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Panagopoulou P, Roilides E. An update on pharmacotherapy for fungal infections in allogeneic stem cell transplant recipients. Expert Opin Pharmacother 2024; 25:1453-1482. [PMID: 39096057 DOI: 10.1080/14656566.2024.2387686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Invasive fungal diseases (IFD) constitute a major cause of morbidity and mortality in hematopoietic stem cell transplantation (HSCT) recipients. AREAS COVERED We describe epidemiology, causes and risk factors of IFD in allogeneic HSCT discussing prophylaxis and treatment in various HSCT phases. We present the most recent studies on this thematic area, including novel data on currently available antifungals, i.e. formulations, dosing, safety, efficacy and therapeutic drug monitoring. Finally, we present the most recent relevant recommendations published. Literature search included PubMed, Scopus, and clinicaltrials.gov between January 2014 and April 2024. EXPERT OPINION The antifungal agents employed for prophylaxis and therapy should be predicated on local epidemiology of IFD. Fluconazole prophylaxis remains a first-line choice before engraftment when the main pathogen is Candida spp. After engraftment, prophylaxis should be with mold-active agents (i.e. triazoles). For candidiasis, echinocandins are suggested as first-line treatment, whereas aspergillosis responds well to mold-active azoles and liposomal amphotericin B (L-AmB). For mucormycosis, treatment of choice includes L-AmB and isavuconazole. Choice between fever-driven and diagnostics-driven strategies remains equivocal. Open research topics remain: 1) optimization of tools to ensure prompt and accurate IFD diagnosis to avoid unnecessary exposure to antifungals, drug interactions and cost; 2) refinement of treatment for resistant/refractory strains.
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Affiliation(s)
- Paraskevi Panagopoulou
- Pediatric Hematology & Oncology, 4th Department of Pediatrics, Aristotle University School of Medicine and Papageorgiou General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University School of Medicine and Hippokration General Hospital, Thessaloniki, Greece
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Prattes J, Giacobbe DR, Bassetti M, Gangneux JP, Hoenigl M. Antifungal prophylaxis of COVID-19 associated pulmonary aspergillosis in ventilated patients: one solution does not fit all. Intensive Care Med 2024; 50:1375-1377. [PMID: 38980361 DOI: 10.1007/s00134-024-07542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/10/2024]
Affiliation(s)
- Juergen Prattes
- Department of Internal Medicine, Division of Infectious Diseases, Excellence Centre for Medical Mycology (ECMM), Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
- BioTechMed Graz, Graz, Austria.
| | - Daniele R Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Jean-Pierre Gangneux
- EHESP, Irset (Institut de Recherche en Santé, Environnement Et Travail)-UMR_S 1085, CHU Rennes, Inserm, Univ Rennes, 35000, Rennes, France
- Laboratoire de Parasitologie-Mycologie, Centre National de Référence Pour Les Aspergilloses Chroniques (CNRMA-LA AspC), ECMM Excellence Center for Medical Mycology, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Martin Hoenigl
- Department of Internal Medicine, Division of Infectious Diseases, Excellence Centre for Medical Mycology (ECMM), Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- BioTechMed Graz, Graz, Austria
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Haberal G, Saglam A, Yildirim T, Yilmaz SR, Yeter HH. Rare case of aspergillosis with solitary renal involvement: micro-fungus ball in graft kidney. CEN Case Rep 2024:10.1007/s13730-024-00898-8. [PMID: 39060835 DOI: 10.1007/s13730-024-00898-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/01/2024] [Indexed: 07/28/2024] Open
Abstract
Kidney transplant recipients are at an increased risk of various infections due to immunosuppressive medications. Among them, fungal infections are associated with high mortality and morbidity. This report presents the case of a 54-year-old kidney-transplant recipient who was diagnosed with aspergillosis with solitary renal involvement. He was diagnosed by kidney biopsy with the micro-fungus ball. In the biopsy sample, consisting mostly of the medulla, a small focus consisting of an aggregate of fungal microorganisms was identified. The micro-fungus ball, which was also present in serial sections, was characterized by slight pigmentation and septate hyphae with acute angle branching, highlighted by the silver stains. The patient was examined for invasive fungal infection. In CT scans, there were no signs of invasive fungal infection. Due to the unexpected kidney biopsy finding, the patient underwent a repeat allograft biopsy from which a culture was sent. Aspergillus fumigatus complex was detected in tissue fungal culture of this repeat biopsy. The patient was started on voriconazole treatment and was successfully treated. It should be kept in mind that fungal infections with isolated subtle renal involvement may be possible in KTR under immunosuppressive treatment without an obvious fungal focus being demonstrated by imaging methods.
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Affiliation(s)
- Guldehan Haberal
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | - Arzu Saglam
- Department of Pathology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Tolga Yildirim
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Seref Rahmi Yilmaz
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Haci Hasan Yeter
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Zhang H, Wang Y, Diao R, Huo X, Zhao Q. The practice and evaluation of antifungal stewardship programs at a tertiary first-class hospital in China. BMC Infect Dis 2024; 24:506. [PMID: 38773459 PMCID: PMC11106957 DOI: 10.1186/s12879-024-09405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/15/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND The sharp increase in fungal infections, insufficient diagnostic and treatment capabilities for fungal infections, poor prognosis of patients with fungal infections as well as the increasing drug resistance of fungi are serious clinical problems. It is necessary to explore the implementation and evaluation methods of antifungal stewardship (AFS) to promote the standardized use of antifungal drugs. METHODS The AFS programme was implemented at a tertiary first-class hospital in China using a plan-do-check-act (PDCA) quality management tool. A baseline investigation was carried out to determine the utilization of antifungal drugs in pilot hospitals, analyse the existing problems and causes, and propose corresponding solutions. The AFS programme was proposed and implemented beginning in 2021, and included various aspects, such as team building, establishment of regulations, information construction, prescription review and professional training. The management effectiveness was recorded from multiple perspectives, such as the consumption of antifungal drugs, the microbial inspection rate of clinical specimens, and the proportion of rational prescriptions. The PDCA management concept was used for continuous improvement to achieve closed-loop management. RESULTS In the first year after the implementation of the AFS programme, the consumption cost, use intensity and utilization rate of antifungal drugs decreased significantly (P < 0.01). The proportion of rational antifungal drug prescriptions markedly increased, with the proportion of prescriptions with indications increasing from 86.4% in 2019 to 97.0% in 2022, and the proportion of prescriptions with appropriate usage and dosage increased from 51.9 to 87.1%. In addition, after the implementation of the AFS programme, physicians' awareness of the need to complete microbial examinations improved, and the number of fungal cultures and serological examinations increased substantially. Statistics from drug susceptibility tests revealed a decrease in the resistance rate of Candida to fluconazole. CONCLUSION This study indicated that the combination of AFS and the PDCA cycle could effectively reduce antifungal consumption and promote the rational use of antifungal drugs, providing a reference for other health care systems to reduce the overuse of antifungal drugs and delay the progression of fungal resistance.
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Affiliation(s)
- Huiyuan Zhang
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Yinglin Wang
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Ruigang Diao
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Xuechen Huo
- Department of Hepatobiliary Surgery, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China.
| | - Quan Zhao
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China.
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Alsalman J, Althaqafi A, Alsaeed A, Subhi A, Mady AF, AlHejazi A, Francis B, Alturkistani HH, Ayas M, Bilbisi M, Alsharidah S. Middle Eastern Expert Opinion: Strategies for Successful Antifungal Stewardship Program Implementation in Invasive Fungal Infections. Cureus 2024; 16:e61127. [PMID: 38919246 PMCID: PMC11198984 DOI: 10.7759/cureus.61127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
In recent years, global public health efforts have increasingly emphasized the critical role of antimicrobial stewardship (AMS) in improving outcomes, reducing costs, and combating the growing threat of antimicrobial resistance. However, antifungal stewardship (AFS) has remained relatively overlooked despite the staggering impact of invasive fungal infections (IFIs). This burden is particularly pronounced in hospitals worldwide, with the Middle East facing significant unmet needs. The rising population of immunocompromised individuals vulnerable to IFI has prompted an increased reliance on antifungal agents for both prevention and treatment. Given the considerable mortality associated with IFIs and the emergence of antifungal resistance, implementing AFS programs in hospital settings is becoming increasingly urgent. In this article, we offer expert insights into the strategies that can be used for successful antifungal stewardship program implementation in IFI. Drawing upon the extensive clinical experience of a multinational and multidisciplinary panel, we present recommendations for optimizing AFS practices. We delve into the challenges and practical considerations of tailoring local AFS initiatives to the evolving landscape of fungal infections. Additionally, we provide actionable recommendations and position statements for the effective implementation of AFS programs, informed by the collective clinical experiences of panel members across their respective countries of practice.
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Affiliation(s)
| | - Abdulhakeem Althaqafi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Infectious Diseases, King Abdullah International Medical Research Center, Jeddah, SAU
- Department of Medicine/Infectious Diseases, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Ahmad Alsaeed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Adult Hematology and Stem Cell Transplantation, Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs, Jeddah, SAU
| | - Ahmad Subhi
- Adult Infectious Diseases, Department of Medicine, Al-Qassimi Hospital, Emirates Health Services, Sharjah, ARE
| | - Ahmed F Mady
- Critical Care Medicine, King Saud Medical City, Riyadh, SAU
| | - Ayman AlHejazi
- Department of Oncology, King Abdulaziz Medical City Riyadh, Riyadh, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Bassam Francis
- Hematology, Hematology and Bone Marrow Transplant Center, Baghdad, IRQ
| | | | - Mouhab Ayas
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Montaser Bilbisi
- Department of Infectious Diseases, Abdali Medical Center, Amman, JOR
| | - Sondus Alsharidah
- Pediatric Stem Cell Transplant Unit, Department of Pediatric Hematology/Oncology, National Bank of Kuwait (NBK) Children's Specialized Hospital, Sabah Central Health Region, KWT
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Patterson CM, Shaw TD, Gerovasili V, Khatana U, Jose RJ. Emerging therapies and respiratory infections: Focus on the impact of immunosuppressants and immunotherapies. Clin Med (Lond) 2024; 24:100015. [PMID: 38387208 PMCID: PMC11024833 DOI: 10.1016/j.clinme.2024.100015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
Host defences to infection are based upon an integrated system of physical and biochemical barriers, innate and adaptive immunity. Weakness in any of these defensive elements leads to increased susceptibility to specific pathogens. Understanding how medical therapies disrupt host defences is key to the successful prevention, diagnosis and management of respiratory infection in the immunocompromised host.
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Affiliation(s)
- Caroline M Patterson
- Consultant in Respiratory Transplant Medicine, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
| | - Timothy D Shaw
- Academic Clinical Lecturer in Infectious Diseases and Medical Microbiology, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Vicky Gerovasili
- Consultant in Respiratory Transplant Medicine, Royal Brompton and Harefield hospital, part of Guys and St Thomas NHS Foundation trust, London, UK
| | - Usman Khatana
- Specialty Trainee in Respiratory Medicine, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Ricardo J Jose
- Consultant in Host Defence, Royal Brompton and Harefield hospital, part of Guys and St Thomas NHS Foundation trust, London, UK
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