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Feys S, Carvalho A, Clancy CJ, Gangneux JP, Hoenigl M, Lagrou K, Rijnders BJA, Seldeslachts L, Vanderbeke L, van de Veerdonk FL, Verweij PE, Wauters J. Influenza-associated and COVID-19-associated pulmonary aspergillosis in critically ill patients. THE LANCET. RESPIRATORY MEDICINE 2024; 12:728-742. [PMID: 39025089 DOI: 10.1016/s2213-2600(24)00151-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 07/20/2024]
Abstract
Influenza-associated pulmonary aspergillosis (IAPA) and COVID-19-associated pulmonary aspergillosis (CAPA) are increasingly recognised as important complications in patients requiring intensive care for severe viral pneumonia. The diagnosis can typically be made in 10-20% of patients with severe influenza or COVID-19, but only when appropriate diagnostic tools are used. Bronchoalveolar lavage sampling for culture, galactomannan testing, and PCR forms the cornerstone of diagnosis, whereas visual examination of the tracheobronchial tract during bronchoscopy is required to detect invasive Aspergillus tracheobronchitis. Azoles are the first-choice antifungal drugs, with liposomal amphotericin B as an alternative in settings where azole resistance is prevalent. Despite antifungal therapy, IAPA and CAPA are associated with poor outcomes, with fatality rates often exceeding 50%. In this Review, we discuss the mechanistic and clinical aspects of IAPA and CAPA. Moreover, we identify crucial knowledge gaps and formulate directions for future research.
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Affiliation(s)
- Simon Feys
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium; Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's Associate Laboratory, Braga/ Guimarães, Portugal
| | - Cornelius J Clancy
- Division of Infectious Diseases, University of Pittsburgh, PA, USA; VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jean-Pierre Gangneux
- Université de Rennes, CHU Rennes, INSERM, EHESP, IRSET, UMR_S 1085, Rennes, France; Centre Hospitalier Universitaire de Rennes, Laboratoire de Parasitologie-Mycologie, ECMM Excellence Center in Medical Mycology, French National Reference Center on Mycoses and Antifungals (CNRMA-LA AspC), Rennes, France
| | - Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center in Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria; Translational Medical Mycology Research Group, Medical University of Graz, Graz, Austria; Bio TechMed-Graz, Graz, Austria
| | - Katrien Lagrou
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases and Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | | | - Lore Vanderbeke
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands; Center of Expertise for Mycology, Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Joost Wauters
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium; Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
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Prattes J, Giacobbe DR, Bassetti M, Gangneux JP, Hoenigl M. Antifungal prophylaxis of COVID-19 associated pulmonary aspergillosis in ventilated patients: one solution does not fit all. Intensive Care Med 2024; 50:1375-1377. [PMID: 38980361 DOI: 10.1007/s00134-024-07542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/10/2024]
Affiliation(s)
- Juergen Prattes
- Department of Internal Medicine, Division of Infectious Diseases, Excellence Centre for Medical Mycology (ECMM), Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
- BioTechMed Graz, Graz, Austria.
| | - Daniele R Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Jean-Pierre Gangneux
- EHESP, Irset (Institut de Recherche en Santé, Environnement Et Travail)-UMR_S 1085, CHU Rennes, Inserm, Univ Rennes, 35000, Rennes, France
- Laboratoire de Parasitologie-Mycologie, Centre National de Référence Pour Les Aspergilloses Chroniques (CNRMA-LA AspC), ECMM Excellence Center for Medical Mycology, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Martin Hoenigl
- Department of Internal Medicine, Division of Infectious Diseases, Excellence Centre for Medical Mycology (ECMM), Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- BioTechMed Graz, Graz, Austria
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3
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Sahin M, Yilmaz M, Mert A, Emecen AN, Rahman S. Al Maslamani MA, Mahmoud A. Hashim S, Ittaman AV, Wadi Al Ramahi J, Gergely Szabo B, Konopnicki D, Baskol Elik D, Lakatos B, Sipahi OR, Khedr R, Jalal S, Pshenichnaya N, Magdalena DI, El-Kholy A, Khan EA, Alkan S, Hakamifard A, Sincan G, Esmaoglu A, Makek MJ, Gurbuz E, Liskova A, Albayrak A, Stebel R, Unver Ulusoy T, Ripon RK, Moroti R, Dascalu C, Rashid N, Cortegiani A, Bahadir Z, Erdem H. Factors affecting mortality in COVID-19-associated pulmonary aspergillosis: An international ID-IRI study. Heliyon 2024; 10:e34325. [PMID: 39082033 PMCID: PMC11284427 DOI: 10.1016/j.heliyon.2024.e34325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 08/02/2024] Open
Abstract
Background This study aimed to identify factors that influence the mortality rate of patients with coronavirus disease (COVID-19)-associated pulmonary aspergillosis (CAPA). Methods In this cross-sectional study, data from 23 centers across 15 countries, spanning the period of March 2020 to December 2021, were retrospectively collected. The study population comprised patients who developed invasive pulmonary aspergillosis while being treated for COVID-19 in the intensive care unit. Cox regression and decision tree analyses were used to identify factors associated with mortality in patients with CAPA. Results A total of 162 patients (males, 65.4 %; median age: 64 [25th-75th: 54.0-73.8] years) were included in the study, of whom 113 died during the 90-day follow-up period. The median duration from CAPA diagnosis to death was 12 (25th-75th: 7-19) days. In the multivariable Cox regression model, an age of ≥65 years (hazard ratio [HR]: 2.05, 95 % confidence interval [CI]: 1.37-3.07), requiring vasopressor therapy at the time of CAPA diagnosis (HR: 1.80, 95 % CI: 1.17-2.76), and receiving renal replacement therapy at the time of CAPA diagnosis (HR: 2.27, 95 % CI: 1.35-3.82) were identified as predictors of mortality. Decision tree analysis revealed that patients with CAPA aged ≥65 years who received corticosteroid treatment for COVID-19 displayed higher mortality rates (estimated rate: 1.6, observed in 46 % of patients). Conclusion This study concluded that elderly patients with CAPA who receive corticosteroids are at a significantly higher risk of mortality, particularly if they experience multiorgan failure.
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Affiliation(s)
- Meyha Sahin
- Istanbul Medipol University, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Mesut Yilmaz
- Istanbul Medipol University, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Ali Mert
- Istanbul Medipol University, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Ahmet Naci Emecen
- Dokuz Eylul University, Research and Application Hospital, Izmir, Turkey
| | | | - Samar Mahmoud A. Hashim
- Communicable Disease Center / Infectious Disease – Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Balint Gergely Szabo
- South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Deborah Konopnicki
- Université Libre de Bruxelles, Saint-Pierre University Hospital, Infectious Diseases Department, Bruxelles, Belgium
| | - Dilsah Baskol Elik
- Ege University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Botond Lakatos
- South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Oguz Resat Sipahi
- Ege University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Reham Khedr
- National Cancer Institute - Cairo University / Children's Cancer Hospital Egypt, Department of Pediatric Oncology, Cairo, Egypt
| | | | - Natalia Pshenichnaya
- Central Research Institute of Epidemiology, Department of Infectious Diseases, Moscow, Russia
| | | | - Amani El-Kholy
- Cairo University, Faculty of Medicine, Department of Clinical Pathology, Cairo, Egypt
| | - Ejaz Ahmed Khan
- Shifa Tameer-e-Millat University and Shifa International Hospital, Infectious Diseases Division, Islamabad, Pakistan
| | - Sevil Alkan
- Canakkale Onsekiz Mart University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Canakkale, Turkey
| | - Atousa Hakamifard
- Department of Infectious Diseases, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gulden Sincan
- Ataturk University, Faculty of Medicine, Department of Haematology, Erzurum, Turkey
| | - Aliye Esmaoglu
- Erciyes University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Kayseri, Turkey
| | - Mateja Jankovic Makek
- University of Zagreb School of Medicine, Zagreb, Croatia
- Clinic for Lung Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Esra Gurbuz
- University of Health Sciences, Van Training and Research Hospital, Van, Turkey
| | - Anna Liskova
- Hospital Nitra, Department of Clinical Microbiology, St. Elizabeth University of Health and Social Sciences Bratislava, Slovakia
| | - Ayse Albayrak
- Ataturk University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Erzurum, Turkey
| | - Roman Stebel
- University Hospital Brno and Faculty of Medicine, Masaryk University, Department of Infectious Diseases, Brno, Czech Republic
| | - Tulay Unver Ulusoy
- University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Rezaul Karim Ripon
- Jahangirnagar University, Department of Public Health and Informatics, Savar, Dhaka, Bangladesh
| | - Ruxandra Moroti
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Infectious Diseases Matei Bals, Bucharest, Romania
| | - Cosmin Dascalu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Naveed Rashid
- Shifa Tameer-e-Millat University and Shifa International Hospital, Infectious Diseases Division, Islamabad, Pakistan
| | - Andrea Cortegiani
- Department of Surgical Oncological and Oral Science (Di.Chir.On.S.), University of Palermo. Department of Anesthesia Intensive Care and Emergency, University Hospital Policlinico “Paolo Giaccone”, Palermo, Italy
| | - Zeynep Bahadir
- Istanbul Medipol University Medical School, Istanbul, Turkey
| | - Hakan Erdem
- University of Health Sciences, Gulhane School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
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Bay P, Audureau E, Fourati S, de Prost N. COVID-19 associated pulmonary aspergillosis in critically-ill patients - authors' reply. Ann Intensive Care 2024; 14:112. [PMID: 39009825 PMCID: PMC11250758 DOI: 10.1186/s13613-024-01320-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/26/2024] [Indexed: 07/17/2024] Open
Affiliation(s)
- Pierre Bay
- Médecine Intensive RéanimationService de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, CHU Henri Mondor, CEDEX, 51, Av. de Lattre de Tassigny, Créteil, 94010, France.
- Groupe de Recherche Clinique CARMAS, Université Paris-Est-Créteil (UPEC), Créteil, France.
- Université Paris-Est-Créteil (UPEC), Créteil, France.
- IMRB INSERM U955, Team « Viruses, Cancer », Hepatology, Créteil, France.
| | - Etienne Audureau
- Université Paris-Est-Créteil (UPEC), Créteil, France
- IMRB INSERM U955, Team CEpiA, Unité de Recherche Clinique, Créteil, France
- Department of Public Health, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France
| | - Slim Fourati
- Université Paris-Est-Créteil (UPEC), Créteil, France
- IMRB INSERM U955, Team « Viruses, Cancer », Hepatology, Créteil, France
- Department of Virology, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Nicolas de Prost
- Médecine Intensive RéanimationService de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, CHU Henri Mondor, CEDEX, 51, Av. de Lattre de Tassigny, Créteil, 94010, France
- Groupe de Recherche Clinique CARMAS, Université Paris-Est-Créteil (UPEC), Créteil, France
- Université Paris-Est-Créteil (UPEC), Créteil, France
- IMRB INSERM U955, Team « Viruses, Cancer », Hepatology, Créteil, France
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Moni M, Sathyapalan DT, Edathadathil F, Razak MA, Nair SG, Nair CV, Samban SS, Prasanna P, Kulirankal KG, Purushothaman SS, Gutjahr G, Ying J, John TM. Predicting COVID 19-Associated Pulmonary Aspergillosis Risk in Low- and Middle-Income Countries: A Matched Case-Control Study. Open Forum Infect Dis 2024; 11:ofae406. [PMID: 39070046 PMCID: PMC11273325 DOI: 10.1093/ofid/ofae406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 07/14/2024] [Indexed: 07/30/2024] Open
Abstract
Background Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a life-threatening fungal infection. Studies focusing on CAPA in low- and middle-income countries are limited. Methods This retrospective matched case-control study was conducted at a tertiary care center in South India. Cases of CAPA were classified using the 2020 European Confederation of Medical Mycology/International Society for Human and Animal Mycology consensus criteria. A total of 95 cases were matched 1:1 with COVID-19 patients without CAPA. Matching was done based on age and period of admission. Inverse probability weighting was used to account for imbalances in COVID-19 severity and intensive care unit (ICU) admission. Data on demographics, clinical details, microbiologic and radiologic data, and treatment outcomes were collected. A predictive score for CAPA was developed from baseline risk factors. Results The predictive score identified lymphopenia, European Organisation for Research and Treatment of Cancer risk factors, and broad-spectrum antibiotic use as the main risk factors for CAPA. Positivity for bacterial pathogens in blood or bronchoalveolar lavage samples reduced the risk of CAPA. The predictive model performed well in cross-validation, with an area under the curve value of 82%. CAPA diagnosis significantly increased mortality and shift to ICU. Conclusions The predictive model derived from the current study offers a valuable tool for clinicians, especially in high-endemic low- and middle-income countries, for the early identification and treatment of CAPA. With further validation, this risk score could improve patient outcomes.
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Affiliation(s)
- Merlin Moni
- Division of Infectious Diseases, Department of General Medicine, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Dipu T Sathyapalan
- Division of Infectious Diseases, Department of General Medicine, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Fabia Edathadathil
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - M Abdul Razak
- Division of Infectious Diseases, Department of General Medicine, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sivapriya G Nair
- Division of Infectious Diseases, Department of General Medicine, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Chithira V Nair
- Division of Infectious Diseases, Department of General Medicine, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Swathy S Samban
- Division of Infectious Diseases, Department of General Medicine, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Preetha Prasanna
- Department of Medical Administration, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Kiran G Kulirankal
- Division of Infectious Diseases, Department of General Medicine, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Shyam Sundar Purushothaman
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Science and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Georg Gutjahr
- Center for Research in Analytics and Technology for Education, Amrita Vishwa Vidyapeetham, Kollam, Kerala, India
| | - Jiang Ying
- Division of Internal Medicine, Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Teny M John
- Division of Internal Medicine, Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Gonçalves SM, Pereira I, Feys S, Cunha C, Chamilos G, Hoenigl M, Wauters J, van de Veerdonk FL, Carvalho A. Integrating genetic and immune factors to uncover pathogenetic mechanisms of viral-associated pulmonary aspergillosis. mBio 2024; 15:e0198223. [PMID: 38651925 PMCID: PMC11237550 DOI: 10.1128/mbio.01982-23] [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: 04/25/2024] Open
Abstract
Invasive pulmonary aspergillosis is a severe fungal infection primarily affecting immunocompromised patients. Individuals with severe viral infections have recently been identified as vulnerable to developing invasive fungal infections. Both influenza-associated pulmonary aspergillosis (IAPA) and COVID-19-associated pulmonary aspergillosis (CAPA) are linked to high mortality rates, emphasizing the urgent need for an improved understanding of disease pathogenesis to unveil new molecular targets with diagnostic and therapeutic potential. The recent establishment of animal models replicating the co-infection context has offered crucial insights into the mechanisms that underlie susceptibility to disease. However, the development and progression of human viral-fungal co-infections exhibit a significant degree of interindividual variability, even among patients with similar clinical conditions. This observation implies a significant role for host genetics, but information regarding the genetic basis for viral-fungal co-infections is currently limited. In this review, we discuss how genetic factors known to affect either antiviral or antifungal immunity could potentially reveal pathogenetic mechanisms that predispose to IAPA or CAPA and influence the overall disease course. These insights are anticipated to foster further research in both pre-clinical models and human patients, aiming to elucidate the complex pathophysiology of viral-associated pulmonary aspergillosis and contributing to the identification of new diagnostic and therapeutic targets to improve the management of these co-infections.
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Affiliation(s)
- Samuel M Gonçalves
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - Inês Pereira
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - Simon Feys
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Cristina Cunha
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - Georgios Chamilos
- Laboratory of Clinical Microbiology and Microbial Pathogenesis, School of Medicine, University of Crete, Heraklion, Crete, Greece
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology, Heraklion, Crete, Greece
| | - Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
| | - Joost Wauters
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães/Braga, Portugal
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Jenks JD, Hoenigl M, Thompson GR. Study protocol: A randomized, double-blind, placebo-controlled trial of isavuconazole prophylaxis for the prevention of covid-19-associated pulmonary aspergillosis. Contemp Clin Trials Commun 2024; 39:101310. [PMID: 38832095 PMCID: PMC11144754 DOI: 10.1016/j.conctc.2024.101310] [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: 01/05/2024] [Revised: 03/28/2024] [Accepted: 05/16/2024] [Indexed: 06/05/2024] Open
Abstract
Background During the early stages of the coronavirus disease 2019 (COVID-19) pandemic, those with severe COVID-19 infection were at risk for a number of opportunistic infections including COVID-19-associated pulmonary aspergillosis (CAPA). We initiated a randomized clinical trial to evaluate whether isavuconazole, a triazole antifungal, could prevent CAPA and improve survival in patients admitted to the ICU with severe COVID-19 infection. Methods We designed a phase III/IV randomized, double-blind, two-arm, placebo-controlled trial evaluating standard of care (SOC) plus isavuconazole versus SOC plus placebo and were to enroll participants admitted to the ICU with severe COVID-19 infection at three medical centers in California, United States. The projected sample size was 162 participants. Results Due to poor enrollment and the declining number of COVID-19 cases over time, the study was terminated after 7 participants were enrolled, all enrolled at one study site (UC San Diego Health). CAPA was suspected in two participants and they were started on open-label isavuconazole. One was withdrawn due to possible isavuconazole-related adverse side effects. Conclusion Enrollment was slower-than-expected due to multiple factors, including competing COVID-19-related studies and hesitancy from potential study participants or their families to join the study. Our experience highlights some of the difficulties in planning and running a clinical trial focused on fungal superinfections involving severely ill patients during the height of the COVID-19 pandemic. Lessons learned from this study will help in the design of proposed studies examining antifungal prophylaxis against aspergillosis following other severe respiratory viral infections.
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Affiliation(s)
- Jeffrey D. Jenks
- Durham County Department of Public Health, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA
| | - Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
| | - George R. Thompson
- University of California Davis Center for Valley Fever, Sacramento, CA, USA
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, Sacramento, CA, USA
- Department of Medical Microbiology and Immunology, University of California Davis, Davis, CA, USA
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van Grootveld R, van Paassen J, Claas ECJ, Heerdink L, Kuijper EJ, de Boer MGJ, van der Beek MT. Prospective and systematic screening for invasive aspergillosis in the ICU during the COVID-19 pandemic, a proof of principle for future pandemics. Med Mycol 2024; 62:myae028. [PMID: 38544330 PMCID: PMC11095538 DOI: 10.1093/mmy/myae028] [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: 01/09/2024] [Revised: 03/07/2024] [Accepted: 03/26/2024] [Indexed: 05/16/2024] Open
Abstract
The diagnostic performance of a prospective, systematic screening strategy for COVID-19 associated pulmonary aspergillosis (CAPA) during the COVID-19 pandemic was investigated. Patients with COVID-19 admitted to the ICU were screened for CAPA twice weekly by collection of tracheal aspirate (TA) for Aspergillus culture and PCR. Subsequently, bronchoalveolar lavage (BAL) sampling was performed in patients with positive screening results and clinical suspicion of infection. Patient data were collected from April 2020-February 2022. Patients were classified according to 2020 ECMM/ISHAM consensus criteria. In total, 126/370 (34%) patients were positive in screening and CAPA frequency was 52/370 (14%) (including 13 patients negative in screening). CAPA was confirmed in 32/43 (74%) screening positive patients who underwent BAL sampling. ICU mortality was 62% in patients with positive screening and confirmed CAPA, and 31% in CAPA cases who were screening negative. The sensitivity, specificity, positive and negative predictive value (PPV & NPV) of screening for CAPA were 0.71, 0.73, 0.27, and 0.95, respectively. The PPV was higher if screening was culture positive compared to PCR positive only, 0.42 and 0.12 respectively. CAPA was confirmed in 74% of screening positive patients, and culture of TA had a better diagnostic performance than PCR. Positive screening along with clinical manifestations appeared to be a good indication for BAL sampling since diagnosis of CAPA was confirmed in most of these patients. Prospective, systematic screening allowed to quickly gain insight into the epidemiology of fungal superinfections during the pandemic and could be applicable for future pandemics.
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Affiliation(s)
- Rebecca van Grootveld
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Medical Microbiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Eric C J Claas
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Laura Heerdink
- Directorate of Education (DOO), Leiden University Medical Center, Leiden, The Netherlands
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martha T van der Beek
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
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9
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Bay P, Audureau E, Préau S, Favory R, Guigon A, Heming N, Gault E, Pham T, Chaghouri A, Turpin M, Morand-Joubert L, Jochmans S, Pitsch A, Meireles S, Contou D, Henry A, Joseph A, Chaix ML, Uhel F, Roux D, Descamps D, Emery M, Garcia-Sanchez C, Levy D, Burrel S, Mayaux J, Kimmoun A, Hartard C, Pène F, Rozenberg F, Gaudry S, Brichler S, Guillon A, Handala L, Tamion F, Moisan A, Daix T, Hantz S, Delamaire F, Thibault V, Souweine B, Henquell C, Picard L, Botterel F, Rodriguez C, Dessap AM, Pawlotsky JM, Fourati S, de Prost N. COVID-19 associated pulmonary aspergillosis in critically-ill patients: a prospective multicenter study in the era of Delta and Omicron variants. Ann Intensive Care 2024; 14:65. [PMID: 38658426 PMCID: PMC11043290 DOI: 10.1186/s13613-024-01296-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND During the first COVID-19 pandemic wave, COVID-19-associated pulmonary aspergillosis (CAPA) has been reported in up to 11-28% of critically ill COVID-19 patients and associated with increased mortality. As new SARS-CoV-2 variants emerged, the characteristics of critically ill COVID-19 patients have evolved, particularly in the era of Omicron. The purpose of this study is to investigate the characteristics of CAPA in the era of new variants. METHODS This is a prospective multicenter observational cohort study conducted in France in 36 participating intensive care units (ICU), between December 7th, 2021 and April 26th 2023. Diagnosis criteria of CAPA relied on European Confederation of Medical Mycology (ECMM)/International Society for Human & Animal Mycology (ISHAM) consensus criteria. RESULTS 566 patients were included over the study period. The prevalence of CAPA was 5.1% [95% CI 3.4-7.3], and rose to 9.1% among patients who required invasive mechanical ventilation (IMV). Univariable analysis showed that CAPA patients were more frequently immunosuppressed and required more frequently IMV support, vasopressors and renal replacement therapy during ICU stay than non-CAPA patients. SAPS II score at ICU admission, immunosuppression, and a SARS-CoV-2 Delta variant were independently associated with CAPA in multivariable logistic regression analysis. Although CAPA was not significantly associated with day-28 mortality, patients with CAPA experienced a longer duration of mechanical ventilation and ICU stay. CONCLUSION This study contributes valuable insights into the prevalence, characteristics, and outcomes of CAPA in the era of Delta and Omicron variants. We report a lower prevalence of CAPA (5.1%) among critically-ill COVID-19 patients than previously reported, mainly affecting intubated-patients. Duration of mechanical ventilation and ICU stay were significantly longer in CAPA patients.
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Affiliation(s)
- Pierre Bay
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), CHU Henri Mondor, 51, Av. de Lattre de Tassigny, CEDEX, 94010, Créteil, France.
- Groupe de Recherche Clinique CARMAS, Université Paris-Est-Créteil (UPEC), Créteil, France.
- Université Paris-Est-Créteil (UPEC), Créteil, France.
- IMRB INSERM U955, Team "Viruses, Hepatology, Cancer", Créteil, France.
| | - Etienne Audureau
- Université Paris-Est-Créteil (UPEC), Créteil, France
- IMRB INSERM U955, Team CEpiA, Créteil, France
- Unité de Recherche Clinique, Department of Public Health, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Sébastien Préau
- U1167-RID-AGE Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, 59000, Lille, France
| | - Raphaël Favory
- U1167-RID-AGE Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, 59000, Lille, France
| | - Aurélie Guigon
- Service de Virologie, CHU de Lille, 59000, Lille, France
| | - Nicholas Heming
- Médecine Intensive Réanimation, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris (AP-HP), Garches, France
| | - Elyanne Gault
- Laboratoire de Virologie, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne, France
| | - Tài Pham
- Groupe de Recherche Clinique CARMAS, Université Paris-Est-Créteil (UPEC), Créteil, France
- Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et des Vaisseaux, FHU Sepsis, Le Kremlin-Bicêtre, France
- Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Amal Chaghouri
- Laboratoire de Virologie, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Matthieu Turpin
- Centre de Recherche Saint-Antoine INSERM, Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Laurence Morand-Joubert
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, Paris, France
- Laboratoire de Virologie, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012, Paris, France
| | | | - Aurélia Pitsch
- Laboratoire de Microbiologie, Hôpital Marc Jacquet, Melun, France
| | - Sylvie Meireles
- Service de Réanimation Médico-Chirurgicale, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne, France
| | - Damien Contou
- Service de Réanimation, Hôpital Victor Dupouy, Argenteuil, France
| | - Amandine Henry
- Service de Virologie, Hôpital Victor Dupouy, Argenteuil, France
| | - Adrien Joseph
- Médecine Intensive Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie-Laure Chaix
- Inserm HIPI, Université Paris Cité, 75010, Paris, France
- Laboratoire de Virologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 75010, Paris, France
| | - Fabrice Uhel
- DMU ESPRIT, Service de Médecine Intensive Réanimation, Université Paris Cité, APHP, Hôpital Louis Mourier, Colombes, France
- INSERM U1151, CNRS UMR 8253, Department of Immunology, Infectiology and Hematology, Institut Necker-Enfants Malades (INEM), Paris, France
| | - Damien Roux
- DMU ESPRIT, Service de Médecine Intensive Réanimation, Université Paris Cité, APHP, Hôpital Louis Mourier, Colombes, France
- INSERM U1151, CNRS UMR 8253, Department of Immunology, Infectiology and Hematology, Institut Necker-Enfants Malades (INEM), Paris, France
| | - Diane Descamps
- IAME INSERM UMR 1137, Service de Virologie, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Malo Emery
- Service de Réanimation, Hôpital Saint-Camille, Bry-Sur-Marne, France
| | | | - David Levy
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Réanimation Médicale, Sorbonne Université, Paris, France
| | - Sonia Burrel
- Service de Virologie, CHU de Bordeaux et CNRS UMR 5234, Fundamental Microbiology and Pathogenicity, Université de Bordeaux, Bordeaux, France
- Département de Virologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Julien Mayaux
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Sorbonne Université, Paris, France
| | - Antoine Kimmoun
- CHRU de Nancy, Médecine Intensive et Réanimation Brabois, Université de Lorraine, Vandœuvre-Lès-Nancy, France
- INSERM U942 and U1116, F-CRIN-INIC RCT, Vandœuvre-Lès-Nancy, France
| | - Cédric Hartard
- Service de Virologie, CHRU de Nancy, Vandœuvre-Lès-Nancy, France
| | - Frédéric Pène
- Médecine Intensive Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Flore Rozenberg
- Laboratoire de Virologie, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Stéphane Gaudry
- Service de Réanimation, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | - Ségolène Brichler
- Laboratoire de Virologie, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | - Antoine Guillon
- Intensive Care Unit, Tours University Hospital, Research Center for Respiratory Diseases (CEPR), INSERM U1100, University of Tours, Tours, France
| | - Lynda Handala
- INSERM U1259, Université de Tours, Tours, France
- CHRU de Tours, National Reference Center for HIV-Associated Laboratory, Tours, France
| | - Fabienne Tamion
- Service de Médecine Intensive-Réanimation, CHU De Rouen, Rouen, France
| | - Alice Moisan
- INSERM, Normandie Univ, DYNAMICURE UMR 1311, CHU Rouen, Department of Virology, Univ Rouen Normandie, Université de Caen Normandie, 76000, Rouen, France
| | - Thomas Daix
- Réanimation Polyvalente, INSERM CIC 1435 and UMR 1092, CHU Limoges, Limoges, France
| | - Sébastien Hantz
- French National Reference Center for Herpesviruses, Bacteriology, Virology, Hygiene Department, CHU Limoges, 87000, Limoges, France
- INSERM, RESINFIT, U1092, 87000, Limoges, France
| | - Flora Delamaire
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Vincent Thibault
- Laboratoire de Virologie, CHU Rennes, 35000, Rennes, France
- Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) UMR_S 1085, Univ Rennes, 35000, Rennes, France
| | - Bertrand Souweine
- Service de Médecine Intensive et Réanimation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Cecile Henquell
- 3IHP, Service de Virologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Lucile Picard
- Département d'Anesthésie Réanimations Chirurgicales, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Françoise Botterel
- Université Paris-Est-Créteil (UPEC), Créteil, France
- Department of Virology, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Christophe Rodriguez
- Université Paris-Est-Créteil (UPEC), Créteil, France
- IMRB INSERM U955, Team "Viruses, Hepatology, Cancer", Créteil, France
- Department of Virology, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Armand Mekontso Dessap
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), CHU Henri Mondor, 51, Av. de Lattre de Tassigny, CEDEX, 94010, Créteil, France
- Groupe de Recherche Clinique CARMAS, Université Paris-Est-Créteil (UPEC), Créteil, France
- Université Paris-Est-Créteil (UPEC), Créteil, France
| | - Jean-Michel Pawlotsky
- Université Paris-Est-Créteil (UPEC), Créteil, France
- IMRB INSERM U955, Team "Viruses, Hepatology, Cancer", Créteil, France
- Department of Virology, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Slim Fourati
- Université Paris-Est-Créteil (UPEC), Créteil, France
- IMRB INSERM U955, Team "Viruses, Hepatology, Cancer", Créteil, France
- Department of Virology, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Nicolas de Prost
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), CHU Henri Mondor, 51, Av. de Lattre de Tassigny, CEDEX, 94010, Créteil, France
- Groupe de Recherche Clinique CARMAS, Université Paris-Est-Créteil (UPEC), Créteil, France
- Université Paris-Est-Créteil (UPEC), Créteil, France
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Zuniga-Moya JC, Papadopoulos B, Mansoor AER, Mazi PB, Rauseo AM, Spec A. Incidence and Mortality of COVID-19-Associated Invasive Fungal Infections Among Critically Ill Intubated Patients: A Multicenter Retrospective Cohort Analysis. Open Forum Infect Dis 2024; 11:ofae108. [PMID: 38567199 PMCID: PMC10986750 DOI: 10.1093/ofid/ofae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
Background An association between coronavirus disease 2019 (COVID-19)-associated invasive fungal infections (CAIFIs) and high mortality among intubated patients has been suggested in previous research. However, some of the current evidence was derived from small case series and multicenter studies conducted during different waves of the COVID-19 pandemic. We examined the incidence of CAIFIs and their associated mortality using a large, multicenter COVID-19 database built throughout the pandemic. Methods We conducted a retrospective analysis of the National COVID Cohort Collaborative (N3C) database collected from 76 medical centers in the United States between January 2020 and August 2022. Patients were 18 years or older and intubated after severe acute respiratory syndrome coronavirus 2 infection. The primary outcomes were incidence and all-cause mortality at 90 days. To assess all-cause mortality, we fitted Cox proportional hazard models after adjusting for confounders via inverse probability weighting. Results Out of the 4 916 229 patients with COVID-19 diagnosed during the study period, 68 383 (1.4%) met our cohort definition. The overall incidence of CAIFI was 2.80% (n = 1934/68 383). Aspergillus (48.2%; n = 933/1934) and Candida (41.0%; n = 793/1934) were the most common causative organisms. The incidence of CAIFIs associated with Aspergillus among patients who underwent BAL was 6.2% (n = 83/1328). Following inverse probability weighting, CAIFIs caused by Aspergillus (hazard ratio [HR], 2.0; 95% CI, 1.8-2.2) and Candida (HR, 1.7; 95% CI, 1.5-1.9) were associated with increased all-cause mortality. Systemic antifungals reduced mortality in 17% of patients with CAIFI with Aspergillus and 24% of patients with CAIFI with Candida. Conclusions The incidence of CAIFI was modest but associated with higher 90-day all-cause mortality among intubated patients. Systemic antifungals modified mortality.
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Affiliation(s)
| | | | | | - Patrick B Mazi
- St Louis School of Medicine, Washington University, St Louis, Missouri, USA
| | - Adriana M Rauseo
- St Louis School of Medicine, Washington University, St Louis, Missouri, USA
| | - Andrej Spec
- St Louis School of Medicine, Washington University, St Louis, Missouri, USA
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11
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Konkel Neabore L. Wake-up Call: Rapid Increase in Human Fungal Diseases under Climate Change. ENVIRONMENTAL HEALTH PERSPECTIVES 2024; 132:42001. [PMID: 38648197 PMCID: PMC11034633 DOI: 10.1289/ehp14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/28/2024] [Indexed: 04/25/2024]
Abstract
Rising temperatures and extreme weather are setting the stage for increases in fungal diseases. As new pathogenic fungi emerge and known threats spread and evolve, scientists and decision makers are responding.
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12
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Feys S, Vanmassenhove S, Kraisin S, Yu K, Jacobs C, Boeckx B, Cambier S, Cunha C, Debaveye Y, Gonçalves SM, Hermans G, Humblet-Baron S, Jansen S, Lagrou K, Meersseman P, Neyts J, Peetermans M, Rocha-Pereira J, Schepers R, Spalart V, Starick MR, Thevissen K, Van Brussel T, Van Buyten T, Van Mol P, Vandenbriele C, Vanderbeke L, Wauters E, Wilmer A, Van Weyenbergh J, Van De Veerdonk FL, Carvalho A, Proost P, Martinod K, Lambrechts D, Wauters J. Lower respiratory tract single-cell RNA sequencing and neutrophil extracellular trap profiling of COVID-19-associated pulmonary aspergillosis: a single centre, retrospective, observational study. THE LANCET. MICROBE 2024; 5:e247-e260. [PMID: 38280387 DOI: 10.1016/s2666-5247(23)00368-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND COVID-19-associated pulmonary aspergillosis (CAPA) is a severe superinfection with the fungus Aspergillus affecting patients who are critically ill with COVID-19. The pathophysiology and the role of neutrophil extracellular traps (NETs) in this infection are largely unknown. We aimed to characterise the immune profile, with a focus on neutrophils and NET concentrations, of critically ill patients with COVID-19, with or without CAPA. METHODS We conducted a single-centre, retrospective, observational study in two patient cohorts, both recruited at University Hospitals Leuven, Belgium. We included adults aged 18 years or older who were admitted to the intensive care unit because of COVID-19 between March 31, 2020, and May 18, 2021, and who were included in the previous Contagious trial (NCT04327570). We investigated the immune cellular landscape of CAPA versus COVID-19 only by performing single-cell RNA sequencing (scRNA-seq) on bronchoalveolar lavage fluid. Bronchoalveolar lavage immune cell fractions were compared between patients with CAPA and patients with COVID-19 only. Additionally, we determined lower respiratory tract NET concentrations using biochemical assays in patients aged 18 years and older who were admitted to the intensive care unit because of severe COVID-19 between March 15, 2020, and Dec 31, 2021, for whom bronchoalveolar lavage was available in the hospital biobank. Bronchoalveolar lavage NET concentrations were compared between patients with CAPA and patients with COVID-19 only and integrated with existing data on immune mediators in bronchoalveolar lavage and 90-day mortality. FINDINGS We performed scRNA-seq of bronchoalveolar lavage on 43 samples from 39 patients, of whom 36 patients (30 male and six female; 14 with CAPA) were included in downstream analyses. We performed bronchoalveolar lavage NET analyses in 59 patients (46 male and 13 female), of whom 26 had CAPA. By scRNA-seq, patients with CAPA had significantly lower neutrophil fractions than patients with COVID-19 only (16% vs 33%; p=0·0020). The remaining neutrophils in patients with CAPA preferentially followed a hybrid maturation trajectory characterised by expression of genes linked to antigen presentation, with enhanced transcription of antifungal effector pathways. Patients with CAPA also showed depletion of mucosal-associated invariant T cells, reduced T helper 1 and T helper 17 differentiation, and transcriptional defects in specific aspects of antifungal immunity in macrophages and monocytes. We observed increased formation of NETs in patients with CAPA compared with patients with COVID-19 only (DNA complexed with citrullinated histone H3 median 15 898 ng/mL [IQR 4588-86 419] vs 7062 ng/mL [775-14 088]; p=0·042), thereby explaining decreased neutrophil fractions by scRNA-seq. Low bronchoalveolar lavage NET concentrations were associated with increased 90-day mortality in patients with CAPA. INTERPRETATION Qualitative and quantitative disturbances in monocyte, macrophage, B-cell, and T-cell populations could predispose patients with severe COVID-19 to develop CAPA. Hybrid neutrophils form a specialised response to CAPA, and an adequate neutrophil response to CAPA is a major determinant for survival in these patients. Therefore, measuring bronchoalveolar lavage NETs could have diagnostic and prognostic value in patients with CAPA. Clinicians should be wary of aspergillosis when using immunomodulatory therapy that might inhibit NETosis to treat patients with severe COVID-19. FUNDING Research Foundation Flanders, KU Leuven, UZ Leuven, VIB, the Fundação para a Ciência e a Tecnologia, the European Regional Development Fund, la Caixa Foundation, the Flemish Government, and Horizon 2020.
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Affiliation(s)
- Simon Feys
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Laboratory of Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Sam Vanmassenhove
- Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium; Center for Cancer Biology, VIB, Leuven, Belgium
| | - Sirima Kraisin
- Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Karen Yu
- Laboratory of Molecular Immunology, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Cato Jacobs
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bram Boeckx
- Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium; Center for Cancer Biology, VIB, Leuven, Belgium
| | - Seppe Cambier
- Laboratory of Molecular Immunology, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Cristina Cunha
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium; Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Samuel M Gonçalves
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Stephanie Humblet-Baron
- Laboratory of Adaptive Immunology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Sander Jansen
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Katrien Lagrou
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium; Laboratory of Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Laboratory of Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Johan Neyts
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Marijke Peetermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Laboratory of Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Joana Rocha-Pereira
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Rogier Schepers
- Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium; Center for Cancer Biology, VIB, Leuven, Belgium
| | - Valérie Spalart
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Marick R Starick
- Laboratory of Clinical and Epidemiological Virology, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Karin Thevissen
- Centre of Microbial and Plant Genetics, Department of Microbial and Molecular Systems, KU Leuven, Leuven, Belgium
| | - Thomas Van Brussel
- Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium; Center for Cancer Biology, VIB, Leuven, Belgium
| | - Tina Van Buyten
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Pierre Van Mol
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium; Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium; Center for Cancer Biology, VIB, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Cardiology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Lore Vanderbeke
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Els Wauters
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Alexander Wilmer
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Laboratory of Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Johan Van Weyenbergh
- Laboratory of Clinical and Epidemiological Virology, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Paul Proost
- Laboratory of Molecular Immunology, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Kimberly Martinod
- Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Diether Lambrechts
- Laboratory of Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium; Center for Cancer Biology, VIB, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Laboratory of Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
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13
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Hoenigl M, Prattes J. Risk of COVID-19-associated pulmonary aspergillosis: time for a nuanced approach to antifungal prophylaxis? THE LANCET. RESPIRATORY MEDICINE 2024; 12:183-185. [PMID: 38185136 DOI: 10.1016/s2213-2600(23)00435-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 01/09/2024]
Affiliation(s)
- Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; BioTechMed, Graz, Austria.
| | - Juergen Prattes
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
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14
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Shekhova E, Salazar F, Da Silva Dantas A, Chakraborty T, Wooding EL, White PL, Warris A. Age difference of patients with and without invasive aspergillosis: a systematic review and meta-analysis. BMC Infect Dis 2024; 24:220. [PMID: 38373908 PMCID: PMC10875810 DOI: 10.1186/s12879-024-09109-2] [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] [Received: 07/19/2023] [Accepted: 02/06/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Invasive Aspergillosis (IA) is a life-threatening fungal disease with significant mortality rates. Timely diagnosis and treatment greatly enhance patient outcomes. This study aimed to explore the association between patient age and the development of IA, as well as the potential implications for risk stratification strategies. METHODS We searched National Center for Biotechnology Information (NCBI) databases for publications until October 2023 containing age characteristics of patients with and without IA. A random-effects model with the application of inverse-variance weighting was used to pool reported estimates from each study, and meta-regression and subgroup analyses were utilized to assess sources of heterogeneity. RESULTS A systematic review was conducted, resulting in the inclusion of 55 retrospective observational studies with a total of 13,983 patients. Meta-analysis revealed that, on average, patients with IA were approximately two and a half years older (95% Confidence Interval [CI] 1.84-3.31 years; I2 = 26.1%) than those without the disease (p < 0.0001). No significant moderators could explain the observed heterogeneity in age difference. However, subgroup analysis revealed that age differences were more pronounced within particular patient groups compared to others. For example, patients with and without IA who had primary severe lung infections exhibited a greater difference in mean age than other patient cohorts. CONCLUSIONS Further research, such as individual patient data meta-analysis, is necessary to better understand the potential relationship between increasing age and the likelihood of IA. Improved risk stratification strategies based on patient age could potentially enhance the early detection and treatment of IA, ultimately improving patient outcomes.
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Affiliation(s)
- Elena Shekhova
- Medical Research Council Centre for Medical Mycology, Geoffrey Pope Building, University of Exeter, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK.
| | - Fabián Salazar
- Medical Research Council Centre for Medical Mycology, Geoffrey Pope Building, University of Exeter, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
| | | | - Tanmoy Chakraborty
- Medical Research Council Centre for Medical Mycology, Geoffrey Pope Building, University of Exeter, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
| | - Eva L Wooding
- Medical Research Council Centre for Medical Mycology, Geoffrey Pope Building, University of Exeter, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
- Royal Devon and Exeter Hospital, Exeter, EX2 5DW, UK
| | - P Lewis White
- Public Health Wales Microbiology Cardiff, Cardiff University, UHW, Cardiff, UK
- Centre for Trials Research, Division of Infection and Immunity, Cardiff University, UHW, Cardiff, UK
| | - Adilia Warris
- Medical Research Council Centre for Medical Mycology, Geoffrey Pope Building, University of Exeter, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
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15
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Asperges E, Pesare R, Bassoli C, Calia M, Lerta S, Citiolo F, Albi G, Cavanna C, Sacchi P, Bruno R. The Prognostic Role of Diagnostic Criteria for COVID-19-Associated Pulmonary Aspergillosis: A Cross-Sectional Retrospective Study. Antibiotics (Basel) 2024; 13:150. [PMID: 38391536 PMCID: PMC10886222 DOI: 10.3390/antibiotics13020150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/27/2024] [Accepted: 02/01/2024] [Indexed: 02/24/2024] Open
Abstract
Several criteria exist to diagnose pulmonary aspergillosis with varying degrees of certainty in specific populations, including oncohaematological patients (EORTC/MSG), ICU patients (mAspICU) and COVID-19 patients (ECMM). At the beginning of the pandemic, however, the diagnosis of COVID-19-Associated Pulmonary Aspergillosis (CAPA) could not be performed easily, and the decision to treat (DTT) was empirical. In this cross-sectional retrospective study including patients with SARS-CoV-2 infection and suspicion of CAPA, we studied the concordance between the DTT and the three diagnostic criteria using Cohen's coefficient, and then we identified the factors associated with the DTT and corrected them by treatment to study the influence of the diagnostic criteria on survival. We showed good concordance of the DTT and mAspICU and ECMM criteria, with "compatible signs", "positive culture" and "positive galactomannan" influencing the DTT. Treatment also showed a positive effect on survival once corrected for a putative, possible or probable diagnosis of CAPA using mAspICU and ECMM criteria. We conclude that EORTC/MSGERC are not considered applicable in clinical practice due to the lack of inclusion of signs and symptoms and do not lead to improved survival. mAspICU and ECMM criteria showed a good degree of agreement with the DTT and a positive correlation with patient recovery.
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Affiliation(s)
- Erika Asperges
- S.C. Malattie Infettive I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Rebecca Pesare
- S.C. Malattie Infettive I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Department of Clinical-Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Cecilia Bassoli
- S.C. Malattie Infettive I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Department of Clinical-Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Matteo Calia
- S.C. Malattie Infettive I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Department of Clinical-Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Sonia Lerta
- S.C. Malattie Infettive I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Department of Clinical-Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Francesco Citiolo
- Department of Clinical-Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Giuseppe Albi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, 27100 Pavia, Italy
| | - Caterina Cavanna
- Microbiology and Virology Department, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Paolo Sacchi
- S.C. Malattie Infettive I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Raffaele Bruno
- S.C. Malattie Infettive I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Department of Clinical-Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
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16
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Frost J, Gornicec M, Reisinger AC, Eller P, Hoenigl M, Prattes J. COVID-19 associated Pulmonary Aspergillosis in Patients Admitted to the Intensive Care Unit: Impact of Antifungal Prophylaxis. Mycopathologia 2024; 189:3. [PMID: 38217742 PMCID: PMC10787678 DOI: 10.1007/s11046-023-00809-y] [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] [Received: 05/22/2023] [Accepted: 10/07/2023] [Indexed: 01/15/2024]
Abstract
Early after the beginning of the coronavirus disease 2019 (COVID-19)-pandemic, it was observed that critically ill patients in the intensive care unit (ICU) were susceptible to developing secondary fungal infections, particularly COVID-19 associated pulmonary aspergillosis (CAPA). Here we report our local experience on the impact of mold active antifungal prophylaxis on CAPA occurrence in critically ill COVID-19 patients. This is a monocentric, prospective cohort study including all consecutive patients with COVID-19 associated acute respiratory failure who were admitted to our local medical ICU. Based on the treating physician's discretion, patients may have received antifungal prophylaxis or not. All patients were retrospectively characterized as having CAPA according to the 2020 ECMM/ISHAM consensus definitions. Seventy-seven patients were admitted to our medical ICU during April 2020 and May 2021 and included in the study. The majority of patients received invasive-mechanical ventilation (61%). Fifty-three patients (68.8%) received posaconazole prophylaxis. Six cases of probable CAPA were diagnosed within clinical routine management. All six cases were diagnosed in the non-prophylaxis group. The incidence of CAPA in the overall study cohort was 0.57 events per 100 ICU days and 2.20 events per 100 ICU days in the non-prophylaxis group. No difference of cumulative 84-days survival could be observed between the two groups (p = 0.115). In this monocentric cohort, application of posaconazole prophylaxis in patients with COVID-19 associated respiratory failure did significantly reduce the rate of CAPA.
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Affiliation(s)
- Jonas Frost
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
| | - Maximilian Gornicec
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
| | - Alexander C Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Philipp Eller
- Intensive Care Unit, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria
- BioTechMed Graz, Graz, Austria
| | - Juergen Prattes
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, ECMM Excellence Center, Graz, Austria.
- BioTechMed Graz, Graz, Austria.
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Gwinn KD, Leung MCK, Stephens AB, Punja ZK. Fungal and mycotoxin contaminants in cannabis and hemp flowers: implications for consumer health and directions for further research. Front Microbiol 2023; 14:1278189. [PMID: 37928692 PMCID: PMC10620813 DOI: 10.3389/fmicb.2023.1278189] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Medicinal and recreational uses of Cannabis sativa, commonly known as cannabis or hemp, has increased following its legalization in certain regions of the world. Cannabis and hemp plants interact with a community of microbes (i.e., the phytobiome), which can influence various aspects of the host plant. The fungal composition of the C. sativa phytobiome (i.e., mycobiome) currently consists of over 100 species of fungi, which includes phytopathogens, epiphytes, and endophytes, This mycobiome has often been understudied in research aimed at evaluating the safety of cannabis products for humans. Medical research has historically focused instead on substance use and medicinal uses of the plant. Because several components of the mycobiome are reported to produce toxic secondary metabolites (i.e., mycotoxins) that can potentially affect the health of humans and animals and initiate opportunistic infections in immunocompromised patients, there is a need to determine the potential health risks that these contaminants could pose for consumers. This review discusses the mycobiome of cannabis and hemp flowers with a focus on plant-infecting and toxigenic fungi that are most commonly found and are of potential concern (e.g., Aspergillus, Penicillium, Fusarium, and Mucor spp.). We review current regulations for molds and mycotoxins worldwide and review assessment methods including culture-based assays, liquid chromatography, immuno-based technologies, and emerging technologies for these contaminants. We also discuss approaches to reduce fungal contaminants on cannabis and hemp and identify future research needs for contaminant detection, data dissemination, and management approaches. These approaches are designed to yield safer products for all consumers.
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Affiliation(s)
- Kimberly D. Gwinn
- Department of Entomology and Plant Pathology, University of Tennessee, Knoxville, TN, United States
| | - Maxwell C. K. Leung
- School of Mathematical and Natural Sciences, Arizona State University, Glendale, AZ, United States
| | - Ariell B. Stephens
- School of Mathematical and Natural Sciences, Arizona State University, Glendale, AZ, United States
| | - Zamir K. Punja
- Department of Biological Sciences, Simon Fraser University, Burnaby, BC, Canada
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