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.

A case report of disseminated aspergillosis in an immunocompetent patient proven by choroid plexus biopsy

We present a case of disseminated aspergillosis diagnosed by choroid plexus biopsy in an immunocompeten 69-year-old male with decreased consciousness and a fever for more than three months. Brain magnetic resonance imaging showed ventriculitis and phlegmon in the paravertebral space. Chest computerized tomography revealed an air-crescent lesion in the upper lobe of the left lung. No microorganism was identified from the blood or CSF cultures. A choroid plexus biopsy was performed and the pathology findings were consistent with fungal abscess caused by invasive aspergillosis. Since disseminated aspergillosis in the immunocompetent patient is very rare, it was difficult to diagnose this invasive fungal infection in this case. Because the choroid plexus has many blood vessels, there is a high risk of bleeding during biopsy. This was a case in which adequate suspicion and an aggressive diagnostic approach were helpful in the management of a patient with an invasive fungal infection.

A bibliometric and visual analysis of the research status and hotspots of Pulmonary Aspergillosis based on web of science

BACKGROUND

Pulmonary Aspergillosis (PA) is a common fungal lung infection. Despite recent advancements, bibliometric studies on PA are scarce. This study uses bibliometric methods to analyze current research trends and key topics, offering insights into future directions in the field.

METHODS

PA-related literature was retrieved from the Web of Science Core Collection (WOSCC) database, and detailed analysis was conducted using CiteSpace, VOSviewer, and Excel 2019 software. This analysis aimed to identify trends and hot topics in the field of PA.

RESULTS

A total of 1,715 articles were analyzed from 1900 to 2024. The number of publications has shown steady growth, with a gradual increase from 1990 to 2019, followed by a sharp rise after 2019. The United States leads in this field. The main research hotspots and frontiers in PA include: the close association between PA and immunocompromised conditions, COVID-19 as a new risk factor for PA, and current clinical research focusing on antifungal treatments and enhancing host immunity.

CONCLUSION

This study reveals trends in PA research, notably the sharp increase in publications post-2019. Novel findings include the identification of COVID-19 as a new risk factor for PA and the growing emphasis on antifungal treatments and host immunity enhancement. These insights provide a clearer direction for future clinical and research priorities in PA.

Infections and lung transplantation: key considerations for eligibility, management, and posttransplant care

PURPOSE OF REVIEW

Lung transplantation is a critical and evolving therapy for patients with end-stage lung disease. As the need for lung transplantation increases, careful candidate selection is vital to maximizing outcomes and ensuring appropriate organ allocation. A key challenge in lung transplant candidates is the colonization or infection of the lungs by environmental and upper airway pathogens. These lung pathogens, along with other chronic infections, can lead to posttransplant complications with high mortality and an increased risk of graft failure.

RECENT FINDINGS

Major infectious considerations for lung transplantation include colonization or infection by multidrug-resistant bacteria (including Burkholderia cepacia complex), nontuberculous mycobacteria, molds, and chronic viral infections. By recognizing the epidemiology, diagnosis, and management of these infections in the peri-transplant period, transplant providers can better mitigate infectious risks and improve transplant success. Similarly, advancements in diagnostics and therapeutics offer novel approaches to managing previously challenging infections.

SUMMARY

As experience grows in treating these difficult infectious syndromes, more candidates are becoming eligible for transplantation. A thorough understanding of infectious considerations in lung transplant candidates is essential for improving candidate selection, reducing posttransplant complications, and expanding transplant eligibility.

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.

Mechanism-Based Pharmacokinetic/Pharmacodynamic Model of Voriconazole for Predicting the Clinical Outcomes of Adult Patients With Invasive Aspergillosis

BACKGROUND

Voriconazole is the first-line therapy for invasive aspergillosis (IA). To determine the minimum inhibitory concentration of Aspergillus, a voriconazole pharmacokinetic-pharmacodynamic (PK-PD) model linked to galactomannan response was developed and evaluated, and its clinical correlation for IA treatment was elucidated.

METHODS

Adult patients with probable or definite IA and at least one serum voriconazole measurement were included. A two-compartment voriconazole PK model was linked to a previously described PD model of galactomannan response. PK and PD parameters were estimated using a nonparametric adaptive grid technique. The relationship between the ratio of voriconazole exposure that induced half-maximum galactomannan response (EC50) and the observed terminal galactomannan concentration was evaluated. The factors associated with the PK-PD parameters and mortality were also determined.

RESULTS

Between January 2013 and December 2022, 41 patients were prescribed voriconazole for IA. The 30-day mortality rate was 17%. A high correlation was found for the observed-predicted Bayesian posterior estimates of voriconazole and galactomannan levels. Moreover, a nonlinear relationship was identified between AUC:EC50 and terminal galactomannan. The factors associated with higher AUC:EC50 were intravenous administration and intubation. In the survival analysis, higher EC50 tended to be associated with mortality, higher AUC was significantly associated with increased mortality, and higher AUC:EC50 tended to be associated with higher mortality. After adjusting for the intravenous route, higher AUC and AUC:EC50 were not associated with mortality.

CONCLUSIONS

Individual EC50 estimation can provide insights into in vivo host and organism responses. Elevated EC50 showed comparable and unfavorable trends to higher minimum inhibitory concentration. Thus, determining EC50 might help guide individualized target serum voriconazole levels.

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.

Uveitis in Adults: A Review

Importance

Uveitis is characterized by inflammation of the uvea-the middle portion of the eye composed of the iris, ciliary body, and choroid-causing eye redness, pain, photophobia, floaters, and blurred vision. Untreated uveitis may cause cataracts, glaucoma, macular edema, retinal detachment, optic nerve damage, and vision loss.

Observations

Uveitis predominantly affects individuals aged 20 to 50 years. Anterior uveitis affects the iris and ciliary body (41%-60% of cases); intermediate uveitis affects the pars plana (attachment point of vitreous humor) and peripheral retina (9%-15%); posterior uveitis involves the choroid and/or retina (17%-23%); and panuveitis involves all uveal layers (7%-32%). Uveitis is classified as noninfectious or infectious, with toxoplasmosis, herpes, tuberculosis, and HIV comprising 11% to 21% of infectious cases in high-income countries and 50% in low- and middle-income countries. Incidence and prevalence of uveitis are influenced by genetic factors (eg, human leukocyte antigen-B27), environmental factors (eg, air pollution), and infection rates. In the US and Europe, 27% to 51% of uveitis cases are idiopathic, and 37% to 49% are associated with systemic disease, such as axial spondyloarthritis. Treatment goals are to induce and maintain remission while minimizing corticosteroid use to reduce corticosteroid-related adverse effects. Infectious uveitis requires systemic antimicrobial treatment. Active inflammatory disorders associated with uveitis should be treated by the appropriate specialist (eg, rheumatologist). Treatment for uveitis depends on subtype; anterior uveitis is treated with topical corticosteroids, and mild intermediate uveitis may be monitored without initial treatment. Patients with moderate to severe intermediate uveitis, posterior uveitis, and panuveitis are at high risk of sight-threatening complications and require systemic and/or intravitreal corticosteroids and immunosuppressive agents. For posterior uveitis, first-line therapy with disease-modifying antirheumatic drugs such as methotrexate achieved remission of inflammation in 52.1% (95% CI, 38.6%-67.1%) of patients, and mycophenolate mofetil controlled inflammation in 70.9% (95% CI, 57.1%-83.5%). In patients who do not improve or worsen with first-line therapy, adalimumab extended time to treatment failure to 24 weeks vs 13 weeks with placebo and reduced frequency of treatment failure from 78.5% to 54.5% (P < .001).

Conclusions and Relevance

Uveitis is characterized by inflammation of the uvea and primarily affects adults aged 20 to 50 years. For noninfectious anterior uveitis, corticosteroid eyedrops are first-line treatment. For posterior noninfectious uveitis, disease-modifying antirheumatic drugs are first-line therapy; biologics such as adalimumab are second-line treatment for patients with inflammation refractory to treatment. Uveitis caused by systemic infection should be treated with antimicrobials, and local or systemic steroids may be used depending on the severity of uveitis and the specific microorganism.

Rapid Therapeutic Drug Monitoring of Voriconazole Based on High-Performance Liquid Chromatography: A Single-Center Pilot Study in Outpatients

Background/Objectives: Voriconazole (VRCZ) use requires accurate monitoring to avoid suboptimal drug levels and adverse effects. In addition, the appearance of resistant fungal strains is a problem that needs attention. Blood concentration measurement is the monitoring technique of choice; however, it is slow, limiting its clinical application. This study aimed to evaluate the clinical utility of rapid therapeutic drug monitoring (TDM) for VRCZ using high-performance liquid chromatography with ultraviolet detection (HPLC-UV) compared to conventional outsourced liquid chromatography-tandem mass spectrometry (LC-MS/MS) testing in outpatient care. Methods: VRCZ blood concentrations were measured using HPLC-UV and LC-MS/MS. Reporting times, accuracy, and clinical outcomes were assessed for outpatients receiving VRCZ treatment. Safety was monitored for renal, hepatic, and visual toxicities. Results: HPLC-UV significantly reduced reporting times (0.433 h vs. 74.3 h, p < 0.001), and Deming's regression analyses showed a strong correlation with LC-MS/MS results (Pearson's r = 0.988). Bland-Altman analysis showed an average difference of 0.025 μg/mL between HPLC-UV and LC-MS/MS. Prospective monitoring of three outpatients revealed no adverse events, enabling safe and effective VRCZ dosing. Conclusions: Rapid VRCZ TDM using HPLC-UV is a cost-effective and feasible approach for outpatient care, significantly improving reporting times and patient safety. Further studies and cross-facility collaboration are needed to expand its application.

Quality improvement project to reduce beta-D-glucan turnaround times in an NHS pathology network

Beta-D-glucan (BDG) is a cell wall component of many fungi, detecting this in patients' serum permits early diagnosis of invasive fungal infections, particularly in patients with haematological malignancy. In critically ill patients in an intensive-care unit, where the prevalence of invasive fungal infection is lower, the high negative predictive value of BDG facilitates withholding or discontinuation of empirical antifungal therapy, contributing to antifungal stewardship. However, for the results of BDG testing to impact patient management, they need to be available within a clinically useful timeframe.The South West London Pathology (SWLP) network routinely sent samples for BDG testing from hospital trusts in our area to the UK Health Security Agency Mycology Reference Laboratory (MRL) at Bristol for analysis. In 2021, the mean turnaround time (TAT) was more than two times the 5-working-days standard stated in the SWLP user handbook. In this quality improvement project (QIP), we identified that the greatest delay was the MRL posting hardcopy reports. We investigated electronic reporting, first for all patient samples, and then only for intensive-care patients. However, we found that information technology (IT) and staffing limitations meant this was not viable.We then investigated commercial solutions and identified an innovative assay, which enabled the implementation of in-house BDG testing that was a good fit with our available staffing resource and laboratory environment. Our aim was to achieve at least 90% of BDG results authorised within 5 working days of sample receipt. Our QIP improved performance on this from 0.88% to 92.8% and reduced the mean TAT from 11.6 to 2.5 days and at lower unit cost. The change has been well received by our laboratory staff, and our pathology operational leads have had very positive feedback from our clinical teams and our antifungal steward.

Successful Management of Spondylodiscitis Caused by Aspergillus nidulans: A Case Report and Literature Review

We report a case of spondylodiscitis caused by Aspergillus nidulans (SCAN). A. nidulans is a saprophytic fungus and emerging pathogen responsible for a variety of infections, although it is rarely implicated in osteoarticular infections. The patient was a 59-year-old immunocompromised patient with a history of lymphoma and splenectomy. Following diagnosis, the patient was promptly and effectively treated with voriconazole. A literature review underlines the distinctive features of the few case reports of SCAN, as well as the original features of the present case report.

Determination of Positivity Cutoff for an Automated Aspergillus fumigatus-Specific Immunoglobulin-G Assay in a National Reference Laboratory

BACKGROUND

Detection of serum-specific immunoglobulin G (sIgG) to Aspergillus fumigatus traditionally relied on precipitin assays, which lack standardization and have poor analytical sensitivity. Automated quantitative immunoassays are now more widely used alternatives. A challenge, however, is determining reference interval (RI) cutoffs indicative of disease presence.

METHODS

Sera from 152 local healthy donors were tested for Aspergillus fumigatus sIgG using the ImmunoCAP assay to calculate a nonparametric RI cutoff. Results from 178 patient samples cotested by the precipitin and ImmunoCAP assays were analyzed using receiver operator characteristic (ROC) curve to determine an optimal sIgG concentration for precipitin positivity. Clinical information available for 46 patients tested by the ImmunoCAP assay was also used to estimate an optimal sIgG cutoff for pulmonary aspergillosis diagnosis.

RESULTS

Specific-IgG concentration at 81.5 mcg/mL corresponded to the 97.5th percentile of tested healthy donors. The ROC-driven optimal IgG cutoff for precipitin positivity was at 40.4 mcg/mL with 67.8% sensitivity [95% confidence interval (CI): 54.4% to 79.4%%] and 72.3% specificity (95% CI: 63.3% to 80.1%). Using clinical diagnoses, an IgG concentration at 64.7 mcg/mL had optimal sensitivity (77.8%; 95% CI: 61.9% to 88.3%) and specificity (66.7%, 95% CI 39.1% to 86.2%) for pulmonary aspergillosis.

CONCLUSIONS

Our healthy donor-driven RI cutoff was higher than estimated optimal sIgG values based on precipitin positivity and disease presence. As fungal sIgG levels can be impacted by local environmental exposures, and given the limited size of our clinical dataset, adopting an assay cutoff based on precipitin results (40.4 mcg/mL) can be more objective.

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.

Lateral Flow Device Aspergillus Routine Testing for Invasive Pulmonary Aspergillosis in Patients Who Are Critically Ill: A Multicenter Intensive Care Unit Cohort Study

Background

The incidence of invasive pulmonary aspergillosis (IPA) is rising among intensive care unit (ICU) patients, with early diagnosis and treatment being critical for survival. Lateral flow assays for Aspergillus antigen detection have recently been introduced, enabling rapid results within an hour and potentially supporting earlier clinical decision making and timely antifungal therapy.

Methods

This retrospective multicenter study included 180 ICU patients, 48 with IPA and 132 controls, across 9 treatment centers. Fungal infections were classified according to the FUNDICU criteria (Invasive Fungal Diseases in Adult Patients in Intensive Care Unit).

Results

Among the 180 patients, 48 were classified as having probable IPA, while 132 exhibited host factors and radiologic findings consistent with IPA but did not meet the FUNDICU criteria. In this cohort, the sensitivity and specificity of the bronchoalveolar lavage lateral flow device test for diagnosing probable IPA vs no IPA were 71% (95% CI, 56%-83%) and 98% (94%-100%), respectively. The area under the receiver operating characteristic curve was 0.84, indicating good diagnostic performance. The positive and negative likelihood ratios were 31.17 (10.03-96.80) and 0.30 (.19-.46), yielding a diagnostic odds ratio of 104 (30-360). The positive and negative predictive values were 92% (78%-98%) and 90% (84%-95%).

Conclusions

Lateral flow device testing may serve as a valuable tool for the rapid diagnosis of IPA in time-critical ICU settings. However, it is not sufficient to definitively rule out the disease, and a comprehensive diagnostic approach remains essential.

Voriconazole in the treatment of pediatric patients with hematologic malignancies and invasive fungal infections: a real-world study

PURPOSE

To evaluate the factors influencing voriconazole (VRC) administration, clinical efficacy, and safety in children with hematological malignancies (HM) and invasive fungal infection (IFD).

METHODS

This is a single-center, retrospective real-world study conducted between July 2018 and December 2023. Univariate and multivariate logistic regression analysis were used to analyze the affecting factors.

RESULTS

A total of 167 patients were included in this study. Among them, 13.77% (23/167) of children under 2 years old received off-label use of VRC, with an initial maintenance dose higher than that of other groups (P < 0.001). There were 8 cases (4.79%) of cured, 148 cases (88.62%) of improved, and 11 cases (6.59%) of ineffective. Thirty-eight cases experienced adverse drug reactions (ADR), with a highest incidence (10.2%) of hepatotoxicity. The concomitant proton pump inhibitors (PPIs), days of central venous catheterization and coagulopathy were independent influencing factors of ADR. Sixty-six patients underwent therapeutic drug monitoring (TDM), which increased the probability of achieving the target plasma trough concentration (Cmin). Among children < 2 years old underwent TDM, 88.89% (8/9) achieved therapeutic concentration, and the probability was higher than that of the older groups. Days of VRC treatment had a positive but not statistically significant effect on achievement of target Cmin. Hypoalbuminemia and days of antimicrobials treatment were independent influencing factors of Cmin distribution.

CONCLUSION

Attention to the off-label use of VRC in children < 2 years old, hypoalbuminemia and coagulopathy correction, potential drug interactions with VRC, and ADR monitoring is crucial for clinical efficacy and safety.

Evaluation of the clinical characteristics and survival outcomes of invasive pulmonary aspergillosis patients

Background

Invasive pulmonary aspergillosis (IPA) is a severe infectious disease caused by Aspergillus spp. It is associated with high mortality, particularly in immunocompromised patients, as well as in those with COVID-19 pneumonia or critically ill individuals in intensive care units (ICUs). Accurate clinical diagnosis remains a significant challenge, often resulting in missed diagnoses.

Methods

This study evaluated IPA inpatients diagnosed through mycological evidence and clinical criteria over 12 months. Inclusion criteria required at least one positive mycological result, including a positive culture from bronchoalveolar lavage fluid (BALF) or high-quality sputum, or a positive galactomannan antigen (GM) test.

Results

A total of 216 patients were diagnosed with IPA, with a mortality rate of 68.5%. Hematologic malignancies were the primary underlying condition in 33.8% of cases. Voriconazole or posaconazole was used in 45% (98/216) of patients overall, but only 26% (32/121) of non-hematologic malignancy patients received these treatments. The 28-day survival rate for patients treated with Voriconazole/Posaconazole was 0.776 ± 0.038, compared to 0.421 ± 0.043 for untreated patients. Median survival was 130 days (95% CI, 35.3-224.7) for treated patients vs. 20 days (95% CI, 15.8-24.2) for untreated patients (p < 0.001). Biomarkers for IPA diagnosis demonstrated high diagnostic value, with area under the curve (AUC) values for GM, G, PCT, IL-6, WBC, NEU%, and D-dimer of 0.953, 0.983, 1.000, 0.999, 0.961, 0.996, and 1.000, respectively. GM levels >0.5 pg/ml had a positive predictive value of 52.9% (27/51), while positive mycological culture had a predictive value of 46.5% (33/71). Multivariable regression analysis identified several significant factors associated with in-hospital mortality: IPA (OR 7.509, 95% CI 4.227-13.339, p < 0.001), Voriconazole/Posaconazole treatment (OR 0.124, 95% CI 0.063-0.242, p < 0.001), ICU hospitalization (OR 5.280, 95% CI 1.549-18.002, p = 0.008), hematologic malignancy (OR 0.316, 95% CI 0.174-0.573, p < 0.001), and NEU% ≥87.25% (OR 3.409, 95% CI 1.455-7.990, p = 0.005).

Conclusion

Non-hematologic malignancy patients with IPA were frequently undertreated with antifungal therapy. A comprehensive diagnostic approach using biomarkers, CT, mycological evidence is crucial. Key risk factors for mortality include lack of Voriconazole/Posaconazole treatment, IPA diagnosis, ICU admission, non-hematologic malignancies, and elevated NEU%.

Doubling of triazole resistance rates in invasive aspergillosis over a 10-year period, Belgium, 1 April 2022 to 31 March 2023

BackgroundDutch national treatment guidelines for fungal infections have been adapted based on surveillance findings of triazole resistance rates >10% in Aspergillus species isolates. In Belgium, nationwide resistance data have not been collected since 2011.AimOur objective was to evaluate changes in antifungal susceptibility among Aspergillus species isolates from patients with invasive aspergillosis.MethodsLaboratories across Belgium were invited to send all clinically relevant Aspergillus species isolates from patients diagnosed with invasive aspergillosis, collected between April 2022 and March 2023, to the National Reference Centre for Mycosis at UZ Leuven for identification and antifungal susceptibility testing.ResultsOverall, 29 clinical laboratories contributed 309 isolates from 297 patients. Median patient age was 66 years (range: 6 months-96 years). Among isolates, 61% (189/309) were from male patients. At species level, Aspergillus fumigatus isolates predominated (278/309, 90%), with a 9.7% (27/278) triazole resistance rate, compared to the 4.6% rate found in 2011. Of 27 resistant isolates, successful Cyp51A sequencing of 26 showed 20 with the TR34/L98H resistance mechanism. Across the country, local A. fumigatus triazole resistance rates varied. Among provinces in the Flanders region, Antwerp had the highest resistance rate (15.4%: 10/65; p = 0.082), Flemish Brabant (6/48) also had a rate >10%, while Limburg (2/46) had the lowest rate.ConclusionsGeographical differences in A. fumigatus triazole resistance rates stress the importance of implementing broad prospective surveillance initiatives, not limited to one region or one hospital. In Belgium, triazole resistance rates have doubled over 10 years, nearly attaining the 10% threshold, warranting re-evaluation of local empirical antifungal treatment regimen decisions.

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.

Extra-pulmonary invasive fungal infection in a post-heart transplant patient

Infectious complications remain a lifelong risk after organ transplantation. Invasive fungal infections (IFIs), including fungal brain abscess, in these patients can be very morbid and fatal. Decreased host immunity due to lifelong immunosuppressive therapy is the single most important risk factor for IFIs. Unlike in the general population, IFIs are difficult to diagnose in immunosuppressed patients because of atypical presentations, low yield of pathogens from microbial cultures, and long turnaround time for culture results. Late diagnosis and delayed initiation of treatment may influence the final outcome.

A fatal case of cytomegalovirus pneumonia with coexisting aspergillus infection in a immunodeficient patient

Introduction: Cytomegalovirus (CMV) disease is common among transplant patients, who are also prone to secondary bacterial or fungal infections. However, coinfection in immunodeficient patients is rare and often makes diagnosis and treatment challenging. Patient concerns: The patient was an older woman with low immune function but was not a transplant patient. Diagnosis: The patient presented with complaints of fever and shortness of breath for 1 day. After a medical evaluation, she was diagnosed with CMV infection and fungal pneumonia. Interventions: The patient received ceftriaxone + human immunoglobulin + voriconazole treatment. Outcome: The patient's condition deteriorated and she eventually died of myocardial infarction. Conclusion: For immunocompromised patients, early recognition of coinfections, along with combination medication, maybe a key factor in improving prognosis.

Role of liposomal amphotericin B in intensive care unit: an expert opinion paper

INTRODUCTION

Invasive fungal infections (IFI) are frequent in patients admitted to the intensive care unit (ICU). The use of first-line antifungals like triazoles or echinocandins may be limited by the global spread of multi-drug resistance species, drug-drug interactions, low organ penetration, and some safety concerns in case of multi-organ failure. Liposomal amphotericin B (L-AmB) is a polyene drug with a broad activity against mold and yeast and an acceptable safety profile. To outline the role of L-AmB in the treatment of IFI in critically ill patients, a panel of experts was invited to draw up an expert opinion paper on the appropriate place in therapy of L-AmB in different clinical scenarios of patients admitted to ICU.

METHODS

A multidisciplinary group of 16 specialists in infectious disease, microbiology, pharmacology, and intensive care elaborated an expert opinion document through a multi-step approach: (1) the scientific panel defined the items and wrote the statements on the management of IFI in ICU, (2) a survey was submitted to an external panel to express agreement or disagreement on the statements, and (3) the panel reviewed the survey and implemented the final document.

RESULTS

The final document included 35 statements that focused on epidemiology and microbiological rationale of the use of systemic L-AmB in critically ill patients and its potential role in specific clinical scenarios in the ICU.

CONCLUSION

Systemic L-AmB may represent an appropriate therapeutic choice for IFI in ICU patients with different underlying conditions, especially when the use of first-line agents is undermined. This expert opinion paper may provide a useful guide for clinicians.

Isavuconazole therapeutic drug monitoring and association with adverse events

OBJECTIVES

Isavuconazole is efficacious in the treatment of aspergillosis, mucormycosis, and other invasive fungal infections. Therapeutic drug monitoring is generally not assessed during treatment with isavuconazole due to its high oral bioavailability, modest drug-drug interactions, and linear pharmacokinetics. This study aimed to determine whether an exposure-toxicity relationship exists for isavuconazole in those experiencing potential adverse drug events.

METHODS

This retrospective study analysed adult outpatients receiving isavuconazole and the occurrence of adverse events. Patients with and without adverse events were compared to identify serum drug concentrations predictive of potential drug-related toxicity.

RESULTS

Ninety-five patients, corresponding to 219 serum levels total, were analysed. Thirty-seven (38.9%) developed adverse events, most commonly transaminitis (29.7%), diarrhoea (24.3%), and nausea (18.9%). Using Youden's index, a serum level of 5.86 µg/mL corresponded to a threshold balancing sensitivity (41.0%) and specificity (87.1%) in the determination of toxicity risk. All 24 patients undergoing isavuconazole dose reduction demonstrated resolution of symptoms.

CONCLUSIONS

Our findings identified an exposure-toxicity relationship for isavuconazole. Therapeutic drug monitoring may be beneficial for those on isavuconazole therapy who develop signs or symptoms of potential toxicity. Additionally, in patients with adverse events attributed to isavuconazole, dose reduction often led to resolution.

A Real-world Pharmacovigilance Study Of FDA Adverse Event Reporting System (FAERS) Events For Gender Of Voriconazole Drugs

To detect the gender variations in adverse events (AEs) of voriconazole, promote personalised medicine.A normalized dataset from Q1 2004 to Q4 2022 from the US Food and Drug Administration's Adverse Event Reporting System (FAERS) was analyses. The reporting odds ratio (ROR), proportional reporting ratio (PRR), and P value were used to examine data from the FAERS database to detect risk signals and quantify the presence and extent of gender variations in voriconazole adverse events.A total of 7670 cases (female/male (2785/4885)) of adverse reactions to voriconazole were analysed, and drug interaction (ROR 1.30 (1.10,1.54)), death and sudden death (ROR 1.31 (1.06,1.61)), actinic keratosis (ROR 1.98 (1.10,3.57)) were found to be significantly more frequent in male patients than in female patients.We found that gender was a determinant in voriconazole-related AEs using FAERS. Our results require future validation due to the inherent limits of this open data source, but they also identify potential contributing elements for a customised side effect profiling.

Isavuconazole as an optimal treatment option for multiple pathogens induced severe pneumonia in immunocompromised hosts: a case series report

Background

Treating severe pneumonia caused by multiple pathogens in immunocompromised hosts (ICHs) presents significant challenges. Isavuconazole (ISA), a next-generation triazole antifungal agent, has shown promise in managing fungal infections. However, clinical evidence regarding its efficacy in cases of complex infections involving multiple pathogens in ICHs remains limited.

Case presentation

This study describes a case series of three ICHs diagnosed with severe pneumonia, including invasive aspergillosis (IA). All three patients received ISA-based personalized antimicrobial regimens. Alleviation of symptoms was observed in all patients following antimicrobial treatment, with notable absorption of pulmonary lesions and no significant hepatorenal toxic side effects, with no recurrence observed.

Conclusion

ICHs are highly susceptible to fungal infections, and the severity of their condition can escalate dramatically, with a significant risk of mortality, when severe pneumonia caused by multiple pathogens occurs concurrently. A stepwise treatment strategy, which balances the use between immunosuppressant and effective antimicrobial treatment, is crucial. The selection of appropriate drugs should account for potential adverse drug reactions (ADRs). In this case series, ISA exhibited robust efficacy in treating IA with minimal ADRs. Therefore, ISA represents a valuable option for managing severe pneumonia in ICHs, particularly in the context of IA and co-infections caused by multiple pathogens.

Is neutropenia still the main risk factor for invasive aspergillosis? A contemporary university hospital retrospective cohort of invasive aspergillosis in neutropenic and non-neutropenic patients

INTRODUCTION

In times of mold active prophylaxis, invasive aspergillosis (IA) epidemiology is evolving. Presentation in non-neutropenic may differ from neutropenic. We investigated the cases of IA in our center with a focus on differences between neutropenic and non-neutropenic, and analyzed the impact of cryptic and non-fumigatus Aspergillus species.

METHODS

Retrospective observational study including all adult patients admitted to the Puerta de Hierro-Majadahonda Hospital between January 2018 and April 2024 with IA.

RESULTS

112 IA were identified. Only 11 (9.8%) had neutropenia as risk factor for IA. Most frequent risk factors were corticosteroids (77.2%), SOT (46.5%), SARS-CoV2 (29.7%) and CMV replication (28.7%). 89.3% were pulmonary IA with 6 cases (5.4%) of disseminated infection. A. fumigatus was the most frequent species 48 (51.6%). 13 cases (14%) were caused by cryptic Aspergillus spp. Non-neutropenic patients, compared to neutropenic patients, were more likely to have positive fungal cultures (83.2% versus 54.5%, p = 0.023[NS]), and not to present a halo sign (7.4% versus 45.5%, p = 0.003 [NS]). In addition, in non-neutropenic patients, compared to neutropenic patients, there was a trend towards a greater probability of positive GM from BAL (81.3% versus 66.7%, p = 0.304) and a trend towards a lower probability of positive serum GM (25.7% versus 45.5%, p = 0.137). 41/112 (36.6%) cases presented breakthrough IFI and in 51.2%, (21/41 cases), the isolate was resistant to the prior antifungal. One presented A. fumigatus with the TR34-L98H mutation.

CONCLUSION

Risk factors different than neutropenia are currently the most common in IA. The clinical presentation in non-neutropenic patients differs from neutropenic. Resistance to antifungals is emerging especially in breakthrough IA.

Impact of physician awareness and microbiological examination on incidence of COVID-19-associated pulmonary aspergillosis: a retrospective study

BACKGROUND

The reported incidence of aspergillosis among COVID-19 patients has varied significantly, which can be partly attributed to differences in diagnostic approaches and levels of physicians' proficiency in diagnosing COVID-19-associated pulmonary aspergillosis (CAPA). Consequently, we conducted a retrospective study to investigate the potential reasons for these discrepancies and analyzed the risk factors for pulmonary aspergillosis in patients with COVID-19.

METHOD

Data were retrospectively collected from December 1, 2022, to September 30, 2023, from patients who were admitted to the First Affiliated Hospital of Wenzhou Medical University. The research platform was used to screen patients with discharge diagnoses of COVID-19 pneumonia. CAPA was defined according to the 2020 ECMM/ISHAM criteria and the Chinese expert consensus. Clinical data that were collected included data about underlying diseases, laboratory examinations and microbiological detection. Analyses were conducted with R software, with continuous variables analyzed with t-tests, categorical variables analyzed with chi-square tests, and logistic regression and ROC curves used to assess risk factors for CAPA.

RESULTS

The incidence of CAPA was 13.4% in the general ward, 30.8% in the RICU, and 6.8% in other ICUs. The average time to CAPA diagnosis was 5.6 days in general wards, 3.7 days in the RICU, and 7.4 days in other ICUs. Diagnostic testing revealed the following sensitivities: 78% for BALF galactomannan (GM), 48% for serum GM, 52% for culture tests, and 71% for BALF mNGS. Risk factors for CAPA included chronic respiratory disease, chronic renal insufficiency, and diabetes. The primary Aspergillus species identified was A. fumigatus, followed by A. flavus.

CONCLUSION

Differences in incidence may arise from varying levels of physician awareness, which can influence the rate at which BALF and serum GM samples are submitted for testing. The sensitivity of BALF GM is higher than that of serum GM. Furthermore, BALF mNGS has the potential to enhance the clinical detection sensitivity of CAPA. Risk factors for CAPA include chronic respiratory disease, chronic renal insufficiency, and diabetes, which may aid in identifying at-risk patients. The primary Aspergillus species identified was A. fumigatus, followed by A. flavus, providing a reference for clinical empirical treatment.

CLINICAL TRIAL NUMBER

Not applicable.

Headache and progressive visual loss

An 88-year-old woman developed persistent unilateral headache followed by bilateral sequential visual loss. She suffered progressive neurological deterioration before her death. This report documents the clinicopathological conference at the Association of British Neurologists Annual Meeting 2024.

Concomitant autoimmunity and late cancers in adult-onset immunodeficiency due to neutralizing anti-IFN-γ autoantibodies

Background

Opportunistic intramacrophagic infections are well-characterized in adult-onset immunodeficiency associated with neutralizing anti-IFN-γ autoantibodies (nAIGA).

Objective

Concomitant autoimmune and neoplastic diseases are rarely described.

Methods

This study included 50 patients diagnosed with adult-onset immunodeficiency due to nAIGA between 2014-2024. Thirty-three were retrospectively included before January 2022, and 17 out of 295 screened patients were enrolled prospectively since January 2022. Ten patients were excluded due to missing records. All patients had regular follow-ups; anti-IFN-γ titers, autoimmune markers and cancer survey were conducted according to the primary physician's evaluation.

Results

The median age at diagnosis of adult-onset immunodeficiency was 57 years, and 53% were men. Malignancy occurred in 25%; genitourinary cancer predominated (n=4). Most (93%) patients had at least one positive autoimmune marker. Fifty-eight percent of patients were diagnosed with concomitant autoimmune diseases, and women (65%) predominated. Anti-nuclear antibody was positive in 61%, lupus anticoagulant in 50%, whilst autoimmune thyroiditis markers in 43%. Twenty-two percent of patients required long-term immunomodulation including biologic agents such as rituximab and daratumumab. Three patients (8%) died after a median interval of 9.4 years due to sepsis (n=2) and aggressive urothelial cancer (n=1). Most patients had decreasing nAIGA titers over time; two outliers with persistently high neutralizing antibodies developed late-onset malignancies.

Conclusion

Adult-onset immunodeficiency due to nAIGA is a syndrome associated with concomitant autoimmunity. Chronic infection and autoimmune-mediated inflammation may foster neoplastic changes, but the underlying mechanism is still undetermined. Autoimmune disease and cancer surveillance for patients with nAIGA is advised.

Posaconazole versus fluconazole as primary antifungal prophylaxis for patients at high risk of invasive fungal infections receiving allogeneic hematopoietic stem cell transplantation

With the aim to reduce the incidence of invasive fungal infections (IFI) after allogeneic hematopoietic stem cell transplantation (allo-HSCT), the ECIL group recommends the use of drugs active against molds such as posaconazole instead of fluconazole in high-risk (HR) IFI patients. But data to support this recommendation are poor. The aim of this monocentric study was to compare retrospectively the use of fluconazole (n = 96) vs. posaconazole (n = 63), as primary antifungal prophylaxis within the first 90 days (D) post-transplant in a cohort of patients at HR-IFI (n = 159). HR-IFI was defined by the use of an alternative donor, post-transplant cyclophosphamide and/or sequential conditioning regimen, and/or an active disease at transplant or a previous allo-HSCT. Incidences of D90, 6-month, 1-year and 2-year CI of IFI as well as D90 primary prophylaxis failure (IFI resulting in the initiation of a curative antifungal therapy or a permanent discontinuation of the prophylaxis for toxicity) were similar between both groups. However, the number of probable/proven IFI that occurred between D0 and D90 was the double in the fluco group (9 vs. 4). Also, no proven IFI (vs. 4) or mucormycoses (vs. 1) or IFI related death (vs. 4) occurred in the posa group in the first 90 days. Posaconazole thus appears to be a good option to prevent IFI after allo-HSCT in patients at HR-IFI.

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.

Serum Type 2 Cytokine Levels Are Elevated in a Chronic Pulmonary Aspergillosis Subgroup with High Serum Total Immunoglobulin E Level

A subgroup of patients with chronic pulmonary aspergillosis (CPA) exhibits elevated serum total immunoglobulin E (IgE) levels, similar to allergic bronchopulmonary aspergillosis; however, the underlying mechanisms remain unclear. This study aimed to clarify the underlying pathophysiology of the CPA subgroup with high serum total IgE levels. In this study, we prospectively collected CPA cases treated at our hospital between January and July 2022 and measured serum cytokine levels along with clinical data. We compared 34 healthy controls (HCs) and 51 patients with CPA and found significantly elevated levels of inflammatory cytokines and tissue repair and destruction-related cytokines in CPA. Among the 51 patients with CPA, 10 had total IgE levels of >500 IU/mL, whereas the remaining 41 did not. The IgE-high group exhibited significantly increased eosinophil counts and elevated levels of type 2 cytokines and pro-inflammatory cytokines. Based on these findings, patients with CPA exhibited an enhanced inflammatory response in terms of cytokines compared with HCs. In particular, the CPA subgroup with high total IgE levels may have an underlying enhancement of type 2 inflammation. Our study provides insights into the potential novel pathomechanisms of CPA and may contribute to the development of new treatment strategies.

Molecular Mechanism of Aflatoxin B1 Synthesis Related AfVerB Regulating the Development, AFB1 Biosyntheis and Virulence of Aspergillus flavus Mainly Through Its CYP Domain

Aspergillus flavus and its secondary metabolites aflatoxins pose a significant threat to the health of humans, animals, and plants. Therefore, there is an urgent need to control A. flavus contamination. AfverB plays a key role in the aflatoxin gene cluster; however, its function and mechanism in fungal development and virulence remain poorly understood. In this study, we constructed afVerB gene deletion mutants (∆afVerB-1 and ∆afVerB-2) and two CYP domain mutants (afVerB∆D1 and afVerB∆D2) through homologous recombination. Phenotype analysis revealed that, via its two CYP domains, AfVerB is deeply involved in fungal morphogenesis and aflatoxin synthesis. Insect and crop colonization models revealed that AfVerB plays a key role in the fungus's ability to infect hosts, and stress experiments discovered that AfVerB plays a significant role in the response to various environmental stresses, which explains why AfVerB is a key factor in fungal infection to some extent. RT-qPCR analysis demonstrated that AfVerB performs its bio-function through corresponding regulatory factors. We ultimately discovered that AfVerB is deeply involved in cell membrane stress stability, thereby participating in the regulation of fungal drug resistance (sensitive to AMB and resistant to VOR in this study). The CYP domain of AfVerB, particularly its second CYP domain, is crucial for the execution of its biological functions. This study elucidated the regulatory mechanisms by which AfVerB regulates fungal pathogenicity and aflatoxin biosynthesis, providing potential strategies for controlling A. flavus and its aflatoxin contamination.

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.

Observational study of the recent efficacy and economy of itraconazole vs. voriconazole in perioperative pulmonary aspergillosis

Background

Antifungal therapy is a common treatment option for pulmonary aspergillosis, but its use to prevent recurrence and relieve symptoms in patients with pulmonary aspergillosis remains controversial. This study aimed to explore the short-term efficacy and cost of itraconazole vs. voriconazole in the treatment of pulmonary aspergillosis during the perioperative period.

Methods

We retrospectively collected the clinical data of 55 patients with pulmonary aspergillosis who underwent surgery and received itraconazole or voriconazole as antifungal therapy between January 1, 2016, and October 31, 2022, at the Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical University. We analyzed the effects of different antifungal therapies on the incidence of adverse events, short-term efficacy, and cost-effectiveness of pulmonary aspergillosis treatment.

Results

Except for the younger average age of patients in the itraconazole group, there were no significant differences in baseline characteristics such as sex, BMI, underlying lung disease, accompanying symptoms, and lesion location between the voriconazole and itraconazole groups. There was no significant difference in the incidence of adverse events or short-term efficacy, including recovery, symptom improvement, and recurrence rates, during the administration of the antifungal regimens between the two groups. Regarding economic cost efficiency, there was no significant difference in the median hospitalization costs between the two groups. However, despite the longer antifungal treatment duration in the itraconazole group, the cost of itraconazole was significantly lower than that of voriconazole.

Conclusion

Both itraconazole and voriconazole effectively prevented the recurrence of pulmonary aspergillosis. They are similar in terms of the incidence of adverse events and short-term efficacy; however, itraconazole is more economical.

Real World Posaconazole Pharmacokinetic Data in Paediatric Stem Cell Transplant Recipients

Background: Invasive fungal disease is a significant cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant (alloHSCT) recipients. Posaconazole, a broad-spectrum triazole, is widely used as prophylaxis. Methods: We conducted a monocentric, retrospective study to present real-world data on posaconazole trough levels in paediatric alloHSCT patients. The main objective was to determine the required daily dose of posaconazole in paediatric patients. We analysed factors influencing posaconazole levels, and the association between posaconazole levels and breakthrough fungal infection. Results: Among 102 allogeneic HSCT recipients, we measured posaconazole plasma concentrations in 548 blood samples. The required daily doses to reach a target range of 0.7-2.0 mg/L were 15.22 (suspension), 7.52 (tablet), and 7.84 mg/kg (intravenous). Patients aged < 13 years needed higher doses to achieve the target range. The presence of enteral symptoms during prophylaxis was associated with lower plasma concentrations (p < 0.001), while co-administration of proton pump inhibitors did not (p = 0.09). Eight breakthrough infections occurred; low levels of posaconazole (<0.7 mg/L) were observed in five out of eight cases. The Cox regression model showed that higher mean plasma concentrations decreased the hazard of breakthrough infections. Conclusions: The tablet and intravenous formulations of posaconazole outperformed the suspension in terms of predictability. Our analyses on breakthrough infections and posaconazole plasma levels suggest an exposure-response relationship.

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.

New Challenges in the Diagnosis and Treatment of Primary Cutaneous Aspergillosis in Extensive Pediatric Burns

The aim of this study is to share our experience regarding the diagnosis and therapeutic management of primary cutaneous aspergillosis (PCA) in the burn patient, an uncommon infection associated with increased mortality, morbidity, and treatment costs. The uniqueness of this article is the presence of PCA in pediatric patients where the Meek micrografting technique was used. We performed a retrospective study from June 2020 to November 2024. The inclusion criteria were the concomitant presence of burn injuries and confirmed PCA. We identified six patients, aged between 12 and 17 years, admitted with deep burns ranging from 55% to 90% of the total body surface area (TBSA). They required complex ICU treatment and underwent extensive excision-grafting surgeries. The suspicion of infection was raised by changes in the appearance of wounds. Systemic and topical antifungal treatment was established in patients after a PCA diagnosis. Five out of the six cases had a favorable outcome. The use of the Meek micrografting technique in burn treatment represents a new challenge in the treatment of PCA due to the polyamide gauze that covers the micrografts. Early detection and appropriate topical antifungal agents combined with systemic treatment may save the infected grafts and limit the infection spread without necessarily removing the polyamide gauze.

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.].

Fungal Infections in People Who Use Drugs

Illicit drug use in the United States continues to rise, alongside an increasing number of severe infections associated with drug use. Surveillance studies report that 28%-34% of candidemia cases are linked to intravenous drug use, with Candida albicans being the most commonly isolated species, followed by Candida parapsilosis and Candida glabrata. Marijuana use is associated with lung infections caused by Aspergillus and the Mucorales, showing a 3.5-fold increased risk of mold infections and a 2.2-fold increased risk for other fungal infections. Intravenous drug use also presents a recognized risk factor for Aspergillus and Mucorales infections. Additionally, substances like cannabis, methamphetamines, and opioids share metabolic pathways with triazoles, a class of antifungal, and terbinafine through the CYP enzyme system. These antifungal drugs strongly inhibit CYP3A4 and CYP2D6, leading to potential drug interactions, adverse effects, overdose risks, and even death.