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AlMaghrabi RS, Al-Musawi T, Albaksami O, Subhi AL, Fakih RE, Stone NR. Challenges in the Management of Invasive Fungal Infections in the Middle East: Expert Opinion to Optimize Management Using a Multidisciplinary Approach. Cureus 2023; 15:e44356. [PMID: 37779746 PMCID: PMC10539715 DOI: 10.7759/cureus.44356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 10/03/2023] Open
Abstract
Invasive fungal infection (IFI) is a significant global healthcare concern among critically ill and immunocompromised patients. In Middle Eastern countries, IFI has been steadily increasing among hospitalized patients in the past two decades. Diagnosis of IFI at an early stage is crucial for efficient management. Invasive fungal infection management is complex and requires the involvement of physicians from different specialties. There are several challenges associated with IFI management in the countries in the Middle East. This review aims to understand the key challenges associated with IFI management in the Middle East, encompassing epidemiology, diagnosis, therapeutic options, and optimizing a multidisciplinary approach. In addition, this review aims to incorporate expert opinions from multidisciplinary fields for optimizing IFI management in different Middle Eastern countries by addressing key decision points throughout the patient's journey. Lack of epidemiological data on fungal infections, slow and poorly sensitive conventional culture-based diagnostic tests, limited availability of biomarker testing, lack of awareness of clinical symptoms of the disease, limited knowledge on fungal infections, lack of local practice guidelines, and complicated disease management are the major challenges associated with IFI diagnosis and management in the Middle Eastern countries. Implementation of a multidisciplinary approach, antifungal stewardship, improved knowledge of fungal infections, the use of rapid diagnostic tests, and enhanced epidemiological research are warranted to lower the IFI burden in the Middle East.
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Affiliation(s)
- Reem S AlMaghrabi
- Department of Medicine, Organ Transplant Center, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Tariq Al-Musawi
- Department of Critical Care Medicine, Al Salam Hospital, Al-Khobar, SAU
- Department of Medicine, Royal College of Surgeons in Ireland - Bahrain, Busaiteen, BHR
| | - Osama Albaksami
- Department of Infectious Diseases, Infectious Disease Hospital, Kuwait City, KWT
| | - Ahmad L Subhi
- Department of Infectious Diseases, Al-Qassimi Hospital, Sharjah, ARE
| | - Riad E Fakih
- Department of Hematology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
- Department of Clinical Research, Alfaisal University, Riyadh, SAU
| | - Neil R Stone
- Department of Microbiology, Hospital for Tropical Diseases, London, GBR
- Department of Microbiology, University College London Hospitals, London, GBR
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Gogineni H, So W, Mata K, Greene JN. Multidisciplinary approach in diagnosis and treatment of COVID-19-associated mucormycosis: a description of current reports. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022; 34:58. [PMID: 35911783 PMCID: PMC9308120 DOI: 10.1186/s43162-022-00143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
We reviewed the epidemiology, risk factors, pathophysiology, and clinical presentations of coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM), then discussed the importance of rapid diagnosis and treatment facilitated by multidisciplinary approach.
Main body
India has reported world’s highest number of CAM cases where Rhizopus arrhizus was the most predominant etiology. CAM caused by Rhizopus microsporus was the most common from the rest of the world. Multiple risk factors for CAM were identified including diabetes mellitus, inappropriate corticosteroid use, COVID-19-related hypoxia, and lung damage.
Rhino-orbito-cerebral mucormycosis (ROCM) accounted for almost 90% of CAM in India while 64% of global cases were ROCM. Less than 10% of CAM from India were pulmonary while the rest of the world reported 21% of pulmonary CAM.
CAM is diagnosed by confirmed SARS-CoV2 infection along with clinical, radiological, histopathological, and/or microbiological evidence of mucormycosis. In patients with risks of CAM and associated symptoms, CT or MRI are recommended. If ROCM is suspected, endoscopy and biopsy are recommended. If pulmonary CAM is suspected, tissue biopsies, nasal samples, or bronchoalveolar lavage is recommended with histopathological exams.
Early diagnosis, surgical, and pharmaceutical interventions are key to treat mucormycosis. Upon diagnosis, antifungal therapy with liposomal amphotericin B (IV) is considered first-line of therapy. Alternatively, posaconazole (PO/IV) or isavuconazole (PO/IV) can be used.
Conclusion
Treating CAM requires a multidisciplinary approach for early diagnosis and prompt initiation of interventions to maximize patient’s chance of survival.
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Colombo AL, De Almeida JN, Lewis RE, Kontoyiannis DP. Quandaries of deciding when to change first-line therapy in invasive pulmonary aspergillosis. J Antimicrob Chemother 2022; 77:2897-2900. [PMID: 36059133 DOI: 10.1093/jac/dkac301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We read the excellent viewpoint by Slavin et al. (J Antimicrob Chemother 2022; 77: 16-23) that draws upon the experience of an advisory board of notable experts to comprehensively address many of the clinical factors that drive the need for changes in antifungal therapy for invasive aspergillosis (IA). As noted by the authors, there remains a paucity of quality data to support many of the decisions faced by clinicians managing patients with IA. However, we would like to highlight several other important issues, not fully addressed in that viewpoint, that play an important role in deciding when to change antifungal therapy for IA.
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Affiliation(s)
- Arnaldo L Colombo
- Department of Medicine, Division of Infectious Diseases, Special Mycology Laboratory-LEMI, Federal University of São Paulo, São Paulo, Brazil
| | - João N De Almeida
- Department of Medicine, Division of Infectious Diseases, Special Mycology Laboratory-LEMI, Federal University of São Paulo, São Paulo, Brazil
| | - Russell E Lewis
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases Infection Control and Employee Health, MD Anderson Cancer Center, Houston, TX, USA
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Groll AH, Gordon K, Buchheidt D, Willinger B, Heinz WJ, Kurzai O, Rickerts V, Cornely OA. State of Medical Mycology at German Academic Medical Centres: A Survey of the German-Speaking Mycological Society (DMYKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG). Mycoses 2021; 64:1177-1182. [PMID: 34180098 DOI: 10.1111/myc.13346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little is known about the infrastructure to translate advances in the management of patients at risk to develop invasive opportunistic fungal diseases. To assess the current state of Medical Mycology support in Germany, we conducted a survey among all 36 academic medical centres. METHODS The survey consisted of a 3-pages questionnaire sent out in the first half of 2019. Information included details of infrastructure, education and teaching; consultation services and interdisciplinary conferences; research activities and participation in network groups; radiology, microbiology and pharmacology support; publication activity; and European Confederation for Medical Mycology (ECMM) Excellence Center designation, if assigned. RESULTS Information was returned from 24 centres (67%). Thirteen institutions (54%) reported an independent infectious disease, and two a separate Medical Mycology department (8%); a Medical Mycology working group was reported for nine institutions (38%). An infectious disease consultation service was existent in 16 institutions (67%) and a multidisciplinary conference in 13 (54%). Fifteen institutions reported a separate study office with activities in infectious disease studies (63%). Laboratory capability for fungal identification and susceptibility testing was confirmed by all 24 institutions; testing of galactomannan by 23 (96%), cryptococcal antigen by 21 (88%), ß-D-Glucan by 9 (38%), and panfungal and Pneumocystis PCR by 21 and 22 (88% and 92%), respectively. Therapeutic drug monitoring of voriconazole was reported to be available in 15 (63%) institutions with a turnaround of ≤24 h during weekdays in 10 (42%). Two of the 24 University hospitals (8%) reported ECMM Diamond Excellence Status. CONCLUSIONS The results of this survey document the continuing need to improve the availability of specialised Medical Mycology support in German academic medical centres.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Kathrin Gordon
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Birgit Willinger
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Werner J Heinz
- Department of Internal Medicine II, Caritas Hospital Bad Mergentheim, Bad Mergentheim, Germany
| | - Oliver Kurzai
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany.,National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institut für Naturstoff-Forschung und Infektionsbiologie - Hans-Knöll-Institut, Jena, Germany
| | - Volker Rickerts
- Unit 16, Mycotic and Parasitic Agents and Mycobacteria, Robert Koch Institute Berlin, Berlin, Germany
| | - Oliver A Cornely
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), and German Centre for Infection Research (DZIF) Partner Site Bonn-Cologne, University of Cologne, Cologne, Germany
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Chikley A, Ben-Ami R, Kontoyiannis DP. Mucormycosis of the Central Nervous System. J Fungi (Basel) 2019; 5:jof5030059. [PMID: 31288475 PMCID: PMC6787740 DOI: 10.3390/jof5030059] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022] Open
Abstract
Mucormycosis involves the central nervous system by direct extension from infected paranasal sinuses or hematogenous dissemination from the lungs. Incidence rates of this rare disease seem to be rising, with a shift from the rhino-orbital-cerebral syndrome typical of patients with diabetes mellitus and ketoacidosis, to disseminated disease in patients with hematological malignancies. We present our current understanding of the pathobiology, clinical features, and diagnostic and treatment strategies of cerebral mucormycosis. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability. Emerging molecular diagnostics, advances in experimental systems and the establishment of large patient registries are key components of ongoing efforts to provide a timely diagnosis and effective treatment to patients with cerebral mucormycosis.
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Affiliation(s)
- Amanda Chikley
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel.
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, The University of Texas, M.D. Anderson Cancer Center, Houston 77030, TexasTX 77030, USA.
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Cojutti P, Candoni A, Forghieri F, Isola M, Zannier ME, Bigliardi S, Luppi M, Fanin R, Pea F. Variability of Voriconazole Trough Levels in Haematological Patients: Influence of Comedications with cytochrome P450(CYP) Inhibitors and/or with CYP Inhibitors plus CYP Inducers. Basic Clin Pharmacol Toxicol 2015; 118:474-9. [PMID: 26572687 DOI: 10.1111/bcpt.12530] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/02/2015] [Indexed: 12/13/2022]
Abstract
Voriconazole plasma exposure greatly varies among haematological patients. The purpose of this study was to identify the magnitude of influence of comedications with CYP inhibitors and/or with CYP inhibitors plus CYP inducers on voriconazole trough level (Cmin ). Voriconazole Cmin was retrospectively assessed among haematological patients who underwent therapeutic drug monitoring (TDM). Univariate and multivariate linear mixed-effect regression analyses were performed to identify the independent predictors of normalized Cmin . Of the 83 included patients, 35 had comedications with CYP inhibitors (omeprazole or pantoprazole) and 21 with CYP inhibitors (omeprazole or pantoprazole) plus CYP inducers (methylprednisolone, dexamethasone, phenobarbital, rifampin or carbamazepine). Median Cmin value (n = 199) was 2.4 mg/L with a wide range of distribution (<0.2-13.5 mg/L). Median (IQR) normalized voriconazole Cmin value was significantly higher in the presence of CYP inhibitors (4.20 mg/L, 3.23-5.51 mg/L) than either in the absence of interacting cotreatments (2.55 mg/L, 1.54-3.47 mg/L) or in the presence of CYP inhibitors plus CYP inducers (2.16 mg/L, 1.19-3.09 mg/L). The presence of CYP inhibitors was highly significantly associated with Cmin >5.5 mg/L (OR: 23.22, 95% CI: 3.01-179.09, p = 0.003). No significant association emerged when CYP inhibitors were coadministered with CYP inducers (OR: 3.53, 95% CI: 0.36-34.95, p = 0.280). The amount of expected Cmin increase was significantly influenced by both the type and the dose of the administered proton pump inhibitor. The study highlights that the benefit from TDM of voriconazole may be maximal in those patients who are cotreated with CYP inhibitors and/or with CYP inhibitors plus CYP inducers, especially when receiving proton pump inhibitors (PPIs) at very high dosages intravenously.
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Affiliation(s)
- Piergiorgio Cojutti
- Institute of Clinical Pharmacology, University Teaching Hospital of Udine, Udine, Italy.,Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - Anna Candoni
- Division of Haematology, University Teaching Hospital of Udine, Udine, Italy
| | - Fabio Forghieri
- Department of Medical and Surgical Sciences, Section of Haematology, University of Modena and Reggio Emilia, University Teaching Hospital of Modena, Modena, Italy
| | - Miriam Isola
- Department of Medical and Biological Sciences, Section of Statistics, University of Udine, Udine, Italy
| | - Maria Elena Zannier
- Division of Haematology, University Teaching Hospital of Udine, Udine, Italy
| | - Sara Bigliardi
- Department of Medical and Surgical Sciences, Section of Haematology, University of Modena and Reggio Emilia, University Teaching Hospital of Modena, Modena, Italy
| | - Mario Luppi
- Department of Medical and Surgical Sciences, Section of Haematology, University of Modena and Reggio Emilia, University Teaching Hospital of Modena, Modena, Italy
| | - Renato Fanin
- Division of Haematology, University Teaching Hospital of Udine, Udine, Italy
| | - Federico Pea
- Institute of Clinical Pharmacology, University Teaching Hospital of Udine, Udine, Italy.,Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
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Pfaller MA, Castanheira M. Nosocomial Candidiasis: Antifungal Stewardship and the Importance of Rapid Diagnosis. Med Mycol 2015; 54:1-22. [PMID: 26385381 DOI: 10.1093/mmy/myv076] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/20/2015] [Indexed: 01/12/2023] Open
Abstract
Candidemia and other forms of candidiasis are associated with considerable excess mortality and costs. Despite the addition of several new antifungal agents with improved spectrum and potency, the frequency of Candida infection and associated mortality have not decreased in the past two decades. The lack of rapid and sensitive diagnostic tests has led to considerable overuse of antifungal agents resulting in increased costs, selection pressure for resistance, unnecessary drug toxicity, and adverse drug interactions. Both the lack of timely diagnostic tests and emergence of antifungal resistance pose considerable problems for antifungal stewardship. Whereas antifungal stewardship with a focus on nosocomial candidiasis should be able to improve the administration of antifungal therapy in terms of drug selection, proper dose and duration, source control and de-escalation therapy, an important parameter, timeliness of antifungal therapy, remains a victim of slow and insensitive diagnostic tests. Fortunately, new proteomic and molecular diagnostic tools are improving the time to species identification and detection. In this review we will describe the potential impact that rapid diagnostic testing and antifungal stewardship can have on the management of nosocomial candidiasis.
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Affiliation(s)
- Michael A Pfaller
- T2Biosystems, Lexington, Massachusetts JMI Laboratories, North Liberty, Iowa University of Iowa College of Medicine College of Public Health, Iowa City, Iowa
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Kontoyiannis DP, Lewis RE. Treatment principles for the management of mold infections. Cold Spring Harb Perspect Med 2014; 5:cshperspect.a019737. [PMID: 25377139 DOI: 10.1101/cshperspect.a019737] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Survival rates among immunocompromised patients with invasive mold infections have markedly improved over the last decade with earlier diagnosis and new antifungal treatment options. Yet, increasing antifungal resistance, breakthrough infections with intrinsically resistant fungi, and potentially life-threatening adverse effects and drug interactions are becoming more problematic, especially with prolonged therapy. Evidence-based recommendations for treating invasive aspergillosis and mucormycosis provide excellent guidance on the initial workup and treatment of these molds, but they cannot address all of the key management issues. Herein, we discuss 10 general treatment principles in the management of invasive mold disease in immunocompromised patients and discuss how these principles can be integrated to develop an effective, individualized treatment plan.
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Affiliation(s)
| | - Russell E Lewis
- Department of Medical Sciences and Surgery, University of Bologna, 40138 Bologna, Italy
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