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Thompson GR, Chen SCA, Alfouzan WA, Izumikawa K, Colombo AL, Maertens J. A global perspective of the changing epidemiology of invasive fungal disease and real-world experience with the use of isavuconazole. Med Mycol 2024; 62:myae083. [PMID: 39138063 PMCID: PMC11382804 DOI: 10.1093/mmy/myae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/29/2024] [Accepted: 08/12/2024] [Indexed: 08/15/2024] Open
Abstract
Global epidemiological data show that the incidence of invasive fungal disease (IFD) has increased in recent decades, with the rising frequency of infections caused by Aspergillus and Mucorales order species. The number and variety of patients at risk of IFD has also expanded, owing in part to advances in the treatment of hematologic malignancies and other serious diseases, including hematopoietic stem cell transplantation (HCT) and other therapies causing immune suppression. Isavuconazonium sulfate (active moiety: isavuconazole) is an advanced-generation triazole antifungal approved for the treatment of invasive aspergillosis and mucormycosis that has demonstrated activity against a variety of yeasts, moulds, and dimorphic fungi. While real-world clinical experience with isavuconazole is sparse in some geographic regions, it has been shown to be effective and well tolerated in diverse patient populations, including those with multiple comorbidities who may have failed to respond to prior triazole antifungal therapy. Isavuconazole may be suitable for patients with IFD receiving concurrent QTc-prolonging therapy, as well as those on venetoclax or ruxolitinib. Data from clinical trials are not available to support the use of isavuconazole prophylactically for the prevention of IFD or for the treatment of endemic IFD, such as those caused by Histoplasma spp., but real-world evidence from case studies suggests that it has clinical utility in these settings. Isavuconazole is an option for patients at risk of IFD, particularly when the use of alternative antifungal therapies is not possible because of toxicities, pharmacokinetics, or drug interactions.
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Affiliation(s)
- George R Thompson
- Department of Internal Medicine, Division of Infectious Disease, UC Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California, Davis, California, USA
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, New South Wales Health Pathology, and the Department of Infectious Diseases, Westmead Hospital, School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Wadha Ahmed Alfouzan
- Department of Laboratories, Farwaniya Hospital, Farwaniya, Kuwait
- Department of Microbiology, College of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Arnaldo L Colombo
- Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
- Antimicrobial Resistance Institute of São Paulo, São Paulo, Brazil
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven and Department of Hematology, University Hospitals Leuven, Leuven, Belgium
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2
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Czech MM, Schulz E, Mina A, Gea-Banacloche J. Infections and antimicrobial prophylaxis in patients with myelodysplastic syndromes. Semin Hematol 2024:S0037-1963(24)00085-4. [PMID: 39198132 DOI: 10.1053/j.seminhematol.2024.07.004] [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: 06/21/2024] [Accepted: 07/29/2024] [Indexed: 09/01/2024]
Abstract
Infectious complications are an important cause of morbidity and mortality in patients with myelodysplastic syndromes (MDS). Preventing infections could significantly improve both survival and quality of life. Unfortunately, both infections and antimicrobial prophylaxis in patients with MDS are incompletely assessed due to the heterogeneity of disorders included in each publication, changing definitions over time, and lack of standardized prophylaxis practices. Despite these limitations, some basic statements can be made. Infections in MDS are associated with neutropenia. Patients with lower-risk (LR) MDS tend to have fewer infections compared to patients with higher-risk (HR) MDS, which may be related to the different prevalence of neutropenia in the 2 groups. Pneumonia is the most common infection, and bacteria are the most common pathogens. Invasive fungal infections (IFI) are uncommon. Reactivation of latent viruses are rare. With the limited data available, we agree that antibacterial prophylaxis can be considered in patients with HR-MDS during severe neutropenia and early cycles of therapy when infections are most likely to occur. Given the low prevalence of IFI and viral reactivation, antimicrobial prophylaxis for these pathogens is less likely to be advantageous for most patients, although antifungal prophylaxis with activity against mold is commonly used in patients with persistent, profound neutropenia. Ultimately, improved data collection regarding infections and antimicrobial prophylaxis is needed to improve care for patients with MDS.
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Affiliation(s)
- Mary M Czech
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.
| | - Eduard Schulz
- Myeloid Malignancy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Alain Mina
- Myeloid Malignancy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Juan Gea-Banacloche
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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3
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Ross JA, Lee B, Ma H, Tegtmeier B, Nanayakkara D, Dickter J, Spielberger R, Smith E, Pullarkat V, Forman SJ, Taplitz R, Nakamura R, Al Malki M, Dadwal SS. Impact of Antifungal Prophylaxis Continuation or Discontinuation After Allogeneic Hematopoietic Cell Transplant on the Incidence of Invasive Mold Infection. Open Forum Infect Dis 2024; 11:ofae409. [PMID: 39135965 PMCID: PMC11317840 DOI: 10.1093/ofid/ofae409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 07/16/2024] [Indexed: 08/15/2024] Open
Abstract
Background Continuing antifungal prophylaxis (AFPx) to prevent invasive mold infections (IMIs) in recipients of allogeneic hematopoietic cell transplantation (alloHCT) after primary hospital discharge from alloHCT admission varies among transplant centers despite recommendations to continue prophylaxis through day +75. Characteristics driving AFPx prescribing at hospital discharge and outcomes are unknown. Methods In this retrospective analysis, we reviewed patients continuing AFPx vs no AFPx at hospital discharge. We included patients with a hospital stay ≥7 days and ≤40 days. We excluded patients with a history of IMI prior to alloHCT, new IMI during admission, or death prior to discharge. Our primary objective was incidence of probable or proven IMI per the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Our secondary objectives were nonrelapse mortality at day +100, overall survival at day +100, and characteristics driving AFPx discontinuation at hospital discharge. Results Of the 430 patients identified, 387 met inclusion criteria. At discharge, 56% (217/387) continued AFPx, and 44% (170/387) had no AFPx. At day +100, 3 probable IMI cases occurred in the group with continued AFPx vs 1 probable IMI case in the no-AFPx group (no proven IMI). Univariate analysis showed no difference in cumulative incidence of probable IMI (P = .440), nonrelapse mortality (P = .072), and overall survival (P = .855) between groups. Multivariable logistic regression demonstrated that patients were less likely to continue AFPx if they had a diagnosis other than acute myeloid leukemia, a length of stay ≤30 days, acute graft-vs-host disease grade 0 or 1, and corticosteroid use ≤5 days. Conclusions There was no difference in probable IMI at day +100 after alloHCT based on continuing vs discontinuing AFPx at hospital discharge after alloHCT admission supporting a risk-adapted prophylaxis approach.
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Affiliation(s)
- Justine Abella Ross
- Department of Pharmacy, City of Hope National Medical Center, Duarte, California, USA
| | - Brian Lee
- Department of Pharmacy, City of Hope National Medical Center, Duarte, California, USA
| | - Huiyan Ma
- Division of Biostatistics, Department of Computational and Quantitative Medicine, Beckman Research Institute of City of Hope, Duarte, California, USA
| | - Bernard Tegtmeier
- Department of Quality Risk and Regulatory Management, City of Hope National Medical Center, Duarte, California, USA
| | - Deepa Nanayakkara
- Division of Infectious Disease, City of Hope National Medical Center, Duarte, California, USA
| | - Jana Dickter
- Division of Infectious Disease, City of Hope National Medical Center, Duarte, California, USA
| | - Ricardo Spielberger
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Eileen Smith
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Randy Taplitz
- Department of Medicine, City of Hope National Medical Center, Duarte, California, USA
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Monzr Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Sanjeet Singh Dadwal
- Division of Infectious Disease, City of Hope National Medical Center, Duarte, California, USA
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Boutin CA, Durocher F, Beauchemin S, Ziegler D, Abou Chakra CN, Dufresne SF. Breakthrough Invasive Fungal Infections in Patients With High-Risk Hematological Disorders Receiving Voriconazole and Posaconazole Prophylaxis: A Systematic Review. Clin Infect Dis 2024; 79:151-160. [PMID: 38752732 PMCID: PMC11259221 DOI: 10.1093/cid/ciae203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Primary antifungal prophylaxis with mold-active azoles is used to prevent invasive fungal infections in patients with high-risk hematological disorders; however, breakthrough infections occur, and the reasons for treatment failure are still not fully understood. To help inform clinical decisions, we sought to define microbiological, clinical, and pharmacological characteristics of proven and probable breakthrough invasive fungal infections (bIFIs) in patients with high-risk hematological disorders receiving voriconazole or posaconazole prophylaxis. METHODS We performed a systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search strategy was last conducted on 19 April 2023. RESULTS We assessed 5293 studies for eligibility, and 300 were selected for data extraction. These studies described 1076 cases of bIFIs occurring under voriconazole (42.5%) or posaconazole (57.5%). The most commonly found pathogens were Aspergillus (40%), Mucorales (20%), Candida (18%), and Fusarium (9%) species. Mucorales were more frequent among voriconazole-emerging cases, whereas Aspergillus and Fusarium were more prevalent among posaconazole-emerging cases. Definitive, putative, or probable antifungal resistance was found in 31% of cases. Therapeutic drug monitoring showed subtherapeutic azole concentration in 32 of 90 (36%) cases. Infection-related mortality was reported in 117 cases and reached 35%. CONCLUSIONS In our systemic review, the most common bIFIs were aspergillosis, mucormycosis, candidiasis, and fusariosis. Antifungal resistance explains only a minority of cases. Subtherapeutic prophylaxis was frequent but rarely reported. Prospective studies are needed to better understand these infections and to establish optimal management.
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Affiliation(s)
- Catherine-Audrey Boutin
- Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, Centre hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Florence Durocher
- Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | | | - Daniela Ziegler
- Direction de l’enseignement et de l’Académie, Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | | | - Simon Frédéric Dufresne
- Department of Microbiology, Infectious Diseases and Immunology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre de Recherche de l’Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
- Division of Infectious Diseases and Clinical Microbiology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Est-de-l’Île-de-Montréal, Montréal, Québec, Canada
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5
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Mutcali SI, Hussain N, Nematollahi S, Lainhart W, Zangeneh TT, Al-Obaidi MM. The performance of bronchoalveolar lavage Aspergillus PCR testing in solid organ transplant recipients with invasive pulmonary aspergillosis. Transpl Infect Dis 2024:e14327. [PMID: 38946124 DOI: 10.1111/tid.14327] [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: 10/09/2023] [Revised: 04/04/2024] [Accepted: 06/17/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Invasive aspergillosis affects solid organ transplant (SOT) recipients, carrying a high risk of mortality and morbidity in this population. Rapid and accurate diagnosis is essential to ensure the initiation of correct antifungal therapy. We aimed to evaluate the performance of the bronchoalveolar lavage (BAL) Eurofins Viracor Aspergillus PCR (AspPCR) in diagnosing invasive pulmonary aspergillosis (IPA) in SOT recipients. METHODS We conducted a multicenter retrospective study of SOT recipients in Arizona from February 2019 to December 2022 who had AspPCR done at the time of the clinical encounter. Probable IPA was defined as a positive BAL culture with Aspergillus spp. with clinical and imaging findings of IPA per EORTC/MSGERC criteria. RESULTS Ninety-nine SOT recipients with 131 encounters with BAL AspPCR testing were included. The median age was 66, the majority were White, non-Hispanics (60%), and males (66%). Among the participants, 93 lung transplant recipients with 87 of the encounters received antifungal prophylaxis active against Aspergillus spp. Sixty-four encounters had BAL galactomannan (GM), all of which had BAL GM <1 OD, and one case had a serum GM of 10 OD. Nine cases met the definition of IPA. The sensitivity of the BAL AspPCR was 67% (95% CI 30%-93%), and the specificity was 98% (95% CI 93%-99%). CONCLUSION BAL AspPCR had moderate sensitivity and high specificity in identifying IPA in our cohort of SOT recipients. Further studies in populations with a higher prevalence of IPA are needed to evaluate the performance of this test.
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Affiliation(s)
- Sibel Islak Mutcali
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Nadeem Hussain
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Saman Nematollahi
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - William Lainhart
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
- Department of Pathology, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Tirdad T Zangeneh
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Mohanad M Al-Obaidi
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
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Little JS, Kampouri E, Friedman DZ, McCarty T, Thompson GR, Kontoyiannis DP, Vazquez J, Baddley JW, Hammond SP. The Burden of Invasive Fungal Disease Following Chimeric Antigen Receptor T-Cell Therapy and Strategies for Prevention. Open Forum Infect Dis 2024; 11:ofae133. [PMID: 38887472 PMCID: PMC11181190 DOI: 10.1093/ofid/ofae133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/05/2024] [Indexed: 06/20/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a novel immunotherapy approved for the treatment of hematologic malignancies. This therapy leads to a variety of immunologic deficits that could place patients at risk for invasive fungal disease (IFD). Studies assessing IFD in this setting are limited by inconsistent definitions and heterogeneity in prophylaxis use, although the incidence of IFD after CAR T-cell therapy, particularly for lymphoma and myeloma, appears to be low. This review evaluates the incidence of IFD after CAR T-cell therapy, and discusses optimal approaches to prevention, highlighting areas that require further study as well as future applications of cellular therapy that may impact IFD risk. As the use of CAR T-cell therapy continues to expand for hematologic malignancies, solid tumors, and most recently to include non-oncologic diseases, understanding the risk for IFD in this uniquely immunosuppressed population is imperative to prevent morbidity and mortality.
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Affiliation(s)
- Jessica S Little
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eleftheria Kampouri
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Daniel Z Friedman
- Section of Infectious Diseases and Global Health, The University of Chicago, Chicago, Illinois, USA
| | - Todd McCarty
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - George R Thompson
- Division of Infectious Diseases, University of California-Davis, Sacramento, California, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jose Vazquez
- Division of Infectious Diseases, Medical College of Georgia/Augusta University, Augusta, Georgia, USA
| | - John W Baddley
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sarah P Hammond
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
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7
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Williams MJ, Cook M, Mejaki B, Buggy BP. In Response to Nguyen et al: Mold Active Triazole Prophylaxis Utilization among Patients with Acute Myeloid Leukemia in a Community Hospital. Open Forum Infect Dis 2024; 11:ofae135. [PMID: 38524233 PMCID: PMC10960594 DOI: 10.1093/ofid/ofae135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/06/2024] [Indexed: 03/26/2024] Open
Affiliation(s)
- Michael J Williams
- Department of Pharmacy, Aurora St Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Margaret Cook
- Department of Pharmacy, Aurora St Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Brittany Mejaki
- Department of Pharmacy, Aurora St Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Brian P Buggy
- Infectious Diseases Section, Aurora St Luke's Medical Center, Milwaukee, Wisconsin, USA
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8
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Nguyen MH, Ostrosky-Zeichner L, Pappas PG, Walsh TJ, Bubalo J, Alexander BD, Miceli MH, Jiang J, Song Y, Thompson GR. Reply to Williams et al. Open Forum Infect Dis 2024; 11:ofae134. [PMID: 38524232 PMCID: PMC10960595 DOI: 10.1093/ofid/ofae134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024] Open
Affiliation(s)
- M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Peter G Pappas
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas J Walsh
- Department of Medicine, Weill Cornell Medicine, Cornell University, New York, New York, USA
- Office of the Director, Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
| | - Joseph Bubalo
- Departments of Pharmacy and Medicine, Oregon Health and Science University Hospital and Clinics, Portland, Oregon, USA
| | | | - Marisa H Miceli
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeanette Jiang
- Department of Medical Affairs, Astellas Pharma Global Development Inc., Northbrook, Illinois, USA
| | - Yi Song
- Department of Medical Affairs, Astellas Pharma Global Development Inc., Northbrook, Illinois, USA
| | - George R Thompson
- Department of Medicine, UC Davis Health, Sacramento, California, USA
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9
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Mori G, Diotallevi S, Farina F, Lolatto R, Galli L, Chiurlo M, Acerbis A, Xue E, Clerici D, Mastaglio S, Lupo Stanghellini MT, Ripa M, Corti C, Peccatori J, Puoti M, Bernardi M, Castagna A, Ciceri F, Greco R, Oltolini C. High-Risk Neutropenic Fever and Invasive Fungal Diseases in Patients with Hematological Malignancies. Microorganisms 2024; 12:117. [PMID: 38257945 PMCID: PMC10818361 DOI: 10.3390/microorganisms12010117] [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: 12/11/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Invasive fungal diseases (IFDs) still represent a relevant cause of mortality in patients affected by hematological malignancies, especially acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) undergoing remission induction chemotherapy, and in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. Mold-active antifungal prophylaxis (MAP) has been established as a standard of care. However, breakthrough IFDs (b-IFDs) have emerged as a significant issue, particularly invasive aspergillosis and non-Aspergillus invasive mold diseases. Here, we perform a narrative review, discussing the major advances of the last decade on prophylaxis, the diagnosis of and the treatment of IFDs in patients with high-risk neutropenic fever undergoing remission induction chemotherapy for AML/MDS and allo-HSCT. Then, we present our single-center retrospective experience on b-IFDs in 184 AML/MDS patients undergoing high-dose chemotherapy while receiving posaconazole (n = 153 induction treatments, n = 126 consolidation treatments, n = 60 salvage treatments). Six cases of probable/proven b-IFDs were recorded in six patients, with an overall incidence rate of 1.7% (6/339), which is in line with the literature focused on MAP with azoles. The incidence rates (IRs) of b-IFDs (95% confidence interval (95% CI), per 100 person years follow-up (PYFU)) were 5.04 (0.47, 14.45) in induction (n = 2), 3.25 (0.0013, 12.76) in consolidation (n = 1) and 18.38 (3.46, 45.06) in salvage chemotherapy (n = 3). Finally, we highlight the current challenges in the field of b-IFDs; these include the improvement of diagnoses, the expanding treatment landscape of AML with molecular targeted drugs (and related drug-drug interactions with azoles), evolving transplantation techniques (and their related impacts on IFDs' risk stratification), and new antifungals and their features (rezafungin and olorofim).
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Affiliation(s)
- Giovanni Mori
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, Ospedale Santa Chiara, 38122 Trento, Italy
| | - Sara Diotallevi
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Francesca Farina
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Riccardo Lolatto
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Laura Galli
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Matteo Chiurlo
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Andrea Acerbis
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Elisabetta Xue
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Centre for Immuno-Oncology, National Cancer Institute, Eliminate NIH, Bethesda, MD 20850, USA
| | - Daniela Clerici
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sara Mastaglio
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | | | - Marco Ripa
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Consuelo Corti
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Jacopo Peccatori
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Massimo Puoti
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20161 Milan, Italy
- Faculty of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Massimo Bernardi
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Antonella Castagna
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Fabio Ciceri
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Raffaella Greco
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Chiara Oltolini
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20161 Milan, Italy
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10
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O'Keeffe JC, Singh N, Slavin MA. Approach to diagnostic evaluation and prevention of invasive fungal disease in patients prior to allogeneic hematopoietic stem cell transplant. Transpl Infect Dis 2023; 25 Suppl 1:e14197. [PMID: 37988269 DOI: 10.1111/tid.14197] [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: 08/14/2023] [Revised: 10/15/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
In recent years, advancements in the treatment landscape for hematological malignancies, such as acute myeloid leukemia and acute lymphoblastic leukemia, have significantly improved disease prognosis and overall survival. However, the treatment landscape is changing and the emergence of targeted oral therapies and immune-based treatments has brought forth new challenges in evaluating and preventing invasive fungal diseases (IFDs). IFD disproportionately affects immunocompromised hosts, particularly those undergoing therapy for acute leukemia and allogeneic hematopoietic stem cell transplant. This review aims to provide a comprehensive overview of the pretransplant workup, identification, and prevention of IFD in patients with hematological malignancy. The pretransplant period offers a critical window to assess each patient's risk factors and implement appropriate prophylactic measures. Risk assessment includes evaluation of disease, host, prior treatments, and environmental factors, allowing a dynamic evaluation that considers disease progression and treatment course. Diagnostic screening, involving various biomarkers and radiological modalities, plays a crucial role in early detection of IFD. Antifungal prophylaxis choice is based on available evidence as well as individual risk assessment, potential for drug-drug interactions, toxicity, and patient adherence. Therapeutic drug monitoring ensures effective antifungal stewardship and optimal treatment. Patient education and counselling are vital in minimizing environmental exposures to fungal pathogens and promoting medication adherence. A well-structured and individualized approach, encompassing risk assessment, prophylaxis, surveillance, and patient education, is essential for effectively preventing IFD in hematological malignancies, ultimately leading to improved patient outcomes and overall survival.
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Affiliation(s)
- Jessica C O'Keeffe
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nikhil Singh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Department of Pharmacy, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Monica A Slavin
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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