Prospective surveillance for invasive fungal infections in hematopoietic stem cell transplant recipients, 2001-2006: overview of the Transplant-Associated Infection Surveillance Network (TRANSNET) Database

Toward Improving Initial Therapy of Acute Graft Versus Host Disease

Acute graft versus host disease (aGVHD) is a major complication of hematopoietic stem cell transplantation; it results from donor-derived immune response against host tissues and typically involves the liver, skin and the GI tract. The incidence of acute GVHD is declining due to the advances in HLA typing, reduced intensity conditioning and GVHD prophylaxis. However, corticosteroids remain the mainstay frontline treatment of aGVHD for many decades and as the number of allogeneic transplants continues to increase, there remains a large unmet need to improve frontline treatment for aGVHD. In this review, we outline risk factors, epidemiology and pathogenesis of aGVHD. We discuss the evolving risk stratification, beginning from the initial Gluckesberg system to more recent biomarker-based strategies. We summarize the completed trials that underpin current frontline management and outline future directions.

Invasive Fungal Disease in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation in China: A Multicenter Epidemiological Study (CAESAR 2.0)

BACKGROUND

This study (China Assessment of Antifungal Therapy in Hematological Diseases [CAESAR 2.0]) aimed to provide updated epidemiological data on invasive fungal disease (IFD) in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

This multicenter, real-world, observational study was conducted at 12 allo-HSCT centers in China between January and December 2021. Consecutive adult patients (aged ≥18 years) who underwent allo-HSCT with antifungal prophylaxis were included. IFD was diagnosed according to the 2019 criteria of the European Organization for Research and Treatment of Cancer and Mycoses Study Group (EORTC/MSG). Follow-up was completed by 31 December 2022.

RESULTS

A total of 2015 patients were included. Mold-active antifungal prophylaxis was used in 76.08%, most of whom received voriconazole (44.37%) or posaconazole (31.71%). The cumulative incidence of IFD (proven or probable) 1 year after allo-HSCT was 6.3%. Pathogens were identified in 47.97% of IFD cases and mainly included Candida spp. (17.89%), Mucorales (13.01%), Aspergillus spp. (8.94%), and Pneumocystis jirovecii (6.5%). Multivariate analysis identified the following factors associated with IFD: disease at advanced stage (hazard ratio, 2.55 [95% confidence interval, 1.58-4.12]; P < .001), absolute neutrophil count engraftment (≤28 days) (0.37 [15-.92]; P = .03), platelet engraftment (≤28 days) (0.41 [.27-.62]; P < .001), and acute graft-vs-host disease grade III-IV (2.97 [1.97-4.49]; P < .001). The IFD-attributable mortality rate was 48.28%.

CONCLUSIONS

Despite the widespread use of mold-active prophylaxis, the risk of IFD after allo-HSCT remains high. The most common pathogens are Candida spp., Mucorales, Aspergillus spp., and P. jirovecii.

CD3 + CD4 + T cells counts reflect the severity and prognosis of invasive pulmonary aspergillosis in patients with connective tissue disease-associated interstitial lung disease

OBJECTIVES

Invasive pulmonary aspergillosis (IPA) is a potentially fatal complication in patients with connective tissue disease-associated interstitial lung disease (CTD-ILD). The aim of this study is to investigate the clinical significance of CD3 + CD4 + T cells counts in CTD-ILD with IPA patients.

METHODS

This retrospective study included 152 CTD-ILD patients admitted to a single center in China between January 2018 and June 2020. A total of 54 CTD-ILD patients with IPA were assigned to the CTD-ILD with IPA group, while 98 uninfected CTD-ILD patients were assigned to the control group. Serum CD3 + CD4 + T cells counts were compared between the above-mentioned two groups, and the correlations between CD3 + CD4 + T cells counts and the clinical features, mortality of CTD-ILD with IPA were also evaluated.

RESULTS

CTD-ILD patients with IPA had significantly lower CD3 + CD4 + T cells counts than those with CTD-ILD without IPA (P < 0.001). The area under the receiver operating characteristic curve (AUROC) of discriminating CTD-ILD with IPA from CTD-ILD without IPA was 0.800 (95% CI, 0.722-0.878, P < 0.001). Correlation analyses showed that serum CD3 + CD4 + T cells counts were positively correlated with PaO2/FiO2 ratio(r = 0.317, P = 0.034) and negatively correlated with C reactive protein (CRP) (r = - 0.358, P = 0.009), erythrocyte sedimentation rate (ESR) (r = - 0.346, P = 0.014), and lactate dehydrogenase (LDH) (r = - 0.306, P = 0.026). In addition, 30 decedents with CTD-ILD infected IPA exhibited lower values of CD3 + CD4 + T cells compared with 24 survivors (P = 0.041). Furthermore, CD3 + CD4 + T cells counts were a prognostic factor and also associated with a higher mortality rate (log-rank test, P = 0.003).

CONCLUSION

CD3 + CD4 + T cells counts could be a useful serum indicator associated with occurrence of IPA in CTD-ILD. Moreover, decreased CD3 + CD4 + T cells counts were associated with a poor survival of IPA in CTD-ILD patients. Key Points • CTD-ILD patients with IPA had significantly lower CD3+CD4+T cells counts than those with CTD-ILD without IPA. • Correlation analyses showed that serum CD3+CD4+T cells counts were positively correlated with PaO2/FiO2 ratio and negatively correlated with C reactive protein (CRP), erythrocyte sedimentation rate (ESR) and lactate dehydrogenase (LDH). • Decreased CD3+CD4+T cells counts were associated with a poor survival of IPA in CTD-ILD patients.

The Dual Pathogen Fusarium: Diseases, Incidence, Azole Resistance, and Biofilms

The increasing resistance of Fusarium species to nearly all first-line antifungal agents in clinical settings has led to its designation as a 'high-priority' human pathogen. As a dual pathogen, Fusarium spp. threaten both human health and crop production, impacting food security. Our recent drug profiling of clinical Fusarium isolates reveals resistance to several front-line antifungals, with notable cross-azole resistance observed in both clinical and plant-associated strains. While the overuse of agricultural azoles has been implicated in the selection of azole-resistant fungi such as Aspergillus, a similar mechanism has been assumed for Fusarium in clinical settings. However, direct genetic evidence supporting this hypothesis remains limited. In this review, part of our Special Interest (SI) series, we discuss the spectrum of human diseases caused by Fusarium. While incidence data are better established for human keratitis and onychomycosis, invasive fusariosis remains globally underreported. We propose reasons for this distinct clinical spectrum bias and explore the potential genetic basis of azole resistance.

The first report of pseudoaneurysm secondary to Cunninghamella bertholletiae infection in a Haematopoietic stem cell transplantation recipient: a case report and literature review

BACKGROUND

Mucormycosis is a life-threatening complication that occurs in haematopoietic stem cell transplantation (HSCT) recipients. Among mucormycosis patients, those infected with Cunninghamella bertholletiae have the poorest prognosis because of the high virulence and angioinvasive nature of this organism. Despite its high vascular invasiveness, pseudoaneurysm caused by C. bertholletiae in HSCT recipients has rarely been reported.

CASE PRESENTATION

An 8-year-old HSCT recipient experienced recurrent fever, cough and pain after HSCT. Teicoplanin, acyclovir, posaconazole and caspofungin were used for infection prophylaxis. The sputum, stool, urine, peripheral blood and central venous catheter (CVC) blood culture results were negative. Next-generation sequencing (NGS) of the peripheral blood, pleural effusion and bronchoalveolar lavage fluid revealed the presence of C. bertholletiae, and amphotericin B combined with posaconazole was administered; however, the infection progressed. Fibreoptic bronchoscopies revealed that C. bertholletiae had invaded the bronchial wall, and enhanced computerized tomography (CT) revealed a pseudoaneurysm of the descending aorta resulting from C. bertholletiae. Debridement and vessel replacement were considered but not performed because of the severity of the infection and the patient's poor physical condition. Unfortunately, the patient died from pseudoaneurysm rupture with no presymptoms 56 d after HSCT.

CONCLUSION

For the first time, we report pseudoaneurysm secondary to C. bertholletiae infection in a HSCT recipient, highlighting the importance of clinical awareness of vessel lesions resulting from C. bertholletiae and emphasizing the value of enhanced CT for the early detection of vessel lesions in this rare infection.

Contemporary review of critical illness following allogeneic hematopoietic stem cell transplant in adults

Significant advancements have been made in the care of the allogeneic hematopoietic stem cell (HCT) recipient. However, they remain one of the most vulnerable groups of patients who may be admitted to the ICU. On the one hand, they have been administered treatment with the goal of achieving cure for their underlying disease, yet their unique immunocompromised trajectory and treatment-associated toxicities continue to challenge the intensivist from a diagnostic and management perspective. While infectious disease, allogeneic HCT and critical care research have improved outcomes, there remain significant areas to advance critical care management to further increase the likelihood of bridging to an acceptable quality of life. This review focuses on care of the critically ill patient undergoing allogeneic HCT for hematologic malignancies, critical care conditions that may arise, contemporary practices in their management, and areas to focus future research.

Disseminated fusariosis after allogenic hematopoietic stem cell transplantation: case report

In allogenic stem cell recipients, invasive fungal disease is a common yet dreaded complication with high mortality. Among these, fusariosis is especially complex to treat due to high intrinsic resistance and few antimycotic options, requiring close cooperation of all involved departments. We here report an instructive case of disseminated fusariosis after allogenic stem cell transplantation with fatal outcome despite maximum treatment.

Incidence and impact of invasive fungal infection comparing post-transplant cyclophosphamide with cyclosporine plus methotrexate GVHD prophylaxis in allogeneic HSCT

BACKGROUND

In recent years, haploidentical hematopoietic stem cell transplantation (haploHSCT) with post-transplant cyclophosphamide (PTCy) has become increasingly prevalent. However, the precise impact of invasive fungal disease (IFD) in relation to graft-versus-host disease (GVHD) prophylaxis and donor type remains to be elucidated.

METHODS

In this study, we analyzed data from 580 HSCT patients, comprising 80 patients who received haploidentical grafts and 500 patients who received grafts from other donor types. PTCy was exclusively administered to haploidentical HSCT recipients, while cyclosporine A (CsA) in combination with short-course methotrexate (scMTX) was used for patients receiving grafts from other donors.

RESULTS

The IFD rate by PTCy and CsA plus scMTX was 15 % and 15.6 %, respectively. At 6 months and 1 year post-transplant, the cumulative incidence of IFD was 9.4 % and 14.8 % for the PTCy group, and 7.9 % and 12.3 % for the CsA plus scMTX group, respectively. Both groups exhibited poor survival outcomes associated with IFD. Identified risk factors for IFD included age ≥ 45 years, disease relapse, and grade III-IV acute GVHD. Aspergillus spp. and Candida spp. were the most commonly isolated pathogens. High rate of cytomegalovirus reactivation was also noticed in PTCy or CsA plus scMTX group, but not a risk factor for IFD.

CONCLUSION

The similar IFD rate between haploHSCT with PTCy and others with CsA plus scMTX was documented, with Aspergillus spp. and Candida spp. as the most common pathogens. Further research is needed to investigate IFD following haploHSCT with PTCy and to explore differences with other types of allogeneic HSCT.

American Society of Transplantation and Cellular Therapy Series: #8-Management and Prevention of Non-Aspergillus Molds in Hematopoietic Cell Transplantation Recipients

The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to create a guideline focusing on non-Aspergillus invasive molds, which are uncommon yet lethal invasive fungal diseases in the peri-hematopoietic cell transplant (HCT) period. We used a compendium-style approach by dissecting this broad, heterogeneous, and highly complex topic into a series of standalone frequently asked questions (FAQs) and tables. Adult and pediatric infectious diseases and HCT content experts developed, then answered FAQs, and finalized topics with harmonized recommendations. All the evidence for non-Aspergillus invasive mold infection is non-RCT and mostly level III, therefore there are no recommendation grades, and instead key references are provided. Through this format, this "8th" topic in the series focuses on the relevant risk factors, diagnostic considerations, prophylaxis, and treatment approaches relevant to rare mold infections in the pre- and post-transplant periods.

Biofilm-Associated Candidiasis: Pathogenesis, Prevalence, Challenges and Therapeutic Options

The rising prevalence of fungal infections, especially those caused by Candida species, presents a major risk to global health. With approximately 1.5 million deaths annually, the urgency for effective treatment options has never been greater. Candida spp. are the leading cause of invasive infections, significantly impacting immunocompromised patients and those in healthcare settings. C. albicans, C. parapsilosis and the emerging species C. auris are categorized as highly dangerous species because of their pathogenic potential and increasing drug resistance. This review comparatively describes the formation of microbial biofilms of both bacterial and fungal origin, including major pathogens, thereby creating a novel focus. Biofilms can further complicate treatment, as these structures provide enhanced resistance to antifungal therapies. Traditional antifungal agents, including polyenes, azoles and echinocandins, have shown effectiveness, yet resistance development continues to rise, necessitating the exploration of novel therapeutic approaches. Antimicrobial peptides (AMPs) such as the anti-biofilm peptides Pom-1 and Cm-p5 originally isolated from snails represent promising candidates due to their unique mechanisms of action and neglectable cytotoxicity. This review article discusses the challenges posed by Candida infections, the characteristics of important species, the role of biofilms in virulence and the potential of new therapeutic options like AMPs.

Real-world use of isavuconazole in adult oncohematology patients

Isavuconazole has emerged as a significant antifungal agent in the treatment and prophylaxis of invasive fungal infections (IFIs) among immunocompromised patients, particularly those undergoing hematopoietic stem cell transplantation (HSCT) or receiving treatment for hematological malignancies. Real-world experience with the use of isavuconazole in oncohematological patients has increasingly been reported. Isavuconazole has demonstrated efficacy against a broad spectrum of fungal pathogens, with a favorable safety profile and lower rates of hepatotoxicity compared to other azoles. Isavuconazole is generally well-tolerated, making it suitable for long-term use in high-risk patients for both treatment and prophylaxis of IFIs. Isavuconazole can be considered a valuable treatment option for IFIs in patients with hematological malignancies and HSCT recipients. It may be a suitable alternative to other azoles, especially in patients with underlying liver dysfunction or those experiencing the effects of multiple drug interactions. Nevertheless, further research is needed to evaluate the long-term safety and efficacy of isavuconazole, particularly in specific patient populations and in combination with other antifungal agents. Overall, isavuconazole represents a promising addition to the antifungal armamentarium, offering a safer and more effective treatment option for patients at high risk of IFIs.

Diagnosis and management of invasive fungal infections due to non-Aspergillus moulds

Invasive fungal infection (IFI) due to moulds other than Aspergillus are a significant cause of morbidity and mortality. Non-Aspergillus mould (NAM) infections appear to be on the increase due to an ever-expanding population of immunocompromised hosts. In this review, Mucorales, Scedosporium species, Lomentospora prolificans and Fusarium species are examined in detail, and the microbiology, risk factors, diagnosis and treatment of emerging NAMs such as Paecilomyces variotti, Purpureocillium lilacinum and Rasamsonia are summarized. The challenges in diagnosis are emphasized and the emerging importance of molecular methods is discussed. Treatment of IFI due to NAMs is a multi-pronged and multi-disciplinary approach. Surgery, correction of underlying risk factors, and augmentation of the host immune response are as important as antifungal therapy. Many of these NAMs are intrinsically resistant to the currently licensed antifungal agents, so selection of therapy needs to be guided by susceptibility testing. There are new antifungal agents in development, and these have the potential to improve the efficacy and safety of antifungal treatment in the future. Ongoing research is required to fully delineate the epidemiology of NAM infections, and to develop better diagnostic tools and treatments so that outcomes from these infections can continue to improve.

Pulmonary Immunocompromise in Stem Cell Transplantation and Cellular Therapy

Hematopoietic cell transplantation (HCT) and cellular therapies, such as chimeric-antigen receptor T-cell (CAR-T) treatments, are potentially curative treatments for certain hematologic malignancies and some nonmalignant disorders. However, pulmonary complications, both infectious and noninfectious, remain a significant cause of morbidity and mortality in patients who receive cellular therapies. This review article provides an overview of pulmonary complications encountered in the context of HCT and CAR-T. The authors discuss mechanisms of underlying immunocompromise that lead to a rise in infections. Additionally, they highlight key noninfectious complications of HCT that can mimic acute infections and suggest diagnostic approaches and preventive strategies to distinguish these entities promptly.

Aspergillus fumigatus Bloodstream Infection in the Absence of Classic Risk Factors: Expanding the Spectrum of Invasive Aspergillosis

We report an unusual case of Aspergillus fumigatus fungemia in a 65-year-old male with multiple comorbidities including, human immunodeficiency virus (HIV), chronic obstructive pulmonary disease (COPD), diabetes mellitus, hepatitis C, and metastatic small cell lung cancer on chemotherapy. He presented with pneumonia and acute hypoxic respiratory failure requiring intubation. The patient developed septic shock and a peripherally inserted central catheter (PICC-line)-associated methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia treated with intravenous (IV) cefazolin. Blood cultures unexpectedly revealed A. fumigatus despite a lack of classic risk factors, other than advanced acquired immune deficiency syndrome (HIV/AIDS), such as prolonged neutropenia or stem cell transplantation. Suspected sources included disseminated infection from the lungs and/or the infected PICC line. This case highlights the diagnostic and therapeutic challenges of invasive aspergillosis, a rarely reported and poorly understood entity with a high mortality rate. Further studies are needed to better characterize the epidemiology, risk factors, and optimal management of Aspergillus fungemia in diverse immunocompromised populations.

Invasive Aspergillosis in the Current Era

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

Evaluating the clinical utility of Aspergillus, Mucorales, and Nocardia bronchoalveolar PCRs for the diagnosis of invasive pulmonary infections in patients with hematological malignancies

Invasive pulmonary infections are a significant cause of morbidity and mortality in patients with hematological malignancies and hematopoietic stem cell transplantation (HCT) recipients. A delay in identifying a causative agent may result in late initiation of appropriate treatment and adverse clinical outcomes. We examine the diagnostic utility of PCR-based assays in evaluating invasive pulmonary infections from bronchoalveolar lavage (BAL). Patients with hematological malignancies and HCT recipients who underwent bronchoscopy with BAL from January 2020 to January 2024 for unexplained pulmonary infiltrates and had ≥1 PCR targeting Aspergillus, Mucorales, or Nocardia (Eurofins-Viracor, KS) were reviewed. Testing for microbiology and pathology except BAL PCRs to identify the etiology of pulmonary infiltrate was defined as standard-of-care. Invasive fungal diseases were defined as per European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSGERC) 2020 guidelines. Pulmonary nocardiosis was defined by a combination of clinical, radiographic, and microbiologic criteria. Of 134 patients, 77 were HCT recipients, and 70% were on antifungal agents. Thirty-two were diagnosed with infection with one of the three target pathogens, including 20 with probable or proven invasive pulmonary aspergillosis (IPA), seven with mucormycosis, and three with nocardiosis. For IPA, 19 were diagnosed by standard-of-care, and one (5%) was solely diagnosed by Aspergillus PCR. Mucorales PCR was positive in three of seven cases of proven mucormycosis, but the cultures were negative in all. All three nocardiosis cases were detected by PCR and culture. In our cohort, PCR targeting Mucorales and Nocardia can improve the early detection of invasive pulmonary infection, whereas Aspergillus PCR has a low added value when done in conjunction with standard-of-care, including BAL galactomannan.IMPORTANCEInvasive pulmonary infections are a significant cause of morbidity and mortality in immunocompromised patients. Timely diagnosis of invasive pulmonary infection reduces the time to targeted treatment initiation and improves clinical outcomes. The recent European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSGERC) update included the addition of serum or bronchoalveolar lavage (BAL) PCR as a method to determine probable Aspergillus disease. This reflects an increased utilization of PCR-based assays in the diagnosis of fungal diseases. Although PCR assays for Aspergillus diagnosis have been well characterized in the literature, their additive clinical utility in conjunction with BAL galactomannan index measurements remains unclear. Moreover, only a few reports characterize the analytic and clinical performance of Mucorales and Nocardia PCR.

Decreased Frequency and Improved Outcomes in Invasive Aspergillosis Caused by Aspergillus terreus After the Introduction of Anti-Mold Azole Agents: A 30-Year Study at a Tertiary Cancer Center

Invasive aspergillosis (IA) is a significant cause of morbidity and mortality in patients with hematological malignancy (HM) and hematopoietic stem cell transplant (HSCT) recipients. Aspergillus terreus is associated with worse outcomes than non-terreus Aspergillus species. Since the introduction of anti-mold azoles in 2002, there have been limited data on the etiology of IA. We retrospectively compared characteristics, antifungal treatments, and outcomes between patients with HM or HSCT infected with A. terreus and those with non-terreus Aspergillus between July 1993 and July 2023. We also examined trends over time in rates of A. terreus and outcomes of this infection. A total of 699 patients with culture-documented IA were analyzed, 537 with non-terreus species and 162 with A. terreus. Types of underlying malignancy, neutropenia, graft-versus-host disease, and anti-mold prophylaxis were similar between the groups. ICU stays and mechanical ventilation were more common among patients with A. terreus (p = 0.002 and 0.003, respectively). The rate of A. terreus decreased significantly from 35.9% during 1993-2003 to 11.2% during 2004-2013 and 16.7% during 2014-2023 (p < 0.0001 each). IA caused by A. terreus showed significant improvements in response to therapy and in overall and IA-associated mortality in the last two decades compared to the first (p < 0.0001). In conclusion, the increased use of anti-mold azoles after 2003 improved outcomes for HM patients with IA caused by A. terreus.

A practical approach to investigating nosocomial acquisition of Aspergillus

Invasive mould disease (IMD) has a high mortality in immunosuppressed patients. Invasive aspergillosis (IA) is the most common IMD. A guideline for preventing IA has been published jointly by the Centers for Disease Control and Prevention, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. Use of high-efficiency particulate air filters, adequate air exchange rates, sealing of patient rooms, and preventing exposure to moulds by nursing patients in areas away from construction sites are recommended by the guideline. However, there is limited information in relation to the actions to be undertaken by infection prevention and control teams in the event of one or more cases of nosocomial aspergillosis. In this review, we describe a systematic approach to aspergillosis by defining possible and probable nosocomial acquisition based on the number of days since hospital admission. We advocate an incremental response to the investigation of nosocomial aspergillosis in patients in protective isolation taking into account the number of cases and the likelihood of nosocomial origin. For single cases of nosocomial IA, we suggest that infection control investigations should focus on case surveillance and walk-through inspection escalating in a stepwise manner to enhanced case surveillance, verification of environmental controls, environmental monitoring, genotyping of clinical and environmental isolates, and review of antifungal prophylaxis for multiple cases and outbreaks. Where applicable, the construction site should be inspected with the aim to reduce the dispersal of conidia. Surveillance systems need to be strengthened to better understand the epidemiology of IA.

Epidemiology of Coronavirus Disease 2019-Associated Fungal Infections in the Intensive Care Unit: A Single-Center Retrospective Study

INTRODUCTION

Invasive fungal disease (IFD) is a morbid superinfection that can arise in critically ill patients with COVID-19 infection. Studies evaluating the full spectrum of COVID-19-associated fungal infections remain limited.

METHODS

Single-center retrospective study assessing IFD in patients with COVID-19, hospitalized for ≥ 72 h in the intensive care unit (ICU) between 02/25/20 and 02/28/22 (n = 1410). IFD was assessed using consensus criteria (EORTC/MSGERC or ISHAM/ECMM criteria). T- and chi-square tests compared demographic/clinical characteristics between IFD and non-IFD patients. Cox proportional hazards regression estimated risk factors for in-hospital mortality.

RESULTS

Of 1410 patients with severe COVID-19, 70 (5%) had a diagnosis of COVID-19-associated fungal infection with invasive candidiasis occurring in 3%, and invasive aspergillosis in 2%. Other fungal infections were rare. Patients with IFD had longer ICU stays (26 vs. 13 days; p < 0.001); increased rates of mechanical ventilation (99% vs. 70%; p < 0.001); and a higher risk of in-hospital death (69% vs. 36%; p < 0.001). On multivariable analysis, COVID-associated fungal infections were associated with an increased risk of in-hospital mortality.

CONCLUSIONS

This real-world study of critically ill patients with COVID-19 demonstrated a low incidence of COVID-19-associated fungal infections with invasive candidiasis occurring most frequently. Fungal infections were associated with an increased risk of in-hospital mortality in this population.

Occurrence of Pathogenic and Allergenic Molds in the Outdoor and Indoor Environment of a Major Hospital and Molecular Epidemiology of Aspergillus fumigatus in Kuwait

Aspergilli and other molds are prevalent in the environment and are an important cause of opportunistic infections and seasonal allergies in susceptible patients. This study determined species distribution of various molds in outdoor/indoor air in and around a major hospital and performed antifungal susceptibility testing and molecular fingerprinting of environmental and clinical Aspergillus fumigatus isolates in Kuwait. Sampling for the isolation of molds was performed for a 17-month-period from the water/indoor air of medical/surgical wards/ICUs and outdoor air. Molds were identified by phenotypic characteristics and/or by the PCR-sequencing of rDNA/β-tubulin/calmodulin genes. Antifungal susceptibility testing was done by Etest. Fingerprinting was performed by nine-loci-based microsatellite analysis. A total of 6179 isolates were obtained from outdoor (n = 4406) and indoor (n = 1773) environments. These included Cladosporium spp. (n = 2311), Aspergillus spp. (n = 1327), Penicillium spp. (n = 1325), Paecilomyces spp. (n = 473), Alternaria spp. (n = 218), Bipolaris spp. (n = 133), and other molds (n = 392). Fingerprinting data revealed heterogeneity among clinical and environmental A. fumigatus and shared genotypes among outdoor air and hospital environmental isolates. Itraconazole-resistant A. fumigatus isolates with TR34/L98H mutations in Cyp51A were also recovered from outdoor air (n = 1), a hospital environment (n = 3), and clinical samples (n = 2). More than 15 fungal genera and all four Aspergillus (Nigri, Flavi, Fumigati, and Terrei) sections and nine rare aspergilli were detected. The isolation frequency was higher during the peak allergy season of October/November. The presence of shared genotypes among outdoor air and the hospital environment including triazole-resistant A. fumigatus suggests a reservoir for invasive infections among susceptible hospitalized patients.

Epidemiology of Infections in Lung Transplant Recipients Treated With Belatacept

BACKGROUND

Belatacept is a costimulatory blocker that can be used to prevent and treat rejection in lung transplant recipients (LuTRs). The epidemiology of infections in belatacept-treated LuTRs has not been systematically evaluated.

METHODS

We performed a single-center retrospective study of all adult LuTRs who received belatacept as prevention or treatment of antibody-mediated rejection (desensitization) or as part of maintenance immunosuppression from January 1, 2011, to June 30, 2022. We assessed the epidemiology of infections that occurred within 12 months following the first belatacept dose.

RESULTS

Fifty-two LuTRs received at least one dose of belatacept as either desensitization (n = 32) or maintenance immunosuppression (n = 20). Among 45 patients who were cytomegalovirus (CMV) donor and/or recipient seropositive, nine (20%) developed CMV infection. Seven (77%) CMV infections occurred despite valganciclovir prophylaxis and four (44%) were associated with antiviral resistance. Three (6%) LuTRs developed Epstein-Barr virus (EBV) associated post-transplant lymphoproliferative disorder (PTLD). Twenty-five (48%) LuTRs developed 43 bacterial infections and five (10%) developed proven or probable invasive fungal disease. Incidence rates of viral, bacterial, and fungal infections were similar between the desensitization and maintenance groups: incidence rate ratios (95% confidence interval) were 0.70 (0.32-1.57), 1.31 (0.70-2.46), and 2.82 (0.31-25.2), respectively. Infection/PTLD prompted belatacept discontinuation in eight (15%) patients.

CONCLUSIONS

In the first year after belatacept initiation, LuTRs commonly developed CMV infections, EBV+ PTLD, and bacterial infections. Multicenter collaborations are needed to better understand infection risks in LuTRs treated with belatacept.

Deep Cutaneous Candidiasis With Costal Osteomyelitis Following Pectoralis Major Myocutaneous Flap Reconstruction: A Case Report

Candida is a yeast commonly found in various environments. It usually coexists with the skin without causing harm. It may exhibit pathogenicity when local or systemic immune defense mechanisms are compromised, which creates conditions favorable for its proliferation. This report discusses a case of invasive cutaneous candidiasis with rib osteomyelitis that developed at the donor site of a pectoralis major myocutaneous flap. The patient was a 58-year-old man who underwent reconstruction with a pectoralis major myocutaneous flap for adenoid cystic carcinoma in the midline floor of the mouth. Six months postoperatively, a reddish mass appeared at the donor site in the anterior chest. C. albicans was isolated from this lesion. Despite undergoing curettage and receiving oral antifungal treatment, the lesion showed no improvement. The reason for the treatment failure remains unclear. Consequently, surgical resection, including the fourth rib, was performed. Based on clinical, histopathological, and microbiological evaluations, the patient was diagnosed with deep-seated cutaneous candidiasis with rib osteomyelitis. The patient has been followed for 19 years postoperatively, with no evidence of recurrence of the primary floor-of-mouth carcinoma or candidiasis.

(1, 3)-beta-D-Glucan in bronchoalveolar lavage fluid: a useful biomarker in diagnosis of invasive pulmonary infection caused by Hormographiella aspergillata?

Hormographiella aspergillata is a rare hyaline mold causing invasive fungal infection in humans, until the frequent use of antifungal prophylaxis in immunocompromised hosts. Due to the high mortality of H. aspergillata infection, early recognition and treatment are crucial. Previous case reports suggested that serum (1,3)-beta-D-Glucan (BG) is one of the diagnostic aids for H. aspergillata infection. Here we report for the first time a case of pulmonary H. aspergillata infection with a negative serum BG but positive bronchoalveolar lavage fluid (BAL) BG. This may suggest that BAL BG is a useful and additional microbiological marker for prompt identification of this fatal invasive fungal infection (IFI). But it should be interpreted together with the clinical presentation, imaging, and other laboratory results.

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.

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.

Posaconazole gastro-resistant tablets for preventing invasive fungal disease after haematopoietic stem cell transplantation: a propensity-matched cohort study

OBJECTIVES

To evaluate posaconazole (POS) gastro-resistant tablets for preventing invasive fungal disease (IFD) in haematopoietic stem cell transplantation (HSCT) patients and analyse POS plasma concentrations.

METHODS

A single-arm trial was designed with a historical cohort as a control. Patients aged 13 years and older undergoing HSCT at the HSCT Center of Blood Diseases Hospital, Chinese Academy of Medical Sciences between December 2020 and May 2022 were enrolled, prospectively taking POS gastro-resistant tablets orally from day 1 to day 90 post-transplant and monitoring plasma concentrations. We also identified a retrospective cohort treated with alternative antifungal prophylaxis between January 2018 and December 2020, matched using propensity score methods. The primary outcome was the cumulative incidence of IFD at day 90 post-transplant.

RESULTS

The prospective study involved 144 patients receiving POS gastro-resistant tablets for IFD prevention, contrasting with 287 patients receiving non-POS tablets. By day 90 post-transplant, the POS tablet group exhibited a significantly lower cumulative incidence of IFD (2.81%; 95% CI, 0.09-5.50% vs. 7.69%; 95% CI, 4.60-10.78%; p 0.044). Adverse events were comparable between the groups with liver changes in 33/144 (22.92%) vs. 84/287 (29.27%) (p 0.162), and renal injuries in 15/144 (10.41%) vs. 37/287 (12.89%) (p 0.457). Mean POS plasma concentrations on days 4, 8, 15, and 22 post-administration were 930.97 ng/mL, 1143.97 ng/mL, 1569.8 ng/mL, and 1652.57 ng/mL, respectively.

DISCUSSION

Patients administered POS gastro-resistant tablets for antifungal prophylaxis experienced a lower cumulative incidence of IFD. POS plasma concentrations in HSCT patients stabilized by day 15 of medication.

Current Analytical Methods and Challenges for the Clinical Diagnosis of Invasive Pulmonary Aspergillosis Infection

In the last decade, pulmonary fungal infections such as invasive pulmonary aspergillosis (IPA) have increased in incidence due to the increased number of immunocompromised individuals. This increase is especially problematic when considering mortality rates associated with IPA are upwards of 70%. This high mortality rate is due to, in part, the length of time it takes to diagnose a patient with IPA. When diagnosed early, mortality rates of IPA decrease by as much as 30%. In this review, we discuss current technologies employed in both medical and research laboratories to diagnose IPA, including culture, imaging, polymerase chain reaction, peptide nucleic acid-fluorescence in situ hybridization, enzyme-linked immunosorbent assay, lateral flow assay, and liquid chromatography mass spectrometry. For each technique, we discuss both promising results and potential areas for improvement that would lead to decreased diagnosis time for patients suspected of contracting IPA. Further study into methods that offer increased speed and both analytical and clinical sensitivity to decrease diagnosis time for IPA is warranted.

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.

Costs for global guideline-based diagnosis of mucormycosis in patients with neutropenia, hematopoietic stem cell or solid organ transplantation - a perspective of the German healthcare system

INTRODUCTION

Mucormycosis is a rare invasive fungal infection (IFI) which is characterized by prolonged antifungal therapy, high morbidity and mortality rates, as well as increased treatment costs.

AREAS COVERED

Appropriate diagnosis of mucormycosis is a fundamental component of successful treatment, however, evidence about health economic expenses does not exist. Based on an international guideline approach for diagnosis of mucormycosis, we calculated costs for imaging-based and laboratory procedures and susceptibility testing from the German statutory health insurance perspective. We therefore analyzed the diagnostic recommendations for patients at increased progression risk, i.e. neutropenia, previous solid organ transplantation or hematopoietic stem cell transplantation.

EXPERT OPINION

From the health economic point of view, our analysis underlines the relevance of appropriate guideline-based diagnosis of mucormycosis. The overall costs are relatively low (€499.40 per case) compared to other components in the management of mucormycosis, such as cost-intensive treatment with antifungal agents. Nevertheless, it is important to bear in mind that the level of diagnostic accuracy in line with the global guidelines by the European Confederation of Medical Mycology and the Mycoses Study Group Education and Research Consortium requires substantial resources, which may not be available in all countries or centers, especially in those with low income.

Review of the novel antifungal drug olorofim (F901318)

There is clearly a need for novel antifungal agents, not only concerning spectrum, but also oral bioavailability, tolerability, and drug-drug interactions. There is growing concern for antifungal resistance for current available antifungals, mainly driven by environmental fungicide use or long-term exposure to antifungals, in the setting of mould-active prophylaxis or for chronic antifungal infections, such as chronic pulmonary aspergillosis. Moreover, the incidence of breakthrough infections is increasing, because of the introduction of (mould-active) prophylaxis (1-4). There is emergence of difficult to treat invasive fungal infections, such as those caused by Lomentospora prolificans, cryptic species of Aspergillus, Scedosporium and Coccidioides. Olorofim (F901318) is the first-in class of the orotomides, a novel antifungal class targeting dihydroorotate dehydrogenase (DHODH), a key enzyme in the biosynthesis of pyrimidines. Olorofim shows good in vitro and in vivo activity against Aspergillus species, rare and difficult to treat moulds and endemic dimorphic fungi, including azole- and amphotericin-resistant isolates. It lacks activity against yeasts and the Mucorales species. It is only orally available and shows very promising results in ongoing clinical trials. In this review we will describe the mechanism of action of olorofim, the spectrum of activity in vitro and in vivo, pharmacokinetics, pharmacodynamics, drug-drug interactions, resistance, and clinical outcomes.

Human cytomegalovirus infection among febrile hematological cancer patients at the Uganda Cancer Institute

Hematological cancers, including Leukemias and Lymphomas, and their associated chemotherapy and disease-specific factors, are linked to impaired granulocyte function and numbers, increasing the risk of opportunistic infections, often presenting as fever. Human cytomegalovirus (HCMV) is one of the significant opportunistic infections in these patients, but limited data exists on its seroprevalence and active infection burden among febrile hematological cancer patients in Uganda. We conducted a cross-sectional study from June to August 2017 at the Uganda Cancer Institute (UCI). Blood samples from 161 febrile hematological cancer patients were collected. HCMV exposure was assessed using indirect enzyme-linked immunosorbent assay for IgG and IgM antibodies, and active infection was confirmed with PCR testing and gel electrophoresis. IgG positivity indicated previous exposure, while positive IgM or PCR results indicated active infection. Overall, HCMV seroprevalence based on IgG and/or IgM positivity was 106/161 (66%). IgG alone, IgM alone, and combined IgG/IgM positivity prevalence rates were 57/161 (35.4%), 22/161 (13.6%), and 27/161 (16.7%), respectively. HCMV DNA PCR was positive in 5 of the 161 (3%) samples. Among PCR-positive patients, one (20%) was positive for IgG alone, two (40%) for IgM alone, and two (40%) for both IgG and IgM. Active infection based on positive IgM and HCMV DNA PCR was found in 23 of the 161 (14.3%) patients. Two-thirds of febrile patients with hematological malignancies in Uganda had been exposed to HCMV infection, with 14.3% showing active infection. Routine testing for active HCMV infection among febrile hematological cancer patients at the UCI is essential for timely and appropriate antiviral treatment.

IMPORTANCE

In this paper, we demonstrated that over two-thirds of feverish patients with blood cancers such as leukemia at the Uganda Cancer Institute are already exposed to a type of virus infection called the human cytomegalovirus (HCMV), and 14% of the patients have active disease due to this virus. This was confirmed through finding blood samples testing positive for a type of protective antibody called IgM and also upon virus DNA detection in the blood of those patients. Routine testing for this virus is not usually done in the study settings. Our findings reveal and emphasize the importance of routinely testing blood samples for active infection with this virus among the feverish patients with blood cancers in the study settings, and prompt initiation of antiviral treatment of the actively infected patients.

Review of neuroimaging findings of intracranial angioinvasive fungal infections

With increasing use of broad-spectrum antibiotics, advances in organ and stem-cell transplant therapy, and the continued diabetes mellitus II epidemic, as well as other risk factors, reports of fungal infections of the CNS have been increasing. The most lethal subset is the angioinvasive fungal infection. Aspergillus fumigatus, Mucor, and Fusarium tend to affect immunocompromised individuals depending on their risk factors. Exserohilum rostratum and Cladophialaphora species tend to infect immunocompetent individuals. Early diagnosis and treatment are imperative for improved outcomes and reduced morbidity and mortality. Clinical presentation is often nonspecific, while neuroimaging can be helpful for accurate diagnosis. CT of the head and/or the maxillofacial structures is the primary imaging modality. Once the infection begins to proliferate, areas of vasogenic and cytotoxic edema, with regional mass effect and shift of the midline structures may be seen. These findings, however, are often nonspecific and may also be seen in underlying neoplasm, inflammatory processes, and other intracranial infections. Characteristic findings on T1, T2, diffusion-weighted imaging (DWI), and gradient echo sequences (GRE) may help to further narrow the differential diagnoses. We present a review of neuroimaging findings that will aid the neuroradiologist in distinguishing intracranial angioinvasive fungal infections and lead to improved patient outcomes.

Aspergillus calidoustus and Talaromyces columbinus infections in chronic graft-versus-host disease

Advancements in allogeneic haematopoietic stem cell transplant (alloHSCT) procedures have improved patient outcomes over the last two decades, though invasive fungal infections (IFIs) remain a significant risk. The incidence of IFIs in alloHSCT recipients is estimated at 6%, with a mortality rate of 13%, and Aspergillus species are the most common pathogens involved. Posaconazole is effective in preventing IFIs post-transplant and is standard care during neutropenia or when managing graft-versus-host disease (GvHD) with high-dose steroids. However, azole prophylaxis may cause resistant Aspergillus species like A. calidoustus, which are difficult to treat. We report a case from our institution where a patient developed a dual infection with Aspergillus calidoustus and Talaromyces columbinus after alloHSCT and posaconazole prophylaxis. While A. calidoustus is known to cause IFIs in HSCT recipients, T. columbinus represents a previously unreported occurrence in medical literature. This case underscores the importance of a multifaceted diagnostic strategy, integrating BAL diagnosis, mycological cultures, direct microscopy, fungal speciation, susceptibility testing, and biomarkers. These comprehensive approaches are indispensable for accurate pathogen identification and effective management of IFIs with appropriate antifungal agents.

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.

Outcomes of Invasive Fungal Infections Treated with Isavuconazole: A Retrospective Review

BACKGROUND

Isavuconazole (ISA) has a favorable side effect profile that makes it attractive for treatment of invasive fungal infections (IFI). It carries FDA approval for invasive aspergillosis and mucormycosis, but there are fewer data for other organisms and non-pulmonary infections. We conducted this review to investigate how ISA performed at treating IFI, with an especial interest in these non-approved indications.

METHODS

We retrospectively identified and reviewed 131 patients who received ISA as treatment for IFI at our institution, some of whom received ISA as their first anti-fungal therapy and others who received ISA as either step-down therapy or salvage therapy. We identified the microbiologic cause of infection as well as the anatomic site involved for each patient. We then classified patients according to their response to ISA: namely cured, partially responded, or stabilized.

RESULTS

The majority of patients were immunocompromised (n = 76, 58%). ISA was used primarily as a secondary therapy (n = 116, 89%); either as a step-down/switching from other agents, or as salvage therapy. The most common reasons for switching to ISA were toxicities with prior agents followed by QT prolongation. Although pulmonary aspergillosis and mucormycosis were represented in more than half of the cohort, ISA was also used off-label for treatment of other organisms such as endemic fungi (n = 19, 15%) as well as central nervous system (CNS) infections (n = 15, 11%). We have described the detailed clinical characteristics of these CNS infections cases. The overall clinical response rate varied by type of infection and site involved (57-73% response rate).

CONCLUSIONS

We demonstrated encouraging clinical responses, particularly outside the FDA-approved indications, as well as good tolerability. This report highlights the critical need for expanded scope of prospective studies to delineate the efficacy of this better-tolerated agent, especially in central nervous system infections.

Calcineurin-NFAT signaling controls neutrophils' ability of chemoattraction upon fungal infection

Calcineurin-nuclear factor of activated T cells (CN-NFAT) inhibitors are widely clinically used drugs for immunosuppression, but besides their required T cell response inhibition, they also undesirably affect innate immune cells. Disruption of innate immune cell function can explain the observed susceptibility of CN-NFAT inhibitor-treated patients to opportunistic fungal infections. Neutrophils play an essential role in innate immunity as a defense against pathogens; however, the effect of CN-NFAT inhibitors on neutrophil function was poorly described. Thus, we tested the response of human neutrophils to opportunistic fungal pathogens, namely Candida albicans and Aspergillus fumigatus, in the presence of CN-NFAT inhibitors. Here, we report that the NFAT pathway members were expressed in neutrophils and mediated part of the neutrophil response to pathogens. Upon pathogen exposure, neutrophils underwent profound transcriptomic changes with subsequent production of effector molecules. Importantly, genes and proteins involved in the regulation of the immune response and chemotaxis, including the chemokines CCL2, CCL3, and CCL4 were significantly upregulated. The presence of CN-NFAT inhibitors attenuated the expression of these chemokines and impaired the ability of neutrophils to chemoattract other immune cells. Our results amend knowledge about the impact of CN-NFAT inhibition in human neutrophils.

Clinical Characteristics and Risk Factors for Cryptococcal Meningitis in Diverse Patient Populations in New York City

Background

Cryptococcal meningitis (CM) is responsible for 15%-20% of human immunodeficiency virus (HIV)-associated mortalities. CM prevalence has also increased in other immunocompromised populations of transplant recipients, patients with cancer, and individuals on immunomodulatory medication.

Methods

This retrospective review included 51 definitive patients with CM hospitalized at a tertiary academic medical center in New York City between 2010 and 2023. We assessed clinical features and outcomes of CM, with additional analysis of factors related to antiretroviral therapy (ART) adherence in HIV-infected cases and immunomodulatory medication history of HIV-negative cases.

Results

The cohort had a mean (standard deviation) age of 47.1 ± 15.1 years, and was predominantly male (37, 72.5%). Of 32 patients with HIV, 3 (9.4%) were newly diagnosed with HIV at the time of CM hospitalization, 5 (15.6%) had recurrent CM, and 2 (6.3%) had a CM relapse. The majority (30, 93.8%) of patients with HIV were ART nonadherent. Of 19 HIV-negative patients, 8 (42.1%) were solid-organ transplant recipients, 5 (26.3%) had autoimmune conditions of sarcoidosis or systemic lupus erythematosus, and 3 (15.8%) had chronic lymphocytic leukemia. Six (11.8%) patients died during hospitalization, 4 of whom had HIV.

Conclusions

The burden of CM in people with HIV and immunocompromised patients continues even in settings with accessible standard antifungal treatment though interventions of increased ART adherence for those with HIV and antifungal prophylaxis may improve morbidity and mortality.

Outcomes in solid organ transplant recipients receiving organs from a donor with Fusarium solani species complex meningitis

BACKGROUND

Five organs (heart, right lung, liver, right, and left kidneys) from a deceased patient were transplanted into five recipients in four US states; the deceased patient was identified as part of a healthcare-associated fungal meningitis outbreak among patients who underwent epidural anesthesia in Matamoros, Mexico.

METHODS

After transplant surgeries occurred, Fusarium solani species complex, a fungal pathogen with a high case-mortality rate, was identified in cerebrospinal fluid from the organ donor by metagenomic next-generation sequencing (mNGS) and fungal-specific polymerase chain reaction and in plasma by mNGS.

RESULTS

Four of five transplant recipients received recommended voriconazole prophylaxis; four were monitored weekly by serum (1-3)-β-d-glucan testing. All five were monitored for signs of infection for at least 3 months following transplantation. The liver recipient had graft failure, which was attributed to an etiology unrelated to fungal infection. No fungal DNA was identified in sections of the explanted liver, suggesting that F. solani species complex did not contribute to graft failure. The remaining recipients experienced no signs or symptoms suggestive of fusariosis.

CONCLUSION

Antifungal prophylaxis may be useful in preventing donor-derived infections in recipients of organs from donors that are found to have Fusarium meningitis.

Meningeal cryptococcosis in a pancreas transplant recipient requiring grafectomy: A case report

BACKGROUND

Through continuous improvement in transplantation medicine, a wider range of solid organ transplant (SOT) recipients is considered suitable for complex procedures. Despite advances in modern transplantation practice, transpiring invasive fungal infections pose a substantial threat for SOT recipients. To our knowledge, cryptococcal infection confined amidst sole pancreas SOT recipients has not been described to date. Enforcement of a multidisciplinary transplant team approach in the management of pancreas SOT recipients presenting with complex cryptococcal complications is fundamental in improving patient outcomes.

CASE SUMMARY

We present the case of a female pancreas transplant recipient, with confirmed meningeal cryptococcosis, referred to our institution for further evaluation and treatment from the Regional Center for Infectious Diseases. On admission, the patient was weaned from the protocolized immunosuppression therapy for two consecutive weeks, in addition to tapering systemic corticosteroid remedial treatment. Our novel multidisciplinary transplant team approach embodied exhaustive discussions of possible complex and diverse multiple organ system physiologic and pathologic challenges associated with distinct management strategies in pancreas transplant recipients. Owing to the potentially devastating impact of invasive cryptococcosis in terms of morbidity and mortality, a definitive surgical intervention of pancreas transplant grafectomy was reinforced, as a pathway towards secure access to early meaningful expertise care. The patient was discharged to the Regional Center for Infectious Diseases 2 mo after the admittance further advancing to a clinical improvement.

CONCLUSION

The precision transplantation approach by tailoring complex medical interventions to individual needs proved indispensable in improving our patient's outcomes.

Effect of isavuconazole on the pharmacokinetics of sunitinib and its mechanism

BACKGROUND

Sunitinib, a newly developed multi-targeted tyrosine kinase inhibitor (TKI), has become a common therapeutic option for managing advanced renal cell carcinoma (RCC). Examining the mechanism underlying the interaction between sunitinib and isavuconazole was the aim of this effort.

METHODS

The concentrations of sunitinib and its primary metabolite, N-desethyl sunitinib, were analyzed and quantified using ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS). Our study evaluated the potential interaction between isavuconazole and sunitinib using rat liver microsomes (RLM), human liver microsomes (HLM), and in vivo rat models. For the in vivo study, two groups (n = 5) of Sprague-Dawley (SD) rats were randomly allocated to receive sunitinib either with or without co-administration of isavuconazole. Additionally, the effects of isavuconazole on the metabolic stability of sunitinib and N-desethyl sunitinib were studied in RLM in vitro.

RESULTS

Our findings demonstrated that in RLM, isavuconazole exhibited a mixed non-competitive and competitive inhibition mechanism, with an IC50 (half maximal inhibitory concentration) value of 1.33 µM. Meanwhile, in HLM, isavuconazole demonstrated a competitive inhibition mechanism, with an IC50 of 5.30 µM. In vivo studies showed that the presence of isavuconazole significantly increased the pharmacokinetic characteristics of sunitinib, with the AUC(0→t), AUC(0→∞), and Tmax rising to approximately 211.38%, 203.92%, and 288.89%, respectively, in contrast to the control group (5 mg/kg sunitinib alone). The pharmacokinetic characteristics of the metabolite N-desethyl sunitinib in the presence of isavuconazole remained largely unchanged compared to the control group. Furthermore, in vitro metabolic stability experiments revealed that isavuconazole inhibited the metabolic processing of both sunitinib and N-desethyl sunitinib.

CONCLUSIONS

Isavuconazole had a major impact on sunitinib metabolism, providing fundamental information for the precise therapeutic administration of sunitinib.

A global perspective of the changing epidemiology of invasive fungal disease and real-world experience with the use of isavuconazole

Global epidemiological data show that the incidence of invasive fungal disease (IFD) has increased in recent decades, with the rising frequency of infections caused by Aspergillus and Mucorales order species. The number and variety of patients at risk of IFD has also expanded, owing in part to advances in the treatment of hematologic malignancies and other serious diseases, including hematopoietic stem cell transplantation (HCT) and other therapies causing immune suppression. Isavuconazonium sulfate (active moiety: isavuconazole) is an advanced-generation triazole antifungal approved for the treatment of invasive aspergillosis and mucormycosis that has demonstrated activity against a variety of yeasts, moulds, and dimorphic fungi. While real-world clinical experience with isavuconazole is sparse in some geographic regions, it has been shown to be effective and well tolerated in diverse patient populations, including those with multiple comorbidities who may have failed to respond to prior triazole antifungal therapy. Isavuconazole may be suitable for patients with IFD receiving concurrent QTc-prolonging therapy, as well as those on venetoclax or ruxolitinib. Data from clinical trials are not available to support the use of isavuconazole prophylactically for the prevention of IFD or for the treatment of endemic IFD, such as those caused by Histoplasma spp., but real-world evidence from case studies suggests that it has clinical utility in these settings. Isavuconazole is an option for patients at risk of IFD, particularly when the use of alternative antifungal therapies is not possible because of toxicities, pharmacokinetics, or drug interactions.

Cerebritis, optic ischemia, and cavernous sinus thrombosis arising from sinonasal mucormycosis

Brain and ocular infections can be the worst and fatal consequences of sinonasal infections in immunomodulated or immunocompromised patients. We report a case of a 35-year-old female who received an allogenic hematopoietic stem cell transplantation for acute myeloid leukemia, suffering from maxillo-spheno-ethmoidal rhinosinusitis which was complicated by cavernous sinus thrombosis, orbital cellulitis, optic ischemia and cerebritis.

An update on pharmacotherapy for fungal infections in allogeneic stem cell transplant recipients

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.

Impact of Antifungal Prophylaxis Continuation or Discontinuation After Allogeneic Hematopoietic Cell Transplant on the Incidence of Invasive Mold Infection

Background

Continuing antifungal prophylaxis (AFPx) to prevent invasive mold infections (IMIs) in recipients of allogeneic hematopoietic cell transplantation (alloHCT) after primary hospital discharge from alloHCT admission varies among transplant centers despite recommendations to continue prophylaxis through day +75. Characteristics driving AFPx prescribing at hospital discharge and outcomes are unknown.

Methods

In this retrospective analysis, we reviewed patients continuing AFPx vs no AFPx at hospital discharge. We included patients with a hospital stay ≥7 days and ≤40 days. We excluded patients with a history of IMI prior to alloHCT, new IMI during admission, or death prior to discharge. Our primary objective was incidence of probable or proven IMI per the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Our secondary objectives were nonrelapse mortality at day +100, overall survival at day +100, and characteristics driving AFPx discontinuation at hospital discharge.

Results

Of the 430 patients identified, 387 met inclusion criteria. At discharge, 56% (217/387) continued AFPx, and 44% (170/387) had no AFPx. At day +100, 3 probable IMI cases occurred in the group with continued AFPx vs 1 probable IMI case in the no-AFPx group (no proven IMI). Univariate analysis showed no difference in cumulative incidence of probable IMI (P = .440), nonrelapse mortality (P = .072), and overall survival (P = .855) between groups. Multivariable logistic regression demonstrated that patients were less likely to continue AFPx if they had a diagnosis other than acute myeloid leukemia, a length of stay ≤30 days, acute graft-vs-host disease grade 0 or 1, and corticosteroid use ≤5 days.

Conclusions

There was no difference in probable IMI at day +100 after alloHCT based on continuing vs discontinuing AFPx at hospital discharge after alloHCT admission supporting a risk-adapted prophylaxis approach.

Clinical Characteristics, Prognosis Factors and Metagenomic Next-Generation Sequencing Diagnosis of Mucormycosis in patients With Hematologic Diseases

INTRODUCTION

New diagnostic methods and antifungal strategies may improve prognosis of mucormycosis. We describe the diagnostic value of metagenomic next⁃generation sequencing (mNGS) and identify the prognostic factors of mucormycosis.

METHODS

We conducted a retrospective study of hematologic patients suffered from mucormycosis and treated with monotherapy [amphotericin B (AmB) or posaconazole] or combination therapy (AmB and posaconazole). The primary outcome was 84-day all-cause mortality after diagnosis.

RESULTS

Ninety-five patients were included, with "proven" (n = 27), "probable" (n = 16) mucormycosis confirmed by traditional diagnostic methods, and "possible" (n = 52) mucormycosis with positive mNGS results. The mortality rate at 84 days was 44.2%. Possible + mNGS patients and probable patients had similar diagnosis processes, overall survival rates (44.2% vs 50.0%, p = 0.685) and overall response rates to effective drugs (44.0% vs 37.5%, p = 0.647). Furthermore, the median diagnostic time was shorter in possible + mNGS patients than proven and probable patients (14 vs 26 days, p < 0.001). Combination therapy was associated with better survival compared to monotherapy at six weeks after treatment (78.8% vs 53.1%, p = 0.0075). Multivariate analysis showed that combination therapy was the protective factor (HR = 0.338, 95% CI: 0.162-0.703, p = 0.004), though diabetes (HR = 3.864, 95% CI: 1.897-7.874, p < 0.001) and hypoxemia (HR = 3.536, 95% CI: 1.874-6.673, p < 0.001) were risk factors for mortality.

CONCLUSIONS

Mucormycosis is a life-threatening infection. Early management of diabetes and hypoxemia may improve the prognosis. Exploring effective diagnostic and treatment methods is important, and combination antifungal therapy seems to hold potential benefits.

Diagnostic accuracy of galactomannan and lateral flow assay in invasive aspergillosis: A diagnostic meta-analysis

Background

Efficient diagnosis of patients at high risk for invasive aspergillosis (IA) improves the outcome of the disease. Lateral flow assay (LFA) is a novel technology and assessing its diagnostic accuracy is of great significance in the clinical management of IA.

Methods

A meta-analysis using case-control studies was performed to assess the diagnostic performance of LFA alone or galactomannan (GM) combined with LFA (GM-LFA) as screening tests for IA. The sensitivity, specificity, and summary receiver operating characteristic curves were constructed.

Results

Nineteen studies with 2838 patients were included. The pooled effect sizes for different indicators included: sensitivity (77 % for LFA and 75 % for GM-LFA), specificity (88 % for LFA and 87 % for GM-LFA), positive likelihood ratio (6.65 for LFA and 12.02 for GM-LFA), negative likelihood ratio (0.26 for LFA and 0.27 for GM-LFA), and the diagnostic odds ratio (25.81 for LFA and 44.87 for GM-LFA). The area under the curve was 0.91 for LFA and 0.94 for GM-LFA with a cut-off value ≥ 0.5.

Conclusion

The present meta-analysis suggested that LFA or GM-LFA at an optical density index (ODI) cutoff of ≥0.5 was a useful diagnostic tool for IA in patients. The results showed no significant differences in the accuracy of LFA alone and GM-LFA in diagnosing IA. In the clinical diagnosis and treatment of IA, LFA can be recommended if timely results are needed.

Breakthrough Invasive Fungal Infections in Patients With High-Risk Hematological Disorders Receiving Voriconazole and Posaconazole Prophylaxis: A Systematic Review

BACKGROUND

Primary antifungal prophylaxis with mold-active azoles is used to prevent invasive fungal infections in patients with high-risk hematological disorders; however, breakthrough infections occur, and the reasons for treatment failure are still not fully understood. To help inform clinical decisions, we sought to define microbiological, clinical, and pharmacological characteristics of proven and probable breakthrough invasive fungal infections (bIFIs) in patients with high-risk hematological disorders receiving voriconazole or posaconazole prophylaxis.

METHODS

We performed a systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search strategy was last conducted on 19 April 2023.

RESULTS

We assessed 5293 studies for eligibility, and 300 were selected for data extraction. These studies described 1076 cases of bIFIs occurring under voriconazole (42.5%) or posaconazole (57.5%). The most commonly found pathogens were Aspergillus (40%), Mucorales (20%), Candida (18%), and Fusarium (9%) species. Mucorales were more frequent among voriconazole-emerging cases, whereas Aspergillus and Fusarium were more prevalent among posaconazole-emerging cases. Definitive, putative, or probable antifungal resistance was found in 31% of cases. Therapeutic drug monitoring showed subtherapeutic azole concentration in 32 of 90 (36%) cases. Infection-related mortality was reported in 117 cases and reached 35%.

CONCLUSIONS

In our systemic review, the most common bIFIs were aspergillosis, mucormycosis, candidiasis, and fusariosis. Antifungal resistance explains only a minority of cases. Subtherapeutic prophylaxis was frequent but rarely reported. Prospective studies are needed to better understand these infections and to establish optimal management.

Clinical Mycology Today: Emerging Challenges and Opportunities

The Mycoses Study Group Education and Research Consortium is a collective of clinicians, researchers, and educators with the common goal to advance awareness, diagnosis, and management of invasive fungal diseases. Clinical Mycology Today, the Mycoses Study Group Education and Research Consortium's biennial meeting, is dedicated to discussing the most pressing contemporary issues facing the field of clinical mycology, promoting clinical, translational, and basic science collaborations, and mentoring the next generation of clinical mycologists. Here, we review the current opportunities and challenges facing the field of mycology that arose from discussions at the 2022 meeting, with emphasis on novel host risk factors, emerging resistant fungal pathogens, the evolving antifungal pipeline, and critical issues affecting the advancement of mycology research.

Clinical characteristics and outcomes of Fusarium infections in adult patients after hematopoietic stem cell transplantation: A meta-summary of case reports

Fusarium infections have increased, particularly among patients with hematological malignancies and in those receiving hematopoietic stem cell transplantation (HSCT). This meta-summary summarizes the clinical characteristics, treatment, and outcomes of Fusarium infections in HSCT recipients. The PubMed, ScienceDirect, and Ovid SP databases were searched from inception to January 2024 to identify relevant case reports. A total of 31 patients diagnosed with Fusarium infections after HSCT were included. The most common infection sites were the skin and soft tissues (74.2%), blood (54.8%), and lungs (41.9%). Fusarium species complex was identified in 67.7% of the patients, and the most common species was Fusarium solani (51.6%). Of the included patients, 58.1% received antifungal monotherapy, whereas 41.9% received antifungal combination therapy. The overall mortality rate was 74.2%. Cutaneous infection was associated with a low mortality rate. The median time to mortality was 28 days. Fusarium infections commonly present as disseminated infections in HSCT recipients.

Epithelial uptake leads to fungal killing in vivo and is aberrant in COPD-derived epithelial cells

Hundreds of spores of Aspergillus fumigatus (Af) are inhaled daily by human beings, representing a constant, possibly fatal, threat to respiratory health. The small size of Af spores suggests that interactions with alveolar epithelial cells (AECs) are frequent; thus, we hypothesized that spore uptake by AECs is important for driving fungal killing and susceptibility to Aspergillus-related disease. Using single-cell approaches to measure spore uptake and its outcomes in vivo, we demonstrate that Af spores are internalized and killed by AECs during whole-animal infection. Moreover, comparative analysis of primary human AECs from healthy and chronic obstructive pulmonary disease (COPD) donors revealed significant alterations in the uptake and killing of spores in COPD-derived AECs. We conclude that AECs contribute to the killing of Af spores and that dysregulation of curative AEC responses in COPD may represent a driver of Aspergillus-related diseases.