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Seybold B, Funk T, Dreger P, Egerer G, Brandt J, Mueller-Tidow C, Giesen N, Merle U. Microbiological risk factors, ICU survival, and 1-year survival in hematological patients with pneumonia requiring invasive mechanical ventilation. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04883-y. [PMID: 38922376 DOI: 10.1007/s10096-024-04883-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 06/19/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE To identify pathogenic microorganisms and microbiological risk factors causing high morbidity and mortality in immunocompromised patients requiring invasive mechanical ventilation due to pneumonia. METHODS A retrospective single-center study was performed at the intensive care unit (ICU) of the Department of Internal Medicine at Heidelberg University Hospital (Germany) including 246 consecutive patients with hematological malignancies requiring invasive mechanical ventilation due to pneumonia from 08/2004 to 07/2016. Microbiological and radiological data were collected and statistically analyzed for risk factors for ICU and 1-year mortality. RESULTS ICU and 1-year mortality were 63.0% (155/246) and 81.0% (196/242), respectively. Pneumonia causing pathogens were identified in 143 (58.1%) patients, multimicrobial infections were present in 51 (20.7%) patients. Fungal, bacterial and viral pathogens were detected in 89 (36.2%), 55 (22.4%) and 41 (16.7%) patients, respectively. Human herpesviruses were concomitantly reactivated in 85 (34.6%) patients. As significant microbiological risk factors for ICU mortality probable invasive Aspergillus disease with positive serum-Galactomannan (odds ratio 3.1 (1.2-8.0), p = 0.021,) and pulmonary Cytomegalovirus reactivation at intubation (odds ratio 5.3 (1.1-26.8), p = 0.043,) were identified. 1-year mortality was not significantly associated with type of infection. Of interest, 19 patients had infections with various respiratory viruses and Aspergillus spp. superinfections and experienced high ICU and 1-year mortality of 78.9% (15/19) and 89.5% (17/19), respectively. CONCLUSIONS Patients with hematological malignancies requiring invasive mechanical ventilation due to pneumonia showed high ICU and 1-year mortality. Pulmonary Aspergillosis and pulmonary reactivation of Cytomegalovirus at intubation were significantly associated with negative outcome.
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Affiliation(s)
- Benjamin Seybold
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| | - Timo Funk
- Department of Dermatology, Venereology and Allergology, Frankfurt University Hospital, Frankfurt, Germany
| | - Peter Dreger
- Department of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gerlinde Egerer
- Department of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Juliane Brandt
- Department of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Carsten Mueller-Tidow
- Department of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Nicola Giesen
- Department of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Hematology, Oncology and Palliative Care, Robert Bosch Hospital, Stuttgart, Germany
| | - Uta Merle
- Department of Internal Medicine IV, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Thorat J, Bhat S, Sengar M, Baheti A, Bothra S, Bhaskar M, Tandon SP, Biswas SK, Salunke GV, Karimundackal G, Tiwari VK, Pramesh C, Sharma N, Kapu V, Eipe T, Bagal BP, Nayak L, Bonda A, Janu A, Shetty A, Jain H. Clinical Utility of Stepwise Bronchoalveolar Lavage Fluid Analysis in Diagnosing and Managing Lung Infiltrates in Leukemia/Lymphoma Patients With Febrile Neutropenia. JCO Glob Oncol 2024; 10:e2300292. [PMID: 38301183 PMCID: PMC10846792 DOI: 10.1200/go.23.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/28/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024] Open
Abstract
PURPOSE Febrile neutropenia (FN) is a serious complication in hematologic malignancies, and lung infiltrates (LIs) remain a significant concern. An accurate microbiological diagnosis is crucial but difficult to establish. To address this, we analyzed the utility of a standardized method for performing bronchoalveolar lavage (BAL) along with a two-step strategy for the analysis of BAL fluid. PATIENTS AND METHODS This prospective observational study was conducted at a tertiary cancer center from November 2018 to June 2020. Patients age 15 years and older with confirmed leukemia or lymphomas undergoing chemotherapy, with presence of FN, and LIs observed on imaging were enrolled. RESULTS Among the 122 enrolled patients, successful BAL was performed in 83.6% of cases. The study used a two-step analysis of BAL fluid, resulting in a diagnostic yield of 74.5%. Furthermore, antimicrobial therapy was modified in 63.9% of patients on the basis of BAL reports, and this population demonstrated a higher response rate (63% v 45%; P = .063). CONCLUSION Our study demonstrates that a two-step BAL fluid analysis is safe and clinically beneficial to establish an accurate microbiological diagnosis. Given the crucial impact of diagnostic delays on mortality in hematologic malignancy patients with FN, early BAL studies should be performed to enable prompt and specific diagnosis, allowing for appropriate treatment modifications.
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Affiliation(s)
- Jayashree Thorat
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Surabhi Bhat
- Hematological Cancer Consortium, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Akshay Baheti
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sweta Bothra
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Maheema Bhaskar
- Department of Pulmonary Medicine, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sandeep Prakashnarain Tandon
- Department of Pulmonary Medicine, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sanjay K. Biswas
- Department of Microbiology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Gaurav V. Salunke
- Department of Microbiology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | | | - Virendra Kumar Tiwari
- Department of Thoracic Surgical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - C.S. Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Neha Sharma
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Venkatesh Kapu
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Thomas Eipe
- Department of Clinical Pharmacology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Bhausaheb Pandurang Bagal
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Lingaraj Nayak
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Avinash Bonda
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Amit Janu
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Alok Shetty
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Hasmukh Jain
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
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Lyons PG, McEvoy CA, Hayes-Lattin B. Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further? Curr Opin Crit Care 2023; 29:472-483. [PMID: 37641516 PMCID: PMC11142388 DOI: 10.1097/mcc.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Care and outcomes of critically ill patients with cancer have improved over the past decade. This selective review will discuss recent updates in sepsis and acute respiratory failure among patients with cancer, with particular focus on important opportunities to improve outcomes further through attention to phenotyping, predictive analytics, and improved outcome measures. RECENT FINDINGS The prevalence of cancer diagnoses in intensive care units (ICUs) is nontrivial and increasing. Sepsis and acute respiratory failure remain the most common critical illness syndromes affecting these patients, although other complications are also frequent. Recent research in oncologic sepsis has described outcome variation - including ICU, hospital, and 28-day mortality - across different types of cancer (e.g., solid vs. hematologic malignancies) and different sepsis definitions (e.g., Sepsis-3 vs. prior definitions). Research in acute respiratory failure in oncology patients has highlighted continued uncertainty in the value of diagnostic bronchoscopy for some patients and in the optimal respiratory support strategy. For both of these syndromes, specific challenges include multifactorial heterogeneity (e.g. in etiology and/or underlying cancer), delayed recognition of clinical deterioration, and complex outcomes measurement. SUMMARY Improving outcomes in oncologic critical care requires attention to the heterogeneity of cancer diagnoses, timely recognition and management of critical illness, and defining appropriate ICU outcomes.
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Affiliation(s)
- Patrick G Lyons
- Department of Medicine, Oregon Health & Science University
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University
- Knight Cancer Institute, Oregon Health & Science University
| | - Colleen A McEvoy
- Department of Medicine, Washington University School of Medicine
- Siteman Cancer Center, Washington University School of Medicine
| | - Brandon Hayes-Lattin
- Department of Medicine, Oregon Health & Science University
- Knight Cancer Institute, Oregon Health & Science University
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Chen Z, Feng Q, Wang X, Tian F. Prophylactic use amphotericin B use in patients with hematologic disorders complicated by neutropenia: a systematic review and meta-analysis. Sci Rep 2023; 13:14008. [PMID: 37635176 PMCID: PMC10460793 DOI: 10.1038/s41598-023-41268-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 08/24/2023] [Indexed: 08/29/2023] Open
Abstract
The purpose of this study is to evaluate the efficacy of prophylactic use amphotericin B in patients with hematologic disorders complicated by neutropenia. We searched the PubMed, EMBASE, The Cochrane Library, CBM, CNKI, VIP and WanFang Data database and the China Clinical Trials Registry ( www.chictr.org.cn ) to collect randomized controlled trials (RCTs) of amphotericin B for patients with hematologic disorders complicated by neutropenia from inception to May 2023. The Cochrane risk-of-bias tool for RCTs was used to assess the bias risk of the included studies. The meta-analysis was performed using RevMan 5.3 software. A total of 6 studies with a total of 1019 patients were included. The results of the meta-analysis showed that the treatment group was superior to the control group in terms of the fungal infection rate, and the differences were statistically significant [RR = 0.47, 95% CI (0.32, 0.69), P < 0.0001]. There was no significant difference between the two groups in terms of the mortality [RR = 0.87, 95% CI (0.61, 1.23), P = 0.43] and the incidence of colonization [OR = 0.51, 95% CI (0.25, 1.03), P = 0.06]. The evidence shows that amphotericin B prophylactic use for patients with hematologic disorders complicated by neutropenia can decrease the fungal infection rate. However, there was no significant difference in reducing mortality or the incidence of colonization. Due to the limited quality and quantity of the included studies, more high-quality studies are needed to verify the above conclusion.
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Affiliation(s)
- Zhaoyan Chen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qiyi Feng
- Sichuan Provincial Key Laboratory of Precision Medicine and National Clinical Research Center for Geriatrics, Precision Medicine Research Center, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiaoxing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
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Shen Z, Wang Y, Bao A, Yang J, Sun X, Cai Y, Wan L, Huang C, Xu X, Niu J, Xia X, Shen C, Wei Y, Qiu H, Zhou K, Zhang M, Tong Y, Song X. Metagenomic Next-Generation Sequencing for Pathogens in Bronchoalveolar Lavage Fluid Improves the Survival of Patients with Pulmonary Complications After Allogeneic Hematopoietic Stem Cell Transplantation. Infect Dis Ther 2023; 12:2103-2115. [PMID: 37541984 PMCID: PMC10505113 DOI: 10.1007/s40121-023-00850-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023] Open
Abstract
INTRODUCTION Unbiased metagenomic next-generation sequencing (mNGS) has been used for infection diagnosis. In this study, we explored the clinical diagnosis value of mNGS for pulmonary complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS From August 2019 to June 2021, a prospective study was performed to comparatively analyze the pathogenic results of mNGS and conventional tests for bronchoalveolar lavage fluid (BALF) from 134 cases involving 101 patients with pulmonary complications after allo-HSCT. RESULTS More pathogens were identified by mNGS than with conventional tests (226 vs 120). For bacteria, the diagnostic sensitivity (P = 0.144) and specificity (P = 0.687) were similar between the two methods. For fungus except Pneumocystis jirovecii (PJ), conventional tests had a significantly higher sensitivity (P = 0.013) with a similarly high specificity (P = 0.109). The sensitivities for bacteria and fungi could be increased with the combination of the two methods. As for PJ, both the sensitivity (100%) and specificity (99.12%) of mNGS were very high. For viruses, the sensitivity of mNGS was significantly higher (P = 0.021) and the negative predictive value (NPV) was 95.74% (84.27-99.26%). Pulmonary infection complications accounted for 90.30% and bacterium was the most common pathogen whether in single infection (63.43%) or mixed infection (81.08%). The 6-month overall survival (OS) of 88.89% in the early group (mNGS ≤ 7 days) was significantly higher than that of 65.52% (HR 0.287, 95% CI 0.101-0.819, P = 0.006) in the late group (mNGS > 7 days). CONCLUSIONS mNGS for BALF could facilitate accurate and fast diagnosis for pulmonary complications. Early mNGS could improve the prognosis of patients with pulmonary complications after allo-HSCT. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT04051372.
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Affiliation(s)
- Zaihong Shen
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
- Department of Hematology, Taizhou First People's Hospital, Huangyan Hospital of Wenzhou Medical University, Taizhou City, 318020, Zhejiang Province, China
| | - Ying Wang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Aihua Bao
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Jun Yang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Xi Sun
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Yu Cai
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Liping Wan
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Chongmei Huang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Xiaowei Xu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Jiahua Niu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Xinxin Xia
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Chang Shen
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Yu Wei
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Huiying Qiu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Kun Zhou
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Min Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Yin Tong
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China
| | - Xianmin Song
- Department of Hematology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China.
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Tober R, Schnetzke U, Fleischmann M, Yomade O, Schrenk K, Hammersen J, Glaser A, Thiede C, Hochhaus A, Scholl S. Impact of treatment intensity on infectious complications in patients with acute myeloid leukemia. J Cancer Res Clin Oncol 2023; 149:1569-1583. [PMID: 35583829 PMCID: PMC10020242 DOI: 10.1007/s00432-022-03995-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Infectious complications reflect a major challenge in the treatment of patients with acute myeloid leukemia (AML). Both induction chemotherapy and epigenetic treatment with hypomethylating agents (HMA) are associated with severe infections, while neutropenia represents a common risk factor. Here, 220 consecutive and newly diagnosed AML patients were analyzed with respect to infectious complications dependent on treatment intensity and antifungal prophylaxis applied to these patients. PATIENTS AND METHODS We retrospectively analyzed 220 patients with newly diagnosed AML at a tertiary care hospital between August 2016 and December 2020. The median age of AML patients undergoing induction chemotherapy (n = 102) was 61 years (25-76 years). Patients receiving palliative AML treatment (n = 118) had a median age of 75 years (53-91 years). We assessed the occurrence of infectious complication including the classification of pulmonary invasive fungal disease (IFD) according to the EORTC/MSG criteria at diagnosis and until day 100 after initiation of AML treatment. Furthermore, admission to intensive care unit (ICU) and subsequent outcome was analyzed for both groups of AML patients, respectively. RESULTS AML patients subsequently allocated to palliative AML treatment have a significantly higher risk of pneumonia at diagnosis compared to patients undergoing induction chemotherapy (37.3% vs. 13.7%, P < 0.001) including a higher probability of atypical pneumonia (22.0% vs. 10.8%, P = 0.026). Furthermore, urinary tract infections are more frequent in the palliative subgroup at the time of AML diagnosis (5.1% vs. 0%, P = 0.021). Surprisingly, the incidence of pulmonary IFD is significantly lower after initiation of palliative AML treatment compared to the occurrence after induction chemotherapy (8.4% vs. 33.3%, P < 0.001) despite only few patients of the palliative treatment group received Aspergillus spp.-directed antifungal prophylaxis. The overall risk for infectious complications at AML diagnosis is significantly higher for palliative AML patients at diagnosis while patients undergoing induction chemotherapy have a significantly higher risk of infections after initiation of AML treatment. In addition, there is a strong correlation between the occurrence of pneumonia including atypical pneumonia and pulmonary IFD and the ECOG performance status at diagnosis in the palliative AML patient group. Analysis of intensive care unit (ICU) treatment (e.g. in case of sepsis or pneumonia) for both subgroups reveals a positive outcome in 10 of 15 patients (66.7%) with palliative AML treatment and in 15 of 18 patients (83.3%) receiving induction chemotherapy. Importantly, the presence of infections and the ECOG performance status at diagnosis significantly correlate with the overall survival (OS) of palliative AML patients (315 days w/o infection vs. 69 days with infection, P 0.0049 and 353 days for ECOG < 1 vs. 50 days for ECOG > 2, P < 0.001, respectively) in this intent-to-treat analysis. CONCLUSION The risk and the pattern of infectious complications at diagnosis and after initiation of AML therapy depends on age, ECOG performance status and subsequent treatment intensity. A comprehensive diagnostic work-up for identification of pulmonary IFD is indispensable for effective treatment of pneumonia in AML patients. The presence of infectious complications at diagnosis contributes to an inferior outcome in elderly AML patients.
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Affiliation(s)
- Romy Tober
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Ulf Schnetzke
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Maximilian Fleischmann
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Olaposi Yomade
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Karin Schrenk
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Jakob Hammersen
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Anita Glaser
- Institut Für Humangenetik, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Christian Thiede
- Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Andreas Hochhaus
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sebastian Scholl
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
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Serce Unat D, Ulusan Bagci O, Unat OS, Kose S, Caner A. The Spectrum of Infections in Patients with Lung Cancer. Cancer Invest 2023; 41:25-42. [PMID: 36445108 DOI: 10.1080/07357907.2022.2153860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Although diagnostic and therapeutic advances in lung cancer (LC) have increased the survival of patients, infection and its complications are still among the most important causes of mortality. The disruption of tissue caused by tumor mass, management of cancer therapy and alteration in the humoral/cellular immune systems due to both cancer itself and therapy considerably increase susceptibility to infection in cancer patients. Particularly, opportunistic microorganisms should be considered, then applying rapid and sensitive diagnostic methods for them. Thus, cancer patients who are already exposed to difficult, long-term and expensive treatments can be prevented from dying from complications related to infections.
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Affiliation(s)
- Damla Serce Unat
- Department of Chest Disease, Dr. Suat Seren Chest Disease and Surgery Training and Research Hospital, Izmir, Turkey
| | - Ozlem Ulusan Bagci
- Department of Microbiology, Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey.,Department of Basic Oncology, Institute of Health Sciences, Ege University, Izmir, Turkey
| | - Omer Selim Unat
- Department of Chest Disease, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Sukran Kose
- Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ayse Caner
- Department of Basic Oncology, Institute of Health Sciences, Ege University, Izmir, Turkey.,Translational Pulmonary Research Group (EGESAM), Ege University, Izmir, Turkey.,Department of Parasitology, Faculty of Medicine, Ege University, Izmir, Turkey.,Cancer Research Center, Ege University, Izmir, Turkey
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8
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The utility of procalcitonin for diagnosing bacteremia and bacterial pneumonia in hospitalized oncology patients. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04419-x. [DOI: 10.1007/s00432-022-04419-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/13/2022] [Indexed: 11/15/2022]
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9
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Classen AY, Sandherr M, Vehreschild JJ, von Lilienfeld-Toal M. Infektionsmanagement in der Hämatologie und Onkologie. DER ONKOLOGE 2022; 28:349-360. [PMID: 35310897 PMCID: PMC8922085 DOI: 10.1007/s00761-022-01120-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 11/24/2022]
Abstract
Hämatologische und onkologische Patienten haben aufgrund der durch die Grunderkrankung bestehenden oder therapieassoziierten Immunsuppression oftmals ein deutlich erhöhtes Infektionsrisiko. Unter Berücksichtigung weltweit zunehmender antimikrobieller Resistenzen und negativer mit der Antibiotikatherapie assoziierter Effekte sollte der angemessene und leitliniengerechte Einsatz von Antiinfektiva auch in diesem Bereich gefördert werden. Die Indikation zur antibakteriellen Prophylaxe sollte streng gestellt werden. Die Infektionsdiagnostik sowie das therapeutische Management unterscheiden sich je nach Ausmaß der erwarteten Immunsuppression und nach vorliegenden patientenindividuellen Risikofaktoren.
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Affiliation(s)
- Annika Yanina Classen
- Medizinische Fakultät und Uniklinik Köln, Klinik I für Innere Medizin, Universität zu Köln, Kerpener Straße 62, 50937 Köln, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Bonn-Köln, Köln, Deutschland
| | - Michael Sandherr
- Schwerpunktpraxis für Hämatologie und Onkologie, MVZ Penzberg, Weilheim, Deutschland
| | - Jörg Janne Vehreschild
- Medizinische Fakultät und Uniklinik Köln, Klinik I für Innere Medizin, Universität zu Köln, Kerpener Straße 62, 50937 Köln, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Bonn-Köln, Köln, Deutschland
- Medizinische Klinik 2, Hämatologie/Onkologie, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Deutschland
- Leibniz-Institut für Naturstoff-Forschung und Infektionsbiologie – Hans-Knöll-Institut, Jena, Deutschland
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10
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Certan M, Garcia Garrido HM, Wong G, Heijmans J, Grobusch MP, Goorhuis A. Incidence and Predictors of Community-Acquired Pneumonia in Patients With Hematological Cancers Between 2016 and 2019. Clin Infect Dis 2022; 75:1046-1053. [PMID: 35195716 PMCID: PMC9522390 DOI: 10.1093/cid/ciac005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Indexed: 11/14/2022] Open
Abstract
Background Patients with hematological cancers (HC) are at high risk of infections, in particular community-acquired pneumonia (CAP). Recent data on incidence and predictors of CAP among patients with HC are scarce. Methods We performed a cohort study (2016–2019) in 2 hospitals in the Netherlands among adults with HC to calculate incidence rates (IRs) of CAP. In addition, we performed a nested case-control study to identify predictors of CAP. Results We identified 275 CAP cases during 6264 patient-years of follow-up. The IR of CAP was 4390/100 000 patient-years of follow-up. Compared with the general population, IR ratios ranged from 5.4 to 55.3 for the different HCs. The case fatality and intensive care unit (ICU) admission rates were 5.5% and 9.8%, respectively. Predictors for CAP in patients with HC were male sex, anemia, lymphocytopenia, chronic kidney disease, cardiovascular disease, autologous and allogeneic stem cell transplantation, treatment with immunosuppressive medication for graft-vs-host disease, treatment with rituximab in the past year, and treatment with immunomodulators (lenalidomide, thalidomide, pomalidomide and/or methotrexate) in the past month. Independent predictors of a severe disease course (death or ICU admission) included neutropenia (odds ratio, 4.14 [95% confidence interval, 1.63–10.2]), pneumococcal pneumonia (10.24 [3.48–30.1]), chronic obstructive pulmonary disease (6.90 [2.07–23.0]), and the use of antibacterial prophylaxis (2.53 [1.05–6.08]). Conclusions The burden of CAP in patients with HC is high, with significant morbidity and mortality rates. Therefore, vaccination against respiratory pathogens early in the disease course is recommended, in particular before starting certain immunosuppressive therapies.
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Affiliation(s)
- Maria Certan
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Hannah M Garcia Garrido
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Gino Wong
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Jarom Heijmans
- Department of Hematology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Martin P Grobusch
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Abraham Goorhuis
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
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11
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Vehreschild JJ, Koehler P, Lamoth F, Prattes J, Rieger C, Rijnders BJA, Teschner D. Future challenges and chances in the diagnosis and management of invasive mould infections in cancer patients. Med Mycol 2021; 59:93-101. [PMID: 32898264 PMCID: PMC7779224 DOI: 10.1093/mmy/myaa079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/31/2020] [Accepted: 08/18/2020] [Indexed: 11/15/2022] Open
Abstract
Diagnosis, treatment, and management of invasive mould infections (IMI) are challenged by several risk factors, including local epidemiological characteristics, the emergence of fungal resistance and the innate resistance of emerging pathogens, the use of new immunosuppressants, as well as off-target effects of new oncological drugs. The presence of specific host genetic variants and the patient's immune system status may also influence the establishment of an IMI and the outcome of its therapy. Immunological components can thus be expected to play a pivotal role not only in the risk assessment and diagnosis, but also in the treatment of IMI. Cytokines could improve the reliability of an invasive aspergillosis diagnosis by serving as biomarkers as do serological and molecular assays, since they can be easily measured, and the turnaround time is short. The use of immunological markers in the assessment of treatment response could be helpful to reduce overtreatment in high risk patients and allow prompt escalation of antifungal treatment. Mould-active prophylaxis could be better targeted to individual host needs, leading to a targeted prophylaxis in patients with known immunological profiles associated with high susceptibility for IMI, in particular invasive aspergillosis. The alteration of cellular antifungal immune response through oncological drugs and immunosuppressants heavily influences the outcome and may be even more important than the choice of the antifungal treatment. There is a need for the development of new antifungal strategies, including individualized approaches for prevention and treatment of IMI that consider genetic traits of the patients. Lay Abstract Anticancer and immunosuppressive drugs may alter the ability of the immune system to fight invasive mould infections and may be more important than the choice of the antifungal treatment. Individualized approaches for prevention and treatment of invasive mold infections are needed.
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Affiliation(s)
- Jörg Janne Vehreschild
- Department of Internal Medicine, Hematology, and Oncology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany; Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany; German Centre for Infection Research, partner site Bonn-Cologne, University of Cologne, Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Excellence Center for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Institute of Microbiology, Department of Laboratories, Lausanne University Hospital, Lausanne, Switzerland
| | - Juergen Prattes
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Bart J A Rijnders
- Internal Medicine and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Daniel Teschner
- Department of Hematology, Medical Oncology, and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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12
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Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
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13
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Raheem A, Rathish B, Charles D, Wilson A, Warrier A. Pneumococcal Bacteremia and Cryptococcal Meningitis Dual Infection in a Patient With Multiple Myeloma. Cureus 2021; 13:e15089. [PMID: 34155458 PMCID: PMC8210704 DOI: 10.7759/cureus.15089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Infections remain one of the major complications in patients with multiple myeloma, having a significant impact on morbidity and mortality. The increased risk of infection in these patients are a result of various factors contributing to the impairment of immune system caused by the disease and the chemotherapy regimens given during the treatment phases. Here we report a rare case of pneumococcal bacteraemia and cryptococcal meningitis dual infection in a patient with underlying multiple myeloma who had a favourable clinical outcome. This case also serves to highlight the importance of adult vaccinations especially in patients with underlying comorbidities.
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Affiliation(s)
| | | | | | - Arun Wilson
- Infectious Diseases, Aster Medcity, Kochi, IND
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14
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Alexander BD, Lamoth F, Heussel CP, Prokop CS, Desai SR, Morrissey CO, Baddley JW. Guidance on Imaging for Invasive Pulmonary Aspergillosis and Mucormycosis: From the Imaging Working Group for the Revision and Update of the Consensus Definitions of Fungal Disease from the EORTC/MSGERC. Clin Infect Dis 2021; 72:S79-S88. [PMID: 33709131 DOI: 10.1093/cid/ciaa1855] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinical imaging in suspected invasive fungal disease (IFD) has a significant role in early detection of disease and helps direct further testing and treatment. Revised definitions of IFD from the EORTC/MSGERC were recently published and provide clarity on the role of imaging for the definition of IFD. Here, we provide evidence to support these revised diagnostic guidelines. METHODS We reviewed data on imaging modalities and techniques used to characterize IFDs. RESULTS Volumetric high-resolution computed tomography (CT) is the method of choice for lung imaging. Although no CT radiologic pattern is pathognomonic of IFD, the halo sign, in the appropriate clinical setting, is highly suggestive of invasive pulmonary aspergillosis (IPA) and associated with specific stages of the disease. The ACS is not specific for IFD and occurs in the later stages of infection. By contrast, the reversed halo sign and the hypodense sign are typical of pulmonary mucormycosis but occur less frequently. In noncancer populations, both invasive pulmonary aspergillosis and mucormycosis are associated with "atypical" nonnodular presentations, including consolidation and ground-glass opacities. CONCLUSIONS A uniform definition of IFD could improve the quality of clinical studies and aid in differentiating IFD from other pathology in clinical practice. Radiologic assessment of the lung is an important component of the diagnostic work-up and management of IFD. Periodic review of imaging studies that characterize findings in patients with IFD will inform future diagnostic guidelines.
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Affiliation(s)
- Barbara D Alexander
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Frédéric Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claus Peter Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik gGmbH, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research.,Diagnostic and Interventional Radiology, Ruprecht-Karls-University, Heidelberg, Germany
| | | | - Sujal R Desai
- Department of Radiology, Royal Brompton and Harefield National Health Service Foundation Trust, London and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - C Orla Morrissey
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
| | - John W Baddley
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
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15
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Ing MK, Williamson JP. Con: Bronchoscopy is essential for pulmonary infections in patients with haematological malignancies. Breathe (Sheff) 2020; 16:200210. [PMID: 33447292 PMCID: PMC7792854 DOI: 10.1183/20734735.0210-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Whilst some patients with haematological malignancy and pulmonary infection may benefit from a bronchoscopy, this uniform approach is not justified by the literature and more studies are required to fill the void in our understanding of this areahttps://bit.ly/3bfUfs7
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Affiliation(s)
- Matthew K Ing
- Dept of Respiratory Medicine, Liverpool Hospital, Sydney, Australia
| | - Jonathan P Williamson
- Dept of Respiratory Medicine, Liverpool Hospital, Sydney, Australia.,South Western Sydney Clinical School, Liverpool Hospital, The University of New South Wales, Sydney, Australia.,MQ Health Respiratory and Sleep, Macquarie University Hospital, Sydney, Australia
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16
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Abstract
ZUSAMMENFASSUNGRasches Handeln ist gefragt, wenn der Verdacht auf eine Infektion bei einem immunsupprimierten Patienten besteht. Wenn es sich nicht gerade um einen tropischen Keim von der Kreuzfahrt bzw. den multiresistenten Keim von einem der letzten Klinikaufenthalte handelt – der Erreger ist meist nicht das Problem! Es ist seine Präsentation, die Ausprägung seiner klinischen Manifestation und seine Reaktion auf die Therapie, die für uns zur Herausforderung wird. Ist stets die Veränderung der Immunreaktion durch immer selektiver wirksame Biologika das Thema? Oder müssen wir uns erst mit den Reaktionen des innaten und adaptiven Immunsystems vertraut machen, um zu verstehen, was wir sehen?
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17
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Mantadakis E. Pneumocystis jirovecii Pneumonia in Children with Hematological Malignancies: Diagnosis and Approaches to Management. J Fungi (Basel) 2020; 6:jof6040331. [PMID: 33276699 PMCID: PMC7761543 DOI: 10.3390/jof6040331] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects children with suppressed cellular immunity. PJP was the most common cause of infectious death in children with acute lymphoblastic leukemia prior to the inclusion of cotrimoxazole prophylaxis as part of the standard medical care in the late 1980s. Children with acute leukemia, lymphomas, and those undergoing hematopoietic stem cell transplantation, especially allogeneic transplantation, are also at high risk of PJP. Persistent lymphopenia, graft versus host disease, poor immune reconstitution, and lengthy use of corticosteroids are significant risk factors for PJP. Active infection may be due to reactivation of latent infection or recent acquisition from environmental exposure. Intense hypoxemia and impaired diffusing capacity of the lungs are hallmarks of PJP, while computerized tomography of the lungs is the diagnostic technique of choice. Immunofluorescence testing with monoclonal antibodies followed by fluorescent microscopy and polymerase chain reaction testing of respiratory specimens have emerged as the best diagnostic methods. Measurement of (1-3)-β-D-glucan in the serum has a high negative predictive value in ruling out PJP. Oral cotrimoxazole is effective for prophylaxis, but in intolerant patients, intravenous and aerosolized pentamidine, dapsone, and atovaquone are effective alternatives. Ιntravenous cotrimoxazole is the treatment of choice, but PJP has a high mortality even with appropriate therapy.
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatrics, Hematology/Oncology Unit, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68 100 Alexandroupolis, Thrace, Greece
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18
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Panse J, von Schwanewede K, Jost E, Dreher M, Müller T. Pulmonary infections in patients with and without hematological malignancies: diagnostic yield and safety of flexible bronchoscopy-a retrospective analysis. J Thorac Dis 2020; 12:4860-4867. [PMID: 33145059 PMCID: PMC7578490 DOI: 10.21037/jtd-20-835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Fiberoptic bronchoscopy (FOB) with broncho-alveolar lavage (BAL) is frequently performed in patients with hematological malignancies and pulmonary opacities. While the safety of the procedure in this patient population has been shown, data about the diagnostic yield widely differ between studies. Furthermore, data comparing diagnostic yield and safety of flexible bronchoscopy to narrow sources of pulmonary infections in patients with and without underlying hematological malignancy are lacking. Methods We carried out a retrospective analysis of bronchoscopies done for the diagnostic work-up of pulmonary infections. Diagnostic yield and the occurrence of complications in patients with and without hematological disease were compared. Results In total n=268 bronchoscopies were done in patients suffering from a hematological malignancy (HM) compared to n=408 bronchoscopies in patients without hematological malignancy (NHM). The overall diagnostic yield was similar and did not differ between the groups (HM: 67.2% vs. NHM: 64.7%; P=0.5622). However, when cultures positive for Candida were not considered as clinically relevant diagnostic yield was higher in the HM group (HM: 62.7% vs. NHM: 53.9%; P=0.0261) due to a higher detection rate of fungi and viruses (both P<0.001). Interestingly, the diagnostic yield for bacteria was not decreased by pre-treatment with antibiotics in either group (both P>0.05). There was no difference in the complication rate between the groups and most complications were considered as minor. Conclusions In summary, our data demonstrate similar diagnostic yield and safety of flexible bronchoscopy for diagnosing pulmonary infection in patients with and without underlying hematological malignancy.
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Affiliation(s)
- Jens Panse
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Kai von Schwanewede
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Edgar Jost
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Tobias Müller
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
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19
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[Antibiotic stewardship : Structure and implementation]. Med Klin Intensivmed Notfmed 2020; 116:81-92. [PMID: 33108477 DOI: 10.1007/s00063-020-00745-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/29/2020] [Accepted: 06/15/2020] [Indexed: 10/23/2022]
Abstract
Antibiotic resistance is a part of bacterial evolution and therefore unavoidable. Scarcity of novel treatment options requires prudent use of available antibiotics in order to decelerate the spread of resistance. This is the aim of antibiotic stewardship (ABS) programmes. The implementation of strategies that optimize antibiotic prescription and therapy necessitates the deployment of personnel as well as of structural resources. Necessary requirements for staff and strategies based on their evidence are described in the updated German S3 ABS Guideline. In the future, patients with infectious diseases will benefit from accelerated microbiological diagnostics as early adequate treatment not only reduces antibiotic consumption but also improves patient outcome. In addition, training of infectious disease specialists will substantially contribute to enhanced quality of care of patients with infectious disease.
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20
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Martos-Benítez FD, Soler-Morejón CDD, Lara-Ponce KX, Orama-Requejo V, Burgos-Aragüez D, Larrondo-Muguercia H, Lespoir RW. Critically ill patients with cancer: A clinical perspective. World J Clin Oncol 2020; 11:809-835. [PMID: 33200075 PMCID: PMC7643188 DOI: 10.5306/wjco.v11.i10.809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/09/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023] Open
Abstract
Cancer patients account for 15% of all admissions to intensive care unit (ICU) and 5% will experience a critical illness resulting in ICU admission. Mortality rates have decreased during the last decades because of new anticancer therapies and advanced organ support methods. Since early critical care and organ support is associated with improved survival, timely identification of the onset of clinical signs indicating critical illness is crucial to avoid delaying. This article focused on relevant and current information on epidemiology, diagnosis, and treatment of the main clinical disorders experienced by critically ill cancer patients.
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Affiliation(s)
| | | | | | | | | | | | - Rahim W Lespoir
- Intensive Care Unit 8B, Hermanos Ameijeiras Hospital, Havana 10300, Cuba
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21
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Christopeit M, Schmidt-Hieber M, Sprute R, Buchheidt D, Hentrich M, Karthaus M, Penack O, Ruhnke M, Weissinger F, Cornely OA, Maschmeyer G. Prophylaxis, diagnosis and therapy of infections in patients undergoing high-dose chemotherapy and autologous haematopoietic stem cell transplantation. 2020 update of the recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2020; 100:321-336. [PMID: 33079221 PMCID: PMC7572248 DOI: 10.1007/s00277-020-04297-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/03/2020] [Indexed: 12/14/2022]
Abstract
To ensure the safety of high-dose chemotherapy and autologous stem cell transplantation (HDC/ASCT), evidence-based recommendations on infectious complications after HDC/ASCT are given. This guideline not only focuses on patients with haematological malignancies but also addresses the specifics of HDC/ASCT patients with solid tumours or autoimmune disorders. In addition to HBV and HCV, HEV screening is nowadays mandatory prior to ASCT. For patients with HBs antigen and/or anti-HBc antibody positivity, HBV nucleic acid testing is strongly recommended for 6 months after HDC/ASCT or for the duration of a respective maintenance therapy. Prevention of VZV reactivation by vaccination is strongly recommended. Cotrimoxazole for the prevention of Pneumocystis jirovecii is supported. Invasive fungal diseases are less frequent after HDC/ASCT, therefore, primary systemic antifungal prophylaxis is not recommended. Data do not support a benefit of protective room ventilation e.g. HEPA filtration. Thus, AGIHO only supports this technique with marginal strength. Fluoroquinolone prophylaxis is recommended to prevent bacterial infections, although a survival advantage has not been demonstrated.
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Affiliation(s)
- Maximilian Christopeit
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, Hamburg, Germany.
| | - Martin Schmidt-Hieber
- Department of Hematology and Oncology, Carl-Thiem-Klinikum, Cottbus, Cottbus, Germany
| | - Rosanne Sprute
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Marcus Hentrich
- Department of Medicine III-Hematology/Oncology, Red Cross Hospital, Munich, Germany
| | - Meinolf Karthaus
- Department of Internal Medicine, Hematology and Oncology, Klinikum Neuperlach, Städtisches Klinikum München, Munich, Germany
| | - Olaf Penack
- Department of Internal Medicine, Division of Hematology and Oncology, Charité Universitätsmedizin Berlin, Campus Rudolf Virchow, Berlin, Germany
| | - Markus Ruhnke
- Department of Hematology, Oncology and Palliative Medicine, Helios Hospital Aue, Aue, Germany
| | - Florian Weissinger
- Department of Internal Medicine, Hematology, Oncology, Stem Cell Transplantation and Palliative Medicine, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Georg Maschmeyer
- Klinikum Ernst von Bergmann, Department of Hematology, Oncology and Palliative Care, Potsdam, Germany
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22
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Gründahl M, Wacker B, Einsele H, Heinz WJ. Invasive fungal diseases in patients with new diagnosed acute lymphoblastic leukaemia. Mycoses 2020; 63:1101-1106. [PMID: 32738006 DOI: 10.1111/myc.13151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with acute leukaemia have a high incidence of fungal infections. This has primarily been shown in acute myeloid leukaemia and is different for acute lymphoblastic leukaemia. Until now no benefit of mould active prophylaxis has been demonstrated in the latter population. METHODS In this retrospective single-centre study, we analysed the incidence, clinical relevance, and outcome of invasive fungal diseases (IFD) as well as the impact of antifungal prophylaxis for the first 100 days following the primary diagnosis of acute lymphoblastic leukaemia. RESULTS In 58 patients a high rate of proven, probable, and possible fungal infections could be demonstrated with a 3.4%, 8.6%, and 17.2% likelihood, respectively. The incidence might be even higher, as nearly 40% of all patients had no prolonged neutropenia for more than 10 days, excluding those from the European Organization of Research and Treatment of cancer and the Mycoses Study Group criteria for probable invasive fungal disease. The diagnosed fungal diseases had an impact on the duration of hospitalisation, which was 13 days longer for patients with proven/probable IFD compared to patients with no signs of fungal infection. Use of antifungal prophylaxis did not significantly affect the risk of fungal infection. CONCLUSION Patients with acute lymphoblastic leukaemia are at high risk of acquiring an invasive fungal disease. Appropriate criteria to define fungal infections, especially in this population, and strategies to reduce the risk of infection, including antifungal prophylaxis, need to be further evaluated.
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Affiliation(s)
- Marie Gründahl
- Department of Neurology, Klinikum Würzburg Mitte, Würzburg, Germany
| | - Beate Wacker
- Department for Internal Medicine I, Klinikum Weiden, Weiden, Germany
| | - Hermann Einsele
- Med. Clinic II, University of Würzburg Medical Center, Würzburg, Germany
| | - Werner J Heinz
- Department for Internal Medicine I, Klinikum Weiden, Weiden, Germany.,Med. Clinic II, University of Würzburg Medical Center, Würzburg, Germany
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23
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Koehler P, Mellinghoff SC, Lagrou K, Alanio A, Arenz D, Hoenigl M, Koehler FC, Lass-Flörl C, Meis JF, Richardson M, Cornely OA. Development and validation of the European QUALity (EQUAL) score for mucormycosis management in haematology. J Antimicrob Chemother 2020; 74:1704-1712. [PMID: 30770712 DOI: 10.1093/jac/dkz051] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/11/2019] [Accepted: 01/14/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Mucormycosis is a life-threatening infection in immunocompromised patients and in haematological malignancy patients in particular. OBJECTIVES Our aim was to develop and evaluate a scoring tool to measure adherence to current guidelines for mucormycosis. METHODS Current guidelines of scientific societies on mucormycosis management were reviewed. We assembled diagnostic, treatment and follow-up milestones and designed the EQUAL Mucormycosis Score. The EQUAL Mucormycosis Score was evaluated in the ECMM Excellence Centres. RESULTS An 18-item tool with one to three points per item resulted in a maximum achievable score depending on disease complexity and ranging from 25 to 32 points. Given variable patient disease course, the diagnostic score is higher in patients with positive fungal culture and biopsy, thus reflecting more decision points and higher management complexity. Eleven patients from two centres were included during the study period. A total of 200 EQUAL Mucormycosis Score points were achieved, which is 62.7% of the maximum EQUAL Mucormycosis Score of 319 points achievable in that cohort (median 18 points, range 7-27). The total score accomplished for diagnostic procedures was 112 of 165 points (67.9%), for first-line treatment 54 of 88 (61.4%) and for follow-up management 34 of 66 points (51.5%). CONCLUSIONS The EQUAL Mucormycosis Score quantitates adherence to current guideline recommendations for mucormycosis management. With 62.7% of maximum achievable score points, a first result is obtained that may serve as a reference for future evaluations. It remains to be shown whether guideline adherence and mortality rates correlate.
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Affiliation(s)
- Philipp Koehler
- Department I for Internal Medicine, Excellence Centre for Medical Mycology (ECMM), University Hospital Cologne, Cologne, Germany.,CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Sibylle C Mellinghoff
- Department I for Internal Medicine, Excellence Centre for Medical Mycology (ECMM), University Hospital Cologne, Cologne, Germany.,CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Katrien Lagrou
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology and Immunology, Excellence Centre for Medical Mycology (ECMM), KU Leuven, Leuven, Belgium.,Department of Laboratory Medicine and National Reference Centre for Mycosis, Excellence Centre for Medical Mycology (ECMM), University Hospitals Leuven, Leuven, Belgium
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Institut Pasteur, Molecular Mycology Unit, CNRS CMR2000, Paris, France
| | - Dorothee Arenz
- Department I for Internal Medicine, Excellence Centre for Medical Mycology (ECMM), University Hospital Cologne, Cologne, Germany
| | - Martin Hoenigl
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria.,Division of Infectious Diseases, Department of Medicine, UCSD, San Diego, CA, USA
| | - Felix C Koehler
- CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Excellence Centre for Medical Mycology (ECMM), Medical University of Innsbruck, Innsbruck, Austria
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Excellence Centre for Medical Mycology (ECMM), Centre of Expertise in Mycology Radboudumc/CWZ, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Malcolm Richardson
- Mycology Reference Centre, Excellence Centre for Medical Mycology (ECMM), Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, Excellence Centre for Medical Mycology (ECMM), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Oliver A Cornely
- Department I for Internal Medicine, Excellence Centre for Medical Mycology (ECMM), University Hospital Cologne, Cologne, Germany.,CECAD Cluster of Excellence, University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
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24
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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25
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Boch T, Spiess B, Heinz W, Cornely OA, Schwerdtfeger R, Hahn J, Krause SW, Duerken M, Bertz H, Reuter S, Kiehl M, Claus B, Deckert PM, Hofmann WK, Buchheidt D, Reinwald M. Aspergillus specific nested PCR from the site of infection is superior to testing concurrent blood samples in immunocompromised patients with suspected invasive aspergillosis. Mycoses 2020; 62:1035-1042. [PMID: 31402465 DOI: 10.1111/myc.12983] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/16/2022]
Abstract
Invasive aspergillosis (IA) is a severe complication in immunocompromised patients. Early diagnosis is crucial to decrease its high mortality, yet the diagnostic gold standard (histopathology and culture) is time-consuming and cannot offer early confirmation of IA. Detection of IA by polymerase chain reaction (PCR) shows promising potential. Various studies have analysed its diagnostic performance in different clinical settings, especially addressing optimal specimen selection. However, direct comparison of different types of specimens in individual patients though essential, is rarely reported. We systematically assessed the diagnostic performance of an Aspergillus-specific nested PCR by investigating specimens from the site of infection and comparing it with concurrent blood samples in individual patients (pts) with IA. In a retrospective multicenter analysis PCR was performed on clinical specimens (n = 138) of immunocompromised high-risk pts (n = 133) from the site of infection together with concurrent blood samples. 38 pts were classified as proven/probable, 67 as possible and 28 as no IA according to 2008 European Organization for Research and Treatment of Cancer/Mycoses Study Group consensus definitions. A considerably superior performance of PCR from the site of infection was observed particularly in pts during antifungal prophylaxis (AFP)/antifungal therapy (AFT). Besides a specificity of 85%, sensitivity varied markedly in BAL (64%), CSF (100%), tissue samples (67%) as opposed to concurrent blood samples (8%). Our results further emphasise the need for investigating clinical samples from the site of infection in case of suspected IA to further establish or rule out the diagnosis.
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Affiliation(s)
- Tobias Boch
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Birgit Spiess
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Oliver A Cornely
- First Department of Internal Medicine and ZKS Köln, BMBF 01KN1106, University Hospital Cologne, Deutsches Zentrum für Infektionsforschung, Cologne, Germany
| | | | - Joachim Hahn
- Regensburg University Hospital, Regensburg, Germany
| | | | - Matthias Duerken
- Department of Pediatric Hematology, Mannheim University Hospital, Mannheim, Germany
| | | | | | | | - Bernd Claus
- Ludwigshafen General Hospital, Ludwigshafen, Germany
| | | | | | - Dieter Buchheidt
- University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Mark Reinwald
- Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
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26
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Azoulay E, Russell L, Van de Louw A, Metaxa V, Bauer P, Povoa P, Montero JG, Loeches IM, Mehta S, Puxty K, Schellongowski P, Rello J, Mokart D, Lemiale V, Mirouse A. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med 2020; 46:298-314. [PMID: 32034433 PMCID: PMC7080052 DOI: 10.1007/s00134-019-05906-5] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/19/2019] [Indexed: 12/23/2022]
Abstract
An increasing number of critically ill patients are immunocompromised. Acute hypoxemic respiratory failure (ARF), chiefly due to pulmonary infection, is the leading reason for ICU admission. Identifying the cause of ARF increases the chances of survival, but may be extremely challenging, as the underlying disease, treatments, and infection combine to create complex clinical pictures. In addition, there may be more than one infectious agent, and the pulmonary manifestations may be related to both infectious and non-infectious insults. Clinically or microbiologically documented bacterial pneumonia accounts for one-third of cases of ARF in immunocompromised patients. Early antibiotic therapy is recommended but decreases the chances of identifying the causative organism(s) to about 50%. Viruses are the second most common cause of severe respiratory infections. Positive tests for a virus in respiratory samples do not necessarily indicate a role for the virus in the current acute illness. Invasive fungal infections (Aspergillus, Mucorales, and Pneumocystis jirovecii) account for about 15% of severe respiratory infections, whereas parasites rarely cause severe acute infections in immunocompromised patients. This review focuses on the diagnosis of severe respiratory infections in immunocompromised patients. Special attention is given to newly validated diagnostic tests designed to be used on non-invasive samples or bronchoalveolar lavage fluid and capable of increasing the likelihood of an early etiological diagnosis.
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Affiliation(s)
- Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
- Université de Paris, Paris, France.
| | - Lene Russell
- Department of Intensive Care, Rigshospitalet and Copenhagen Academy for Medical Simulation and Education, University of Copenhagen, Copenhagen, Denmark
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, NOVA Medical School, New University of Lisbon, Lisbon, Portugal
| | - José Garnacho Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James Street, Dublin 8, Ireland
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Kathryn Puxty
- Department of Intensive Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria
| | - Jordi Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Salud Carlos III, Madrid, Spain
- CRIPS Department, Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Djamel Mokart
- Critical Care Department, Institut Paoli Calmettes, Marseille, France
| | - Virginie Lemiale
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Adrien Mirouse
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
- Université de Paris, Paris, France
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27
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Abstract
Infectious diseases are one of the main causes of morbidity and mortality worldwide. With new pathogens continuously emerging, known infectious diseases reemerging, increasing microbial resistance to antimicrobial agents, global environmental change, ease of world travel, and an increasing immunosuppressed population, recognition of infectious diseases plays an ever-important role in surgical pathology. This becomes particularly significant in cases where infectious disease is not suspected clinically and the initial diagnostic workup fails to include samples for culture. As such, it is not uncommon that a lung biopsy becomes the only material available in the diagnostic process of an infectious disease. Once the infectious nature of the pathological process is established, careful search for the causative agent is advised. This can often be achieved by examination of the hematoxylin and eosin-stained sections alone as many organisms or their cytopathic effects are visible on routine staining. However, ancillary studies such as histochemical stains, immunohistochemistry, in situ hybridization, or molecular techniques may be needed to identify the organism in tissue sections or for further characterization, such as speciation.
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Affiliation(s)
- Annikka Weissferdt
- Associate Professor, Department of Pathology, Division of Pathology and Laboratory Medicinec, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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28
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Mark C, McGinn C. From Culture to Fungal Biomarkers: the Diagnostic Route of Fungal Infections in Children with Primary Immunodeficiencies. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-00356-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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Abstract
Die Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.
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30
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Zhu J, Zhou K, Jiang Y, Liu H, Bai H, Jiang J, Gao Y, Cai Q, Tong Y, Song X, Wang C, Wan L. Bacterial Pathogens Differed Between Neutropenic and Non-neutropenic Patients in the Same Hematological Ward: An 8-Year Survey. Clin Infect Dis 2019; 67:S174-S178. [PMID: 30423039 DOI: 10.1093/cid/ciy643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Bacterial infections are very common among patients with hematological diseases. Scant data are available regarding differences in the epidemiology and biological features of bacterial infections in neutropenic and non-neutropenic patients. Methods The aim of this survey was to compare the bacterial pathogens in neutropenic and non-neutropenic patients in the same ward during an 8-year period. Results A total of 1139 bacterial strains were isolated from 1071 patients with hematological diseases. The percentage of Gram-negative bacteria was significantly higher in neutropenic patients than in non-neutropenic patients (70.4% vs. 55.0%, respectively, P < .01). In neutropenic patients, the most commonly-isolated bacterium was Pseudomonas aeruginosa, followed by Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii, and Stenotrophomonas maltophilia. In respiratory exudates, Gram-negative bacteria were also more frequently isolated from neutropenic patients than from non-neutropenic patients (79.1% vs. 56.1%, respectively, P < .01). The proportion of non-fermentative Gram-negative bacilli was significantly higher in neutropenic patients than in non-neutropenic patients (52.9% vs. 30.5%, respectively, P < .01). In blood culture samples from neutropenic patients, the most frequently identified pathogens, apart from coagulase negative staphylococcus, were Gram-negative bacilli (58.2%). In addition, the proportion of Escherichia coli in neutropenic patients was significantly higher than that in non-neutropenic patients (P < .01). Escherichia coli and Klebsiella pneumoniae strains from neutropenic patients also produced extended-spectrum β-lactamases at a higher rate of than those strains from non-neutropenic patients (Escherichia coli, 57.6% vs. 30.3%, respectively, P < .01; Klebsiella pneumonia, 31.9% vs. 13.0%, respectively, P < .01). Conclusions This study showed that there are significant differences in the epidemiology and biological features of bacteria isolated from neutropenic and non-neutropenic patients.
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Affiliation(s)
- Jun Zhu
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Kun Zhou
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Ying Jiang
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Huixia Liu
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Haitao Bai
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Jieling Jiang
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Yanrong Gao
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Qi Cai
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Yin Tong
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Xianmin Song
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Chun Wang
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
| | - Liping Wan
- Department of Hematology, Shanghai Jiao Tong University-affiliated Shanghai General Hospital, China
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31
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Abstract
INTRODUCTION The diagnosis of pulmonary invasive fungal infection (IFI) in the pediatric oncology patient is challenging. Consensus criteria developed in 2008 state that bronchioalveolar lavage (BAL) results cannot confirm this diagnosis. A video-assisted thoracoscopic biopsy (VATS-biopsy) of lungs has been increasingly used to assist in evaluating these children for IFI. Our goal was to evaluate the impact of BAL and VATS-biopsy results on the management of IFI among pediatric oncology patients. METHODS A retrospective review of all oncology patients evaluated for IFI with VATS-biopsy and/or BAL over 9 years was carried out at a single free-standing children's hospital. The primary outcome was management changes in the use of antifungal therapy on the basis of diagnostic procedure, fungal culture results, lung imaging, and serological markers. RESULTS A total of 102 patients underwent 122 diagnostic evaluations for IFI. Ninety-one workups included only BAL, 17 evaluations involved only VATS-biopsy, and 14 cases involved both BAL and VATS-biopsy. The diagnostic yield of VATS-biopsy (38.7%) was superior to that of BAL (27.6%). There was poor concordance between VATS-biopsy and BAL results in the 14 cases where both were performed. Upon workup completion, IFI was proven in 12 children, probable in 29, and possible in 52. The odds of continuing antifungals increased 3-fold for patients with probable IFI and 12.7 times for those with the proven disease. DISCUSSION On the basis of the inferior diagnostic yield of BAL, we believe that VATS-biopsy may be a more useful diagnostic adjuvant in the diagnosis of IFI in the immunocompromised pediatric oncologic patient population.
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32
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Periselneris J, Brown JS. A clinical approach to respiratory disease in patients with hematological malignancy, with a focus on respiratory infection. Med Mycol 2019; 57:S318-S327. [PMID: 31292655 PMCID: PMC7107627 DOI: 10.1093/mmy/myy138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 01/12/2023] Open
Abstract
Respiratory complications, in particular infections, are common in the setting of hematological malignancy and after hematopoetic stem cell transplant. The symptoms can be nonspecific; therefore, it can be difficult to identify and treat the cause. However, an understanding of the specific immune defect, clinical parameters such as speed of onset, and radiological findings, allows the logical diagnostic and treatment plan to be made. Radiological findings can include consolidation, nodules, and diffuse changes such as ground glass and tree-in-bud changes. Common infections that induce these symptoms include bacterial pneumonia, invasive fungal disease, Pneumocystis jirovecii and respiratory viruses. These infections must be differentiated from inflammatory complications that often require immune suppressive treatment. The diagnosis can be refined with the aid of investigations such as bronchoscopy, computed tomography (CT) guided lung biopsy, culture, and serological tests. This article gives a schema to approach patients with respiratory symptoms in this patient group; however, in the common scenario of a rapidly deteriorating patient, treatment often has to begin empirically, with the aim to de-escalate treatment subsequently after targeted investigations.
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Affiliation(s)
| | - J S Brown
- Centre for Inflammation & Tissue Repair, University College London
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33
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Radiologische Diagnostik von Thorax und Abdomen bei immunkompromittierten Patienten. Med Klin Intensivmed Notfmed 2019; 114:526-532. [DOI: 10.1007/s00063-017-0331-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 11/25/2022]
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Das CK, Gogia A, Kumar L, Sharma A, Thulkar S, Xess I, Madan K. Evaluation of Pulmonary Infiltrate in Febrile Neutropenic Patients of Hematologic Malignancies. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_39_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Background: Pulmonary infection is the major risk during neutropenia induced by chemotherapy as well as stem cell transplantation. In spite of potent new-generation antifungal and broad-spectrum antibiotics, one-third of patients usually die from infectious complications. Early diagnosis and prompt administration of appropriate therapy improve the survival. Materials and Methods: We prospectively carried out the study to identify the infectious etiology of pulmonary infiltrates in febrile neutropenia patients by imaging and bronchoscopy. Bacterial culture, fungal culture, galactomannan and molecular diagnosis for pneumocystis, and other infectious agent were carried out in the bronchoalveolar lavage (BAL) fluid and blood. Results: A total of 27 patients were evaluated. Half of the patients belonged to acute leukemia (46%). We had a diagnostic yield of 65% with the most common isolates being Gram-negative bacteria and Aspergillus species. Conclusion: Gram-negative organisms were the predominant infectious agents of pulmonary infection. Our finding emphasizes the importance of BAL in evaluating pulmonary infiltrates in neutropenic patients with hematological malignancies.
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Affiliation(s)
- Chandan K Das
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Gogia
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Immaculata Xess
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
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BAL fluid analysis in the identification of infectious agents in patients with hematological malignancies and pulmonary infiltrates. Folia Microbiol (Praha) 2019; 65:109-120. [PMID: 31073843 PMCID: PMC7090732 DOI: 10.1007/s12223-019-00712-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/25/2019] [Indexed: 11/02/2022]
Abstract
The present study aims to evaluate the diagnostic yield of bronchoalveolar lavage (BAL) fluid in patients with hematological malignancies and describe the most common pathogens detected in BAL fluid (BALF.) An analysis of 480 BALF samples was performed in patients with hematological malignancies over a period of 7 years. The results of culture methods, PCR, and immunoenzymatic sandwich microplate assays for Aspergillus galactomannan (GM) in BALF were analyzed. Further, the diagnostic thresholds for Aspergillus GM and Pneumocystis jiroveci were also calculated. Microbiological findings were present in 87% of BALF samples. Possible infectious pathogens were detected in 55% of cases; 32% were classified as colonizing. No significant difference in diagnostic yield or pathogen spectrum was found between non-neutropenic and neutropenic patients. There was one significant difference in BALF findings among intensive care units (ICU) versus non-ICU patients for Aspergillus spp. (22% versus 9%, p = 0.03). The most common pathogens were Aspergillus spp. (n = 86, 33% of BAL with causative pathogens) and Streptococcus pneumoniae (n = 46, 18%); polymicrobial etiology was documented in 20% of cases. A quantitative PCR value of > 1860 cp/mL for Pneumocystis jirovecii was set as a diagnostic threshold for pneumocystis pneumonia. The absorbance index of GM in BALF of 0.5 was set as a diagnostic threshold for aspergillosis. The examination of BAL fluid revealed the presence of pathogen in more than 50% of cases and is, therefore, highly useful in this regard when concerning pulmonary infiltrates.
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Kochanek M, Schalk E, von Bergwelt-Baildon M, Beutel G, Buchheidt D, Hentrich M, Henze L, Kiehl M, Liebregts T, von Lilienfeld-Toal M, Classen A, Mellinghoff S, Penack O, Piepel C, Böll B. Management of sepsis in neutropenic cancer patients: 2018 guidelines from the Infectious Diseases Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2019; 98:1051-1069. [PMID: 30796468 PMCID: PMC6469653 DOI: 10.1007/s00277-019-03622-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
Sepsis and septic shock are major causes of mortality during chemotherapy-induced neutropenia for malignancies requiring urgent treatment. Thus, awareness of the presenting characteristics and prompt management is most important. Improved management of sepsis during neutropenia may reduce the mortality of cancer therapies. However, optimal management may differ between neutropenic and non-neutropenic patients. The aim of the current guideline is to give evidence-based recommendations for hematologists, oncologists, and intensive care physicians on how to manage adult patients with neutropenia and sepsis.
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Affiliation(s)
- Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany.
| | - E Schalk
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - M von Bergwelt-Baildon
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Medical Department III, University Medical Center & Comprehensive Cancer Center Munich, Munich, Germany
| | - G Beutel
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department for Hematology, Hemostasis, Oncology and Stem Cell Transplantation Hannover Medical School, Hannover, Germany
| | - D Buchheidt
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Hematology and Oncology, Mannheim University Hospital, Mannheim, Germany
| | - M Hentrich
- Department of Medicine III - Hematology and Oncology, Red Cross Hospital, Munich, Germany
| | - L Henze
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Medicine, Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - M Kiehl
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Internal Medicine I, Clinic Frankfurt (Oder), Frankfurt, Germany
| | - T Liebregts
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - M von Lilienfeld-Toal
- Department for Hematology and Medical Oncology, University Hospital Jena, Jena, Germany
| | - A Classen
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Mellinghoff
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - O Penack
- Department for Hematology, Oncology and Tumorimmunology, Campus Virchow Clinic, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - C Piepel
- Department of Hematology, Oncology and Infectious Diseases, Klinikum Bremen-Mitte, Bremen, Germany
| | - B Böll
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
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37
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Heinz WJ, Vehreschild JJ, Buchheidt D. Diagnostic work up to assess early response indicators in invasive pulmonary aspergillosis in adult patients with haematologic malignancies. Mycoses 2019; 62:486-493. [PMID: 30329192 DOI: 10.1111/myc.12860] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/03/2018] [Accepted: 10/07/2018] [Indexed: 12/20/2022]
Abstract
In immunocompromised patients with acute leukaemia as well as in allogeneic hematopoietic stem cell transplant patients, pulmonary lesions are commonly seen. Existing guidelines provide useful algorithms for diagnostic procedures and treatment options, but they do not give recommendations on how to evaluate early success or failure and if or when it is best to change therapy. Here, we review the diagnostic techniques currently used in association with clinical findings and propose an approach using a combination of computer tomography, clinical and all available biomarkers and inflammation parameters, especially those positive at baseline, to assess early response in invasive pulmonary aspergillosis. Computed tomography scans should be carried out at regular intervals during early and long-term follow-up. Imaging on day seven, or even earlier in clinically unstable patients, combined with an additional testing of biomarkers and inflammatory markers in between, is needed for a reliable assessment at day 14. If no improvement is seen after 2 weeks of therapy or the clinical condition is deteriorating, a change of antifungal therapy should be considered. Alleged breakthrough infections or treatment failure should undergo early diagnostic workup, including tissue biopsies when possible, to retrieve fungal cultures for resistance testing.
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Affiliation(s)
- Werner J Heinz
- Klinikum Weiden, Weiden, Würzburg university medical center, Würzburg, Germany
| | - Jörg J Vehreschild
- Department for Internal Medicine, German Centre for Infection Research, University Hospital of Cologne, Partner Site Bonn-Cologne, University of Cologne, Köln, Germany
| | - Dieter Buchheidt
- Department of Internal Medicine-Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
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38
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Douglas AP, Thursky KA, Worth LJ, Harrison SJ, Hicks RJ, Slavin MA. FDG-PET/CT in managing infection in patients with hematological malignancy: clinician knowledge and experience in Australia. Leuk Lymphoma 2019; 60:2471-2476. [PMID: 30947578 DOI: 10.1080/10428194.2019.1590571] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PET/CT is useful for investigation of neutropenic fever (NF) and potential invasive fungal infection (IFI) in those with hematological malignancies (HM). An online survey evaluating the utility and current practices regarding PET/CT scanning for investigation of NF was distributed to infectious diseases (ID) clinicians and hematologists via email lists hosted by key professional bodies. One-hundred and forty-five clinicians responded (120 ID; 25 hematologists). Access to PET/CT was fair but timeliness of investigation was limited (within 3 days in 35% and 46% of ID and hematology respondents, respectively). Among those with experience with PET/CT for infection (n = 109), 40% had utilized PET/CT for prolonged NF and 20% for diagnosing IFI. The majority of respondents indicated the desire to utilize PET/CT more frequently for infection indications. There is a strong desire among surveyed Australian clinicians to use PET/CT for prolonged NF and potential IFI. However, access to PET/CT is a current barrier to uptake.
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Affiliation(s)
- Abby P Douglas
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne , Melbourne , Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne , Melbourne , Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Immunity and Infection, Royal Melbourne Hospital , Melbourne , Australia.,National Centre for Antimicrobial Stewardship , Melbourne , Australia
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne , Melbourne , Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,National Centre for Antimicrobial Stewardship , Melbourne , Australia
| | - Simon James Harrison
- Sir Peter MacCallum Department of Oncology, University of Melbourne , Melbourne , Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,Department of Haematology, Peter MacCallum Cancer Centre , Melbourne , Australia.,Department of Haematology, Royal Melbourne Hospital , Melbourne , Australia
| | - Rod John Hicks
- Sir Peter MacCallum Department of Oncology, University of Melbourne , Melbourne , Australia.,Cancer Imaging, Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne , Melbourne , Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Immunity and Infection, Royal Melbourne Hospital , Melbourne , Australia
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39
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Schmidt-Hieber M, Teschner D, Maschmeyer G, Schalk E. Management of febrile neutropenia in the perspective of antimicrobial de-escalation and discontinuation. Expert Rev Anti Infect Ther 2019; 17:983-995. [PMID: 30686067 DOI: 10.1080/14787210.2019.1573670] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Infections are among the most frequent complications in patients with hematological and oncological diseases. They might be classified as fever of unknown origin and microbiologically or clinically documented infections. Optimal duration of antimicrobial treatment is still unclear in these patients.Areas covered: We provide an overview on the management of febrile neutropenia in the perspective of antimicrobial de-escalation and discontinuation.Expert opinion: Patients with febrile high-risk neutropenia should be treated empirically with an anti-pseudomonal agent such as piperacillin/tazobactam. Several clinical studies support the assumption that the primary antibiotic regimen might be safely discontinued prior to neutrophil reconstitution if the patient is afebrile for several days and all infection-related symptoms have been resolved. Primary empirical treatment with carbapenems or antibiotic combinations should commonly only be considered in selected patient subgroups, such as patients with severe neutropenic sepsis or colonization with multidrug-resistant bacteria. Preemptive antifungal treatment guided by lung imaging and other parameters (e.g. serial Aspergillus galactomannan antigen screening) might reduce the consumption of antifungals compared to the classical empirical approach.Multidrug-resistant pathogens are emerging, and novel anti-infective agents under development are scarce. Therefore, a rational use of antimicrobials based on the principles of antibiotic stewardship is crucial.
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Affiliation(s)
| | - Daniel Teschner
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Georg Maschmeyer
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Enrico Schalk
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University, Magdeburg, Germany
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40
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Trump LR, Nayak RC, Singh AK, Emberesh S, Wellendorf AM, Lutzko CM, Cancelas JA. Neutrophils Derived from Genetically Modified Human Induced Pluripotent Stem Cells Circulate and Phagocytose Bacteria In Vivo. Stem Cells Transl Med 2019; 8:557-567. [PMID: 30793529 PMCID: PMC6525559 DOI: 10.1002/sctm.18-0255] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/08/2019] [Indexed: 01/01/2023] Open
Abstract
Bacterial and fungal infections are a major cause of morbidity and mortality in neutropenic patients. Donor‐derived neutrophil transfusions have been used for prophylaxis or treatment for infection in neutropenic patients. However, the short half‐life and the limited availability of large numbers of donor‐derived neutrophils for transfusion remain a significant hurdle in the implementation of neutrophil transfusion therapy. Here, we investigate the in vitro and in vivo activity of neutrophils generated from human induced pluripotent stem cells (iPSC), a potentially unlimited resource to produce neutrophils for transfusion. Phenotypic analysis of iPSC‐derived neutrophils reveal reactive oxygen species production at similar or slightly higher than normal peripheral blood neutrophils, but have an ∼50%–70% reduced Escherichia coli phagocytosis and phorbol 12‐myristate 13‐acetate induced formation of neutrophil extracellular traps (NET). Signaling of granulocytic precursors identified impaired AKT activation, but not ERK or STAT3, in agonist‐stimulated iPSC‐derived neutrophils. Expression of a constitutively activated AKT in iPSC‐derived neutrophils restores most phagocytic activity and NET formation. In a model of bacterial induced peritonitis in immunodeficient mice, iPSC‐derived neutrophils, with or without corrected AKT activation, migrate similarly to the peritoneal fluid as peripheral blood neutrophils, whereas the expression of activated AKT significantly improves their phagocytic activity in vivo. stem cells translational medicine2019;8:557–567
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Affiliation(s)
- Lisa R Trump
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ramesh C Nayak
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Abhishek K Singh
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Hoxworth Blood Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sana Emberesh
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ashley M Wellendorf
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carolyn M Lutzko
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Hoxworth Blood Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jose A Cancelas
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Hoxworth Blood Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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41
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Azoulay E, Mokart D, Kouatchet A, Demoule A, Lemiale V. Acute respiratory failure in immunocompromised adults. THE LANCET. RESPIRATORY MEDICINE 2019; 7:173-186. [PMID: 30529232 PMCID: PMC7185453 DOI: 10.1016/s2213-2600(18)30345-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/12/2022]
Abstract
Acute respiratory failure occurs in up to half of patients with haematological malignancies and 15% of those with solid tumours or solid organ transplantation. Mortality remains high. Factors associated with mortality include a need for invasive mechanical ventilation, organ dysfunction, older age, frailty or poor performance status, delayed intensive care unit admission, and acute respiratory failure due to an invasive fungal infection or unknown cause. In addition to appropriate antibacterial therapy, initial clinical management aims to restore oxygenation and predict the most probable cause based on variables related to the underlying disease, acute respiratory failure characteristics, and radiographic findings. The cause of acute respiratory failure must then be confirmed using the most efficient, least invasive, and safest diagnostic tests. In patients with acute respiratory failure of undetermined cause, a standardised diagnostic investigation should be done immediately at admission before deciding whether to perform more invasive diagnostic procedures or to start empirical treatments. Collaborative and multidisciplinary clinical and research networks are crucial to improve our understanding of disease pathogenesis and causation and to develop less invasive diagnostic strategies and more targeted treatment options.
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Affiliation(s)
- Elie Azoulay
- Assistance Publique Hôpitaux de Paris, Service de Médecine Intensive et Réanimation, Hôpital Saint-Louis, Paris, France; ECSTRA Team, Biostatistics and Clinical Epidemiology, Center of Epidemiology and Biostatistics Sorbonne Paris Cité, Institut national de la santé et de la recherche médicale, Paris Diderot Sorbonne University, Paris, France.
| | - Djamel Mokart
- Medical Surgical Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Centre hospitalier universitaire d'Angers, Angers, France
| | - Alexandre Demoule
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France; Neurophysiologie respiratoire expérimentale et clinique, Institut national de la santé et de la recherche médicale, Sorbonne Universités, Paris, France
| | - Virginie Lemiale
- Assistance Publique Hôpitaux de Paris, Service de Médecine Intensive et Réanimation, Hôpital Saint-Louis, Paris, France; ECSTRA Team, Biostatistics and Clinical Epidemiology, Center of Epidemiology and Biostatistics Sorbonne Paris Cité, Institut national de la santé et de la recherche médicale, Paris Diderot Sorbonne University, Paris, France
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Respiratory Infections. INFECTIONS IN NEUTROPENIC CANCER PATIENTS 2019. [PMCID: PMC7120562 DOI: 10.1007/978-3-030-21859-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pneumonia is defined as the presence of a new pulmonary infiltrate on radiologic imaging in the patient with appropriate clinical symptoms such as fever, cough, production of purulent sputum, shortness of breath and/or hypoxia, in the absence of pulmonary edema [1, 2].
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Febrile Neutropenia in Transplant Recipients. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7122322 DOI: 10.1007/978-1-4939-9034-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Febrile neutropenic patients are at increased risk of developing infections. During the initial stages of neutropenia, most of these infections are bacterial. The spectrum of bacterial infections depends to some extent on whether or not patients receive antimicrobial prophylaxis when neutropenic. Since most transplant recipients do, Gram-positive organisms predominate, due to the fact prophylaxis is directed primarily against Gram-negative organisms. Staphylococcus species (often methicillin-resistant), Streptococcus species (viridans group streptococci, beta-hemolytic streptococci), and Enterococcus species (including vancomycin-resistant strains) are isolated most often. Therefore, potent empiric Gram-positive coverage is recommended by many in this setting. Escherichia coli, Pseudomonas aeruginosa, and Klebsiella species are the most common Gram-negative pathogens isolated. Non-fermentative Gram-negative bacilli (Stenotrophomonas maltophilia, Acinetobacter species) are emerging as important pathogens. Many of these organisms acquire multiple mechanisms of resistance that render them multidrug resistant. The administration of prompt, broad-spectrum, empiric, antimicrobial therapy is essential and is generally based on local epidemiology and susceptibility/resistance patterns. Response rate to the initial regimen is generally in the range of 75–85%. Fungal infections develop in patients with prolonged neutropenia (greater than 7–10 days). Candida species and Aspergillus species are the predominant fungal pathogens, although many other fungi are opportunistic pathogens in this setting. Fungal infections are seldom documented microbiologically or on histopathology, and the administration of empiric antifungal therapy, when such infections are suspected, is the norm. Therapy is often prolonged, and outcomes are still suboptimal. The importance of infection control and antimicrobial stewardship cannot be overemphasized.
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Darvall JN, Byrne T, Douglas N, Anstey JR. Intensive Care Practice in the Cancer Patient Population:
Special Considerations and Challenges. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0293-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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45
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Ventilatory Strategies in Patients With Hematologic Malignancies and Acute Respiratory Failure: New Insights, New Questions, What Now? Crit Care Med 2018; 44:1444-6. [PMID: 27309171 DOI: 10.1097/ccm.0000000000001887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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46
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Dumas G, Bigé N, Lemiale V, Azoulay E. Patients immunodéprimés, quel pathogène pour quel déficit immunitaire ? (en dehors de l’infection à VIH). MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le nombre de patients immunodéprimés ne cesse d’augmenter en raison de l’amélioration du pronostic global du cancer et de l’utilisation croissante d’immunosuppresseurs tant en transplantation qu’au cours des maladies auto-immunes. Les infections sévères restent la première cause d’admission en réanimation dans cette population et sont dominées par les atteintes respiratoires. On distingue les déficits primitifs, volontiers révélés dans l’enfance, des déficits secondaires (médicamenteux ou non), les plus fréquents. Dans tous les cas, les sujets sont exposés à des infections inhabituelles de par leur fréquence, leur type et leur sévérité. À côté des pyogènes habituels, les infections opportunistes et la réactivation d’infections latentes font toute la complexité de la démarche diagnostique. Celle-ci doit être rigoureuse, orientée par le type de déficit, les antécédents, les prophylaxies éventuelles et la présentation clinicoradiologique. Elle permettra seule de guider le traitement probabiliste et les examens étiologiques, l’absence de diagnostic étant associée à une mortalité élevée.
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47
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Blau IW, Heinz WJ, Schwartz S, Lipp HP, Schafhausen P, Maschmeyer G. [Pulmonary infiltrates in haematological patients]. MMW Fortschr Med 2018; 160:12-17. [PMID: 29974434 DOI: 10.1007/s15006-018-0727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 01/30/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Pulmonary complications are frequent in haematologic patients. METHOD This review article summarizes the outcome of a discussion that took place during an expert meeting on the subject of pulmonary infiltrates. RESULTS AND CONCLUSIONS The most common causes of pulmonary infiltrates in haematologic patients are bacterial infections. Viral infections are subject to relevant seasonal variations, but they may also cause an important proportion of pulmonary infiltrates. Microbiological examination of respiratory tract material (if possible, bronchoalveolar lavage, BAL) is the most important diagnostic procedure. Particularly in the case of prolonged (> 7 days) neutropenia, the likelihood of infiltrates being caused by fungal infections increases. For a differential diagnosis, however, also non-infectious causes, e.g. drug-induced infiltrates, have to be taken into consideration. The diagnostic workup, however, should not delay a timely start of an adequate antimicrobial therapy.
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Affiliation(s)
- Igor-Wolfgang Blau
- Medizinische Klinik für Hämatologie, Onkologie und Tumorimmunologie, Leitender Oberarzt Knochenmarktransplantation, Campus Virchow Klinikum der Charité - Universitätsmedizin Berlin, Berlin, Deutschland.
- Klinik für Hämatologie, Onkologie und Tumorimmunologie, Campus Virchow Klinikum der Charité - Universitätsmedizin Berlin, Augustenburgerplatz 1, D-13353, Berlin, Deutschland.
| | - Werner J Heinz
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Stefan Schwartz
- Medizinische Klinik für Hämatologie, Onkologie und Tumorimmunologie, Campus Benjamin Franklin der Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | | | - Philippe Schafhausen
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, UKE Hamburg, Hamburg, Deutschland
| | - Georg Maschmeyer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Klinikum Ernst von Bergmann gemeinnützige GmbH, Potsdam, Deutschland
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Lee HY, Rhee CK, Choi JY, Lee HY, Lee JW, Lee DG. Diagnosis of cytomegalovirus pneumonia by quantitative polymerase chain reaction using bronchial washing fluid from patients with hematologic malignancies. Oncotarget 2018; 8:39736-39745. [PMID: 28061469 PMCID: PMC5503648 DOI: 10.18632/oncotarget.14504] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 12/27/2016] [Indexed: 12/04/2022] Open
Abstract
Background The incidence of cytomegalovirus (CMV) pneumonia is increasing in patients diagnosed with hematologic malignancies. The utility of CMV-DNA viral load measurement has not been standardized, and viral cut-off values have not been established. This study was designed to investigate the utility of CMV quantitative real-time PCR (qRT-PCR) using bronchial washing fluid. Methods We retrospectively reviewed the microbiologic and pathologic results of bronchial washing fluid and biopsy specimens in addition to the patients' clinical characteristics. Results A total of 565 CMV qRT-PCR assays were performed using bronchial washing fluid from patients with hematologic malignancies. Among them, 101 were positive for CMV by qRT-PCR; of these, 24 were diagnosed with CMV pneumonia and 70 with CMV infection, and 7 were excluded due to a diagnosis of invasive pulmonary aspergillosis rather than viral pneumonia. The median CMV load determined by qPCR was 1.8 × 105 copies/mL (3.6 103-1.5 × 108) in CMV pneumonia patients and 3.0 × 103 copies/mL (5.0 × 102-1.1 × 105) in those diagnosed with CMV infection (P < 0.01). Using the ROC curve, the optimal inflection points were 18,900 copies/mL (137,970 IU/mL) in post-bone marrow transplantation (BMT) patients, 316,415 copies/mL (2,309,825 IU/mL) in no-BMT patients and 28,774 copies/mL (210,054 IU/mL) in all patients. Conclusions The CMV titers in bronchial washing fluid determined by qRT-PCR differed significantly between patients diagnosed with CMV pneumonia and those with CMV infection. The viral cut-off values in bronchial washing fluid were suggested for the diagnosis of CMV pneumonia, which were different depending on the BMT status.
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Affiliation(s)
- Hwa Young Lee
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chin Kook Rhee
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Young Choi
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hea Yon Lee
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Internal Medicine, Division of Hematology, The Catholic University of Korea, Seoul, Korea.,The Catholic Blood and Marrow Transplantation Center, The Catholic University of Korea, Seoul, Korea
| | - Dong Gun Lee
- The Catholic Blood and Marrow Transplantation Center, The Catholic University of Korea, Seoul, Korea.,Department of Internal Medicine, Division of Infectious Diseases, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Korea
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49
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von Lilienfeld-Toal M, Maschmeyer G. Challenges in Infectious Diseases for Haematologists. Oncol Res Treat 2018; 41:406-410. [PMID: 29734194 DOI: 10.1159/000487439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/06/2018] [Indexed: 01/11/2023]
Abstract
Infections remain a threat for patients with haematological malignancies. In accordance with the European Hematology Association roadmap we provide a concise overview regarding the most relevant current challenges in infectious diseases for haematologists. These include bacterial infections and the need for antibiotic stewardship as well as infections with community-acquired respiratory viruses, infections in patients receiving targeted therapies, re-activations of latent infections and vaccination strategies. The following review intends to summarise the most relevant information for clinicians currently caring for patients with haematological malignancies. Recommendations given are based on the guidelines published by the Infectious Diseases Working Party of the German Society of Haematology and Medical Oncology.
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50
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Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K, Lass-Flörl C, Lewis RE, Munoz P, Verweij PE, Warris A, Ader F, Akova M, Arendrup MC, Barnes RA, Beigelman-Aubry C, Blot S, Bouza E, Brüggemann RJM, Buchheidt D, Cadranel J, Castagnola E, Chakrabarti A, Cuenca-Estrella M, Dimopoulos G, Fortun J, Gangneux JP, Garbino J, Heinz WJ, Herbrecht R, Heussel CP, Kibbler CC, Klimko N, Kullberg BJ, Lange C, Lehrnbecher T, Löffler J, Lortholary O, Maertens J, Marchetti O, Meis JF, Pagano L, Ribaud P, Richardson M, Roilides E, Ruhnke M, Sanguinetti M, Sheppard DC, Sinkó J, Skiada A, Vehreschild MJGT, Viscoli C, Cornely OA. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect 2018; 24 Suppl 1:e1-e38. [PMID: 29544767 DOI: 10.1016/j.cmi.2018.01.002] [Citation(s) in RCA: 823] [Impact Index Per Article: 137.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.
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Affiliation(s)
- A J Ullmann
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J M Aguado
- Infectious Diseases Unit, University Hospital Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - S Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D W Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; European Confederation of Medical Mycology (ECMM)
| | - A H Groll
- Department of Paediatric Haematology/Oncology, Centre for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - K Lagrou
- Department of Microbiology and Immunology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lass-Flörl
- Institute of Hygiene, Microbiology and Social Medicine, ECMM Excellence Centre of Medical Mycology, Medical University Innsbruck, Innsbruck, Austria; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R E Lewis
- Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - P Munoz
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - F Ader
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France; Inserm 1111, French International Centre for Infectious Diseases Research (CIRI), Université Claude Bernard Lyon 1, Lyon, France; European Respiratory Society (ERS)
| | - M Akova
- Department of Medicine, Section of Infectious Diseases, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M C Arendrup
- Department Microbiological Surveillance and Research, Statens Serum Institute, Copenhagen, Denmark; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R A Barnes
- Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK; European Confederation of Medical Mycology (ECMM)
| | - C Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; European Respiratory Society (ERS)
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; European Respiratory Society (ERS)
| | - E Bouza
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R J M Brüggemann
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG)
| | - D Buchheidt
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Cadranel
- Department of Pneumology, University Hospital of Tenon and Sorbonne, University of Paris, Paris, France; European Respiratory Society (ERS)
| | - E Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India; European Confederation of Medical Mycology (ECMM)
| | - M Cuenca-Estrella
- Instituto de Salud Carlos III, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - G Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece; European Respiratory Society (ERS)
| | - J Fortun
- Infectious Diseases Service, Ramón y Cajal Hospital, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J-P Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Garbino
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - W J Heinz
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R Herbrecht
- Department of Haematology and Oncology, University Hospital of Strasbourg, Strasbourg, France; ESCMID Fungal Infection Study Group (EFISG)
| | - C P Heussel
- Diagnostic and Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany; European Confederation of Medical Mycology (ECMM)
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, London, UK; European Confederation of Medical Mycology (ECMM)
| | - N Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia; European Confederation of Medical Mycology (ECMM)
| | - B J Kullberg
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lange
- International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany; Clinical Infectious Diseases, Research Centre Borstel, Leibniz Center for Medicine & Biosciences, Borstel, Germany; German Centre for Infection Research (DZIF), Tuberculosis Unit, Hamburg-Lübeck-Borstel-Riems Site, Lübeck, Germany; European Respiratory Society (ERS)
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Confederation of Medical Mycology (ECMM)
| | - J Löffler
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Lortholary
- Department of Infectious and Tropical Diseases, Children's Hospital, University of Paris, Paris, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Maertens
- Department of Haematology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - L Pagano
- Department of Haematology, Universita Cattolica del Sacro Cuore, Roma, Italy; European Confederation of Medical Mycology (ECMM)
| | - P Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Richardson
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece; Hippokration General Hospital, Thessaloniki, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Ruhnke
- Department of Haematology and Oncology, Paracelsus Hospital, Osnabrück, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Sanguinetti
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Rome, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D C Sheppard
- Division of Infectious Diseases, Department of Medicine, Microbiology and Immunology, McGill University, Montreal, Canada; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Sinkó
- Department of Haematology and Stem Cell Transplantation, Szent István and Szent László Hospital, Budapest, Hungary; ESCMID Fungal Infection Study Group (EFISG)
| | - A Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M J G T Vehreschild
- Department I of Internal Medicine, ECMM Excellence Centre of Medical Mycology, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology, Cologne-Bonn, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; European Confederation of Medical Mycology (ECMM)
| | - C Viscoli
- Ospedale Policlinico San Martino and University of Genova (DISSAL), Genova, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O A Cornely
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; CECAD Cluster of Excellence, University of Cologne, Cologne, Germany; Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM); ESCMID European Study Group for Infections in Compromised Hosts (ESGICH).
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