Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America

Cost-utility analysis of isavuconazole compared with the standard of care as a first-line therapy for patients with invasive fungal infection prior to differential pathogen diagnosis in Japan

AIMS

This study aimed to evaluate the cost-effectiveness of isavuconazole compared with voriconazole as a first-line therapy for patients with invasive aspergillosis prior to differential pathogen diagnosis.

MATERIALS AND METHODS

Using a state-transition model, a cost-utility analysis of isavuconazole compared with voriconazole was conducted in patients with presumptive invasive aspergillosis. The study population consisted of patients with hematological malignancies undergoing hematopoietic stem cell transplantation (HSCT) or chemotherapy who developed invasive fungal infections. The incremental cost-effectiveness ratio (ICER) was analyzed from the perspective of public healthcare. In patients with presumptive invasive aspergillosis, 6.6% were assumed to have mucormycosis. Efficacy data were sourced from the SECURE and VITAL trials, which included patients with invasive aspergillosis and mucormycosis. Expected survival was based on data for acute myeloid leukemia. The cost of voriconazole was based on its generic price. Different parameters were set for quality of life, expected survival period, and hospitalization costs in the HSCT and chemotherapy models, and the robustness of the model was evaluated using probabilistic and deterministic sensitivity analyses.

RESULTS

In the HSCT model, the base case showed an incremental quality-adjusted life-years (QALYs) of 0.37 and an incremental cost of JPY 918,682 for isavuconazole compared with voriconazole, with an ICER of JPY 2,515,813. In the chemotherapy model, the incremental QALYs was 0.16, and the incremental cost was JPY 723,111, with an ICER of JPY 4,411,564. The probability sensitivity analysis showed that the proportion of ICERs below JPY 5 million was 100.0% in the HSCT model and 79.1% in the chemotherapy model.

LIMITATIONS

Reference efficacy data were obtained from non-Japanese clinical trials.

CONCLUSIONS

Assuming a willingness-to-pay threshold of JPY 5 million for additional QALYs, isavuconazole was shown to be cost-effective compared with voriconazole in both the HSCT and chemotherapy models as a first-line therapy for patients with presumptive invasive aspergillosis.

Automatic identification of clinically important Aspergillus species by artificial intelligence-based image recognition: proof-of-concept study

While morphological examination is the most widely used for Aspergillus identification in clinical laboratories, PCR-sequencing and MALDI-TOF MS are emerging technologies in more financially-competent laboratories. However, mycological expertise, molecular biologists and/or expensive equipment are needed for these. Recently, artificial intelligence (AI), especially image recognition, is being increasingly employed in medicine for fast and automated disease diagnosis. We explored the potential utility of AI in identifying Aspergillus species. In this proof-of-concept study, using 2813, 2814 and 1240 images from four clinically important Aspergillus species for training, validation and testing, respectively; the performances and accuracies of automatic Aspergillus identification using colonial images by three different convolutional neural networks were evaluated. Results demonstrated that ResNet-18 outperformed Inception-v3 and DenseNet-121 and is the best algorithm of choice because it made the fewest misidentifications (n = 8) and possessed the highest testing accuracy (99.35%). Images showing more unique morphological features were more accurately identified. AI-based image recognition using colonial images is a promising technology for Aspergillus identification. Given its short turn-around-time, minimal demand of expertise, low reagent/equipment costs and user-friendliness, it has the potential to serve as a routine laboratory diagnostic tool after the database is further expanded.

The tell-tale hearts: Donor-derived invasive fungal infections among orthotopic heart transplant recipients

Donor-derived invasive fungal infections among solid organ transplant recipients are rare but sometimes devastating events associated with notable morbidity and mortality. Here we describe two donor-derived fungal infections - one Candida parapsilosis complex infection and one Aspergillus fumigatus infection - that occurred among heart transplant recipients at a quaternary care center. Both recipients survived their infections, though with substantial morbidity despite aggressive surgical intervention and antifungal therapy.

Insights into the antifungal properties and modes of action of a recombinant hepcidin, rAd-Hep from the shrimp scad, Alepes djedaba (Forsskål, 1775)

Antimicrobial peptides are short, mostly cationic and amphipathic molecules crucial for host defence. Among these, hepcidins are a family of cysteine rich peptides, with HAMP1 hepcidins playing a dual role in iron metabolism and antimicrobial defense. Recently, recombinantly produced Alepes djedaba hepcidin, rAd-Hep was characterized and its antibacterial potential against various pathogens have been discerned. Herein, we investigated the antifungal nature and modes of action of rAd-Hep against some fungal pathogens. The peptide was found to be active against both filamentous fungi and yeasts viz., Aspergillus flavus, Aspergillus sydowii, Fusarium solani, Penicillium citrinum, Candida albicans and Saccharomyces cerevisiae. The peptide acted via membrane permeabilization creating pores of ∼0.7-1.4 nm radii, ROS generation, chromatin condensation and DNA binding. The recombinant hepcidin, rAd-Hep can be considered as a promising candidate for future endeavors in antifungal therapies.

Diagnostic Significance of Metagenomic Next-Generation Sequencing in Immunocompromised Patients With Suspected Pulmonary Infection

Immunocompromised hosts are highly vulnerable to lung infections, but the efficacy of traditional diagnosis is unsatisfactory. Metagenomic next-generation sequencing (mNGS) has high throughput and broad coverage. Its value in different types of immunocompromised patients has yet to be fully explored. Therefore, the study aims to evaluate the value of mNGS in immunocompromised patients. Clinical data from immunocompromised patients with suspected pulmonary infection (PI) (September 2018-2021) were retrospectively analysed. Patients were categorised into PI (87 cases) and non-pulmonary infection (NPI, 14 cases) groups. The diagnostic performance between mNGS and conventional microbiological tests (CMTs) was compared. Subgroup analyses were also conducted based on whether the patients received organ transplantation, including the comparison of the diagnostic performance of mNGS and culture and the spectrum of characteristics among them. mNGS demonstrated significantly elevated diagnostic sensitivity (p < 0.001) over traditional methods, with a pronounced advantage in identifying mixed PIs (p < 0.05). Among immunocompromised cohorts, mNGS outperformed cultures, showing higher positivity rates in both organ transplant (p < 0.001) and non-transplant patients (p < 0.001). Mixed infections, predominantly bacterial-fungal, were more prevalent in transplant recipients with reduced lymphocytes and CD4+ T cells. Pathogen profiles differed, with Pneumocystis jirovecii, Cytomegalovirus, and Pseudomonas aeruginosa predominating in organ transplant recipients, and P. jirovecii, P. aeruginosa , Streptococcus pneumoniae and Streptococcus pallidum in non-transplant individuals. mNGS is valuable in diagnosing PI and mixed infections in immunocompromised patients, which may be particularly suitable for identifying mixed infections in patients with organ transplants and low lymphocyte and CD4+ T lymphocyte counts.

Clinical Features of Invasive Fungal Disease in China Tertiary Hospital: A Prospective, Multicenter Study

Invasive fungal disease (IFD) has high morbidity and mortality, the spectrum of pathogenic fungi and high-risk groups have also changed. Fewer literature focus on the overall incidence of IFD in various departments of general hospitals. Among the adult inpatients in four Chinese tertiary hospitals located in Beijing, Shanghai, Nanning and Nanchang, proven or probable cases of IFD were included prospectively in this study between May 1, 2021 and May 1, 2022. The clinical data were collected and analyzed. A total of 330 patients (342 episodes) with 278 of proven and 64 of probable IFDs were included, including invasive candidiasis (IC) (132, 40.0%), cryptococcosis (64, 19.4%), invasive aspergillosis (IA) (54, 16.4%), Talaromyces marneffei (TsM) infection (43, 13.0%), Pneumocystis pneumonia (PCP) (16, 4.8%), mixed fungal infection (10, 3.0%), other mold or yeast infection. 37.9% occurred in elderly patients (age ≥ 65 years). Nosocomial infection accounted for 44.5%, the proportion of nosocomial infection was highest in patients with IC (81.8%). Diabetes (19.7%) was the most common underlying disease. 83.9% of the 342 episodes of IFD had evidence of fungal culture, while the proportion of microscopic examination and histopathology as mycological evidence was 26.9% and 3.5%, respectively. The cumulative all-cause mortality at 180 days after diagnosis of IFD was 38.5%. Age ≥ 65 years old (HR = 1.670, P = 0.009), ICU (HR = 2.002, P = 0.001), nosocomial infection (HR = 1.630, P = 0.016) and diabetes (HR = 1.679, P = 0.013) were associated with increased death in IFD patients. The prognosis of IFD patients was poor. Doctors should pay attention to nosocomial fungal infection especially in old and diabetes.

Early fungal colonization and infection as an independent predictor of in-hospital mortality in mechanically ventilated COVID-19 patients: A nationwide target trial emulation study in Taiwan

PURPOSE

To evaluate the impact of fungal colonization and infection phenotypes and other prognostic factors on in-hospital mortality among mechanically ventilated COVID-19 patients (n = 376) admitted to ICUs during the first wave of the pandemic in Taiwan.

MATERIALS AND METHODS

A target trial emulation framework was used to minimize immortal time bias. Patients were matched 1:1:2 for age and gender and classified into three groups: 94 in the "Early" group (fungal colonization or infection within 10 days), 94 in the "Late" group (10-30 days), and 188 in the "No" group (no fungal colonization or infection within 30 days). In-hospital mortality and clinical outcomes were compared across groups.

RESULTS

Patients in the "Early" group received higher cumulative corticosteroid doses, had lower PaO2/FiO2 ratios, and exhibited higher rates of comorbidities, cytomegalovirus viremia, and lung, heart, and kidney complications. They also had a longer duration of ventilator use, ICU stay, and total hospitalization compared to the "Late" and "No" groups. Time-dependent multivariate Cox regression analysis identified the "Early" phenotype as a strong predictor of in-hospital mortality (adjusted hazard ratio [aHR]= 3.992, 95 % CI: 2.676-5.956, p < 0.001). Additional independent risk factors included Charlson Comorbidity Index (aHR = 1.213, 95 % CI: 1.113-1.323, p < 0.001) and APACHE II score (aHR = 1.028, 95 % CI: 1.011-1.045, p = 0.001). In contrast, higher PaO2/FiO2 ratios (aHR = 0.998, 95 % CI: 0.997-1.000, p = 0.021) and ganciclovir use (aHR = 0.419, 95 % CI: 0.245-0.717, p = 0.002) were associated with reduced mortality.

CONCLUSIONS

"Early" fungal colonization and infection within 10 days of corticosteroid initiation is an independent risk factor for in-hospital mortality in mechanically ventilated COVID-19 patients. Future research should explore early intervention strategies, including antifungal prophylaxis, optimized corticosteroid dosing, and immune modulation, to improve survival outcomes.

Invasive cerebral aspergillosis in a pregnant woman: a rare case of intracranial giant granuloma

BACKGROUND

Invasive Cerebral Aspergillosis (ICA) is a rare fungal infection affecting the brain, primarily seen in individuals with compromised immune systems. Despite various treatment options, substantial cerebral granulomas caused by ICA still result in high mortality and recurrence rates.

CASE PRESENTATION

We report a rare instance of ICA in a 30-year-old pregnant woman. The infection initiated in the nasal cavity and progressed to form a large intracranial granuloma, leading to brain herniation. Diagnosis was confirmed through histopathology, Polymerase Chain Reaction (PCR), and metagenomic next-generation sequencing (mNGS) following decompressive craniotomy and sinus window drainage surgery. Prompt administration of antifungal medication resulted in a favorable prognosis.

CONCLUSION

This case highlights the critical roles of mNGS and PCR in the early diagnosis of ICA, as well as the pivotal importance of surgical interventions and prompt initiation of antifungal therapy in enhancing patient outcomes.

Incorporating microbial cell-free DNA testing into healthcare-associated invasive fungal infection surveillance: benefits and challenges

Surveillance by clinical epidemiology teams for invasive fungal infections (IFIs) in healthcare settings can be challenging due to several factors including low sensitivity of noninvasive conventional microbiologic diagnostics, nonspecific clinical presentation, and complex patient populations. Recently, availability of microbial cell-free DNA testing (cfDNA) via the Karius Test has shown promise for increased diagnostic sensitivity of IFIs. However, how to best incorporate cfDNA results into IFI surveillance remains a vexing challenge. Herein, we provide perspectives on the benefits and challenges of use of cfDNA for IFI surveillance.

Siglec-targeted liposomes to identify sialoglycans present on fungal pathogens

The sialic acid Ig-like lectins Siglec-3 and Siglec-15 are pathogen receptors that bind sialic acid-modified glycoproteins, best characterized in metastatic cancers. Because fungi produce sialoglycans and sialo-glycoproteins, we wondered if Siglecs had the potential for targeted delivery of antifungal drugs. We purified the extracellular V-region Ig-like C2 ligand-binding domains and stalk regions of SIG3 and SIG15. We floated the two polypeptides on the surface of liposomes loaded with amphotericin B (AmB) and labeled with rhodamine B to prepare SIG3-Ls and SIG15-Ls. Using these two reagents, we explored the sialoglycans of two evolutionarily distant and deadly human fungal pathogens, the Mucormycete Rhizopus delemar and the Ascomycete Aspergillus fumigatus. We found that SIG3-Ls and SIG15-Ls localized in a continuous layer over the cell wall surface of germ tubes and hyphae of both fungal species and to the conidia of A. fumigatus. Binding was Neu5Ac-specific and appeared confined to N-linked sialoglycans on fungal proteins. SIG3 and SIG15 proteins bound to diverse sialo-glycoproteins extracted from the hyphae of both species. SIG3-Ls and SIG15-Ls delivering sub-micromolar concentrations of AmB were moderately more effective at inhibiting and/or killing both species relative to control liposomes. We discuss the roles that sialo-glycoproteins may play in fungal pathogens.

Molecular Identification of Aspergillus Species, Antifungal Susceptibility, and Phenotypic Identification of Azole-Resistant Mutations in Cyp51A Gene Isolated from Xinjiang

Purpose

This study aimed to determine the clinical distribution characteristics, in vitro antifungal susceptibility, and cyp51A mutation types of clinically isolated Aspergillus species in Xinjiang.

Methods

In this study, a total of 111 Aspergillus species were identified by sequencing the internal transcribed spacer (ITS) and β-tubulin (BenA) genes for molecular identification, performed antifungal susceptibility testing on these isolates using Sensititre YeastOne, selected azole-resistant isolates based on the antifungal susceptibility results and amplified the cyp51A gene for identification of the azole resistance mutation phenotype in the selected isolates.

Results

The most common Aspergillus species was A. fumigatus (40.54%), followed by A. niger (18.02%), A. tubingensis (16.22%), A. terreus (13.51%), A. flavus (6.31%), A. welwitschiae (2.70%), A. fumigatiaffinis (1.80%), and A. lentulus (0.90%). The antifungal susceptibility test results showed that A. fumigatus, A. niger, A. tubingensis, A. flavus and A. terreus were completely sensitive to itraconazole, with sensitivity rates of posaconazole and voriconazole were 99.10% and 88.29%, respectively. The sensitivity rate to amphotericin B was the lowest (62.16%). The MIC values of amphotericin B and voriconazole for the two cryptic Aspergillus species, A. lentulus and A. fumigatiaffinis with high (>1mg/L). The azole non-susceptible or non-wild type rate was (15/111, 13.51%). Eleven azole-resistant Aspergillus species had cyp51A mutations, while four strains did not have any cyp51A mutations.

Conclusion

In this study, the pathogenic Aspergillus species isolated from clinical cases in Xinjiang were diverse. Common pathogenic species showed the best in vitro antifungal activity against itraconazole, posaconazole, and echinocandins, whereas the MIC distribution of amphotericin B was significantly higher. Resistant strains may be mediated by point mutations in cyp51A, and phenotypic mutations are diverse. This information is of great significance for guiding the early diagnosis and antifungal therapy for aspergillosis.

Respiratory infections in lung transplant recipients

PURPOSE OF REVIEW

Morbidity and mortality rates after lung transplantation still remain higher than after other forms of solid organ transplantation, primarily due to a higher risk of infections and the development of chronic lung allograft dysfunction. Thus, a tiered approach highlighting the most significant respiratory pathogens including common opportunistic infections along with diagnostic, treatment and prevention strategies, including vaccination and prophylaxis is needed.

RECENT FINDINGS

The need for intense immunosuppressive therapy to prevent rejection, coupled with the transplanted lung's constant exposure to environment and impaired local defence mechanisms leads to frequent infections. Viral and bacterial infections are most frequent while fungal infections mainly involve the tracheobronchial tract but may be fatal in case of disseminated disease. Some infectious agents are known to trigger acute rejection or contribute to chronic allograft dysfunction. Invasive testing in the form of bronchoscopy with bronchoalveolar lavage is standard and increasing experience in point of care testing is gained to allow early preemptive therapy.

SUMMARY

Timely diagnosis, treatment, and ongoing monitoring are essential, but this can be difficult due to the wide variety of potential pathogens.

Potential of Albumin-Bilirubin Score for Estimating the Voriconazole-Induced Hepatotoxicity Undergoing Therapeutic Drug Monitoring: A Single-Center Retrospective Cohort Study

PURPOSE

Despite implementation of therapeutic drug monitoring (TDM) for voriconazole, the incidence of hepatotoxicity remains high. The albumin-bilirubin (ALBI) score may be useful for estimating voriconazole-induced hepatotoxicity. This pilot study aimed to investigate whether the ALBI score could estimate voriconazole-induced hepatotoxicity during TDM implementation.

METHODS

This single-center, retrospective cohort study included 134 patients. The primary outcome was voriconazole-induced hepatotoxicity. The cutoff value of the ALBI score was determined using a receiver operating characteristic curve. The cumulative risk of hepatotoxicity was evaluated using Kaplan-Meier curve analysis with a log-rank test for the cutoff value and ALBI grade. Moreover, the group of patients with the trough concentration of voriconazole 1-4 μg/mL was also investigated.

FINDINGS

The incidence of hepatotoxicity was 13.4% (18/134). The cutoff value of the ALBI score was -1.91 (sensitivity, 0.611; specificity, 0.655; area under the curve, 0.615). The cumulative risk of hepatotoxicity was significantly higher in the ALBI score ≥-1.91 group than in the ALBI score <-1.91 group (P = 0.024) and patients with higher ALBI grades tended to be at higher risk (P = 0.080). The cumulative risk tended to be higher with ALBI ≥-1.91 in the trough concentration 1-4 μg/mL group; however, no significant difference was found (P = 0.134).

IMPLICATIONS

The pilot study indicated that the ALBI score ≥-1.91 may be an indicator for voriconazole-induced hepatotoxicity even when TDM is conducted. Because this study was a single-center and small cohort design, further studies should be conducted using a large datasets and translational research.

Severe Cutaneous Aspergillosis in a Neonate With Extremely Low Birth Weight: A Case Requiring Multiple Surgical Interventions

Fungal infections are associated with high risk of morbidity and mortality in the neonatal population. Infants who are premature and extremely low birth weight (ELBW) are at increased risk for fungal infections due to their fragile skin barrier, immature immune systems, disruption of normal flora with antibiotic exposure, presence of central catheters, and corticosteroid use. In neonates, most invasive fungal infections are caused by the Candida species. Infections from other fungal species, such as Aspergillus, are rare. The case presented in this article describes an infant who is ELBW born at 23 weeks' gestation and their course with severe cutaneous A. fumigatus infection requiring multiple surgical debridement procedures. These fungal infections require a high index of suspicion for prompt identification and early treatment. Primary cutaneous aspergillosis should be suspected in high-risk infants with rapidly progressive ulcerative or necrotic skin lesions. [Pediatr Ann. 2025;54(4):e130-e134.].

Combined ImmunoCAP and Western Blot for the Diagnosis of Aspergillus Lung Disease

BACKGROUND

Pulmonary aspergillosis is a major global health concern, yet its diagnosis remains challenging. Aspergillus-specific IgG measurement is essential for identifying chronic and allergic forms.

OBJECTIVE

This study aimed to evaluate a quantitative method, the ImmunoCAP assay IgG m3 (ICAP) (Phadia-ThermoFisher Scientific, Waltham, USA), a qualitative method, the Aspergillus IgG Western blot kit (Asp-WB) (LDBio Diagnostics, Lyon, France) and a combination of both methods for the diagnosis of Aspergillus lung disease.

METHODS

A retrospective study was conducted at the University Hospital of Marseille, France, during 1 year. Patients undergoing Aspergillus serology were divided into three groups: Group 1 (G1) with ICAP ≥ 40 mgA/L and positive Asp-WB, Group 2 (G2) with ICAP ≥ 40 mgA/L and negative Asp-WB and Group 3 (G3) with ICAP < 40 mgA/L and positive Asp-WB. Data were collected on demographics, underlying diseases, imaging and biological outcomes. Patients were classified according to their Aspergillus lung disease, whether acute pulmonary aspergillosis, chronic pulmonary aspergillosis (CPA), allergic broncho-pulmonary aspergillosis (ABPA), colonisation or Aspergillus sensitisation.

RESULTS

A total of 536 patients were studied: 173 in G1, 204 in G2 and 200 in G3, with 38 patients found in several groups. The primary underlying disease was cystic fibrosis in 44.6% of patients. Twenty-two patients were diagnosed with ABPA. The number of diagnosed ABPA cases in G1 (20; 11.6%) combining positive ICAP and Asp-WB was significantly higher than that found in the groups with a single positive test result (p < 0.001). Fifteen patients were diagnosed with CPA. Isolated positive Western blot (G3) identified five cases of aspergilloma. Significantly fewer Aspergillus lung diseases were diagnosed in isolated positive ICAP G2 (8.8%) than in G1 (53.8%) and G3 (42.5%) (p < 0.001).

CONCLUSIONS

This study highlights the benefits of combining Asp-WB and ICAP for the diagnosis of Aspergillus lung disease and the relatively high false-positive rate in patients with isolated positive ICAP results.

Appraisal of guidelines and variations in recommendations on drug therapy for invasive aspergillosis prevention and treatment

Background

In recent years, many guidelines related to aspergillosis have been published worldwide. However, no studies have applied assessment tools to systematically evaluate the quality of these guidelines.

Objectives

This study aimed to assess the quality of clinical practice guidelines and compared their recommendations related to drug therapy for the prevention and treatment of invasive aspergillosis.

Methods

Electronic databases, guideline development organizations, and professional society websites were searched to identify clinical practice guidelines for invasive aspergillosis published between 1 January 2013, and 12 September 2023. The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. Recommendations for the drug prevention and treatment of invasive aspergillosis were extracted and descriptively analyzed.

Results

Among the 18 included clinical practice guidelines, the median scores and interquartile range for each AGREE II domain were: scope and purpose, 76.39% (69.1%, 80.21%); stakeholder involvement, 59.72% (50.35%, 67.02%); rigor of development, 64.58% (44.4%, 72.27%); clarity and presentation, 81.25% (68.06%, 91.32%); applicability, 41.67% (36.46%, 47.92%); and editorial independence, 76.05% (50%, 87.5%). Voriconazole and isavuconazole are recommended as first-line therapy for invasive aspergillosis currently. Posaconazole remains the first choice for invasive aspergillosis prophylaxis in patients with hematological malignancies.

Conclusion

The development processes and reporting of invasive aspergillosis -related clinical practice guidelines varied and their quality requires improvement. The guideline recommendations have changed since the approval of isavuconazole.

Invasive Aspergillosis in the Current Era

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

Recent developments in Aspergillus fumigatus research: diversity, drugs, and disease

SUMMARYAdvances in modern medical therapies for many previously intractable human diseases have improved patient outcomes. However, successful disease treatment outcomes are often prevented due to invasive fungal infections caused by the environmental mold Aspergillus fumigatus. As contemporary antifungal therapies have not experienced the same robust advances as other medical therapies, defining mechanisms of A. fumigatus disease initiation and progression remains a critical research priority. To this end, the World Health Organization recently identified A. fumigatus as a research priority human fungal pathogen and the Centers for Disease Control has highlighted the emergence of triazole-resistant A. fumigatus isolates. The expansion in the diversity of host populations susceptible to aspergillosis and the complex and dynamic A. fumigatus genotypic and phenotypic diversity call for a reinvigorated assessment of aspergillosis pathobiological and drug-susceptibility mechanisms. Here, we summarize recent advancements in the field and discuss challenges in our understanding of A. fumigatus heterogeneity and its pathogenesis in diverse host populations.

Impact of current clinical guidelines on the management of invasive fungal disease

Isavuconazole is a new broad-spectrum antifungal triazole with a better safety profile in terms of drug-drug interactions, adverse effects, and tolerance compared to other azoles. Increasing evidence supports the usefulness of isavuconazole in the treatment of invasive fungal diseases. In this review, we aim to analyze the influence of this new evidence on the main clinical guidelines. We reviewed the most recent consensus guidelines issued by the major infectious diseases societies worldwide, focusing on the novelties regarding the recommendations for the use of isavuconazole in different invasive fungal infections and management strategies. Isavuconazole has been included as first-line therapy for invasive aspergillosis, with slight differences in preference for voriconazole or isavuconazole depending on the clinical scenario. In mucormycosis, isavuconazole is considered an alternative first-line therapy to liposomal amphotericin B, especially in those patients with underlying renal impairment. Additionally, the use of isavuconazole is suggested in salvage scenario for both conditions, and the combination with other mold-active drugs is considered. The guidelines report the promising results obtained with the use of this drug for treating mycoses caused by other molds and rare yeasts, as well as endemic mycoses, but since solid evidence is still lacking, the recommendations in this area are generally weak. Isavuconazole is a suitable therapeutic option for invasive fungal infections, offering efficacy against a range of pathogens, including Aspergillus and fungi within the order Mucorales. Its safety profile and its favorable drug interaction profile make it a valuable alternative to traditional agents like voriconazole or liposomal amphotericin B in certain scenarios. However, continued research is essential to better understand its role in combination therapies and to assess its effectiveness against other fungal species.

Lateral-flow device for the diagnosis of invasive aspergillosis: a systematic review and diagnostic meta-analysis

BACKGROUND

Early diagnosis of invasive aspergillosis (IA) can significantly enhance patient survival rates; however, accurately diagnosing IA remains a formidable challenge. Lateral flow device (LFD), as a non-invasive detection method, have been extensively investigated in numerous clinical studies. The objective of this study was to elucidate the diagnostic accuracy of LFD in detecting IA through a meta-analysis.

METHODS

The PubMed, Embase, and Web of Science database were searched to obtain clinical studies on the diagnosis of IA by LFD. A random-effects meta-analysis with a bivariate hierarchical model was used, the estimates and 95% confidence intervals (CI) were used to present pooled sensitivity, specificity, and summary receiver operating characteristic curves (SROC).

RESULTS

Twenty-five cohort or case-control studies were included. The pooled sensitivity of LFD in the diagnosis of IA was 0.67 (95% CI: 0.57-0.75), specificity was 0.90 (95% CI: 0.85-0.93), diagnostic odds ratio was 15.70 (95% CI: 9.69-25.44), the area under the SROC curve (AUC) was 0.87 (95% CI: 0.82-0.93). Subgroup analysis showed that the sensitivity of bronchoalveolar lavage fluid specimen was higher than serum specimen (0.72, 95% CI: 0.67-0.78 vs. 0.49, 95% CI: 0.41-0.56), bronchoalveolar lavage fluid specimens also have higher diagnostic accuracy (AUC = 0.89).

CONCLUSIONS

LFD is an effective technique for the detection of IA infection, but attention should be paid to the influence of specimen source on the accuracy of this technique.

Synergistic Antifungal Activity of PIT and ITZ Against Varied Aspergillus Species via Affecting The Ergosterol Content and Intracellular Drug Retention

Aspergillus species are a significant cause of aspergillosis, with invasive pulmonary aspergillosis (IPA) being particularly severe and often fatal. The increasing resistance to azole antifungals and limited treatment options highlight the need for new therapeutic strategies. This study explores the synergistic effects of pitavastatin (PIT), a statin, combined with itraconazole (ITZ) against various Aspergillus species. In vitro assessments included plate inoculation, liquid medium incubation, and microscopic observation of spore germination, alongside ergosterol content analysis, intracellular itraconazole retention, and rhodamine 6G (Rh6G) uptake and efflux assays. The PIT and ITZ combination exhibited significant synergistic antifungal activity against Aspergillus flavus, Aspergillus niger, Aspergillus terreus, and Aspergillus fumigatus. The synergistic mechanism was attributed to decreased ergosterol levels, increased intracellular itraconazole retention, reduced spore germination, and abnormal hyphal formation in fungal cells. An in vivo Galleria mellonella infectious model demonstrated reduced mortality in larvae treated with the drug combination compared to those treated with ITZ alone. These findings suggest that the PIT and ITZ combination enhances antifungal effects against Aspergillus species, potentially offering a novel therapeutic strategy for IPA treatment. Further clinical trials are warranted to explore the potential of this drug combination in treating aspergillosis.

Duration of systemic antifungal therapy for patients with invasive fungal diseases: A reassessment

Invasive fungal diseases are associated with significant morbidity and mortality, especially among immunocompromised patients, and often prompt for rapid and aggressive treatment aiming cure. Due to the expanding magnitude of patients burdened by chronic immunosuppression and affected by fungal diseases, the diversity of clinical settings has risen. This often results in prolonged therapy (induction, consolidation and maintenance) associated with potentially severe side effects, and clinicians face the challenging decisions of when and how to stop anti-fungal therapy. Adequate duration of therapy is poorly defined, hampered by the lack of dedicated trials to the question, the heterogeneity of cases (type of fungal pathogen, localization of infection, underlying host conditions) and various confounding factors that may influence the clinical response (e.g. persistence vs recovery of immunosuppression, impact of surgery). In this review, we aim to evaluate the existing data underlying the guidelines and recommendations of treatment duration for the most frequent invasive fungal diseases (cryptococcal meningitis, Pneumocystis pneumonia, invasive aspergillosis, invasive candidiasis and mucormycosis), as well as specific localizations of deep-seated diseases (osteo-articular or central nervous system diseases and endocarditis) and emerging considerations and strategies.

Baicalein combined with azoles against fungi in vitro

Background

Invasive fungal infections (IFIs) constitute a significant health challenge, particularly among immunocompromised individuals, characterized by a high prevalence and associated mortality rates. The synergistic administration of Baicalein (BE) with azole antifungal agents could potentially herald a novel therapeutic paradigm.

Materials and methods

54 Aspergillus strains and 23 strains of dematiaceous fungi were selected. The standard M38-A2 microbroth dilution method was used to test the minimum inhibitory concentration (MIC) and the fractional inhibitory concentration index (FICI) of fungi when BE combined with itraconazole (ITC), voriconazole (VRC), posaconazole (POS) and Isavuconazole (ISV).

Results

BE shows synergistic effects with POS and ITC, with 89.61% and 25.97% of fungal strains. The BE/POS regimen exerted synergistic effects in 87.04% of Aspergillus and an impressive 95.65% of dematiaceous fungi. In comparison, the BE/ITC combination showed significantly lower synergy, affecting 33.33% of Aspergillus and a mere 8.70% of dematiaceous strains. Antagonistic interactions were sporadically observed with BE in combination with ITC, VRC, POS and ISV. Within the azole class, the BE/POS pairing stood out for its frequent synergistic activity, in contrast to the absence of such effects when BE was paired with VRC or ISV. Highlighting the potential of BE/POS as a notably effective antifungal strategy.

Conclusion

In vitro, BE/POS combination emerged as the most effective antifungal strategy, exhibiting synergistic effects in the majority of Aspergillus and dematiaceous fungi strains, whereas BE/ITC showed significantly less synergy, and BE with VRC or ISV displayed no synergistic activity.

Effect of isavuconazole on the concentration of tacrolimus in a patient with genotype CYP3A5*1/*3: a case report

BACKGROUND

Azole antifungals are the standard treatment for pulmonary mycosis, which may develop during long-term immunotherapy for kidney transplant. Isavuconazole (ISCZ) is a cytochrome P450 (CYP) 3 A inhibitor that has a risk of interacting with the immunosuppressive drug tacrolimus (TAC). We report a case of simple pulmonary aspergilloma with renal dysfunction due to increased trough levels of TAC after ISCZ coadministration.

CASE PRESENTATION

A male in his 60s was treated with TAC 3.0 mg/day orally to prevent graft rejection after kidney transplantation. He received a loading dose of ISCZ 600 mg/day orally for two days, followed by a maintenance dose of 200 mg/day for simple pulmonary aspergilloma. The TAC trough concentration increased markedly from 2.4 to 9.9 ng/mL on day 6 after coadministration. The creatinine level increased from 0.70 to 1.08 mg/dL, suggesting renal dysfunction due to TAC. Subsequently, the TAC dosage was reduced, leading to a decreased blood TAC concentration and improved renal function. The patient's genotype was CYP3A5*1/*3.

CONCLUSIONS

In the early stages of ISCZ treatment, the blood TAC concentration is higher, and CYP3A5 polymorphisms may partially explain the extent of this interaction. We recommend more careful monitoring of TAC and serum creatinine levels for approximately one week after ISCZ administration.

Fungal arthritis

Fungal arthritis is a rare infection with a global distribution that affects neonates, the elderly, and immunocompromised individuals, resulting in severe outcomes. It presents a challenge for healthcare professionals due to its rarity, lack of characteristic features, and difficulty isolating and identifying responsible organisms. Studies on their pathophysiology and treatment have been limited, and evidence-based treatment options are lacking. The pathogens infect through direct inoculation, extension from adjacent infective foci, or distant dissemination via the bloodstream. Typically, it manifests as either monoarthritis or oligoarthritis, with the knee joint being the most common target. Systemic disease is often absent, while pulmonary and cutaneous diseases are the most frequent extra-articular manifestations. Diagnosis frequently necessitates the direct visualisation of the organism in specimens and cultures of synovial fluid and membranes. A combination of medical (antifungal) and surgical treatments is often required.

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

INTRODUCTION

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

CASE PRESENTATION

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

CONCLUSION

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

Aspergillus in Children and Young People with Cystic Fibrosis: A Narrative Review

Cystic fibrosis is a severe, inherited, life-limiting disorder, and over half of those living with CF are children. Persistent airway infection and inflammation, resulting in progressive lung function decline, is the hallmark of this disorder. Aspergillus colonization and infection is a well-known complication in people with CF and can evolve in a range of Aspergillus disease phenotypes, including Aspergillus bronchitis, fungal sensitization, and allergic bronchopulmonary aspergillosis (ABPA). Management strategies for children with CF are primarily aimed at preventing lung damage and lung function decline caused by bacterial infections. The role of Aspergillus infections is less understood, especially during childhood, and therefore evidence-based diagnostic and treatment guidelines are lacking. This narrative review summarizes our current understanding of the impact of Aspergillus on the airways of children and young people with CF.

Survey of current national and international guidance to reduce risk of aspergillosis in hospitals

Aspergillus spp. are most commonly associated with disease in the severely immunocompromised host and those with chronic chest disease. The scope of patients at risk is expanding, including intensive care (inclusive of severe viral pneumonia), trauma, burns and major surgery. As exposure or colonization is a prerequisite to Aspergillus-related disease, this has prompted a global review of preventative measures recommended in healthcare establishments. This global review includes 75 documents from 24 countries, categorized into clinical, infection prevention and control, and building-related guidance for prevention of invasive aspergillosis (IA). We overview the IA incubation period and different acceptable levels of airborne Aspergilli in protected environments (PEs), including critical care and operating rooms. Few documents cover all aspects of prevention, prophylaxis, avoidance, preventative measures and monitoring (environmental and clinical). A multi-disciplinary approach is required to identify and minimize the multiple risks and ensure adequate preventative measures. Most building-related guidance addresses construction and internal hospital alterations, but we also review the importance of good management of the healthcare environment (including ventilation systems) and uncertainties of environmental monitoring. We highlight the differences in standards recommended for protective patient environments including the critical care environment. The large capital investment required for PEs is often limited to patient groups most at risk. Single document comprehensive guidance is lacking, and many countries provide no guidance. Reduction in healthcare-associated acquisition of invasive aspergillosis during vulnerable inpatient episodes requires heightened awareness of patients at risk, careful risk assessment and attentive maintenance of the general hospital environment.

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

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

Pulmonary Immunocompromise in Stem Cell Transplantation and Cellular Therapy

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

Evidence-based clinical standard for the diagnosis and treatment of invasive lung aspergillosis in the patient with oncohematologic disease

Aspergillosis is a disease caused by the filamentous fungus Aspergillus spp. with a spectrum of clinical presentation that includes invasive and noninvasive forms. The invasive clinical presentation of aspergillosis most frequently affects people with compromised immune systems. In patients with oncohematologic pathology, invasive lung aspergillosis is a significant opportunistic mycosis, because it occurs frequently and has a major impact on morbidity, mortality, and high costs. The global problem of antimicrobial resistance, to which improper use of antifungals contributes, has put Aspergilus spp. in the spotlight, so it is important to generate guidelines for guidance in the proper use of antifungals in the management of invasive lung aspergillosis, to obtain better clinical outcomes and promote rational use of antifungals. This guideline contains recommendations for diagnosing and treating invasive lung aspergillosis in patients with oncohematologic disease, based on evidence and defined through a participatory process of expert consensus, for the Latin American context.

Invasive Urinary Tract Aspergillosis: A Rare Entity

We report a rare case of severe acute kidney injury (AKI) due to invasive urinary aspergillosis in a 59-year-old male. Our patient underwent extracorporeal shock wave lithotripsy (ESWL) for bilateral renal calculi followed by bilateral ureteral stent placement. Initially, urine bacteriological cultures were sterile, and renal function was normal. Days later, he developed rapidly progressive oligo-anuric AKI requiring hemodialysis. Despite stent replacement and empirical antibiotics, infection markers continued to rise, and the newly replaced stents became obstructed for the second time. Ureteroscopy-guided urine culture identified Aspergillus fumigatus. A few days after the initiation of voriconazole therapy, the patient demonstrated significant clinical and biological improvement, including urine clarification and normalization of renal function. This case highlights the need to consider fungal infections in persistent unexplained obstructive AKI and underscores the importance of early diagnosis and antifungal therapy.

Outcomes of severe aspergillosis in patients undergoing extracorporeal membrane oxygenation: A systematic review

BACKGROUND

Invasive aspergillosis (IA) can lead to life-threatening respiratory failure necessitating extracorporeal membrane oxygenation (ECMO) support. However, data on ECMO experience in the management of IA patients are scarce.

OBJECTIVES

The purpose of this systematic review was to evaluate the potential benefits and risks of ECMO as a supportive intervention for critically ill patients with IA.

METHODS

We conducted a systematic review of the literature using the search terms ECMO, extracorporeal membrane oxygenation, Aspergillus and Aspergillosis in two databases (Medline and Scopus). Clinical data were extracted by two independent investigators. Clinical parameters, such as mode of ECMO support, duration of treatment and clinical outcomes, were assessed.

RESULTS

Overall, 32 patients were included in the analysis. The age ranged from 5 to 69 years, 59% were male, and 38% were female. The majority of patients suffered from ARDS (82%). 82% received VV-ECMO, and 18% received VA-ECMO. Aspergillus fumigatus was the most frequent cause of IA, coinfections were frequently observed (51%). The overall mortality was 78%. Complications during ECMO support were observed in 21 of the 39 cases (53.8%).

CONCLUSIONS

IA poses significant management challenges for critically ill ICU patients, even with ECMO support. Although ECMO appears to improve survival of patients at high risk of AI, potential risks such as bacterial superinfection and altered pharmacokinetics of antifungal drugs must be carefully considered.

Aspergillus-mediated allergic airway inflammation is triggered by dendritic cell recognition of a defined spore morphotype

BACKGROUND

Exposure to fungi, especially Aspergillus fumigatus, can elicit potent allergic inflammation that triggers and worsens asthmatic disease. Dendritic cells (DCs) initiate allergic inflammatory responses to allergic stimuli. However, it is unclear if Af spores during isotropic growth (early spore swelling) can activate DCs to initiate allergic responses or if germination is required. This lack of basic understanding of how Af causes disease is a barrier to developing new treatments.

OBJECTIVE

We sought to show that a precise Af morphotype stage during spore swelling can trigger DCs to mediate allergic inflammatory responses and ascertain if antifungal therapeutics can be effective at suppressing this process.

METHODS

We used an Af strain deficient in pyrimidine biosynthesis (ΔpyrG) to generate populations of Af spores arrested at different stages of isotropic growth (swelling) via temporal removal of uracil and uridine from growth media. These arrested spore stages were cultured with bone marrow-derived DCs (BMDCs), and their activation was measured via flow cytometry and ELISA to examine which growth stage was able to activate BMDCs. These BMDCs were then adoptively transferred into the airways to assess if they were able to mediate allergic inflammation in naïve recipient mice. Allergic airway inflammation in vivo was determined via flow cytometry, ELISA, and real-time quantitative PCR. This system was also used to determine if antifungal drug (itraconazole) treatment could alter early stages of spore swelling and therefore BMDC activation and in vivo allergic inflammation upon adoptive transfer.

RESULTS

We found that Af isotropic growth is essential to trigger BMDC activation and mediate allergic airway inflammation. Furthermore, using time-arrested Af stages, we found that at least 3 hours in growth media enabled spores to swell sufficiently to activate BMDCs to elicit allergic airway inflammation in vivo. Incubation of germinating Af with itraconazole reduced spore swelling and partially reduced their ability to activate BMDCs to elicit in vivo allergic airway inflammation.

CONCLUSION

Our results have pinpointed the precise stage of Af development when germinating spores are able to activate DCs to mediate downstream allergic airway inflammation. Furthermore, we have identified that antifungal therapeutics partially reduced the potential of Af spores to stimulate allergic responses, highlighting a potential mechanism by which antifungal treatment might help prevent the development of fungal allergy.

Deletion of core septin gene aspB in Aspergillus fumigatus results in fungicidal activity of caspofungin

Septins are a family of GTP-binding proteins found in many eukaryotic lineages. Although highly conserved throughout many eukaryotes, their functions vary across species. In Aspergillus fumigatus, the etiological agent of invasive aspergillosis, septins participate in a variety of processes such as cell wall organization of conidia, septation, and response to cell wall stress. Previous studies determined that the ΔaspB strain had a greater sensitivity to anti-cell wall drugs, especially the echinocandin caspofungin, yet mechanisms behind this augmented sensitivity are unknown. We performed cell viability staining of the deletion strains post-caspofungin exposure and found that the ΔaspA, ΔaspB, and ΔaspC strains have significantly lower cell viability. Concomitant with the reduced viability, deletion strains are more susceptible to caspofungin on solid media. These results indicate that the septin cytoskeleton is important for A. fumigatus survival in the presence of caspofungin. Due to the potential of improved therapeutic outcome, we followed up using a neutropenic murine model of invasive aspergillosis. Animals infected with the ΔaspB strain and treated with caspofungin showed improved survival compared to the animals infected with akuB KU80 wild-type or complemented strains. Additionally, histological analysis showed reduced fungal burden and inflammation in the ΔaspB infected, caspofungin-treated group. Affinity purification coupled with quantitative proteomics identified proteins involved in the septin-dependent response to caspofungin, includng four candidate interactors involved in cell wall stress response. Deletion of these candidate genes resulted in increased susceptibility to caspofungin and moderately reduced viability post-drug exposure. Taken together, these data suggest that septin AspB contributes to the fungistatic response to caspofungin.

Follow-up of Surgical and Nonsurgical Patients With Pulmonary Aspergillosis: A Real-World Study

Objective

In the real clinical world, both surgery and medication are used to treat pulmonary aspergillosis (PA), but the prognosis of different treatments is unclear. The purpose of this study was to investigate the diagnosis and treatment, follow-up results and prognostic factors of PA patients in the real world, so as to deepen our understanding of PA and improve the prognosis of PA patients.

Materials and Methods

Eligible patients with pathologically diagnosed PA (n = 125) were retrospectively enrolled and followed up. Further comparisons and subgroup analyses were performed between patients receiving surgical and nonsurgical treatments. Univariate and multivariate logistic regression analyses were used to investigate the factors associated with treatment failure.

Results

A total of 125 patients with PA were included in the study. Of these, 49 (39.2%) received surgical treatment (25 of whom also received postoperative antifungal therapy), while 76 (60.8%) received antifungal therapy alone. The median age was 59 years (46.5-67 years). Compared with the nonsurgical group, the surgical group had lower inflammatory cell counts and less inflammatory response, and higher hemoglobin and albumin levels. Multivariate logistic regression analysis showed that white blood cell (WBC) levels >9.5×109/L and C-reactive protein (CRP) levels >8 mg/L were independent predictors linked to treatment failure.

Conclusion

PA patients with severe inflammation and poor general health are usually treated with antifungal drugs only. Risk factors including elevated WBC levels and high CRP levels can help identify PA patients who may have a less favorable response to treatment at an early stage. It should be noted that increasing the dose and duration of antifungal therapy may improve patient prognosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of voriconazole to predict susceptibility and resistance to isavuconazole for Aspergillus fumigatus using CLSI methods and interpretive criteria

Aspergillus fumigatus is a common cause of pulmonary and invasive mold infections among immunocompromised hosts. Mortality in immunocompromised hosts with invasive Aspergillus infections (IAI) has been reported to be as high as 80%. Therefore, appropriate therapy is essential in treating IAI. Both isavuconazole and voriconazole are first-line agents in treatment guidelines for IAI, but isavuconazole has favorable properties, often leading it to be preferred over voriconazole, given the lengthy duration of treatment. It is difficult to perform mold antifungal susceptibility testing, which often requires a reference lab and several weeks to determine results. Therefore, use of surrogate markers can be helpful to infer susceptibility when testing is not possible or delayed. We performed isavuconazole and voriconazole broth microdilution susceptibility testing by the Clinical and Laboratory Standards Institute (CLSI) method on a collection of 976 non-duplicate A. fumigatus isolates from a global surveillance program between 2017 and 2022. We found that voriconazole and isavuconazole have a very high essential agreement within two doubling dilutions at 99.9% and a categorical agreement of 92.7% with no very major errors, one major error (0.11%), and <10% minor errors. Many of the minor errors were in the setting of voriconazole testing at a MIC of 0.5 mg/L (susceptible) but isavuconazole at 2 mg/L (intermediate). Genetic analysis of cyp51 genes confirmed that isavuconazole and voriconazole susceptibility testing identified isolates with cyp51A and cyp51B mutations. Voriconazole can be used to predict the isavuconazole susceptibility testing result when A. fumigatus is tested by CLSI broth microdilution methodology.

Efficacy and safety of isavuconazole versus voriconazole for the treatment of invasive fungal infections: a meta-analysis with trial sequential analysis

BACKGROUND

Isavuconazole has been used to treat invasive fungal infections, however, it is unclear whether the efficacy of isavuconazole is superior to that of voriconazole. The purpose of this meta-analysis was to assess the efficacy and safety of isavuconazole compared to voriconazole in treating invasive fungal infections.

METHODS

Electronic databases, including PubMed, EMBASE, Cochrane Library, and Web of Science, were searched to identify relevant studies. Studies evaluating the effect of isavuconazole in the treatment of patients with invasive fungal infections were included. Pooled rates of overall response, all-cause mortality, drug-related adverse events (AEs), and discontinuation due to drug-related AEs were calculated.

RESULTS

Seven studies involving 890 patients were included. Meta-analysis showed that there was no significant difference between isavuconazole and voriconazole in overall response (risk ratio [RR]: 1.02, 95% confidence interval [CI]: 0.83 to 1.25, p = 0.86) and all-cause mortality (RR: 0.95, 95% CI: 0.78 to 1.16, p = 0.61). However, isavuconazole had a significantly lower incidence of drug-related AEs (RR: 0.70, 95% CI: 0.61 to 0.81, p < 0.001) and discontinuation due to drug-related AEs (RR: 0.56, 95% CI: 0.39 to 0.82, p = 0.003) compared with voriconazole. Trial sequential analysis (TSA) confirmed that the difference between isavuconazole and voriconazole in discontinuation due to drug-related AEs need further valiadation, but the results of other outcomes were conclusive.  < 0.001) and discontinuation due to drug-related AEs (RR: 0.56, 95% CI: 0.39 to 0.82, p = 0.003) compared with voriconazole. Trial sequential analysis (TSA) confirmed that the difference between isavuconazole and voriconazole in discontinuation due to drug-related AEs needs further validation, but the results of other outcomes were conclusive.

CONCLUSIONS

Our findings support the use of isavuconazole as the primary therapy for invasive fungal infections. More research is needed to compare the discontinuation rates of isavuconazole and voriconazole.

Side effects associated with itraconazole therapy

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic Review of Granulomatous Invasive Fungal Sinusitis Management

Objectives

Granulomatous invasive fungal sinusitis (GIFS) affects immunocompetent individuals. There is ongoing debate over whether surgery, antifungal medication, or a combined approach is the best treatment. This article summarizes reports about GIFS and its management.

Methods

Eight search engines, gray literature, and review articles were searched. Two independent reviewer groups screened the eligibility of articles. An independent reviewer solved disagreements. Exclusion criteria included non-English language reports, papers with unavailable full-texts, reviews, publications before 1980, and studies lacking information about GIFS management.

Results

Of the 279 identified articles, 41 studies were included (n = 89 patients). Sinonasal GIFS with skull-base/intracranial extension was associated with an increase in mortality (p = 0.002, OR = 14.083; 95% CI = 1.753-113.157). Treatment was associated with an 87.2% remission rate (p < 0.001, OR = 7.818; 95% CI = 4.502-13.576); a combined medical and surgical approach had a 74.2% recovery rate. Of surgical interventions, the highest recovery rates were associated with endoscopic debulking (52.5%), extensive surgical debulking (32.5%), and open sinonasal approach (15%, p = 0.132). The utilization of voriconazole was associated with higher recovery rates, but this was not significant (76.9 vs. 56%, p = 0.548).

Conclusion

Sinonasal GIFS with skull-base/intracranial extension is associated with higher mortality rates. The superiority of the endoscopic debulking and voriconazole protocol in managing these cases warrants further investigation.

Level of Evidence

Level 4.

Aspergillus spondylodiscitis successfully treated with a long course of isavuconazole

We present a case of spondylodiscitis caused by Aspergillus fumigatus, which we successfully treated with isavuconazole after voriconazole severe intolerance. Aspergillus spondylodiscitis is a severe and relatively rare form of extra-pulmonary invasive aspergillosis. Typically, voriconazole is the first-choice antifungal drug for treating Aspergillus osteomyelitis or spondylodiscitis. However, isavuconazole, a new antifungal medication, has been demonstrated as non-inferior to voriconazole in cases of invasive aspergillosis. It has the added benefits of fewer hepatobiliary, ocular, and cutaneous side effects. It generally does not demand serum level monitoring and poses fewer risks of drug interactions. Nonetheless, there are no studies yet that support its use in spondylodiscitis, and published experiences are very limited and based on isolated cases, albeit mainly positive. The case we present here aims to provide additional evidence on the efficacy and tolerability of isavuconazole in treating this condition.

Invasive fungal rhinosinusitis: current evidence and research opportunities

PURPOSE OF REVIEW

To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs.

RECENT FINDINGS

New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed.

SUMMARY

Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.

Therapeutic drug monitoring of azole antifungal agents

Deep-seated mycoses are generally opportunistic infections that are difficult to diagnose and treat. They are expected to increase with the spread of advanced medical care and aging populations, thus highlighting the need for safe, effective, and rapid drug-based treatments. Depending on a patient's age, sex, underlying diseases, and immune system status, therapeutic drug monitoring (TDM) may be important for assessing variable pharmacokinetic parameters, as well as preventing drug-drug interactions, adverse events, and breakthrough infections caused by fungal resistance. Azole antifungal agents play an important role in the prevention and treatment of deep-seated fungal infections, with each azoles having its own unique pharmacokinetic properties and specific adverse events. Therefore, it is necessary to use national and international guidelines to build evidence for the expansion of TDM indications. This review focuses on the clinical utility and future perspectives of TDM using azole antifungal agents, in the context of recent evidence in the literature.

An update on newer antifungals

INTRODUCTION

Fungal infections constitute a significant global health threat, with an estimated incidence of 6.5 million invasive fungal infections and 2.5 million associated deaths each year. New antifungal agents are being developed to address the challenges of fungal infections management, driven by the evolving fungal epidemiology, the emergence of antifungal resistance, and the limitations of existing treatments.

AREA COVERED

This review provides a thorough overview of the latest developments in novel antifungal agents, highlighting pivotal evidence obtained from clinical trials.

EXPERT OPINION

New antifungal agents hold promising future for difficult-to-treat fungal infections, providing for improved bioavailability, pharmacokinetic properties, adverse events and drug interactions, as well as, spectrum of activity. However, further data is needed before incorporating these agents in everyday clinical practice for the management of invasive fungal infections.

Anti-IL-4Ra therapy is superior to other biologic classes in treating allergic bronchopulmonary aspergillosis

Background

Allergic bronchopulmonary aspergillosis (ABPA) is a disease resulting from an overactive type 2 response to Aspergillus. Initial studies suggest that asthma biologics can effectively treat ABPA, but it is unclear which biologic class is superior.

Objective

We sought to compare the effectiveness of asthma biologics in the treatment of ABPA.

Methods

We performed a retrospective analysis of patients with ABPA treated with asthma biologics, and measured outcomes of respiratory exacerbations, daily oral corticosteroids, and antifungals. We assessed these variables while individuals were treated with 1 of 3 biologic classes: anti-IgE, anti-IL-5/IL-5 receptor alpha (IL-5Ra), anti-IL-4 receptor alpha (IL-4Ra).

Results

A total of 21 patients were included in our analysis. Anti-IL-4Ra was associated with a significantly lower number of exacerbations and oral corticosteroid use compared with anti-IgE or anti-IL-5/IL-5Ra therapies. Anti-IL-4Ra also had significantly lower antifungal use than anti-IgE, and there was a trend toward lower antifungal use when compared with anti-IL-5/IL-5Ra. In a subgroup of 10 patients treated with 2 or more biologics sequentially, we found that 8 of them achieved clinical control on anti-IL-4Ra therapy after failing anti-IgE and/or anti-IL-5/IL-5Ra therapies.

Conclusions

Dupilumab blocks the IL-4Ra, resulting in the downstream inhibition of both IL-4 and IL-13 effector pathways. Dupilumab may benefit patients with ABPA by inhibiting the generation of airway mucus (IL-13), and by reducing local B-cell differentiation into IgE antibody-secreting cells (IL-4). On the basis of our findings and with the known molecular mechanisms of dupilumab, we believe that anti-IL-4Rα-targeted therapy may be more effective than anti-IgE or anti-IL-5/IL-5Rα therapies to treat ABPA.