Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group

Systematic Review of the Presentation, Treatment, and Outcome of Chronic Disseminated Candidiasis in Children With Cancer or Following Hematopoietic Cell Transplant

Chronic disseminated candidiasis (CDC) is a rare complication of immunosuppression. This review describes the presentation, management, and outcomes of CDC in pediatric patients with cancer or following hematopoietic cell transplant (HCT). PubMed, Embase, and Medline were searched identifying 32 studies, describing 95 cases of CDC. CDC occurred almost exclusively in patients with leukemia (91%), with only 5% occurring in lymphoma, 1% post HCT, and 3% in solid tumor. The most frequent presenting symptoms were fever (97%) and abdominal pain (45%), with lesions in liver in 63% and spleen in 54% (less common in kidney, lungs and skin/soft tissue). Of the 67 (71%) episodes with microbiological confirmation, Candida tropicalis (28%) was the most common causative species. Antifungal treatment durations varied from 14 days to 28 months. Additionally, 31 (33%) patients received an adjuvant therapy, the most common being corticosteroids. Mortality, directly attributable to CDC, occurred in nine (9%). There remains insufficient data to guide a unified approach to management.

Macrophage ferroptosis inhibits Aspergillus conidial killing in lung transplantation

Immune suppression heightens the risk for fungal infections, but the mechanisms that result in clinical disease are poorly understood. Here we demonstrate that macrophage ferroptosis, an iron-dependent form of regulated cell death, inhibits Aspergillus fumigatus ( Af ) killing. In a mouse tracheal transplant model of Af infection, we observed an increase in macrophage lipid peroxidation, a decreased expression of negative ferroptosis regulators Gpx4 and Slc7a11 , and an increase in positive regulators Ptgs2 and Nox2 , relative to syntransplants. Depletion of macrophages in transplant recipients decreased Af invasion. In vitro , iron overload reduced macrophage viability and decreased their capability to kill Af spores, through a decrease in lysosomal acidification and lysosomal loss. Treatment with ferrostatin-1, a ferroptosis inhibitor, and deferasirox (an iron chelator) restored Af killing. Ferroptotic alveolar macrophages isolated from lung transplant patients also showed a decreased ability to kill Af spores and the patients' bronchoalveolar lavage was characterized by higher iron levels and markers of ferroptotic stress compared to non-lung transplants. These characteristics were strongly correlated with a clinical history of fungal infections, independent of immune suppressive medications. Our findings indicate that macrophage ferroptosis augments the risk of invasive aspergillosis, representing a novel mechanism for host immune dysfunction.

Early prediction of invasive fungal infection risk in acute-on-chronic liver failure: a prediction model based on admission indicators

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome, and the incidence of invasive fungal infection (IFI) among hospitalized patients with ACLF is steadily increasing. The aim of this study is to develop a diagnostic nomogram to assist in the identification of IFI in these patients.

METHODS

A retrospective study included 705 patients from January 1, 2019, to October 31, 2023, randomly divided into training (n = 493) and validation (n = 212) cohorts. The diagnosis of IFI includes proven diagnosis and probable diagnosis. Kaplan analysis was performed to analyze the survival prognosis of ACLF patients with and without IFI. A nomogram was developed based on a logistic regression model derived through least absolute shrinkage and selection operator (LASSO) regression. The discrimination, accuracy, and clinical utility of the model were assessed using receiver operating characteristic curves, Hosmer-Lemeshow tests, calibration plots, and decision curve analysis.

RESULTS

Kaplan-Meier survival analysis confirmed that the median survival time of ACLF patients with IFI was significantly lower (by 68 days) than that of ACLF patients without IFI, and there were significant differences in the 90-day, 180-day, and 360-day survival rates between the two groups (P < 0.05). Based on LASSO regression, the following factors were identified as significant risk factors for predicting IFI: aminotransferase levels, prothrombin activity, hemoglobin, neutrophil-to-lymphocyte ratio, and serum total bilirubin. A nomogram was constructed incorporating these variables. The nomogram demonstrated good discriminative ability, with an area under the receiver operating characteristic curve (AUC) of 0.78 (95% confidence interval [CI]: 0.72-0.84) in the training cohort and 0.79 (95% CI: 0.70-0.87) in the validation cohort. Decision curve analysis further validated the clinical applicability of the nomogram.

CONCLUSION

ACLF patients with IFI have lower survival time than those without IFI. A nomogram was developed and validated to assist clinicians in the early prediction of IFI in hospitalized patients with ACLF.

CLINICAL TRIAL NUMBER

Not applicable.

Airway-centered invasive pulmonary aspergillosis featuring histopathologic fruiting bodies in an immunocompetent patient with a rare incidental finding of thyroid gland Schwannoma: a case report

INTRODUCTION

Invasive pulmonary aspergillosis (IPA) is typically associated with immunocompromised patients, but rare occurrences have been documented in immunocompetent individuals. This presents diagnostic and therapeutic challenges due to atypical presentations and less apparent risk factors.

CASE PRESENTATION

A 67-year-old Cambodian American female with a history of stable pulmonary nodules and a left neck schwannoma presented with a two-week history of cough and hemoptysis. Imaging revealed a left lower lobe lung mass suspicious for malignancy. Biopsy and bronchoalveolar lavage confirmed the diagnosis of invasive pulmonary aspergillosis, despite the patient's lack of traditional immunosuppressive risk factors. Her environmental exposures, including a recent trip to Cambodia and a history of gardening, were likely contributing factors. The diagnosis of IPA in this immunocompetent patient was established through a combination of clinical presentation, radiographic findings, and microbiological evidence. Bronchoalveolar lavage and galactomannan testing were crucial in identifying the presence of Aspergillus. Histopathological examination of the biopsy specimen revealed the presence of Aspergillus fruiting bodies, an uncommon finding indicative of invasive disease. The patient was promptly started on voriconazole, the first-line antifungal agent for IPA, which led to an improvement in her symptoms. Moreover, her left neck mass schwannoma in the thyroid bed was also a rare entity.

CONCLUSION

This case highlights the importance of considering IPA as a differential diagnosis in immunocompetent individuals with relevant environmental exposures and preexisting lung conditions, even in the absence of classic immunosuppressive risk factors.

Invasive pulmonary aspergillosis evaluation in hematology patients: Three years results of tertiary hospital

Invasive pulmonary aspergillosis (IPA) is the most frequent invasive fungal disease occurring in patients with hematological malignancies. Serum galactomannan (GM) antigen monitoring is thought to be helpful in the diagnosis of IPA. The aim of this study was to determine the role of a GM assay in serum samples for the diagnosis of IPA in patients with hematological disease. The data of 366 immunosuppressed patients that were hospitalized and followed up in the hematology clinic from January 2017 to December 2019 were retrospectively analyzed. The clinical and radiological findings of the patients and the GM results, requested twice a week, were evaluated. In this study, the incidence of probable and possible IPA was determined to be 15.3% (56/366). Of the cases detected, 28 (50.0%) were patients diagnosed with acute myeloid leukemia (AML), and 34 (60.7%) patients who had compatible clinical and examination findings were started on antifungal treatment. Additionally, area under the curve (AUC) values were calculated by receiver operating characteristic (ROC) analysis, and it was determined that the diagnostic efficiency was more predictive when the cut-off was 0.5 in the GM test for IPA disease. The detection of GM antigen in serum is a very useful and rapid method for diagnosing IPA disease in immunosuppressed hematology patients. However, GM results should be evaluated together with clinical and radiological findings for early diagnosis, and the treatment approach should be determined accordingly.

Different Epidemiology of Invasive Pulmonary Aspergillosis in Acute Lymphoblastic Leukemia in Comparison With Acute Myeloid Leukemia: Results of a Prospective Multicentric Observational Study of the Rete Ematologica Lombarda

The negative impact of invasive pulmonary aspergillosis (IPA) in acute myeloid leukemia (AML) is well known whereas its clinical relevance in acute lymphoid leukemia (ALL) is still unclear. We have carried out a prospective multicentric observational study within the Rete Ematologica Lombarda to describe the incidence of IPA in acute leukemia (AL) patients, focusing on differences between AML and ALL. Between 2018 and 2020, 207 AL patients (AML: 165, ALL: 42) were evaluated. During induction, proven/probable and possible IPA were diagnosed in 32/207 patients (15.4%), equally divided into proven/probable and possible (16 each, 7.7%). IPA diagnosis was made in 23/165 (13.9%) AML and in 9/42 (21.4%) ALL patients (p = 0.2374). Proven/probable IPA were more frequent in ALL than in AML (ALL: 7/42, 16.6% vs. AML: 9/165, 5.4%; p = 0.0235). OS was similar in patients with or without proven/probable IPA (not reached vs. 63 months, p = 0.588), while OS was significantly reduced in possible IPA (22 months vs. not reached, p = 0.0167). More than 15 days of neutropenia duration and lack of antimold prophylaxis were associated with IPA. Achieving complete remission was protective, whereas age over 60 years and, with a borderline significance, possible IPA were associated with risk of death. In conclusion, Ph-negative ALL should be considered at the same high risk for IPA as AML. Antimold prophylaxis should be probably extended also to ALL.

Incidence and risk factors of serious infections occurred in patients with lung cancer following immune checkpoint blockade therapy

BACKGROUND

Immune checkpoint inhibitors (ICIs) therapy has revolutionized anti-cancer therapy, with lung cancer exhibiting sustained clinical responses to it. However, there remains a lack of research into the risk factors of serious infections in patients with lung cancer following ICIs therapy. Therefore, we aimed to investigate the incidence and risk factors of serious infections in these patients.

METHODS

Medical records were retrospectively collected and reviewed from 710 patients with lung cancer receiving ICIs therapy at Zhongshan Hospital between January 2021 and February 2023. Serious infections were defined as infections requiring hospitalization or parenteral antimicrobials occurring at any time from the initiation of the ICIs therapy to 3 months after its discontinuation.

RESULTS

Among the study population, 191 patients had suffered from serious infections, with an overall infection rate of 26.90% during an average follow-up period of (432.62 ± 377.09) days. The predominant site of infection was the lung (75.61%), and the most prevalent pathogens were bacteria (85.07%), followed by Mycobacterium tuberculosis (6.47%), viruses (4.98%), and fungi (3.48%). In addition to chronic obstructive pulmonary disease (COPD), asthma, and systemic glucocorticoids use, low lymphocyte count and CD4/CD8 ratio were identified as independent risk factors (all p < 0.05).

CONCLUSION

Laboratory parameters may serve as strong predictors for serious infections in patients with lung cancer following ICIs therapy. Chronic airway diseases including COPD and asthma should be managed effectively. Systemic glucocorticoids should be used prudently to prevent serious infections in these patients.

Outcome Analysis of Breakthrough Invasive Aspergillosis on Anti-Mold Azole Prophylaxis and Treatment: 30-Year Experience in Hematologic Malignancy Patients

BACKGROUND

Anti-mold azoles have improved the outcomes of invasive aspergillosis (IA) when used therapeutically, but they are extensively used as prophylaxis. There are limited data regarding the outcomes of patients with hematologic malignancy who develop breakthrough IA on anti-mold azoles. We aimed to determine whether breakthrough IA on azole prophylaxis shows worse outcomes compared to no prophylaxis.

METHODS

We compared outcomes including therapy response and mortality between antifungal regimens in hematologic malignancy patients with IA between July 1993 and July 2023.

RESULTS

Compared to an amphotericin B-containing regimen (AMB), an anti-mold azole as the primary therapy was independently associated with successful response at the end of therapy (OR = 4.38, p < 0.0001), protective against 42-day IA-associated mortality (OR = 0.51, p = 0.024) or all cause mortality (OR = 0.35, p < 0.0001), and protective against 84-day mortality, both IA-associated (OR = 0.50, p = 0.01) and all-cause mortality (OR = 0.27, p < 0.0001). Azole prophylaxis was independently associated with higher IA-associated mortality at 42 days (OR = 1.91, p = 0.012) and 84 days (OR = 2.03, p = 0.004), compared to fluconazole or no prophylaxis.

CONCLUSIONS

Patients with breakthrough IA on anti-mold azole prophylaxis show a worse prognosis than those on other or no prophylaxis, possibly related to the emergence of azole resistance due to their widespread use as prophylaxis agents. On the other hand, anti-mold azole primary therapy is superior to AMB therapy in the treatment of IA.

Side effects associated with itraconazole therapy

BACKGROUND

Itraconazole is the treatment of choice for many fungal infections, including histoplasmosis. While the tolerability of itraconazole has been described in short-term trial settings, there are few studies on side effects during long-term therapy. Fluconazole, which is usually thought to be less toxic, is associated with 52% toxicity in long-term treatment.

OBJECTIVES

To determine the frequency, types, and timing of side effects from itraconazole therapy, the resulting changes to treatment plans, and associations between patient characteristics and itraconazole serum levels with side effect status.

METHODS

We conducted a single-centre, retrospective study of adult patients with histoplasmosis receiving itraconazole therapy for at least 28 days from 2002 to 2021. Reported side effects were characterized, and propensity score matching was used to compare itraconazole serum levels between patients with and without side effects.

RESULTS

Sixty-three out of 227 (27.8%) patients experienced at least one side effect, the most common of which were hepatotoxicity (7.0%), nausea/vomiting (6.6%), and diarrhoea (6.2%). 12 (19.0%) patients with side effects underwent an itraconazole dose reduction and 29 (46.0%) had itraconazole discontinued. The median time to side effect was 45 days. Median itraconazole serum levels were significantly higher among patients with side effects than in a propensity score-matched population without side effects (2.9 versus 1.8 mcg/mL, P = 0.009).

CONCLUSIONS

Side effects were experienced by approximately one-quarter of patients with histoplasmosis receiving long-term itraconazole therapy. About two-thirds of these patients had a therapeutic intervention. Itraconazole resulted in a lower frequency of side effects than fluconazole, as measured in other studies.

Predicting the risk of invasive fungal infections in ICU sepsis population: the AMI risk assessment tool

BACKGROUND

Invasive fungal infections (IFI) represent a significant contributor to mortality among sepsis patients in the Intensive Care Unit (ICU). Early diagnosis of IFI is challenging, and currently, there are no predictive tools for identifying sepsis patients who may develop IFI. Our study aims to develop a predictive scoring system to assess the risk of IFI in patients with sepsis admitted to the ICU.

METHODS

A retrospective collection of data from a total of 549 patients was conducted. Data-driven, clinically knowledge-driven, and decision tree models were used to identify predictive variables for risk of IFI in ICU patients with sepsis. Demographic data, vital signs, laboratory values, comorbidities, medication use, and clinical outcomes were all collected. The optimal model was selected based on model performance and clinical utility to establish a risk score.

RESULTS

Among adult patients with sepsis admitted to the ICU, 127 patients (23.1%) developed IFI. The final data-driven model included four predictive factors, the clinically knowledge-driven model included three predictive factors, and the decision tree model included two. Based on the good performance and clinical utility of the clinically knowledge-driven model, it was chosen as the optimal risk scoring model (C-statistics: 0.79 (95% confidence interval (CI): 0.75-0.83); Hosmer-Lemeshow (H-L) test P = 0.884). The ICU sepsis patient invasive fungal infection risk (AMI) score, created based on the clinically knowledge-driven model, includes mechanical ventilation, application of immunosuppressants, and the types of antibiotics used. The C-statistics for this risk score was 0.79 (95% CI:0.75-0.84) with good calibration (H-L test P = 0.992 and see calibration curve: Fig. 2). Moreover, in terms of clinical utility, the decision curve analysis for AMI showed a favorable net benefit.

CONCLUSIONS

The application of the AMI score can effectively distinguish whether ICU sepsis patients will develop IFI, which is beneficial for clinicians to formulate targeted and timely preventive and treatment measures based on the risk of IFI.

Pulmonary infection by Lophomonas spp. and Aspergillus spp. in a B-cell acute lymphocytic leukemia patient from Chile

The flagellated protozoan Lophomonas spp. is a commensal microorganism found in the intestinal tracts of cockroaches, termites, mites, and certain birds. It is the causative agent of a rare infection in humans called lophomoniasis, primarily affecting the lungs and mainly immunocompromised individuals. This parasitosis is transmitted to humans by air or through ingestion of the cystic forms of the parasite. We describe the case of a 50-year-old patient treated at a tertiary hospital in southern Chile with a history of B-cell acute lymphocytic leukemia. Radiological findings, along with increased levels of inflammatory parameters and galactomannan antigen in serum and Bronchoaveolar Lavage (BAL) raised the suspicion of a pulmonary infection. Microscopic study of BAL revealed oval to pyriform cells with mobile flagella at the anterior end, which were identified as Lophomonas spp. trophozoites, which based on EORTC/MSG criteria were associated with diagnosis of a probable pulmonary aspergillosis. Lophomoniasis was treated with metronidazole (500 mg IV every 8 h) for 14 days and pulmonary aspergillosis required a combination of fluconazole, voriconazole, anidulafungin, liposomal amphotericin B and isavuconazole. The patient responded favorably and was discharged after 95 days of hospitalization. This case highlights the importance of recognizing lophomoniasis as a parasitic infection in respiratory samples from immunocompromised patients who present pulmonary symptoms, especially those who do not respond satisfactorily to conventional antimicrobial treatments. Further research is needed to understand the various sources of Lophomonas spp. infection and develop infection prevention strategies particularly for high-risk patients.

HLA-matched related peripheral blood stem cell and bone marrow transplantation with RIC regimens yield comparable outcomes for adult AML

Introduction

Understanding differences in clinical outcomes between PBSCT and BMT is important, and this study compared outcomes of HLA-matched related PBSCT and BMT using reduced-intensity conditioning (RIC) in adult acute myeloid leukemia (AML) patients.

Methods

Data from 402 patients who underwent either PBSCT (n = 294) or BMT (n = 108) between 2000 and 2022 were analyzed using the Japanese nationwide registry database. The primary endpoint was overall survival (OS), and secondary endpoints included disease-free survival (DFS), non-relapse mortality (NRM), and GVHD.

Results

Results indicated no significant difference in 3-year OS (44.6% for PBSCT vs. 46.9% for BMT, HR 1.173, P = 0.299) and DFS (42.1% vs. 41.8%, HR 1.073, P = 0.639). PBSCT was more beneficial for avoiding relapse (20.3% vs. 12.4%, HR, 0.715, P = 0.059). However, PBSCT was associated with higher NRM (20.3% vs. 12.4%, HR 1.801, P = 0.025) due to more frequent, chronic GVHD (HR 1.889, P = 0.035). Subgroup analysis did not reveal specific patient groups that benefited more from PBSCT or BMT. Incidence of extensive chronic GVHD and NRM has improved in PBSCT recipients in recent years (2014-2022).

Conclusions

We conclude that related PBSCT with RIC regimens offers comparable prognosis to BMT for adult AML patients. Further optimization of prophylactic strategies for chronic GVHD is required to improve outcomes after PBSCT.

Diagnosis of Aspergillus Osteomyelitis of the Clivus and Sella Turcica in a Patient With Type 2 Diabetes and a History of Prolonged Intranasal Corticosteroid Use

A 69-year-old immunocompetent male with uncontrolled type 2 diabetes mellitus (T2DM) presented with atypical left-sided headaches, diverging from his usual migraine pattern. Historically experiencing right-sided migraines, the patient's shift to left-sided headaches occurred after a month of using fluticasone for cold-like symptoms and potential mold exposure at home. Computed tomography (CT) and magnetic resonance imaging (MRI) suggested the diagnosis of skull base osteomyelitis. Endoscopic sphenoidotomy revealed Aspergillus species, leading to treatment with voriconazole. Despite the rarity of skull base Aspergillus osteomyelitis in patients who are not classically immunocompromised, this case underscores its possibility, especially in the context of diabetes and prolonged corticosteroid use. Similar literature is limited but highlights the high fatality rate of invasive fungal infections in diabetic patients and the complexity of diagnosing skull base osteomyelitis due to its varied presentations. Management involved surgical debridement and systemic antifungal therapy. This case aims to add to the limited literature on cranial Aspergillus osteomyelitis, advocating for heightened clinical vigilance, a multifaceted approach involving prompt evaluation, surgical intervention, and tailored antifungal therapy. The case highlights the need for considering fungal etiologies in atypical headache presentations and emphasizes multidisciplinary management for favorable outcomes in an otherwise morbid condition.

Outcomes in hematopoetic cell transplantation in the setting of mold infections in patients with chronic granulomatous disease

Chronic granulomatous disease (CGD) is a disorder of immunity characterized by phagocyte dysfunction. Mold infections in patients with CGD are often severe and disseminated. We present patient characteristics, microbiological data, and outcomes for 26 patients with CGD who received hematopoietic cell transplantation (HCT) or gene therapy-modified cells (GT) between 2008 and 2019, with proven fungal infection either before or during their transplant. All patients engrafted, and all but one GT recipient had neutrophil recovery and evidence of functional correction. Eighteen patients (69%) are currently alive and 19 patients (73% of total, 90% of patients with repeat imaging performed) had evidence of radiographic improvement. With 3 exceptions, deaths were not principally related to the fungal infection and duration of antecedent infection did not correlate with death. Aspergillus species accounted for the majority of disease (50%), followed by Phellinus species (18%). Osteomyelitis and disseminated disease were common, as only 11 patients (42%) had disease restricted to pneumonia. Triazole therapy was used in all 26 patients, with combination therapy used in 25 (96%). HCT or gene therapy, with appropriate antifungal therapy, are viable therapies for refractory fungal infections in patients with CGD.

The efficacy and safety of first-line monotherapies in primary therapy of invasive aspergillosis: a systematic review

Objective

Several antifungals are available for the treatment of patients with invasive aspergillosis (IA). This study aims to evaluate the relative efficacy and safety of the first-line monotherapies in primary therapy of IA through network meta-analysis (NMA).

Methods

We systematically searched PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, VIP database, Wanfang database, and China Biology Medicine for randomized controlled trials (RCTs) up to July 2023 that evaluated the efficacy and safety of monotherapies. We performed NMA with a frequentist random effects model and assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Primary outcomes were the all-cause mortality at week 12, and secondary outcomes included overall response rate, and incidence of adverse events (AEs) and severe adverse events (SAEs).

Results

A total of three RCTs involving 1,368 participants (four antifungals) were included. The NMA showed that compared to amphotericin B deoxycholate (D-AmB), the triazoles (posaconazole (POS), isavuconazole (ISA) and voriconazole (VCZ)) can improve the overall response rate in primary therapy of IA, but only VCZ and ISA can reduce the all-cause mortality at week 12 for patients with proven and probable IA (VCZ vs D-AmB: RR = 0.66, 95%CI = 0.47-0.93, moderate certainty; ISA vs D-AmB: RR = 0.52, 95%CI = 0 .31-0.86, low certainty). ISA (SUCRA = 93.50%; mean rank, 1.20) seemed to be the most effective therapy in the above population. As to proven, probable, and possible IA patients, the triazoles were superior to D-AmB in terms of reducing all-cause mortality. Furthermore, the risk of AEs and SAEs was comparable for the three triazoles, but the risk of SAEs was significantly higher for D-AmB than others.

Conclusion

The efficacy and safety of triazoles are more favorable than D-AmB in the primary therapy of IA, with ISA being the optimal choice.

Systematic Review Registration

PROSPERO CRD42023407632.

Implications for the diagnosis of aspiration and aspergillosis in critically ill patients with detection of galactomannan in broncho-alveolar lavage fluids

Invasive infections with Aspergillus fumigatus in ICU patients are linked to high morbidity and mortality. Diagnosing invasive pulmonary aspergillosis (IPA) in non-immunosuppressed patients is difficult, as Aspergillus antigen (galactomannan [GM]) may have other causes. This retrospective study analyzed 160 ICU surgical patients with positive GM in broncho-alveolar lavage fluid (BALF), classifying them based on AspICU criteria for suspected IPA (pIPA) or aspiration. Patients with pIPA had higher disease severity than those with aspiration, including higher dialysis rates, organ transplantation, corticosteroid use, and Sequential Organ Failure Assessment (SOFA) score. Aspergillus culture was positive in 47.0% of pIPA cases but only 2.6% of aspiration cases (p < 0.001). SOFA score at first positive GM in BALF independently predicted 28-day mortality. In surgical patients with a positive GM in BALF, aspiration is more likely if there's no corticosteroid therapy, negative Aspergillus culture, and a history of aspiration events. Diagnosis of pIPA requires Aspergillus culture or prior corticosteroid therapy in this cohort of critically ill patients.

Aspergillus identification through bronchoscope in intensive care unit - a retrospective, databased cohort study

Introduction

Invasive pulmonary aspergillosis (IPA) increases the risk of mortality of critically ill patients. Diagnostic criteria specifically targeting patients in intensive care units(ICUs) have been developed to improve diagnostic sensitivity. This study investigated health outcomes among patients in ICUs with Aspergillus isolates identified using bronchoscopy.

Methods

This retrospective cohort study obtained data from the Chang Gung Research Database of Chang Gung Memorial Hospital. Patients admitted to the ICU between January 2017 and December 2022 who received bronchoalveolar lavage were enrolled. Patients with a fungus culture yielding Aspergillus spp. isolates or who had an Aspergillus galactomannan antigen index value of >1.0 were categorized into the Aspergillus-positive group.

Results

A total of 2372 patients were enrolled, and 146 patients (6.16%) tested positive for Aspergillus. Of the patients who tested positive for Aspergillus, 37.67% had a positive culture result, and 77.4% had a positive galactomannan antigen result. Patients with Aspergillus isolates were more likely to have a recent influenza infection, concurrent bacterial sepsis, and a cavitation and to die in hospital (in-hospital mortality rate 58.9% vs. 48.57%, P = 0.016).

Discussion

Identifying Aspergillus through bronchoscopy in the ICU is associated with higher mortality rates than in patients who test negative for Aspergillus. Galactomannan antigen from bronchoalveolar lavage may provide higher diagnostic sensitivity.

Audit for antifungal treatment usage in adults with invasive fungal infection: A prospective observational study

OBJECTIVE

The antifungal audit aimed to evaluate antifungal usage in a tertiary care center. It focused on patient profiles, the appropriateness of antifungal use, associated adverse drug reactions, reasons for suboptimal usage, and the economic burden caused by prolonged non-optimal antifungal use.

METHODOLOGY

Conducted at All India Institute of Medical Sciences, New Delhi, India from January 2019 to December 2020, the study evaluated systemic antifungal use in 100 hospitalized adults with invasive fungal infections. Data collected included patient characteristics, evidence of disease, antifungal agents used, drug ADRs, appropriateness, and economic impact. Antifungal use was assessed using a predefined score (score <10 considered non-optimal), and ideal therapy duration was calculated based on treatment guidelines (IDSA & ECIL).

RESULTS

Optimal antifungal use was observed in 66.0 % of cases. Common reasons for non-optimal use included alternate drug selection (18 %), inappropriate dosage (12 %), lack of adjustment after microbiological results (14 %), and incorrect therapy duration (16 %). Targeted antifungal therapy was observed in 39 out of 100 patients, while pre-emptive antifungal therapy was used in 32 out of 100 patients. Voriconazole (35.1 %), caspofungin (23.1 %), and liposomal amphotericin B (20.1 %) were commonly prescribed. Liposomal amphotericin B had the highest adverse reaction rate (81.4 %). The total cost of antifungal therapy for 100 patients was ₹67,06,840 (approximately 80,350 $), with non-optimal prolonged therapy leading to an additional economic burden of ₹1,149,191 (approximately 13,841 $). Overall, 748 (39.7 %) day of therapy were non-optimal, contributing to 17.1 % of the total cost of antifungal therapy.

CONCLUSION

We observed non-optimal use of antifungal agents in 34 % of the study participants. The study results show that the antifungal audit enhances stewardship by pinpointing causes of non-optimal use, ensuring adherence to prescribing standards, optimizing clinical outcomes, and minimizing drug-related toxicities in tertiary care centres.

Is a Consensus Case Definition for Viral Associated Lower Respiratory Tract Disease (LRTD) in Clinical Trials Possible?

Lower respiratory tract illness or disease (LRTI/LRTD) represents a significant source of morbidity and mortality following viral respiratory illnesses, yet a consensus definition for this outcome is lacking. Recent studies of novel vaccines against respiratory syncytial virus (RSV) for older adults used LRTI/LRTD as the primary outcome to assess vaccine efficacy. However, the different vaccine trials have used highly variable criteria to define this outcome, leading to difficulty in comparison of vaccine efficacy results between trials. Here we review the key differences in criteria for case definitions, highlight strategies to best approximate compatibility between definitions, and review vaccine efficacy results among currently US Food and Drug Administration (FDA)-approved vaccines using these strategies. We hope this overview will support the need to develop a consensus definition for LRTI/LRTD to improve future research related to viral respiratory disease.

Antifungal Prophylaxis and Treatment of Breakthrough Invasive Fungal Diseases in High-Risk Hematology Patients: A Prospective Observational Multicenter Study

We aimed to investigate the approaches for antifungal prophylaxis (AFP) and antifungal treatment in breakthrough invasive fungal diseases (IFDs) under AFP in high-risk hematology patients. Patients ≥ 18-years who received chemotherapy for acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL) or a conditioning regimen for allogeneic hematopoietic stem cell transplantation (AHSCT) with a duration of neutropenia (< 500 cells/mm3) ≥ 10 days were included in a prospective multicenter observational study. Patients were followed until one week after recovery from neutropenia, discharge from the hospital, or death, which comes first to define the success of AFP. A total of 230 patients were recruited from 18 centers in seven months. Posaconazole prophylaxis was used in 134 (44 of whom failed) and 96 patients received fluconazole (28 of whom failed). The survival rate at 12 weeks after the initiation of AFP was higher in patients with successful prophylaxis (96.2% vs 56.9%, p < 0.001). IFDs were diagnosed in 27 patients. Duration of neutropenia was the only risk factor (OR: 1.03; 95% CI: 1.004-1.053) for development of IFDs. The types of breakthrough IFDs were; possible IFD in 15 patients, probable invasive aspergillosis (IA) in 9 patients, proven IA in 2 patients; and proven mucormycosis in 1 patient. Voriconazole was the drug of choice in 16 patients (5 of whom failed). Liposomal amphotericin B was used in the treatment of 8 patients (4 of whom failed). Posaconazole was the most frequently prescribed AFP in AML patients with high compliance to international guidelines. Approximately, one-third of ALL patients and AHSCT recipients received off-label posaconazole prophylaxis.

Establishment and Validation of a Machine-Learning Prediction Nomogram Based on Lymphocyte Subtyping for Intra-Abdominal Candidiasis in Septic Patients

This study aimed to develop and validate a nomogram based on lymphocyte subtyping and clinical factors for the early and rapid prediction of Intra-abdominal candidiasis (IAC) in septic patients. A prospective cohort study of 633 consecutive patients diagnosed with sepsis and intra-abdominal infection (IAI) was performed. We assessed the clinical characteristics and lymphocyte subsets at the onset of IAI. A machine-learning random forest model was used to select important variables, and multivariate logistic regression was used to analyze the factors influencing IAC. A nomogram model was constructed, and the discrimination, calibration, and clinical effectiveness of the model were verified. High-dose corticosteroids receipt, the CD4+T/CD8+ T ratio, total parenteral nutrition, gastrointestinal perforation, (1,3)-β-D-glucan (BDG) positivity and broad-spectrum antibiotics receipt were independent predictors of IAC. Using the above parameters to establish a nomogram, the area under the curve (AUC) values of the nomogram in the derivation and validation cohorts were 0.822 (95% CI 0.777-0.868) and 0.808 (95% CI 0.739-0.876), respectively. The AUC in the derivation cohort was greater than the Candida score [0.822 (95% CI 0.777-0.868) vs. 0.521 (95% CI 0.478-0.563), p < 0.001]. The calibration curve showed good predictive values and observed values of the nomogram; the Decision Curve Analysis (DCA) results showed that the nomogram had high clinical value. In conclusion, we established a nomogram based on the CD4+/CD8+ T-cell ratio and clinical risk factors that can help clinical physicians quickly rule out IAC or identify patients at greater risk for IAC at the onset of infection.

Effectiveness and safety of the simulation-based first-dose design of voriconazole

BACKGROUND

We investigated whether the initial voriconazole (VRCZ) dosing design, as determined using simulation software with a population pharmacokinetic model of Japanese patients, impacts the effectiveness and safety when compared with VRCZ initiation according to the package insert.

METHODS

In this single-center retrospective observational study, we employed records from Tosei General Hospital (a 633-bed hospital), dated April 2017 to September 2023. Eligible patients were divided into the software-based simulation group, comprising patients administered initial VRCZ dosage adjustment by pharmacists using software-based simulation, and the standard therapy group, whose dosage was administered by a physician following the package insert recommendations without simulation. The primary objective of this study was to determine the efficacy of VRCZ first-dose design in reducing the incidence of hepatotoxicity and visual symptoms.

RESULTS

The median ages of enrolled participants (n = 93) were 75 (68-79) and 72 (65-78) years in the software-based simulation and standard therapy groups, respectively. Regardless of formulation, initial trough concentrations were lower in the VRCZ software-based first dosage adjustment group and higher rate within the appropriate range (1-4 μg/mL). The incidence of all-grade hepatotoxicity or visual symptoms was significantly lower in the software-based simulation group. The log-rank test revealed a significant impact on the occurrence of ≥grade 2 hepatotoxicity in the software-based first dosage adjustment group compared to that in the standard therapy group.

CONCLUSIONS

The initial VRCZ dosing design using simulation software improved the achievement of appropriate initial trough concentrations and resulted in fewer occurrences of hepatotoxicity (≥grade 2) when compared with the standard therapy.

Acute Infusion-Related Side Effects of Amphotericin B Lipid Complex (ABLC) in Oncohematological Patients: Real-World Data from Brazilian Reference Centers

INTRODUCTION

Amphotericin B lipid complex (ABLC) is an effective antifungal agent for treating invasive fungal infections (IFIs) even though its formulation is associated with potential adverse events, including those related to its infusion. This study aimed to analyze the incidence of acute infusion-related side effects (IRSE) associated with ABLC and their relationship with the profile of patients with oncohematological disease admitted in Brazilian reference tertiary hospitals.

METHODS

This is an observational retrospective study that included clinical records of patients hospitalized, in a period of 6 years, diagnosed with probable or proved IFI and treated with at least two doses of ABLC.

RESULTS

A total of 229 patients were included, with a male prevalence and an average age of 44 years for adults and 10 years for children. Seventy-nine (34.5%) developed some IRSE, 5.1% of which progressed in severe form to discontinuation of treatment. The most prevalent events in adults were fever (66.7%), tremor/chills (53.3%), and tachycardia (24.4%). In children, the most common were fever (64.7%), tremors/chills (50%), and skin rash/itching (17.6%). Statistical significance was found for premedication use from the first dose of ABLC in relation to the onset of infusion reactions (P = 0.006). Multivariate analysis revealed that ABLC, when compared to liposomal AMB (L-AMB), and neutropenia were associated with a higher risk of developing IRSE (odds ratio [OR] 3.04, P = 0.008; and OR 11.02, P = 0.025, respectively).

CONCLUSIONS

The use of premedication was a protective factor against the occurrence of IRSE. Therefore, services providing amphotericin B (AMB) must reinforce protocols or implement new measures that optimize tolerability and safety during the treatment of patients with oncohematological disease, with special attention to patients with neutropenia, prioritizing the liposomal formulation of AMB whenever possible.

Presentation and Outcomes of Histoplasmosis in Transplant Recipients: A Retrospective Single-Centre Cohort Study

BACKGROUND

Histoplasmosis is an important infection among transplant recipients. Few studies have described its epidemiology and outcomes in the modern era.

METHODS

We conducted a retrospective analysis using medical records from a single center in the United States. We included patients 18 years or older with histoplasmosis. We divided the cohort into transplant recipients and immunocompetent groups to assess the outcomes in both groups. We utilized Cox hazard models to assess 90-day all-cause mortality.

RESULTS

The study included 137 patients; with 28 (20%) transplant recipients. After the first year post-transplant, patients with lung transplant (30%) had a diagnosis of histoplasmosis. Transplant recipients exhibited a significantly higher incidence of disseminated histoplasmosis than immunocompetent patients (64% vs. 34%, p = 0.001), higher admission to ICU (39% vs. 16%; p = 0.01) and higher but not significant 90-day crude all-cause mortality (14% vs. 11%, p = 0.71). Patients with transplants had a higher, but not significant hazard of all-cause mortality at 90 days (hazard ratio: 1.5; 95% confidence interval: 0.4-3.9) when compared to immunocompetent patients.

CONCLUSION

Transplant recipients were more commonly diagnosed with histoplasmosis after the first year post-transplantation, and although they exhibited a higher hazard for death at 90 days, this increase was not statistically significant.

Diagnosis and management of invasive fungal diseases by next-generation sequencing: are we there yet?

INTRODUCTION

Invasive fungal diseases (IFDs) are a serious threat to immunocompromised patients. Routine diagnostic methods have limited performance in identifying IFDs. Next-generation sequencing (NGS), including metagenomic NGS (mNGS) and whole-genome sequencing (WGS), recently emerged as diagnostic methods that could provide more accurate and timely diagnoses and management of IFDs.

AREAS COVERED

This article describes the emergence of NGS as a diagnostic tool to address the limitations of current tests. The literature regarding its application and clinical utility in the diagnosis of IFDs is reviewed. Practical considerations, challenges, and opportunities as they relate to the development and implementation of mNGS and WGS for fungal pathogens are discussed.

EXPERT OPINION

NGS emerged over a decade ago with the potential to solve many of the challenges in diagnosing infectious diseases, including IFDs. However, published literature has yielded conflicting data about its clinical utility. The increased clinical adoption of NGS is improving our understanding of how to interpret and use its results to guide actionable decisions. Still, several gaps remain. As the cost, effort, and expertise involved in performing NGS decrease and the reporting of its results becomes standardized, NGS is poised to fill current gaps in the diagnosis of IFDs.

Predicting intra-abdominal candidiasis in elderly septic patients using machine learning based on lymphocyte subtyping: a prospective cohort study

Objective

Intra-abdominal candidiasis (IAC) is difficult to predict in elderly septic patients with intra-abdominal infection (IAI). This study aimed to develop and validate a nomogram based on lymphocyte subtyping and clinical factors for the early and rapid prediction of IAC in elderly septic patients.

Methods

A prospective cohort study of 284 consecutive elderly patients diagnosed with sepsis and IAI was performed. We assessed the clinical characteristics and parameters of lymphocyte subtyping at the onset of IAI. A machine-learning random forest model was used to select important variables, and multivariate logistic regression was used to analyze the factors influencing IAC. A nomogram model was constructed, and the discrimination, calibration, and clinical effectiveness of the model were verified.

Results

According to the results of the random forest and multivariate analyses, gastrointestinal perforation, renal replacement therapy (RRT), T-cell count, CD28+CD8+ T-cell count and CD38+CD8+ T-cell count were independent predictors of IAC. Using the above parameters to establish a nomogram, the area under the curve (AUC) values of the nomogram in the training and testing cohorts were 0.840 (95% CI 0.778-0.902) and 0.783 (95% CI 0.682-0.883), respectively. The AUC in the training cohort was greater than the Candida score [0.840 (95% CI 0.778-0.902) vs. 0.539 (95% CI 0.464-0.615), p< 0.001]. The calibration curve showed good predictive values and observed values of the nomogram; the DCA results showed that the nomogram had high clinical value.

Conclusion

We established a nomogram based on the T-cell count, CD28+CD8+ T-cell count, CD38+CD8+ T-cell count and clinical risk factors that can help clinical physicians quickly rule out IAC or identify elderly patients at greater risk for IAC at the onset of infection.

Clinical Trial Registration

[chictr.org.cn], identifier [ChiCTR2300069020].

CT imaging findings of invasive pulmonary fungal infections in hemato-oncologic children

Hemato-oncologic children form a heterogeneous group with a wide spectrum of ages, malignancy types, and immunosuppression grades during the different phases of their treatment. Immunosuppression is caused by multiple factors, including the malignancy itself, bone marrow suppression secondary to therapy, and wide use of steroids and antibiotics, among others. At the same time, the risk of infections in these patients remains high because of prolonged hospitalizations or the need for long-timing implanted devices between other features. In this context, a pulmonary fungal infection can rapidly turn into a life-threatening condition that requires early diagnosis and appropriate management. This pictorial essay illustrates the main imaging findings detected in chest computed tomography examinations performed in pediatric hemato-oncologic patients with proven pulmonary invasive fungal infections caused by Candida, Aspergillus, or Mucor. In addition, it describes useful clues for limiting differential diagnoses, reviews the literature on pediatric patients, and compares imaging findings in adults and children. CRITICAL RELEVANCE STATEMENT: The main fungal pathogens causing invasive fungal infections (IFI) in hemato-oncologic children are Candida, Aspergillus, and Mucor. This review describes the most frequently affected organs and the most common imaging findings detected in chest CT exams in children with pulmonary IFI. KEY POINTS: To review the main computed tomography imaging findings suggesting pulmonary invasive fungal infection (IFI) in hemato-oncologic children. To describe differences between pediatric and adult patients with proven pulmonary IFI. To provide useful clues for limiting the differential diagnosis of pulmonary IFI in pediatric patients.

Safety, outcomes, and pharmacokinetics of isavuconazole as a treatment for invasive fungal diseases in pediatric patients: a non-comparative phase 2 trial

Invasive aspergillosis (IA) and mucormycosis (IM) cause significant morbidity and mortality in immunocompromised and/or hospitalized patients. Isavuconazonium sulfate, a prodrug of the antifungal triazole isavuconazole, has been approved for treatment of IA and IM in adults; and was recently approved in children. This study describes the outcomes, safety, and pharmacokinetics of isavuconazole for the treatment of proven, probable, or possible IA or IM in children. In this phase 2, open-label, non-comparative study, patients aged 1 to <18 years with at least possible invasive mold disease were enrolled across 10 centers in the US, Spain, and Belgium from 2019 to 2022. Patients received 10 mg/kg isavuconazonium sulfate daily (maximum 372 mg; equivalent to 5.4 mg/kg or 200 mg isavuconazole) for up to 84 (IA) or 180 days (IM). Outcomes included rates of all-cause case fatality, overall response, treatment-emergent adverse events (TEAEs), and pharmacokinetics. Of 31 patients enrolled, 61.3% were 1-<12 years old; 58.1% had underlying hematologic malignancies. The successful overall response rate at the end of treatment was 54.8%. Day 42 all-cause case fatality was 6.5%; 93.5% experienced TEAEs, and two patients discontinued treatment due to drug-related TEAEs. Dosing at 10 mg/kg (maximum dose: 372 mg) met the pre-defined exposure threshold of above the 25th percentile for the area under the concentration-time curve (≥60 mg·h/L). Simulated doses of 15 mg/kg improved drug exposures in patients aged 1-<3 years. Isavuconazole was well tolerated in children, with exposure consistent with adult studies. Successful response was documented in 54.8% of patients.CLINICAL TRIALSThis study is registered at ClinicalTrials.gov as NCT03816176.

Clinical features and risk factors of invasive pulmonary aspergillosis in interstitial lung disease patients

BACKGROUND

The prevalence of invasive pulmonary aspergillosis (IPA) among patients with interstitial lung disease (ILD) is steadily increasing, leading to high mortality. The purpose of this study is to analyze the clinical features and risk factors of IPA in patients with ILD.

METHODS

353 hospitalized ILD patients admitted in Nanjing Drum Tower Hospital from March 2023 and April 2024 were enrolled. The enrolled patients were divided into the IPA group (proven and probable IPA) and non-IPA group, and the clinical characteristics and prognosis were compared between the two groups.

RESULTS

Among 353 patients with ILD, 58 who suffered from IPA were identified. Among them, 2 (3.4%) episodes of proven IPA and 56 (96.6%) of probable IPA were diagnosed. The median age was 68.4 ± 8.6 years, and 35 patients were men. The forms of ILD included idiopathic pulmonary fibrosis (n = 21), interstitial pneumonia with autoimmune features (n = 13), rheumatoid arthritis related interstitial pneumonia (n = 11) and Sjögren's syndrome (n = 4). The clinical features of IPA in ILD were cough (100.0%), dyspnea (93.1%) and fever (55.2%). Chest CT images showed reticulation (87.9%), traction bronchiectasis (84.5%), GGO (77.6%), honeycombing (69.0%), consolidation (44.8%) and pleural effusion (24.1%). The incidence of honeycombing and consolidation were higher in ILD patients with IPA compared to control group (P < 0.05). The main pathogens were A. fumigatus (50.0%) and A. flavus (29.3%). Following the diagnosis of IPA, all patients were treated with antifungal drugs. The overall survival rate after 90 days was 74.1%. Multivariate conditional Logistic regression analysis showed that lymphopenia (OR = 2.745, 95% CI 1.344-5.607) and honeycombing (OR = 2.915, 95% CI 1.429-5.949) were the risk factors of ILD with IPA (P < 0.05).

CONCLUSION

IPA is one of the major complications of ILD and its prognosis is poor. Lymphopenia and honeycombing increased the risk of IPA in ILD patients.

The clinical impact of primary granulocyte-colony stimulating factor prophylaxis in children with acute lymphoblastic leukemia who underwent induction chemotherapy

BACKGROUND

Data describing the risk factors for the occurrence of severe infections in acute lymphoblastic leukemia (ALL) patients following induction chemotherapy and the role of prophylactic granulocyte-colony stimulating factor (G-CSF) in the era of antimicrobials prophylaxis are limited.

METHODS

This study enrolled 188 children aged ≤18 years with newly diagnosed ALL who received Taiwan Pediatric Oncology Group ALL-2002 and 2013 treatments between January 1, 2010 and June 30, 2021. Prophylactic G-CSF was administered when a patient continues neutropenia after achieving the first bone marrow remission since June 1, 2015. Clinical factors were assessed for their association with severe infections.

RESULTS

From January 2010 to May 2015, 80 children experienced a total of 11 (13.5%) episodes of severe infections; while 10 (9.2%) episodes were reported to occur in 108 patients who received prophylactic G-CSF. Reduction of severe infections occurrence did not achieve statistical significance during prophylactic G-CSF administration in ALL patients. Compared with ALL-high risk (HR) and very high risk patients with no G-CSF prophylaxis, the use of G-CSF prophylaxis significantly reduced episodes of febrile neutropenia. Occurrence of grade III-IV intestinal ileus, grade II-III oral mucositis, prolonged neutropenia, central venous catheter (CVC) placement, or the requirement insulin therapy for hyperglycemia were associated with higher risk of bloodstream infections.

CONCLUSIONS

ALL-HR patients with G-CSF prophylaxis were associated with reduction of febrile neutropenia episodes. Occurrence of severe ileus, oral mucositis, hyperglycemia, CVC placement, or prolonged neutropenia were associated with severe infections in ALL patients receiving induction chemotherapy.

Microcosting analysis of haematopoietic stem cell transplantation and chemotherapy with intermediate doses of cytarabine in the treatment of acute myeloid leukaemia

BACKGROUND

Acute myeloid leukaemia (AML) is considered a costly disease. Depending on the risk stratification, the patient may receive consolidation with cycles of intermediate doses of cytarabine, auto-HSCT or allo-HSCT according to availability in each service and the availability of a compatible donor. Literature data indicate that safety and effectiveness do not differ between consolidation therapy with intermediate-dose cytarabine or auto-HSCT, and so the cost can help physicians and health managers in their choice.

METHOD

The cost of the second consolidation was compared in 18 to 60-year-old patients with de novo AML who were included in the International Consortium of Acute Myeloid Leukaemia (ICAML) protocol. Patients treated with auto-HSCT or intermediate doses of cytarabine (IDAC) were analysed during four years using the microcosting methodology.

RESULTS

The mean costs for auto-HSCT and IDAC were BRL$ 34,900.95 (range: 23,611.36-41,229.59) and 15,231.64 (range: 6,546.36-23,253.53), respectively. The mean duration of in-hospital stay was 88.4 (93-133) and 94 (50-153) days, respectively. The mean cost of the four cycles of treatment was BRL$ 114.212,78 for auto-HSCT and BRL$ 121.980,93 for the chemotherapy group. Regardless of the type of treatment, the input that had the greatest economic impact was hospital admission, mainly due to infections.

CONCLUSION

Auto-HSCT had a lower average cost per patient and hospitalization rate than chemotherapy.

Novel intervention based on an individualized bundle of care to decrease infection in kidney transplant recipients

BACKGROUND

Infection remains a relevant complication after kidney transplantation (KT). A well-established strategy in modern medicine is the application of bundles of evidence-based practice in clinical settings. The objective of this study is to explore the application of a personalized bundle of measures aimed to reduce the incidence of infection in the first 12 months after KT.

METHODS

A single-center prospective cohort of 148 patients undergoing KT between February 2018 and September 2019 that received an individualized infection prevention strategy was compared to a preintervention cohort (n = 159). The bundle comprised a review of the patient's immunization history, infection risk by country of origin, screening for latent tuberculosis infection (LTBI), antimicrobial prophylaxis, and immunological assessment. Individualized recommendations were accordingly provided at a scheduled visit at day +30 after transplantation.

RESULTS

The intervention cohort showed a higher compliance rate with the recommended vaccine schedule, screening for geographically restricted infections and LTBI, and intravenous immunoglobulin and vitamin D supplementation (p values <.001). The 1-year incidence rate of infection was lower in the intervention cohort (42.6% vs. 57.9%; p value = .037), as was the rate of infection-related hospitalization (17.6% vs. 32.1%; p value = .003) and the incidence of severe bacterial infection. There were no differences in graft rejection or mortality rates between groups.

CONCLUSIONS

A multifaceted intervention, including a bundle of evidence-based practices, enhanced compliance with recommended preventive measures and was correlated with a reduction in the 12-month incidence of infection after KT.

Invasive fungal infections are rare in pediatric and young adult autologous hematopoietic stem cell transplant patients

BACKGROUND

Pediatric and young adult patients undergoing autologous hematopoietic stem cell transplant (auto-HSCT) face a crucial, yet understudied, risk of invasive fungal infections (IFI), especially compared to allogeneic transplants. This gap underscores the need for research in pediatric patients undergoing auto-HSCT. Our objective was to evaluate the incidence of IFI in pediatric and young adult patients during the first year after auto-HSCT.

MATERIALS AND METHODS

We conducted a single-center retrospective analysis of 150 pediatric and young adult auto-HSCT patients who underwent transplant from January 2013 to January 2023. We focused on IFI incidence within the first-year post transplant, using the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria for IFI identification.

RESULTS

Among the 150 patients analyzed, with 240 unique transplant episodes, the primary indication was neuroblastoma (37.3%), and micafungin was extensively used for prophylaxis (82.7%). There was an absence of IFI from yeast and mold species, suggesting a low IFI risk in this cohort. The incidence of IFI in pediatric auto-HSCT recipients receiving micafungin primary antifungal prophylaxis is rare.

CONCLUSIONS

The findings advocate for further research to refine prophylaxis guidelines and highlight the need for individualized risk assessment to optimize post-transplant care.

Refractory fungal infection: Three case reports highlighting good practice

Refractory invasive fungal disease is a significant clinical problem, with high morbidity, mortality and costs. The complex causes of refractory infection include breakthrough infection due to antifungal resistance (both innate and acquired), suboptimal therapy and impaired immune responses in critically ill or immunocompromised patients. This case series details three reports on the identification and management of refractory fungal infections, two cases of azole resistance and one case of resistant candidiasis, highlighting the importance of accurate diagnosis, monitoring, implementation of biomarkers (serological markers, PCR), antifungal susceptibility testing and antifungal stewardship to optimise management and minimise risks of emergence of drug resistance.

The prophylactic application of low-dose rabbit antithymocyte globulin in matched siblings HSCT with high-risk factors for graft-versus-host disease

Relapse and graft-versus-host disease (GVHD) are currently the predominant causes of mortality post allogeneic hematopoietic stem cell transplantation (allo-HSCT). The contentious use of antithymocyte globulin (ATG) for preventing GVHD in matched sibling HSCT scenarios has been a topic of significant debate. A retrospective analysis was conducted on matched sibling HSCT cases with high-risk factors for GVHD in our center from January 2018 to June 2023. Our assessment revealed that the group administered with ATG exhibited a 30 % incidence of acute GVHD (aGVHD), in contrast to 81.8 % in the non-ATG cohort (P = 0.037) among matched sibling HSCT cases with high GVHD risk factors. Furthermore, chronic GVHD (cGVHD) occurred in 20 % of the ATG group and 72.7 % of the non-ATG group (P = 0.03). Notably, the administration of ATG did not significantly impact disease relapse (p = 0.149), infection rates (p = 0.64), granulocyte recovery time (p = 0.15), platelet recovery time (p = 0.12), overall survival (p = 0.889), or disease-free survival time (p = 0.787). The use of rabbit antithymocyte globulin (r-ATG) at a 5 mg/kg dosage demonstrated a notable reduction in aGVHD and cGVHD incidences within sibling matched HSCT cases with high-risk factors for GVHD, without increasing rates of disease recurrence or infections. These findings highlight the potential benefit of using low-dose r-ATG in high-risk of GVHD sibling matched allogeneic HSCTs, although further validation with a larger cohort is necessary.

Effectiveness, Safety, and Patterns of Real-World Isavuconazole Use in Europe (2015-2019)

INTRODUCTION

Real-world data from multinational observational studies are required to better understand the role and performance of isavuconazole in real-world practice in Europe.

METHODS

A retrospective medical record review was conducted at 16 sites in Europe (France, Germany, Italy, Spain, and the United Kingdom). Eligible records were from patients aged ≥ 18 years at the time of isavuconazole initiation and received at least one dose of isavuconazole for suspected or confirmed invasive aspergillosis (IA) or invasive mucormycosis (IM) during the eligibility period (October 15, 2015 to June 30, 2019). Data were descriptively analysed. Success rates, overall survival, and times to these events were descriptively analysed.

RESULTS

Data were abstracted from 218 patients (201, IA; 17, IM) who received isavuconazole as monotherapy (initiated as infusion, 52%; oral, 46%). Isavuconazole was initiated as primary therapy in 92 patients (42.2%) and salvage therapy in 121 patients (55.5%) (unknown for five patients). Mean (standard deviation) age was 56.8 (15.6) years, 66% were men and 62% had at least three comorbidities, most frequently haematologic malignancy (62%). Estimated clinical response rate at week 24 was 54.5% (95% confidence interval [CI], 38.2-66.5%) for primary treatment and 73.5% (95% CI, 62.7-81.1%) for salvage therapy. Overall, 45 patients (21%) experienced at least one adverse event (AE). Serious AEs were experienced by 37 patients (17%), with seven related to isavuconazole; five patients (2.3%) discontinued isavuconazole monotherapy due to the serious AE. A total of 137 patients (63%) died, with 17 deaths (12.4%) related to their invasive fungal infection, 11 of whom initiated isavuconazole as salvage therapy.

CONCLUSIONS

This study adds to the growing body of evidence that whether used as first-line therapy or after the failure of other antifungal therapies, isavuconazole appears to have a promising clinical response and a good safety profile as an antifungal agent in patients with varied underlying conditions.

Using staged tree models for health data: Investigating invasive fungal infections by aspergillus and other filamentous fungi

Machine learning models are increasingly used in the medical domain to study the association between risk factors and diseases to support practitioners in understanding health outcomes. In this paper, we showcase the use of machine-learned staged tree models for investigating complex asymmetric dependence structures in health data. Staged trees are a specific class of generative, probabilistic graphical models that formally model asymmetric conditional independence and non-regular sample spaces. An investigation of the risk factors in invasive fungal infections demonstrates the insights staged trees provide to support medical decision-making.

Antifungal prophylaxis in high-risk patients with hematologic malignancy: a comparison of practice and guidelines in Türkiye

Background/aim

Primary antifungal prophylaxis (AFP) is as considered the gold standard therapy for patients with hematologic malignancies based on the available guidelines. The aim behind this study was to investigate the level of guideline knowledge and the translation of guideline recommendations into real-life settings among physicians in Türkiye.

Materials and methods

In this prospective, observational study, the physicians' knowledge of AFP guideline recommendations for patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing first remission-induction (Group I) or graft-versus-host-disease (GvHD) after allogeneic stem cell transplant (Group II) was compared with clinical practice via an 11-item multiple-choice questionnaire evaluating the patients in whom AFP was initiated, the timing, the AFP duration, and the drugs used.

Results

The mean patient age was 48.3 years and 79% had AML/MDS. AFP was initiated in 75.3% of Group I patients on the first day of induction chemotherapy before baseline and in 26.2% of Group II patients at baseline. For 98.8% of the Group I patients, the physician's plan was to continue AFP until recovery from neutropenia and complete remission (CR), whereas it was to be used during immunosuppression in Group II. The median (IQR) duration of AFP was 0.8 (0.5-1.9) and 5.5 (2.4-8.1) months for Groups I and II, respectively. Breakthrough invasive fungal infections (bIFIs) were observed in 35.8% and 14.3% of Groups I and II, respectively.The mean survey scores were 8.5 ± 2.3 for the AML/MDS patient group and 9.9 ± 3.2 for the GvHD patient group. Most of the surveyed sites adhered to the guidelines from the European Conference on Infections in Leukemia (80.6%), followed by the fever and neutropenia guidelines of the Infectious Diseases Society of America (51.6%). Posaconazole was the drug of choice in both groups (96.8% in Group I vs. 71% in Groups II).

Conclusion

The data indicate an inconsistency between real-life clinical practice and the guideline recommendations for primary AFP and bIFI management in high-risk patients with hematologic malignancies in Türkiye.

A pilot study on nasal wash galactomannan as a surrogate marker for invasive aspergillosis among hematology patients in Thailand

Universal antifungal treatment has been recommended among hematology patients during chemotherapy to prevent invasive aspergillosis (IA) in developed countries, but it remains a significant challenge in resource-limited settings. Identifying at-risk individuals could enhance clinical outcomes. A prospective pilot study was conducted at four Thai tertiary care hospitals from April 2021 to January 2023, aiming to assess the correlation and the potential of nasal wash galactomannan (GM) as an IA predictor in hematology patients. It enrolled all patients with acute myeloid leukemia (AML) requiring induction chemotherapy and those admitted for stem cell transplantation (SCT). Nasal wash fluid samples were collected for galactomannan testing and fungal culture to assess Aspergillus spp. colonization before chemotherapy. The study included 34 AML and SCT patients. Among them, 3/34 tested positive for Aspergillus spp. colonization via nasal wash fungal culture. After six months, 18 (52.9%) patients were diagnosed with IA-15/25 patients with AML and 3/9 SCT recipients. The traditional culture did not predict IA, whereas nasal wash fluid galactomannan cutoff value of 0.46 yielded a sensitivity of 40% and a specificity of 80% for predicting probable and possible IA in patients with AML. However, in the subgroup analysis, the test did not reveal any correlation with IA development. More extensive studies are needed to validate the optimal IA risk prediction strategy.

Treatment of Invasive Pulmonary Aspergillosis and Preventive and Empirical Therapy for Invasive Candidiasis in Adult Pulmonary and Critical Care Patients. An Official American Thoracic Society Clinical Practice Guideline

BACKGROUND

The incidence of invasive fungal infections is increasing in immune-competent and immune-compromised patients. An examination of the recent literature related to the treatment of fungal infections was performed to address two clinical questions. First, in patients with proven or probable invasive pulmonary aspergillosis, should combination therapy with a mold-active triazole plus echinocandin be administered vs. mold-active triazole monotherapy? Second, in critically ill patients at risk for invasive candidiasis who are non-neutropenic and are not transplant recipients, should systemic antifungal agents be administered either as prophylaxis or as empiric therapy?

METHODS

A multidisciplinary panel reviewed the available data concerning the two questions. The evidence was evaluated, and recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

A conditional recommendation was made for patients with proven or probable invasive pulmonary aspergillosis to receive either initial combination therapy with a mold-active triazole plus an echinocandin or initial mold-active triazole monotherapy based on low-quality evidence. Further, a conditional weak recommendation was made against routine administration of prophylactic or empiric antifungal agents targeting Candida species for critically ill patients without neutropenia or a history of transplant based on low-quality evidence.

CONCLUSIONS

The recommendations presented in these Guidelines are the result of an analysis of currently available evidence. Additional research and new clinical data will prompt an update in the future.

Association of multilocus sequence typing, MSH2 gene mutations, and antifungal resistance in Candida glabrata: implications for clinical outcomes in Chinese hospitals

BACKGROUND

Candida glabrata is the second most common cause of invasive candidiasis worldwide. In this study, we determined the clinical characteristics and drug sensitivity of C. glabrata isolates and investigated the associations between MSH2 gene mutations, sequence types (ST), and drug resistance.

METHODS

A total of 154 C. glabrata isolates were collected from patients being treated in three hospitals in China. The antifungal sensitivity of the strains was assessed using the broth microdilution method. Multilocus sequence typing (MLST) was also performed, followed by MSH2 sequencing. The clinical features and outcomes of C. glabrata infection were analysed for a total of 49 strains, which were collected from patients with invasive Candida infection at Longhua Hospital.

RESULTS

All 154 isolates were found to be susceptible to amphotericin, 5-fluorocytosine, anidulafungin, caspofungin, and micafungin, whereas 11.7% were fluconazole-resistant, 18.8% were itraconazole non-wild type, and 35.7% were voriconazole non-wild type. ST7 (62.34%) was the most common ST genotype, followed by ST10 (16.88%) and ST15 (7.79%). The total azole resistance rates for all isolates, ST7, ST10, and other STs were 36.4, 42.7, 34.6, and 18.8%, respectively. The ST7 and ST10 isolates were characterised by a higher drug resistance rate than the other minor ST isolates. Moreover, 59.09% of isolates had one or more MSH2 non-synonymous mutations, with V239L being the most commonly detected mutation. The frequency of MSH2 mutations was significantly higher in azole-resistant isolates than in other isolates, whereas P6L or L87P mutations were associated with the highest azole resistance rates of up to 87.5% and 80%, respectively. Our results indicated that ST7 and ST15 are independent predictors of mortality caused by C. glabrata infection and revealed a higher 30-day mortality in patients infected with these strains than in those infected with other ST isolates.

CONCLUSIONS

Our findings revealed the relationships between MLST, MSH2 gene mutations, and drug resistance in the common pathogenic fungus C. glabrata, and thereby enabled us to identify strains that are associated with higher rates of mortality. These findings will contribute to enhancing our understanding of the pathogenesis of C. glabrata infection.

CAF to the Rescue! Potential and Challenges of Combination Antifungal Therapy for Reducing Morbidity and Mortality in Hospitalized Patients With Serious Fungal Infections

The global burden of invasive fungal disease is substantial and escalating. Combination antifungal therapy (CAF) may improve patient outcomes by reducing development of resistance, improving drug penetration and rate of fungal clearance, and allowing for lower and less toxic antifungal drug doses; yet, increased cost, antagonism, drug-drug interactions, and toxicity are concerns. Clinical practice guidelines recommend antifungal monotherapy, rather than CAF, for most invasive fungal diseases due to a lack of comparative randomized clinical trials. An examination of the existing body of CAF research should frame new hypotheses and determine priorities for future CAF clinical trials. We performed a systematic review of CAF clinical studies for invasive candidiasis, cryptococcosis, invasive aspergillosis, and mucormycosis. Additionally, we summarized findings from animal models of CAF and assessed laboratory methods available to evaluate CAF efficacy. Future CAF trials should be prioritized according to animal models showing improved survival and observational clinical data supporting efficacy and safety.

Identifying Gaps in the International Consensus Case Definitions for Invasive Aspergillosis: A Review of Clinical Cases Not Meeting These Definitions

Background

International consensus definitions for invasive aspergillosis (IA) in research are rigorous, yet clinically significant cases are often excluded from clinical studies for not meeting proven/probable IA case definitions. To better understand reasons for the failure to meet criteria for proven/probable infection, we herein review 47 such cases for their clinical and microbiological characteristics and outcomes.

Methods

Data on 47 cases that did not meet consensus IA definitions but were deemed significant were derived from a retrospective, observational, multicenter survey of 382 presumed IA cases across Australasia, of which findings of 221 proven/probable infections were recently published. The clinical, microbiological, and radiologic characteristics of these cases were analyzed. Mortality outcomes were compared with those of 221 proven/probable cases.

Results

Of 47 cases studied, 15 lacked classical host factors; 22 exhibited only a single positive Aspergillus polymerase chain reaction result; 7 lacked typical IA radiologic findings on chest computed tomography; and 3 had borderline galactomannan optical density indices (<1.0 but ≥0.5) in bronchoalveolar lavage fluid. The median age of patients was 61 years (IQR, 52-68); 34 were male (72%). Seven patients (15%) required intensive care admission. All patients had lung as the primary site of infection. Antifungal treatment was initiated in 42 patients (89%). All-cause 90-day mortality was 33%, similar to the 30% mortality in the comparative cohort (n = 221).

Conclusions

Our findings highlight the limitations of current consensus definitions for IA. Notably, the mortality of patients not meeting these definitions was similar to that of patients with proven/probable IA. Further studies, especially of patients with a single positive Aspergillus polymerase chain reaction result and those without host factors, are needed to determine if future consensus definitions may benefit from modifications.

[An invasive cutaneous aspergillosis during a granulomatosis with polyangiitis]

INTRODUCTION

Aspergillosis is an opportunistic infection that can complicate any situation of immunosuppression. The primary manifestations are pulmonary, and more rarely, in cases of severe immunosuppression, the infection can become invasive with extra-pulmonary involvement.

OBSERVATION

We report the case of a 76-year-old female patient, experiencing a relapse of granulomatosis with polyangiitis treated with corticosteroids, rituximab and cyclophosphamide, who presented with diffuse erythematous nodular skin lesions. A biopsy with histological analysis confirmed a diagnosis of invasive cutaneous aspergillosis. Treatment with voriconazole led to a favorable outcome.

CONCLUSION

The appearance of skin lesions in an inflammatory context in a patient receiving immunosuppressive therapy should prompt a comprehensive microbiological assessment for opportunistic pathogens, as well as a skin biopsy to investigate for invasive cutaneous aspergillosis.

Invasive aspergillosis in liver transplant recipients in the current era

Invasive aspergillosis (IA) is a rare but fatal disease among liver transplant recipients (LiTRs). We performed a multicenter 1:2 case-control study comparing LiTRs diagnosed with proven/probable IA and controls with no invasive fungal infection. We included 62 IA cases and 124 matched controls. Disseminated infection occurred only in 8 cases (13%). Twelve-week all-cause mortality of IA was 37%. In multivariate analyses, systemic antibiotic usage (adjusted odds ratio [aOR], 4.74; P = .03) and history of pneumonia (aOR, 48.7; P = .01) were identified as independent risk factors associated with the occurrence of IA. Moreover, reoperation (aOR, 5.99; P = .01), systemic antibiotic usage (aOR, 5.03; P = .04), and antimold prophylaxis (aOR, 11.9; P = .02) were identified as independent risk factors associated with the occurrence of early IA. Among IA cases, Aspergillus colonization (adjusted hazard ratio [aHR], 86.9; P < .001), intensive care unit stay (aHR, 3.67; P = .02), disseminated IA (aHR, 8.98; P < .001), and dialysis (aHR, 2.93; P = .001) were identified as independent risk factors associated with 12-week all-cause mortality, while recent receipt of tacrolimus (aHR, 0.11; P = .001) was protective. Mortality among LiTRs with IA remains high in the current era. The identified risk factors and protective factors may be useful for establishing robust targeted antimold prophylactic and appropriate treatment strategies against IA.

Knowledge framework and emerging trends of invasive pulmonary fungal infection: A bibliometric analysis (2003-2023)

The rising number of immunocompromised people has increased concerns about fungal infections as a severe public health issue. Invasive pulmonary fungal infections (IPFIs) are prevalent and often fatal, particularly for those with weakened immune systems. Understanding IPFIs is crucial. The work aims to offer a concise overview of the field's characteristics, main research areas, development paths, and trends. This study searched the Web of Science Core Collection on June 5, 2024, collecting relevant academic works from 2003 to 2023. Analysis was conducted using CiteSpace, VOSviewer, Bibliometrix Package in R, Microsoft Excel 2019, and Scimago Graphica. The study indicated that the USA, the University of Manchester, and Denning DW led in productivity and impact, while the Journal of Fungi topped the list in terms of publication volume and citations. High-frequency terms include "fungal infection," "invasive," "diagnosis," and "epidemiology." Keyword and trend analysis identified "influenza," "COVID-19," "invasive pulmonary aspergillosis," and "metagenomic next-generation sequencing" as emerging research areas. Over the last 2 decades, research on IPFI has surged, with topics becoming more profound. These insights offer key guidance on current trends, gaps, and the trajectory of IPFI studies.

Effectiveness of high efficiency particulate (HEPA) air condition combined with the antifungal prophylaxis on incidence, morbidity and mortality of invasive fungal infections in patients with acute myeloid leukemia: a retrospective single-center study

Introduction

Our monocentric and retrospective study aimed to investigate the clinical effectivity of HEPA filters in combination with the antifungal drug prophylaxis in patients with AML undergoing intensive chemotherapy and allogeneic stem cell transplantation (SCT).

Methods/Results

We included 177 patients between 2005 and 2015 representing a total of 372 in-hospital stays, 179 in the HEPA cohort (+HEPA) and 193 in the cohort without HEPA filters (-HEPA). No significant additional benefit of HEPA filtration on the risk reduction of IFI was observed. HEPA filtration did not significantly affect the risk of intensive care unit (ICU) admissions or early mortality rates. In patients who received allogeneic SCT in first complete remission with antifungal drug prophylaxis during prior induction treatment, a numerical but not significant improvement in long-term overall survival was noted in the +HEPA cohort compared to the -HEPA cohort (55% to 66%, p = 0.396). For better depicting of the clinical reality, we determined the so-called clinical suspected IFI (csIFI) -defined as cases with antifungal treatment after recommended prophylaxis without fulfilling current EORTC criteria. Especially in patients with a high risk for second IFI, significant risk reduction of csIFI and frequency of ICU admissions was observed when voriconazole was used as secondary antifungal prophylaxis. (csIFI, adjusted effect: OR 0.41, 95% CI (0.21 - 0.82), p = 0.01; csIFI, subgroup-specific effect: OR 0.35, 95% CI (0.15 - 0.78), p = 0.01; ICU, adjusted effect: OR 0.44, 95 CI (0.19 - 1.01), p = 0.05; respectively).

Discussion

In summary, the study suggests the efficacy of secondary antifungal prophylaxis in preventing IFI in AML patients undergoing intensive treatment. The addition of HEPA filtration also demonstrated additional numerous benefits in reducing the frequency of IFI-associated complications.

Establishment and Validation of a Nomogram Clinical Prediction Model for Nosocomial Candidemia: An 18-Year Retrospective Analysis

Background

Nosocomial candidemia is a life-threatening condition, and the incidence has increased in recent years. Thorough epidemiological data is still lacking in China.

Methods

A retrospective cohort study was conducted to investigate the patients admitted to Zhongshan Hospital Xiamen University from 1 January 2004 to 31 December 2022. This study included 205 individuals who were diagnosed with candidemia as subjects. Additionally, 303 cases with blood cultures were negative during the same period and were from the same department as a control group. We randomly assigned them to the training and validation groups in a 7:3 ratio. The least absolute shrinkage and selection operator regression, univariate and multivariate logistic regression analyses were used to filtrate independent factors associated with nosocomial candidemia. A nomogram model was established based on the selected variables. Receiver operating characteristic (ROC) curve, calibration plots and decision curve analysis (DCA) were used to evaluate clinical utility.

Results

Two hundred and five nosocomial candidemia patients were reported, containing a high proportion of Candida albicans (n = 91,44.39%), followed by Candida parapsilosis (n = 40, 19.51%), Candida tropicalis (n = 37,18.05%), Candida glabrata (n = 23, 11.22%) and Candida guilliermondii (n = 9,4.39%). Multiple organ dysfunction syndrome (OR = 10.372, 95% CI: 4.745-24.14 P < 0.001), increased urea nitrogen of serum (OR=1.088,95% CI: 1.039-1.144 P<0.001), decreased albumin of serum (OR = 0.922 95% CI: 0.850-0.997 P=0.045), mechanical ventilation (OR=4.074,95% CI: 1.397-12.77 P=0.012), central venous indwelling catheter (OR=7.422,95% CI: 3.189-18.41 P<0.001) and solid tumor (OR = 3.036 95% CI: 1.276-7.359 P=0.012) were identified as independent risk factors of candidemia. The area under the curve (AUC) of the nomogram model was 0.925 (95% CI: 0.898-0.952) in the training group and 0.946 (95% CI: 0.881-0.963) in the validation group. The calibration curve revealed good agreement between the probability and the observed values. DCA indicated that this nomogram might be clinically beneficial.

Conclusion

The nomogram including multiple organ dysfunction syndrome, elevated blood urea nitrogen, decreased albumin, mechanical ventilation, central venous indwelling catheter and solid tumor could provide reference value to clinicians for identifying nosocomial candidemia.