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Casalini G, Giacomelli A, Galimberti L, Colombo R, Milazzo L, Cattaneo D, Castelli A, Antinori S. Navigating Uncertainty: Managing Influenza-Associated Invasive Pulmonary Aspergillosis in an Intensive Care Unit. J Fungi (Basel) 2024; 10:639. [PMID: 39330399 PMCID: PMC11433123 DOI: 10.3390/jof10090639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 09/04/2024] [Accepted: 09/05/2024] [Indexed: 09/28/2024] Open
Abstract
We present a challenging case of a patient admitted to an intensive care unit with influenza-associated pulmonary aspergillosis (IAPA). The clinical course was characterised by refractory fungal pneumonia and tracheobronchitis, suspected drug-induced liver injury due to triazole antifungals, and secondary bacterial infections with multidrug-resistant microorganisms, resulting in a fatal outcome despite the optimisation of antifungal treatment through therapeutic drug monitoring. This case underscores the complexity that clinicians face in managing critically ill patients with invasive fungal infections.
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Affiliation(s)
- Giacomo Casalini
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Andrea Giacomelli
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
- Department of Biomedical and Clinical Sciences, DIBIC, Università degli Studi di Milano, 20157 Milan, Italy
| | - Laura Galimberti
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Riccardo Colombo
- Anesthesia and Intensive Care Unit, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Laura Milazzo
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Dario Cattaneo
- Unit of Clinical Pathology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy
| | - Antonio Castelli
- Anesthesia and Intensive Care Unit, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
| | - Spinello Antinori
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
- Department of Biomedical and Clinical Sciences, DIBIC, Università degli Studi di Milano, 20157 Milan, Italy
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Tashiro M, Takazono T, Izumikawa K. Chronic pulmonary aspergillosis: comprehensive insights into epidemiology, treatment, and unresolved challenges. Ther Adv Infect Dis 2024; 11:20499361241253751. [PMID: 38899061 PMCID: PMC11186400 DOI: 10.1177/20499361241253751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/23/2024] [Indexed: 06/21/2024] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a challenging respiratory infection caused by the environmental fungus Aspergillus. CPA has a poor prognosis, with reported 1-year mortality rates ranging from 7% to 32% and 5-year mortality rates ranging from 38% to 52%. A comprehensive understanding of the pathogen, pathophysiology, risk factors, diagnosis, surgery, hemoptysis treatment, pharmacological therapy, and prognosis is essential to manage CPA effectively. In particular, Aspergillus drug resistance and cryptic species pose significant challenges. CPA lacks tissue invasion and has specific features such as aspergilloma. The most critical risk factor for the development of CPA is pulmonary cavitation. Diagnostic approaches vary by CPA subtype, with computed tomography (CT) imaging and Aspergillus IgG antibodies being key. Treatment strategies include surgery, hemoptysis management, and antifungal therapy. Surgery is the curative option. However, reported postoperative mortality rates range from 0% to 5% and complications range from 11% to 63%. Simple aspergilloma generally has a low postoperative mortality rate, making surgery the first choice. Hemoptysis, observed in 50% of CPA patients, is a significant symptom and can be life-threatening. Bronchial artery embolization achieves hemostasis in 64% to 100% of cases, but 50% experience recurrent hemoptysis. The efficacy of antifungal therapy for CPA varies, with itraconazole reported to be 43-76%, voriconazole 32-80%, posaconazole 44-61%, isavuconazole 82.7%, echinocandins 42-77%, and liposomal amphotericin B 52-73%. Combinatorial treatments such as bronchoscopic triazole administration, inhalation, or direct injection of amphotericin B at the site of infection also show efficacy. A treatment duration of more than 6 months is recommended, with better efficacy reported for periods of more than 1 year. In anticipation of improvements in CPA management, ongoing advances in basic and clinical research are expected to contribute to the future of CPA management.
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Affiliation(s)
- Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Takahiro Takazono
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
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Bosetti D, Neofytos D. Invasive Aspergillosis and the Impact of Azole-resistance. CURRENT FUNGAL INFECTION REPORTS 2023; 17:1-10. [PMID: 37360857 PMCID: PMC10024029 DOI: 10.1007/s12281-023-00459-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review IA (invasive aspergillosis) caused by azole-resistant strains has been associated with higher clinical burden and mortality rates. We review the current epidemiology, diagnostic, and therapeutic strategies of this clinical entity, with a special focus on patients with hematologic malignancies. Recent Findings There is an increase of azole resistance in Aspergillus spp. worldwide, probably due to environmental pressure and the increase of long-term azole prophylaxis and treatment in immunocompromised patients (e.g., in hematopoietic stem cell transplant recipients). The therapeutic approaches are challenging, due to multidrug-resistant strains, drug interactions, side effects, and patient-related conditions. Summary Rapid recognition of resistant Aspergillus spp. strains is fundamental to initiate an appropriate antifungal regimen, above all for allogeneic hematopoietic cell transplantation recipients. Clearly, more studies are needed in order to better understand the resistance mechanisms and optimize the diagnostic methods to identify Aspergillus spp. resistance to the existing antifungal agents/classes. More data on the susceptibility profile of Aspergillus spp. against the new classes of antifungal agents may allow for better treatment options and improved clinical outcomes in the coming years. In the meantime, continuous surveillance studies to monitor the prevalence of environmental and patient prevalence of azole resistance among Aspergillus spp. is absolutely crucial.
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Affiliation(s)
- Davide Bosetti
- Division of Infectious Diseases, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland
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Giordano ALPL, Pontes L, Beraquet CAG, Lyra L, Schreiber AZ. Matrix-assisted laser desorption/ionisation-time of flight mass spectrometry azole susceptibility assessment in Candida and Aspergillus species. Mem Inst Oswaldo Cruz 2023; 118:e220213. [PMID: 36921145 PMCID: PMC10014031 DOI: 10.1590/0074-02760220213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/26/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Matrix-assisted laser desorption/ionisation-time of flight mass spectrometry (MALDI-TOF MS) allows rapid pathogen identification and potentially can be used for antifungal susceptibility testing (AFST). OBJECTIVES We evaluated the performance of the MALDI-TOF MS in assessing azole susceptibility, with reduced incubation time, by comparing the results with the reference method Broth Microdilution. METHODS Resistant and susceptible strains of Candida (n = 15) were evaluated against fluconazole and Aspergillus (n = 15) against itraconazole and voriconazole. Strains were exposed to serial dilutions of the antifungals for 15 h. Microorganisms' protein spectra against all drug concentrations were acquired and used to generate a composite correlation index (CCI) matrix. The comparison of autocorrelations and cross-correlations between spectra facilitated by CCI was used as a similarity parameter between them, enabling the inference of a minimum profile change concentration breakpoint. Results obtained with the different AFST methods were then compared. FINDINGS The overall agreement between methods was 91.11%. Full agreement (100%) was reached for Aspergillus against voriconazole and Candida against fluconazole, and 73.33% of agreement was obtained for Aspergillus against itraconazole. MAIN CONCLUSIONS This study demonstrates MALDI-TOF MS' potential as a reliable and faster alternative for AFST. More studies are necessary for method optimisation and standardisation for clinical routine application.
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Affiliation(s)
| | - Lais Pontes
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
| | | | - Luzia Lyra
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
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Abstract
PURPOSE OF REVIEW This review examines recent cases and updated literature on emerging or newly resistant fungal infections in solid organ transplantation. RECENT FINDINGS Candida auris, a newly described candida capable of drug resistance and persistence in the environment, is a growing concern with both published cases on donor-derived transmission and a hospital outbreak involving liver transplant recipients. Infections with non-albicans candida species are also increasing in incidence in SOT recipients, leading to increasing antifungal resistance and higher mortality. Aspergillus usti has emerged in immunocompromised patients on antifungal prophylaxis. Cryptococcus species continue to be responsible for a number of infections in SOT recipients. Dimorphic fungi, endemic to geographic areas and responsible for sporadic infections in SOT recipients are noted to have an expanding geographic area. Emergomyces are newly classified groups of five species of dimorphic fungi noted to disseminated disease in immunocompromised patients including SOT recipients. SUMMARY Emerging fungal species and the development of resistance in well entrenched fungal pathogens impacts SOT recipients and those caring for them. Knowledge of these trends aids in the successful identification and optimal treatment of these challenging conditions.
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Affiliation(s)
- Aaron Mishkin
- Lewis Katz School of Medicine at Temple University: Philadelphia, Pennsylvania, USA
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Abstract
Infections due to Aspergillus species are an acute threat to human health; members of the Aspergillus section Fumigati are the most frequently occurring agents, but depending on the local epidemiology, representatives of section Terrei or section Flavi are the second or third most important. Aspergillus terreus species complex is of great interest, as it is usually amphotericin B resistant and displays notable differences in immune interactions in comparison to Aspergillus fumigatus. The latest epidemiological surveys show an increased incidence of A. terreus as well as an expanding clinical spectrum (chronic infections) and new groups of at-risk patients being affected. Hallmarks of these non-Aspergillus fumigatus invasive mold infections are high potential for tissue invasion, dissemination, and possible morbidity due to mycotoxin production. We seek to review the microbiology, epidemiology, and pathogenesis of A. terreus species complex, address clinical characteristics, and highlight the underlying mechanisms of amphotericin B resistance. Selected topics will contrast key elements of A. terreus with A. fumigatus. We provide a comprehensive resource for clinicians dealing with fungal infections and researchers working on A. terreus pathogenesis, aiming to bridge the emerging translational knowledge and future therapeutic challenges on this opportunistic pathogen.
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Pasula S, Chandrasekar PH. Azole resistance in Aspergillus species: promising therapeutic options. Expert Opin Pharmacother 2021; 22:2071-2078. [PMID: 34129410 DOI: 10.1080/14656566.2021.1940134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Azoles are the first-line antifungal agents used for the treatment of Aspergillus infection. There is an increasing concern for azole resistance all over the world mainly from agricultural fungicide use. Choosing safe and effective antifungal regimens has become a challenge. AREAS COVERED Here, the authors review the epidemiology, mechanisms, and detection of azole resistance along with management options for azole-resistant Aspergillus infection, including new antifungal agents under development. EXPERT OPINION Routine global epidemiological surveillance is required to understand azole resistance prevalence. Azole-resistant Aspergillus infections are associated with high mortality. No good therapeutic options are currently available. High index of suspicion of resistance is required if a patient is not responding to 4-7 days of azole therapy, particularly in the areas of resistance. Susceptibility testing for Aspergillus is not routinely available in many parts of the world, which makes it difficult to diagnose azole resistance in Aspergillus infection. There are several new antifungal classes with novel mechanisms of action; clinical trials are ongoing.
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Affiliation(s)
- Shirisha Pasula
- Department of Internal medicine, Division of Infectious diseases, Detroit Medical Center/Wayne State University, Detroit, MI, USA
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Prigitano A, Esposto MC, Grancini A, Biffi A, Innocenti P, Cavanna C, Lallitto F, Mollaschi EMG, Bandettini R, Oltolini C, Passera M, De Lorenzis G, Sargolzaei M, Crespan M, Cogliati M, Tortorano AM, Romanò L. Azole resistance in Aspergillus isolates by different types of patients and correlation with environment - An Italian prospective multicentre study (ARiA study). Mycoses 2021; 64:528-536. [PMID: 33438319 DOI: 10.1111/myc.13241] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND A wide range of frequency of azole-resistance in A fumigatus in different patient populations worldwide was observed threatening to reduce therapeutic options. OBJECTIVES Estimate the prevalence of azole-resistance, investigate the molecular mechanisms of resistance, compare the genotypes of resistant clinical isolates with those from the surrounding environment. METHODS Aspergillus isolates were collected by seven Italian hospital microbiology laboratories. Strains were isolated from different clinical samples from unselected patients. The azole-resistance was evaluated using screening test and microdilution EUCAST method. The molecular mechanism of resistance was performed sequencing the cyp51A gene. Resistant isolates were genotyped by microsatellite analysis and their profiles compared with those of azole-resistant isolates from previous Italian studies. RESULTS 425 Aspergillus isolates from 367 patients were analysed. The azole-resistance rates were 4.9% and 6.6% considering all Aspergillus spp. isolates and the A fumigatus sensu stricto, respectively. All resistant isolates except one were from a single hospital. Two rare azole-resistant species were identified: A thermomutatus and A lentulus. The predominant resistance mechanism was TR34 /L98H. No correlation between the clinical resistant strains and environmental isolates from patients' home/work/ward was observed. The analysis of the molecular correlation between the resistant clinical strains collected in the present study and those of environmental and clinical origin collected in previous Italian studies reveals a progressive diversification of azole-resistant genotypes starting from a founder azole-resistant genotype. CONCLUSIONS This study confirms the trend of azole-resistance rate in Italy, showing a geographical difference. Data reinforce the importance of surveillance programmes to monitor the local epidemiological situation.
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Affiliation(s)
- Anna Prigitano
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | - Maria C Esposto
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | - Anna Grancini
- UOS Microbiology, Central Laboratory IRCCS Foundation, Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Arianna Biffi
- Cystic Fibrosis Microbiology Laboratory and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Patrizia Innocenti
- Laboratory of Microbiology and Virology, Comprensorio Sanitario di Bolzano-A.S. Alto Adige, Bolzano, Italy
| | - Caterina Cavanna
- Microbiology and Virology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabiola Lallitto
- Microbiology and Virology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Roberto Bandettini
- Clinical Pathology and Microbiology Laboratory Unit, Istituto Giannina Gaslini, Genova, Italy
| | | | - Marco Passera
- Microbiology and Virology Unit, ASST 'Papa Giovanni XXIII', Bergamo, Italy
| | - Gabriella De Lorenzis
- Department of Agricultural and Environmental Sciences-Production, Landscape, Agroenergy, Università degli Studi di Milano, Milano, Italy
| | - Maryam Sargolzaei
- Department of Agricultural and Environmental Sciences-Production, Landscape, Agroenergy, Università degli Studi di Milano, Milano, Italy
| | - Manna Crespan
- CREA- Research Center for Viticulture and Enology, Conegliano, Italy
| | - Massimo Cogliati
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | - Anna Maria Tortorano
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | - Luisa Romanò
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
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