaluate its efficacy and tolerability in this population. Material and methods Retrospective multicentre observational study including all consecutive adult patients admitted for allo-SCT in participating centres of the Grupo Español de Trasplante Hematopoyético (GETH), from January 2010 to December 2013, who received micafungin as primary prophylaxis during the neutropenic period. Results A total of 240 patients from 13 centres were identified and 159 patients were included for the analysis. Most patients (95.6%) received 50 mg/day of micafungin. During the follow-up, 7 (4.4%) patients developed breakthrough invasive fungal disease, 1 proven and 6 probable; one patient discontinued the drug because of serious drug interactions. Prophylaxis with micafungin was considered effective in 151 (94.9%) patients. Conclusions According to our experience, micafungin is an appropriate alternative for antifungal prophylaxis in patients undergoing an allo-HSCT, because its efficacy, its low profile of drug interactions and side-effects.
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Affiliation(s)
| | | | | | | | | | | | | | | | - I Ruiz
- Isabel Ruiz Camps, Infectious Diseases Department. University Hospital Vall d'Hebron. Paseo de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
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Warris A, Lehrnbecher T, Roilides E, Castagnola E, Brüggemann RJM, Groll AH. ESCMID-ECMM guideline: diagnosis and management of invasive aspergillosis in neonates and children. Clin Microbiol Infect 2019; 25:1096-1113. [PMID: 31158517 DOI: 10.1016/j.cmi.2019.05.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 01/01/2023]
Abstract
SCOPE Presenting symptoms, distributions and patterns of diseases and vulnerability to invasive aspergillosis (IA) are similar between children and adults. However, differences exist in the epidemiology and underlying conditions, the usefulness of newer diagnostic tools, the pharmacology of antifungal agents and in the evidence from interventional phase 3 clinical trials. Therefore, the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the European Confederation of Medical Mycology (ECMM) have developed a paediatric-specific guideline for the diagnosis and management of IA in neonates and children. METHODS Review and discussion of the scientific literature and grading of the available quality of evidence was performed by the paediatric subgroup of the ESCMID-ECMM-European Respiratory Society (ERS) Aspergillus disease guideline working group, which was assigned the mandate for the development of neonatal- and paediatric-specific recommendations. QUESTIONS Questions addressed by the guideline included the epidemiology of IA in neonates and children; which paediatric patients may benefit from antifungal prophylaxis; how to diagnose IA in neonates and children; which antifungal agents are available for use in neonates and children; which antifungal agents are suitable for prophylaxis and treatment of IA in neonates and children; what is the role of therapeutic drug monitoring of azole antifungals; and which management strategies are suitable to be used in paediatric patients. This guideline provides recommendations for the diagnosis, prevention and treatment of IA in the paediatric population, including neonates. The aim of this guideline is to facilitate optimal management of neonates and children at risk for or diagnosed with IA.
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Affiliation(s)
- A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands.
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University 96 School of Health Sciences, Thessaloniki, Greece; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Castagnola
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - R J M Brüggemann
- Radboud Center for Infectious Diseases, Radboud University Medical Centre, Center of Expertise in Mycology Radboudumc/CWZ, European Confederation of Medical Mycology (ECMM) Excellence Center of Medical Mycology, Nijmegen, the Netherlands; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - A H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Paediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
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Abstract
PURPOSE OF REVIEW Fever during neutropenia is a common occurrence in children with cancer. A number of studies have recently been performed to refine algorithms regarding initiation, modification, and termination of antimicrobial treatment and are the basis for international pediatric-specific guidelines for the treatment of fever and neutropenia in children with cancer. RECENT FINDINGS Although hospitalization and prompt initiation of intravenous broad-spectrum antibiotics remains the mainstay in the treatment of febrile neutropenic children with cancer, recent research has addressed a number of questions to optimize the management of these patients. Risk prediction rules have been evaluated to allow for individualized treatment intensity and to evaluate the safety of early discontinuation of empirical antibiotic therapy. In addition, the use of preemptive antifungal therapy has been evaluated to decrease the use of antifungal agents. SUMMARY Based on the results of studies in children, pediatric-specific guidelines have been established and are regularly updated.
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Kulkarni, AP, Sengar, M, Chinnaswamy, G, Hegde, A, Rodrigues, C, Soman, R, Khilnani, GC, Ramasubban, S, Desai, M, Pandit, R, Khasne, R, Shetty, A, Gilada, T, Bhosale, S, Kothekar, A, Dixit, S, Zirpe, K, Mehta, Y, Pulinilkunnathil, JG, Bhagat, V, Khan, MS, Narkhede, AM, Baliga, N, Ammapalli, S, Bamne, S, Turkar, S, K, VB, Choudhary, J, Kumar, R, Divatia JV. Indian Antimicrobial Prescription Guidelines in Critically Ill Immunocompromised Patients. Indian J Crit Care Med 2019; 23:S64-S96. [PMID: 31516212 PMCID: PMC6734470 DOI: 10.5005/jp-journals-10071-23102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
How to cite this article: Kulkarni AP, Sengar M, Chinnaswamy G, Hegde A, Rodrigues C, Soman R, Khilnani GC, Ramasubban S, Desai M, Pandit R, Khasne R, Shetty A, Gilada T, Bhosale S, Kothekar A, Dixit S, Zirpe K, Mehta Y, Pulinilkunnathil JG, Bhagat V, Khan MS, Narkhede AM, Baliga N, Ammapalli S, Bamne S, Turkar S, Bhat KV, Choudhary J, Kumar R, Divatia JV. Indian Journal of Critical Care Medicine 2019;23(Suppl 1): S64-S96.
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Affiliation(s)
- Atul P Kulkarni,
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Manju Sengar,
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy,
- Department of Paediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Ashit Hegde,
- Consultant in Medicine and Critical Care, PD Hinduja National Hospital, Mahim, Mumbai, Maharashtra, India
| | - Camilla Rodrigues,
- Consultant Microbiologist and Chair Infection Control, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Rajeev Soman,
- Consultant ID Physician, Jupiter Hospital, Pune, DeenanathMangeshkar Hospital, Pune, BharatiVidyapeeth, Deemed University Hospital, Pune, Courtsey Visiting Consultant, Hinduja Hospital Mumbai, Maharashtra, India
| | - Gopi C Khilnani,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Suresh Ramasubban,
- Pulmomary and Critical Care Medicine, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata, West Bengal, India
| | - Mukesh Desai,
- Department of Immunology, Prof of Pediatric Hematology and Oncology, Bai Jerbaiwadia Hospital for Children, Consultant, Hematologist, Nanavati Superspeciality Hospital, Director of Pediatric Hematology, Surya Hospitals, Mumbai, Maharashtra, India
| | - Rahul Pandit,
- Intensive Care Unit, Fortis Hospital, Mulund Goregaon Link Road, Mulund (W), Mumbai, Maharashtra, India
| | - Ruchira Khasne,
- Critical Care Medicine, Ashoka - Medicover Hospital, Indira Nagar, Wadala Nashik, Maharashtra, India
| | - Anjali Shetty,
- Microbiology Section, 5th Floor, S1 Building, PD Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Trupti Gilada,
- Consultant Physician in Infectious Disease, Unison Medicare and Research Centre and Prince Aly Khan Hospital, Maharukh Mansion, Alibhai Premji Marg, Grant Road, Mumbai, Maharashtra, India
| | - Shilpushp Bhosale,
- Intensive Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Amol Kothekar,
- Division of Critical Care Medicine, Departemnt of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Subhal Dixit,
- Consultant in Critical Care, Director, ICU Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Kapil Zirpe,
- Neuro-Trauma Unit, Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Yatin Mehta,
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Jacob George Pulinilkunnathil,
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr E Borges Road, Mumbai, Maharashtra, India
| | - Vikas Bhagat,
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, HomiBhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Mohammad Saif Khan,
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Amit M Narkhede,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Nishanth Baliga,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Srilekha Ammapalli,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Shrirang Bamne,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Siddharth Turkar,
- Department of Medical Oncology, Tata Memorial Hospital, HomiBhabha National Institute, Mumbai, Maharashtra, India
| | - Vasudeva Bhat K,
- Department of Pediatric Oncology, Tata Memorial Hospital, HomiBhabha National Institute, Dr E. Borges Marg, Parel, Mumbai, Maharashtra, India
| | - Jitendra Choudhary,
- Critical Care, Fortis Hospital, 102, Nav Sai Shakti CHS, Near Bhoir Gymkhana, M Phule Road, Dombivali West Mumbai, Maharashtra, India
| | - Rishi Kumar,
- Critical Care Medicine, PD Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
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Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K, Lass-Flörl C, Lewis RE, Munoz P, Verweij PE, Warris A, Ader F, Akova M, Arendrup MC, Barnes RA, Beigelman-Aubry C, Blot S, Bouza E, Brüggemann RJM, Buchheidt D, Cadranel J, Castagnola E, Chakrabarti A, Cuenca-Estrella M, Dimopoulos G, Fortun J, Gangneux JP, Garbino J, Heinz WJ, Herbrecht R, Heussel CP, Kibbler CC, Klimko N, Kullberg BJ, Lange C, Lehrnbecher T, Löffler J, Lortholary O, Maertens J, Marchetti O, Meis JF, Pagano L, Ribaud P, Richardson M, Roilides E, Ruhnke M, Sanguinetti M, Sheppard DC, Sinkó J, Skiada A, Vehreschild MJGT, Viscoli C, Cornely OA. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect 2018; 24 Suppl 1:e1-e38. [PMID: 29544767 DOI: 10.1016/j.cmi.2018.01.002] [Citation(s) in RCA: 812] [Impact Index Per Article: 135.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.
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Affiliation(s)
- A J Ullmann
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J M Aguado
- Infectious Diseases Unit, University Hospital Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - S Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D W Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; European Confederation of Medical Mycology (ECMM)
| | - A H Groll
- Department of Paediatric Haematology/Oncology, Centre for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - K Lagrou
- Department of Microbiology and Immunology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lass-Flörl
- Institute of Hygiene, Microbiology and Social Medicine, ECMM Excellence Centre of Medical Mycology, Medical University Innsbruck, Innsbruck, Austria; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R E Lewis
- Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - P Munoz
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - F Ader
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France; Inserm 1111, French International Centre for Infectious Diseases Research (CIRI), Université Claude Bernard Lyon 1, Lyon, France; European Respiratory Society (ERS)
| | - M Akova
- Department of Medicine, Section of Infectious Diseases, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M C Arendrup
- Department Microbiological Surveillance and Research, Statens Serum Institute, Copenhagen, Denmark; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R A Barnes
- Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK; European Confederation of Medical Mycology (ECMM)
| | - C Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; European Respiratory Society (ERS)
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; European Respiratory Society (ERS)
| | - E Bouza
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R J M Brüggemann
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG)
| | - D Buchheidt
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Cadranel
- Department of Pneumology, University Hospital of Tenon and Sorbonne, University of Paris, Paris, France; European Respiratory Society (ERS)
| | - E Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India; European Confederation of Medical Mycology (ECMM)
| | - M Cuenca-Estrella
- Instituto de Salud Carlos III, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - G Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece; European Respiratory Society (ERS)
| | - J Fortun
- Infectious Diseases Service, Ramón y Cajal Hospital, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J-P Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Garbino
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - W J Heinz
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R Herbrecht
- Department of Haematology and Oncology, University Hospital of Strasbourg, Strasbourg, France; ESCMID Fungal Infection Study Group (EFISG)
| | - C P Heussel
- Diagnostic and Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany; European Confederation of Medical Mycology (ECMM)
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, London, UK; European Confederation of Medical Mycology (ECMM)
| | - N Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia; European Confederation of Medical Mycology (ECMM)
| | - B J Kullberg
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lange
- International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany; Clinical Infectious Diseases, Research Centre Borstel, Leibniz Center for Medicine & Biosciences, Borstel, Germany; German Centre for Infection Research (DZIF), Tuberculosis Unit, Hamburg-Lübeck-Borstel-Riems Site, Lübeck, Germany; European Respiratory Society (ERS)
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Confederation of Medical Mycology (ECMM)
| | - J Löffler
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Lortholary
- Department of Infectious and Tropical Diseases, Children's Hospital, University of Paris, Paris, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Maertens
- Department of Haematology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - L Pagano
- Department of Haematology, Universita Cattolica del Sacro Cuore, Roma, Italy; European Confederation of Medical Mycology (ECMM)
| | - P Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Richardson
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece; Hippokration General Hospital, Thessaloniki, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Ruhnke
- Department of Haematology and Oncology, Paracelsus Hospital, Osnabrück, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Sanguinetti
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Rome, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D C Sheppard
- Division of Infectious Diseases, Department of Medicine, Microbiology and Immunology, McGill University, Montreal, Canada; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Sinkó
- Department of Haematology and Stem Cell Transplantation, Szent István and Szent László Hospital, Budapest, Hungary; ESCMID Fungal Infection Study Group (EFISG)
| | - A Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M J G T Vehreschild
- Department I of Internal Medicine, ECMM Excellence Centre of Medical Mycology, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology, Cologne-Bonn, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; European Confederation of Medical Mycology (ECMM)
| | - C Viscoli
- Ospedale Policlinico San Martino and University of Genova (DISSAL), Genova, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O A Cornely
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; CECAD Cluster of Excellence, University of Cologne, Cologne, Germany; Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM); ESCMID European Study Group for Infections in Compromised Hosts (ESGICH).
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14
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Heinz WJ, Buchheidt D, Christopeit M, von Lilienfeld-Toal M, Cornely OA, Einsele H, Karthaus M, Link H, Mahlberg R, Neumann S, Ostermann H, Penack O, Ruhnke M, Sandherr M, Schiel X, Vehreschild JJ, Weissinger F, Maschmeyer G. Diagnosis and empirical treatment of fever of unknown origin (FUO) in adult neutropenic patients: guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2017; 96:1775-1792. [PMID: 28856437 PMCID: PMC5645428 DOI: 10.1007/s00277-017-3098-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/06/2017] [Indexed: 02/07/2023]
Abstract
Fever may be the only clinical symptom at the onset of infection in neutropenic cancer patients undergoing myelosuppressive chemotherapy. A prompt and evidence-based diagnostic and therapeutic approach is mandatory. A systematic search of current literature was conducted, including only full papers and excluding allogeneic hematopoietic stem cell transplant recipients. Recommendations for diagnosis and therapy were developed by an expert panel and approved after plenary discussion by the AGIHO. Randomized clinical trials were mainly available for therapeutic decisions, and new diagnostic procedures have been introduced into clinical practice in the past decade. Stratification into a high-risk versus low-risk patient population is recommended. In high-risk patients, initial empirical antimicrobial therapy should be active against pathogens most commonly involved in microbiologically documented and most threatening infections, including Pseudomonas aeruginosa, but excluding coagulase-negative staphylococci. In patients whose expected duration of neutropenia is more than 7 days and who do not respond to first-line antibacterial treatment, specifically in the absence of mold-active antifungal prophylaxis, further therapy should be directed also against fungi, in particular Aspergillus species. With regard to antimicrobial stewardship, treatment duration after defervescence in persistently neutropenic patients must be critically reconsidered and the choice of anti-infective agents adjusted to local epidemiology. This guideline updates recommendations for diagnosis and empirical therapy of fever of unknown origin in adult neutropenic cancer patients in light of the challenges of antimicrobial stewardship.
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Affiliation(s)
- W J Heinz
- Department of Internal Medicine II, University of Würzburg Medical Center, Würzburg, Germany
| | - D Buchheidt
- Department of Internal Medicine-Hematology and Oncology, Mannheim University Hospital, Mannheim, Germany
| | - M Christopeit
- Department of Stem Cell Transplantation, University Hospital UKE, Hamburg, Germany
| | | | - O A Cornely
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Centre for Infection Research, partner site Bonn-Cologne, Cologne, Germany.,Clinical Trials Centre Cologne, ZKS Köln, Cölogne, Germany.,Center for Integrated Oncology CIO Köln-Bonn, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Medical Faculty, University of Cologne, Cologne, Germany
| | - H Einsele
- Department of Internal Medicine II, University of Würzburg Medical Center, Würzburg, Germany
| | - M Karthaus
- Department of Hematology, Oncology and Palliative Care, Klinikum Neuperlach and Klinikum Harlaching, München, Germany.,Department of Hematology, Oncology and Palliative Care, Klinikum Harlaching, Munich, Germany
| | - H Link
- Hematology and Medical Oncology Private Practice, Kaiserslautern, Germany
| | - R Mahlberg
- Klinikum Mutterhaus der Borromäerinnen, Trier, Germany
| | - S Neumann
- Medical Oncology, AMO MVZ, Wolfsburg, Germany
| | - H Ostermann
- Department of Hematology and Oncology, University of Munich, Munich, Germany
| | - O Penack
- Internal Medicine, Hematology, Oncology and Tumor Immunology, University Hospital Charité, Campus Virchow Klinikum, Berlin, Germany
| | - M Ruhnke
- Department of Hematology and Oncology, Paracelsus-Klinik, Osnabrück, Germany
| | - M Sandherr
- Hematology and Oncology Practice, Weilheim, Germany
| | - X Schiel
- Department of Hematology, Oncology and Palliative Care, Klinikum Harlaching, Munich, Germany
| | - J J Vehreschild
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Centre for Infection Research, partner site Bonn-Cologne, Cologne, Germany
| | - F Weissinger
- Department of Internal Medicine, Hematology, Oncology and Palliative Care, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany.
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15
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Mercier T, Maertens J. Clinical considerations in the early treatment of invasive mould infections and disease. J Antimicrob Chemother 2017; 72:i29-i38. [PMID: 28355465 DOI: 10.1093/jac/dkx031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Different therapeutic strategies for invasive fungal diseases have been explored, each with particular strengths and weaknesses. Broad-spectrum antifungal prophylaxis seems logical, but selective use is important due to its substantial disadvantages, including interference with diagnostic assays, selection for resistance, drug toxicity and drug-drug interactions. Antimould prophylaxis should be restricted to high-risk groups, such as patients undergoing intensive chemotherapy for acute myeloid leukaemia or myelodysplastic syndrome, allogeneic HSCT patients with prior invasive fungal infection, graft-versus-host-disease or extended neutropenia, recipients of a solid organ transplant, or patients with a high-risk inherited immunodeficiency. An empirical approach, whereby mould-active therapy is started in neutropenic patients with fever unresponsive to broad-spectrum antibiotics, is widely applied but incurs the clinical and cost penalties associated with overtreatment. A benefit for all-cause mortality using empirical therapy has not been shown, but it is recommended for high-risk patients who remain febrile after 4-7 days of broad-spectrum antibiotics and in whom extended neutropenia is anticipated. There is growing interest in delaying antifungal treatment until an invasive fungal infection is confirmed ('pre-emptive' or 'diagnostics-driven' management), prompted by the development of more sensitive diagnostic techniques. Comparisons of empirical versus pre-emptive regimens are sparse, particularly with modern triazole agents, but treatment costs are lower with pre-emptive therapy and the available evidence has not indicated reduced efficacy. Pre-emptive treatment may be appropriate in neutropenic patients who remain febrile after administration of broad-spectrum antibiotics but who are clinically stable. Further work is required to define accurately the specific patient subgroups in which each management approach is optimal.
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Chen K, Wang Q, Pleasants RA, Ge L, Liu W, Peng K, Zhai S. Empiric treatment against invasive fungal diseases in febrile neutropenic patients: a systematic review and network meta-analysis. BMC Infect Dis 2017; 17:159. [PMID: 28219330 PMCID: PMC5319086 DOI: 10.1186/s12879-017-2263-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/11/2017] [Indexed: 02/07/2023] Open
Abstract
Background The most optimal antifungal agent for empiric treatment of invasive fungal diseases (IFDs) in febrile neutropenia is controversial. Our objective was evaluate the relative efficacy of antifungals for all-cause mortality, fungal infection-related mortality and treatment response in this population. Methods Pubmed, Embase and Cochrane Library were searched to identify randomized controlled trials (RCTs). Two reviewers performed the quality assessment and extracted data independently. Pairwise meta-analysis and network meta-analysis were conducted to compare the antifungals. Results Seventeen RCTs involving 4583 patients were included. Risk of bias of included studies was moderate. Pairwise meta-analysis indicated the treatment response rate of itraconazole was significantly better than conventional amphotericin B (RR = 1.33, 95%CI 1.10–1.61). Network meta-analysis showed that amphotericin B lipid complex, conventional amphotericin B, liposomal amphotericin B, itraconazole and voriconazole had a significantly lower rate of fungal infection-related mortality than no antifungal treatment. Other differences in outcomes among antifungals were not statistically significant. From the rank probability plot, caspofungin appeared to be the most effective agent for all-cause mortality and fungal infection-related mortality, whereas micafungin tended to be superior for treatment response. The results were stable after excluding RCTs with high risk of bias, whereas micafungin had the lowest fungal infection-related mortality. Conclusions Our results highlighted the necessity of empiric antifungal treatment and indicates that echinocandins appeared to be the most effective agents for empiric treatment of febrile neutropenic patients based on mortality and treatment response. However, more studies are needed to determine the best antifungal agent for empiric treatment. Our systematic review has been prospectively registered in PROSPERO and the registration number was CRD42015026629. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2263-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ken Chen
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
| | - Qi Wang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Roy A Pleasants
- Duke University Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Long Ge
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Wei Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
| | - Kangning Peng
- School of Basic Medical Sciences, Peking University Health Science Center, Beijing, 100191, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China.
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Lukas RV, Kumthekar P, Rizvi S, Salgia R. Systemic therapies in the treatment of non-small-cell lung cancer brain metastases. Future Oncol 2016; 12:1045-58. [DOI: 10.2217/fon.16.17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Non-small-cell lung cancer (NSCLC) brain metastases are common. Even though there are various subsets of NSCLC with molecular alterations, there is a common theme of brain metastases. Current treatment modalities are suboptimal. Systemic therapies for the treatment of NSCLC brain metastases have been explored and recent advances may pave the way for their successful employment in this patient population. While no specific agents have been associated with a marked benefit, stability of disease as well as radiographic responses have been noted in some patients. Biological activity of systemic therapies in some patients with NSCLC brain metastases raises hope for future advances and supports further investigation for this patient population with limited treatment options.
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Affiliation(s)
- Rimas V Lukas
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Priya Kumthekar
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | | | - Ravi Salgia
- Department of Medical Oncology & Therapeutics Research, City of Hope, Duarte, CA, USA
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Castagnola E, Mikulska M, Viscoli C. Prophylaxis and Empirical Therapy of Infection in Cancer Patients. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7173426 DOI: 10.1016/b978-1-4557-4801-3.00310-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Groll AH, Castagnola E, Cesaro S, Dalle JH, Engelhard D, Hope W, Roilides E, Styczynski J, Warris A, Lehrnbecher T. Fourth European Conference on Infections in Leukaemia (ECIL-4): guidelines for diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or allogeneic haemopoietic stem-cell transplantation. Lancet Oncol 2014; 15:e327-40. [PMID: 24988936 DOI: 10.1016/s1470-2045(14)70017-8] [Citation(s) in RCA: 257] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Invasive opportunistic fungal diseases (IFDs) are important causes of morbidity and mortality in paediatric patients with cancer and those who have had an allogeneic haemopoietic stem-cell transplantation (HSCT). Apart from differences in underlying disorders and comorbidities relative to those of adults, IFDs in infants, children, and adolescents are unique with respect to their epidemiology, the usefulness of diagnostic methods, the pharmacology and dosing of antifungal agents, and the absence of interventional phase 3 clinical trials for guidance of evidence-based decisions. To better define the state of knowledge on IFDs in paediatric patients with cancer and allogeneic HSCT and to improve IFD diagnosis, prevention, and management, the Fourth European Conference on Infections in Leukaemia (ECIL-4) in 2011 convened a group that reviewed the scientific literature on IFDs and graded the available quality of evidence according to the Infectious Diseases Society of America grading system. The final considerations and recommendations of the group are summarised in this manuscript.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany.
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, Istituto "Giannina Gaslini", Genova, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Jean-Hugues Dalle
- Hemato-Immunology Department, Robert Debré Hospital, Université Paris 7, Paris-Diderot, France
| | - Dan Engelhard
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences and Hippokration Hospital, Thessaloniki, Greece
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Adilia Warris
- Aberdeen Fungal Group, University of Aberdeen, Institute of Medical Sciences, Aberdeen, Scotland, UK
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Children's Hospital, Johann Wolfgang Goethe-University, Frankfurt, Germany
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Mikulska M, Novelli A, Aversa F, Cesaro S, de Rosa FG, Girmenia C, Micozzi A, Sanguinetti M, Viscoli C. Voriconazole in clinical practice. J Chemother 2013; 24:311-27. [DOI: 10.1179/1973947812y.0000000051] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Namikawa T, Kitagawa H, Yamatsuji T, Naomoto Y, Kobayashi M, Hanazaki K. Pre-emptive treatment of fungal infection based on plasma β-D-glucan levels after gastric surgery for gastric cancer in elderly patients. J Gastroenterol Hepatol 2013; 28:1457-61. [PMID: 23574148 DOI: 10.1111/jgh.12219] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Invasive fungal infection (IFI) related to surgery in elderly patients is often associated with high morbidity and mortality. The aim of the present study was to determine 1,3-β-D-glucan (βDG) levels after gastric cancer surgery in elderly patients and to prospectively evaluate the efficacy of pre-emptive antifungal therapy using βDG as an aid for the early diagnosis of IFI. METHODS In all, 81 patients aged ≥70 years who had undergone gastric cancer surgery between 2009 and 2011 were prospectively enrolled in the study. Patients with plasma βDG levels >11 pg/mL (the cut-off value) were randomly assigned to either receive antifungal treatment or not (n=13 in each group). Postoperative outcomes were assessed using various clinical parameters. RESULTS After gastric cancer surgery, plasma βDG levels were ≥11 pg/mL in 26 of 81 elderly patients (32.1%). Of the βDG-positive patients, significantly more had stages III and IV rather than stages I and II disease (44.1% vs 23.4%, respectively; P=0.049). Fever on postoperative day 8 was significantly reduced in the pre-emptive antifungal-treated group than in the control group (36.8°C vs 37.2°C, respectively; P=0.045). However, there were no significant differences in mortality, morbidity, βDG levels, white blood cell count, and C-reactive protein levels between the two groups. CONCLUSIONS Pre-emptive antifungal treatment based on βDG after gastric surgery in elderly patients may help reduce the incidence of postoperative fever and suppress IFI. However, this needs to be confirmed in a larger prospective randomized, controlled trial.
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Affiliation(s)
- Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Nankoku, Kochi, Japan
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Bhatt VR, Viola GM, Ferrajoli A. Invasive fungal infections in acute leukemia. Ther Adv Hematol 2013; 2:231-47. [PMID: 23556092 DOI: 10.1177/2040620711410098] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Invasive fungal infection (IFI) is among the leading causes for morbidity, mortality, and economic burden for patients with acute leukemia. In the past few decades, the incidence of IFI has increased dramatically. The certainty of diagnosis of IFI is based on host factors, clinical evidence, and microbiological examination. Advancement in molecular diagnostic modalities (e.g. non-culture-based serum biomarkers such as β-glucan or galactomannan assays) and high-resolution radiological imaging has improved our diagnostic approach. The early use of these diagnostic tests assists in the early initiation of preemptive therapy. Nonetheless, the complexity of IFI in patients with leukemia and the limitations of these diagnostic tools still mandate astute clinical acumen. Its management has been further complicated by the increasing frequency of infection by non-Aspergillus molds (e.g. zygomycosis) and the emergence of drug-resistant fungal pathogens. In addition, even though the antifungal armamentarium has expanded rapidly in the past few decades, the associated mortality remains high. The decision to initiate antifungal treatment and the choice of anti-fungal therapy requires careful consideration of several factors (e.g. risk stratification, local fungal epidemiologic patterns, concomitant comorbidities, drug-drug interactions, prior history of antifungal use, overall cost, and the pharmacologic profile of the antifungal agents). In order to optimize our diagnostic and therapeutic management of IFI in patients with acute leukemia, further basic research and clinical trials are desperately needed.
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Affiliation(s)
- Vijaya R Bhatt
- Department of Internal Medicine, Staten Island University Hospital, New York, USA
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Canadian clinical practice guidelines for invasive candidiasis in adults. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2012; 21:e122-50. [PMID: 22132006 DOI: 10.1155/2010/357076] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Candidemia and invasive candidiasis (C/IC) are life-threatening opportunistic infections that add excess morbidity, mortality and cost to the management of patients with a range of potentially curable underlying conditions. The Association of Medical Microbiology and Infectious Disease Canada developed evidence-based guidelines for the approach to the diagnosis and management of these infections in the ever-increasing population of at-risk adult patients in the health care system. Over the past few years, a new and broader understanding of the epidemiology and pathogenesis of C/IC has emerged and has been coupled with the availability of new antifungal agents and defined strategies for targeting groups at risk including, but not limited to, acute leukemia patients, hematopoietic stem cell transplants and solid organ transplants, and critical care unit patients. Accordingly, these guidelines have focused on patients at risk for C/IC, and on approaches of prevention, early therapy for suspected but unproven infection, and targeted therapy for probable and proven infection.
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Empiric antifungal therapy and outcomes in extremely low birth weight infants with invasive candidiasis. J Pediatr 2012; 161:264-9.e2. [PMID: 22424952 PMCID: PMC3380169 DOI: 10.1016/j.jpeds.2012.01.053] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 10/14/2011] [Accepted: 01/27/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess the impact of empiric antifungal therapy for invasive candidiasis on subsequent outcomes in premature infants. STUDY DESIGN This was a cohort study of infants with a birth weight ≤ 1000 g receiving care at Neonatal Research Network sites. All infants had at least one positive culture for Candida. Empiric antifungal therapy was defined as receipt of a systemic antifungal on the day of or the day before the first positive culture for Candida was drawn. We created Cox proportional hazards and logistic regression models stratified on propensity score quartiles to determine the effect of empiric antifungal therapy on survival, time to clearance of infection, retinopathy of prematurity, bronchopulmonary dysplasia, end-organ damage, and neurodevelopmental impairment (NDI). RESULTS A total of 136 infants developed invasive candidiasis. The incidence of death or NDI was lower in infants who received empiric antifungal therapy (19 of 38; 50%) compared with those who had not (55 of 86; 64%; OR, 0.27; 95% CI, 0.08-0.86). There was no significant difference between the groups for any single outcome or other combined outcomes. CONCLUSION Empiric antifungal therapy was associated with increased survival without NDI. A prospective randomized trial of this strategy is warranted.
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Herbrecht R, Caillot D, Cordonnier C, Auvrignon A, Thiebaut A, Brethon B, Michallet M, Mahlaoui N, Bertrand Y, Preziosi P, Ruiz F, Gorin NC, Gangneux JP. Indications and outcomes of antifungal therapy in French patients with haematological conditions or recipients of haematopoietic stem cell transplantation. J Antimicrob Chemother 2012; 67:2731-8. [DOI: 10.1093/jac/dks266] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Heinz WJ, Weissinger F. Frühe antimykotische Therapiestrategien: empirisch oder diagnostisch gesteuert? Mycoses 2012; 55 Suppl 2:17-24. [DOI: 10.1111/j.1439-0507.2012.02179.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fungal pneumonia in patients with hematologic malignancies: current approach and management. Curr Opin Infect Dis 2011; 24:323-32. [PMID: 21666457 DOI: 10.1097/qco.0b013e3283486d1d] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Fungal pneumonia is the most frequent presentation of invasive mold infections (IMIs) in patients with hematologic malignancies. In this review, we summarize recent advances in the epidemiology, diagnosis, and treatment of fungal pneumonia and improvement in the outcome of such patients. RECENT FINDINGS The epidemiology of IMIs in hematopoietic stem cell transplant recipients has evolved in response to changes in conditioning regimens, increasing use of alternative sources of stem cells and antifungal prophylaxis, among other factors. PCR analysis and serologic tests, used in combination with imaging findings, have improved the timing and accuracy of diagnosis of these infections.Recent guidelines incorporated evidence-based treatment recommendations; however, application in real world situations is often difficult. A new treatment approach known as preemptive therapy, based on screening with biomarkers combined with early clinical and imaging findings, is being compared with the traditional empirical therapy in neutropenic patients with persistent or recurrent fever. The use of new triazoles and prompt diagnosis has contributed to improved outcomes in these patients. In addition, therapeutic drug monitoring may be useful when administering voriconazole. SUMMARY Evidence-based diagnosis and treatment of fungal pneumonia in patients with hematologic malignancies are becoming increasingly institution-specific and patient-specific, integrating host factors, new diagnostic methods, and epidemiologic and pharmacologic considerations.
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Lee DG, Kim SH, Kim SY, Kim CJ, Park WB, Song YG, Choi JH. Evidence-based guidelines for empirical therapy of neutropenic fever in Korea. Korean J Intern Med 2011; 26:220-52. [PMID: 21716917 PMCID: PMC3110859 DOI: 10.3904/kjim.2011.26.2.220] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Neutrophils play an important role in immunological function. Neutropenic patients are vulnerable to infection, and except fever is present, inflammatory reactions are scarce in many cases. Additionally, because infections can worsen rapidly, early evaluation and treatments are especially important in febrile neutropenic patients. In cases in which febrile neutropenia is anticipated due to anticancer chemotherapy, antibiotic prophylaxis can be used, based on the risk of infection. Antifungal prophylaxis may also be considered if long-term neutropenia or mucosal damage is expected. When fever is observed in patients suspected to have neutropenia, an adequate physical examination and blood and sputum cultures should be performed. Initial antibiotics should be chosen by considering the risk of complications following the infection; if the risk is low, oral antibiotics can be used. For initial intravenous antibiotics, monotherapy with a broad-spectrum antibiotic or combination therapy with two antibiotics is recommended. At 3-5 days after beginning the initial antibiotic therapy, the condition of the patient is assessed again to determine whether the fever has subsided or symptoms have worsened. If the patient's condition has improved, intravenous antibiotics can be replaced with oral antibiotics; if the condition has deteriorated, a change of antibiotics or addition of antifungal agents should be considered. If the causative microorganism is identified, initial antimicrobial or antifungal agents should be changed accordingly. When the cause is not detected, the initial agents should continue to be used until the neutrophil count recovers.
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Affiliation(s)
- Dong-Gun Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.
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Klastersky J, Awada A, Paesmans M, Aoun M. Febrile neutropenia: A critical review of the initial management. Crit Rev Oncol Hematol 2011; 78:185-94. [DOI: 10.1016/j.critrevonc.2010.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 03/10/2010] [Accepted: 03/24/2010] [Indexed: 11/28/2022] Open
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Best practice in treating infants and children with proven, probable or suspected invasive fungal infections. Curr Opin Infect Dis 2011; 24:225-9. [DOI: 10.1097/qco.0b013e3283460e22] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zengin E, Sarper N, Kılıç SC. Piperacillin/tazobactam monotherapy versus piperacillin/tazobactam plus amikacin as initial empirical therapy for febrile neutropenia in children with acute leukemia. Pediatr Hematol Oncol 2011; 28:311-20. [PMID: 21524156 DOI: 10.3109/08880018.2011.557144] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The purpose of this study is to compare the efficacy and safety of piperacillin/tazobactam (PIP/TAZO) versus PIP/TAZO plus amikacin in febrile neutropenic children with acute leukemia (AL). Children with AL who had febrile neutropenic episodes were randomized to treatment with PIP/TAZO versus PIP/TAZO plus amikacin. Modification was defined as addition of other antimicrobials and/or antifungal agents to the empirical therapy. Protocol failure was defined as withdrawal of the empirical regimen and introduction of other antimicrobials due to failure in controlling infection. Seventy-two febrile episodes of 42 patients with a median age of 4.5 years (3.5 months to 19 years) were evaluated. There were 37 and 35 episodes in PIP/TAZO and combination arms, respectively. Success without modification, with modification, protocol failure, duration of treatment were 45.9%, 35.1%, 18.9%, and 10 days in PIP/TAZO arm and 42.9%, 37.1%, 20%, and 12 days in combination arm, respectively (P > .05). There was no significant difference between the empirical therapy arms regarding median duration of neutropenia and defervescence of fever. Empirical therapy was substituted by other drugs in 6 and 5 episodes in PIP/TAZO and combination arms, respectively. There was no infection-related death. There was reversible increase in serum creatinine in 1 episode on the combination arm. Monotherapy with PIP/TAZO was effective and safe for initial empirical treatment of febrile neutropenic episodes in children with AL. However, local bacterial resistance patterns should be considered in daily practice. Combination of amikacin with PIP/TAZO did not improve treatment success, but it may increase nephrotoxicity.
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Affiliation(s)
- Emine Zengin
- Department of Pediatric Hematology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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Efficacy and safety of antifungal prophylaxis with oral itraconazole solution among patients receiving corticosteroids: who should be given prophylaxis? J Infect Chemother 2011; 17:744-9. [PMID: 21523410 DOI: 10.1007/s10156-011-0251-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 03/31/2011] [Indexed: 10/18/2022]
Abstract
The incidence of systemic fungal infections has risen, as shown by increases in the numbers of immunosuppressed or immunocompromised patients. The consequences of these fungal infections are occasionally serious. However, the efficacy of antifungal prophylaxis in patients receiving corticosteroid treatment has not been well investigated, even though they are susceptible to severe fungal infections. Therefore, we retrospectively evaluated the prophylactic efficacy of an antifungal agent-oral itraconazole solution (ITCZ-OS)-for immunosuppressed patients receiving corticosteroids in a single institution. Of 39 patients, 18 received prophylaxis with ITCZ-OS at a dose of 200 mg/day, and 21 did not. As a result, no fungal infections developed in the prophylactic group, but 7 of the 21 patients (33%) in the non-prophylactic group suffered from fungal infections consisting of 3 non-invasive candidiases, 2 invasive candidiases, and 2 invasive pulmonary aspergilloses. Among the non-prophylactic group, aging and hypoalbuminemia were statistically significantly associated with incidence of invasive fungal infections. Of the four patients with invasive fungal infections, three had concomitant chronic illness such as diabetes. Toxicity among the prophylactic group was not statistically significantly different from that of the non-prophylactic group. In addition, none needed discontinuation of the drug. These results indicate the potential antifungal prophylactic effect of ITCZ-OS for a subset of patients treated with moderate or high doses of corticosteroids.
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Lee DG, Kim SH, Kim SY, Kim CJ, Min CK, Park WB, Park YJ, Song YG, Jang JS, Jang JH, Jin JY, Choi JH. Evidence-based Guidelines for Empirical Therapy of Neutropenic Fever in Korea. Infect Chemother 2011. [DOI: 10.3947/ic.2011.43.4.285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Dong-Gun Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo Young Kim
- Department of Family Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Chung-Jong Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chang-Ki Min
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeon-Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Goo Song
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joung-Soon Jang
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jun Ho Jang
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Youl Jin
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hyun Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Agrawal S, Hope W, Sinko J, Kibbler C. Optimizing management of invasive mould diseases. J Antimicrob Chemother 2010; 66 Suppl 1:i45-53. [DOI: 10.1093/jac/dkq441] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wang JL, Chang CH, Young-Xu Y, Chan KA. Systematic review and meta-analysis of the tolerability and hepatotoxicity of antifungals in empirical and definitive therapy for invasive fungal infection. Antimicrob Agents Chemother 2010; 54:2409-19. [PMID: 20308378 PMCID: PMC2876415 DOI: 10.1128/aac.01657-09] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2009] [Revised: 12/29/2009] [Accepted: 03/10/2010] [Indexed: 01/13/2023] Open
Abstract
To evaluate the tolerability and liver safety profiles of the systemic antifungal agents commonly used for the treatment of invasive fungal infection, we conducted a systematic review and meta-analysis of randomized controlled trials published before 31 August 2009. Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. We used the beta-binomial model to account for variation across studies and the maximum likelihood method to estimate the pooled risks. We identified 39 studies with more than 8,000 enrolled patients for planned comparisons. The incidence rates of treatment discontinuation due to adverse reactions and liver injury associated with antifungal therapy ranged widely. The pooled risks of treatment discontinuation due to adverse reactions were above 10% for amphotericin B formulations and itraconazole, whereas they were 2.5% to 3.8% for fluconazole, caspofungin, and micafungin. We found that 1.5% of the patients stopped itraconazole treatment due to hepatotoxicity. Furthermore, 19.7% of voriconazole users and 17.4% of itraconazole users had elevated serum liver enzyme levels, although they did not require treatment discontinuation, whereas 2.0% or 9.3% of fluconazole and echinocandin users had elevated serum liver enzyme levels but did not require treatment discontinuation. The results were similar when we stratified the data by empirical or definitive antifungal therapy. Possible explanations for antifungal agent-related hepatotoxicity were confounded by antifungal prescription to patients with a high risk of liver injury, the increased chance of detection of hepatotoxicity due to prolonged treatment, or the pharmacological entity.
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Affiliation(s)
- Jiun-Ling Wang
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, EpiPatterns, Haverhill, New Hampshire, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Chia-Hsuin Chang
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, EpiPatterns, Haverhill, New Hampshire, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Yinong Young-Xu
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, EpiPatterns, Haverhill, New Hampshire, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - K. Arnold Chan
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, EpiPatterns, Haverhill, New Hampshire, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
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Blyth CC, Hale K, Palasanthiran P, O'Brien T, Bennett MH. Antifungal therapy in infants and children with proven, probable or suspected invasive fungal infections. Cochrane Database Syst Rev 2010; 2010:CD006343. [PMID: 20166083 PMCID: PMC10576261 DOI: 10.1002/14651858.cd006343.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Invasive fungal infections are associated with significant morbidity and mortality in children. Optimal treatment strategies are yet to be defined. OBJECTIVES This review aims to systematically identify and summarise the effects of different antifungal therapies in children with proven, probable or suspected invasive fungal infections. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1966 to September 2008), EMBASE (1980 to September 2008) and CINAHL (1988 to September 2008) without language restrictions. We also handsearched reference lists and abstracts of conference proceedings and scientific meetings, and contacted authors of included studies and pharmaceutical manufacturers. SELECTION CRITERIA We included randomised clinical trials (RCTs) comparing a systemic antifungal agent with a comparator (including placebo) in children (one month to 16 years) with proven, probable or suspected invasive fungal infection. DATA COLLECTION AND ANALYSIS Two review authors independently applied selection criteria, performed quality assessment, and extracted data using an intention-to-treat approach. We synthesised data using the random-effects model and expressed results as relative risks (RR) with 95% confidence intervals (CIs). MAIN RESULTS We included seven trials of antifungal agents in children with prolonged fever and neutropenia (suspected fungal infection) and candidaemia or invasive candidiasis (proven fungal infection). Four trials compared a lipid preparation of amphotericin B with conventional amphotericin B (395 participants), one trial compared an echinocandin with a lipid preparation of amphotericin B (82 participants) in suspected infection; one trial compared an echinocandin with a lipid preparation of amphotericin B in children with candidaemia or invasive candidiasis (109 participants) and one trial compared different azole antifungals in children with candidaemia (43 participants). No difference in all-cause mortality and other primary endpoints (mortality related to fungal infection or complete resolution of fungal infections) were observed. No difference in breakthrough fungal infection was observed in children with prolonged fever and neutropenia.When lipid preparations and conventional amphotericin B were compared in children with prolonged fever and neutropenia, nephrotoxicity was less frequently observed with a lipid preparation (RR 0.43, 95% CI 0.21 to 0.90, P = 0.02) however substantial heterogeneity was observed (I(2) = 59%, P = 0.06). Children receiving liposomal amphotericin B were less likely to develop infusion-related reactions compared with conventional amphotericin B (chills: RR 0.37, 95% CI 0.21 to 0.64, P = 0.0005). Children receiving a colloidal dispersion were more likely to develop such reactions than with liposomal amphotericin B (chills: RR 1.76, 95% CI 1.09 to 2.85, P = 0.02). The rate of other clinically significant adverse reactions attributed to the antifungal agent (total reactions; total reactions leading to treatment discontinuation, dose reduction or change in therapy; hypokalaemia and hepatotoxicity) were not significantly different. When echinocandins and lipid preparations were compared, the rate of clinically significant adverse reactions (total reactions; total reactions leading to treatment discontinuation, dose reduction or change in therapy) were not significantly different. AUTHORS' CONCLUSIONS Limited paediatric data are available comparing antifungal agents in children with proven, probable or suspected invasive fungal infection. No differences in mortality or treatment efficacy were observed when antifungal agents were compared. Children are less likely to develop nephrotoxicity with a lipid preparation of amphotericin B compared with conventional amphotericin B. Further comparative paediatric antifungal drug trials and epidemiological and pharmacological studies are required highlighting the differences between neonates, children and adults with invasive fungal infections.
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Affiliation(s)
- Christopher C Blyth
- University of Western AustraliaSchool of Paediatrics and Child HealthPrincess Margaret HospitalRoberts RoadSubiacoWAAustralia6008
| | - Katherine Hale
- Children's Hospital at WestmeadDepartment of Allergy, Immunology & Infectious DiseasesWestmeadNew South WalesAustralia2145
| | - Pamela Palasanthiran
- Sydney Children's HospitalDepartment of Immunology and Infectious DiseasesHigh StreetRandwickNew South WalesAustralia2031
| | - Tracey O'Brien
- Sydney Children's HospitalCentre for Children's Cancer & Blood DisordersHigh StreetRandwickNew South WalesAustralia2031
| | - Michael H Bennett
- Prince of Wales Clinical School, University of NSWDepartment of AnaesthesiaSydneyNSWAustralia
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Bow EJ. Neutropenic fever syndromes in patients undergoing cytotoxic therapy for acute leukemia and myelodysplastic syndromes. Semin Hematol 2009; 46:259-68. [PMID: 19549578 DOI: 10.1053/j.seminhematol.2009.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fever represents the major surrogate of infection in neutropenic cancer patients. A number of neutropenic fever syndromes have been recognized, the causes and significance of which will vary depending upon the clinical context. First neutropenic fever syndromes are typically of bacterial origin, the character of which may be influenced by whether antibacterial chemoprophylaxis has been administered. Persistent neutropenic fevers are documented during the empirical systemic antibacterial therapy for the first neutropenic fever, the cause of which is likely outside the spectrum of activity of the initial therapy. Recrudescent neutropenic fevers, defined by the appearance of a new fever after defervescence of the first fever, are often a function of invasive fungal infection or gram-positive infections outside the spectrum of the initial empirical antibacterial regimen. The myeloid reconstitution syndrome occurs in parallel with neutrophil recovery from aplasia and may not necessarily represent new infection. Recognition of these patterns can help the clinician make better clinical judgments and management plans.
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Affiliation(s)
- E J Bow
- Sections of Hematology/Oncology and Infectious Diseases, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Invasive mould infections in the setting of hematopoietic cell transplantation: current trends and new challenges. Curr Opin Infect Dis 2009; 22:376-84. [PMID: 19491674 DOI: 10.1097/qco.0b013e32832db9f3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Invasive mould infections remain major causes of infection-related mortality following hematopoietic stem cell transplantation (HSCT). In this review, we summarize the recent advances in the diagnosis, prevention, and management of invasive mould infections in HSCT recipients. RECENT FINDINGS The evolving epidemiologic characteristics of post-HSCT invasive mould infections, specifically the rising incidence of Aspergillus and non-Aspergillus mould infections in the postengraftment period, necessitate the development of preventive strategies. The efficacy of prophylactic broad-spectrum triazoles against invasive mould infections in HSCT recipients has now been demonstrated in two large prospective studies. However, concerns over drug absorption, interactions, and costs may shift attention from universal prophylaxis to risk stratification and preemptive strategies. In this regard, recent studies have highlighted the potential of genetic polymorphism analysis to identify HSCT recipients at risk for invasive aspergillosis, and efforts are underway to improve the predictive values of antigen and nucleic acid detection assays. Emerging data on risk factors for invasive aspergillosis relapse after HSCT, antifungal drug monitoring, and the use of galactomannan testing to monitor treatment response may help inform therapeutic decisions for HSCT recipients. SUMMARY Evidence-driven management of invasive mould infections in HSCT recipients is becoming increasingly individualized, integrating host factors and pharmacologic and epidemiologic considerations. However, the optimal approach to invasive mould infection prevention in HSCT recipients remains to be resolved by prospective clinical studies.
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Espinel-Ingroff A, Canton E, Martin-Mazuelos E, Pemán J. Pharmacotherapy of Candida Infections with Echinocandins. ACTA ACUST UNITED AC 2009. [DOI: 10.4137/cmt.s2311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The classic recommended antifungal agents for the treatment of invasive Candida infections were amphotericin B, a lipid formulation of amphotericin B and fluconazole in both neutropenic or nonneutropenic patients as either primary or alternative therapies. Voriconazole has been recommended when additional coverage for filamentous fungi is needed (e.g. neutropenic patients). More recently and based on well designed comparative clinical trials, the three echinocandins, caspofungin, anidulafungin and micafungin have been added as primary or alternative therapies especially for critically ill or neutropenic patients. In general, the echinocandins are most useful when patients have previously been exposed to an azole or are unstable.
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Affiliation(s)
| | - Emilia Canton
- Unidad de Microbiología Experimental, Centro de investigación, Hospital Universitario La Fe, valencia, Spain
| | | | - Javier Pemán
- Servicio de Microbiología, Hospital Universitario La Fe, Valencia, Spain
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Ellis M, Bernsen R, Ali-Zadeh H, Kristensen J, Hedström U, Poughias L, Bresnik M, Al-Essa A, A Stevens D. A safety and feasibility study comparing an intermittent high dose with a daily standard dose of liposomal amphotericin B for persistent neutropenic fever. J Med Microbiol 2009; 58:1474-1485. [PMID: 19589901 DOI: 10.1099/jmm.0.012401-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A high intermittent dose regimen (group A: 10 mg kg(-1) on day 1, 5 mg kg(-1) on days 3 and 6) was compared with standard dosing (group B: 3 mg kg(-1) per day for 14 days) of liposomal amphotericin B (LAB) for empirical treatment of persistent febrile neutropenia. A total cumulative dose of 1275 mg (group A) and 2800 mg (group B) was administered. Infusion-related adverse drug events, mainly rigors/chills, occurred more frequently with group A (11/45, 24 % infusions) than with group B (12/201, 6 % infusions) (P=0.002), which extended the mean infusion time by 20 min (P=0.001). Creatinine levels were similar in the two regimens: the A : B ratio of the area under the curve for creatinine (AUC(CREATININE)) for days 2-7 was 1.09 (P=0.27) and for days 2-14 was 1.05 (P=0.51). Rises in creatinine were mild (clinical toxicity criteria 1) in all patients with elevations. Hypokalaemia tended to be less severe in group A with a lower proportion of hypokalaemic days [57/143 (39 %) vs 80/137 (58 %), P=0.21], a higher AUC(POTASSIUM) (A : B ratio of 1.06, P=0.12), a lower proportion of patients with hypokalaemia at the end of study (10 vs 61 %, P=0.01) and fewer potassium-supplemented days [12/210 (6 %) vs 41/210 (19.5 %), P<0.1]. There were mildly elevated median levels of serum bilirubin, alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase, which were similar for the two regimens and were usually associated with other co-existing co-morbid conditions. The AUC for these enzymes was also similar in the two groups. No patient had discontinuation of the study drug due to toxicity. Composite success was identical for each regimen (11/15 patients, 73 %). Three of the fifteen patients in group B and none in group A developed invasive fungal infections (IFIs). Beta-D-Glucan levels were similar in both groups for patients without an IFI [AUC(GLUCAN) of 362 and 683 (P=0.36) for groups A and B, respectively]. The rate of defervescence was similar for each regimen (P=0.75). This feasibility study suggests that a short intermittent high-dose course of 10/5/5 mg LAB kg(-1) on days 1, 3 and 6 may be as safe and effective as a standard 14 day course of 3 mg kg(-1) per day, with drug-acquisition cost savings and reduced drug exposure. A larger study is indicated for confirmation of this.
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Affiliation(s)
- Michael Ellis
- Department of Community Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE.,Department of Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Roos Bernsen
- Department of Community Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Hussein Ali-Zadeh
- Department of Oncology, Tawam-Johns Hopkins Hospital, Al Ain, UAE.,Department of Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Jörgen Kristensen
- Department of Oncology, Tawam-Johns Hopkins Hospital, Al Ain, UAE.,Department of Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Ulla Hedström
- Department of Medicine, Al-Ain Hospital, Al Ain, UAE.,Department of Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | | | | | - Awad Al-Essa
- Department of Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
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Leibovici L, Falagas ME. Systematic reviews and meta-analyses in infectious diseases: how are they done and what are their strengths and limitations? Infect Dis Clin North Am 2009; 23:181-94. [PMID: 19393904 DOI: 10.1016/j.idc.2009.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In infectious diseases, as in other domains, systematic reviews and meta-analyses are the type of research most easily translated into clinical practice. Practitioners should familiarize themselves with the methodology of systematic reviews and meta-analyses, their interpretation, and their limitations.
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Affiliation(s)
- Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Petah-Tiqva, Israel.
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