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Bettelli F, Vallerini D, Lagreca I, Barozzi P, Riva G, Nasillo V, Paolini A, D'Amico R, Forghieri F, Morselli M, Pioli V, Gilioli A, Giusti D, Messerotti A, Bresciani P, Cuoghi A, Colaci E, Marasca R, Pagano L, Candoni A, Maertens J, Viale P, Mussini C, Manfredini R, Tagliafico E, Sarti M, Trenti T, Lewis R, Comoli P, Eccher A, Luppi M, Potenza L. Identification and validation of diagnostic cut-offs of the ELISpot assay for the diagnosis of invasive aspergillosis in high-risk patients. PLoS One 2024; 19:e0306728. [PMID: 38980880 PMCID: PMC11233002 DOI: 10.1371/journal.pone.0306728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 06/21/2024] [Indexed: 07/11/2024] Open
Abstract
OBJECTIVE We investigated the performance of enzyme linked immunospot (ELISpot) assay for the diagnosis of invasive aspergillosis (IA) in high-risk patients with hematologic malignancies. METHODS We prospectively enrolled two cohorts of patients undergoing intensive myelosuppressive or immunosuppressive treatments at high risk for IA. ELISpot was performed to detect Aspergillus-specific T cells producing Interleukin-10. RESULTS In the discovery cohort, a derived cut-off of 40 spot forming cells (SFCs)/106 PBMCs has shown to correctly classify IA cases with a sensitivity and specificity of 89.5% and 88.6%, respectively. This cut-off is lowered to 25 SFC when considering the subset of possible IA patients, with sensitivity and specificity of 76% and 93%, respectively. The application of the 40 SFCs cut-off to the validation cohort resulted in a positivity rate of 83.3% in proven/probable cases and a negativity rate of 92.5% in possible/non-IA cases. Adopting the 25 SCFs cut-off, the assay resulted positive in 83.3% of proven/probable cases while it resulted negative in 66.7% of possible/non-IA cases. CONCLUSIONS ELISpot shows promises in the diagnosis of IA and the possibility to use two distinct cut-offs with similar diagnostic performances according to patients' different pre-test probability of infection can widen its use in patients at risk.
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Affiliation(s)
- Francesca Bettelli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Daniela Vallerini
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Ivana Lagreca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Patrizia Barozzi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Giovanni Riva
- Diagnostic Hematology and Clinical Genomics, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, Modena, Italy
| | - Vincenzo Nasillo
- Diagnostic Hematology and Clinical Genomics, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, Modena, Italy
| | - Ambra Paolini
- Diagnostic Hematology and Clinical Genomics, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, Modena, Italy
| | - Roberto D'Amico
- Statistic Unit, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Fabio Forghieri
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Monica Morselli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Valeria Pioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Andrea Gilioli
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Davide Giusti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Andrea Messerotti
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Paola Bresciani
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Angela Cuoghi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Elisabetta Colaci
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Roberto Marasca
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Livio Pagano
- Hematology Division, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli - IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Candoni
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Johan Maertens
- Department of Hematology, University Hospital UZ Leuven, Leuven, Belgium
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, University of Bologna, IRCCS-AOU Policlinico Santorsola, Bologna, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, Dipartimento Chirurgico, Medico, Odontoiatrico e di Scienze Morfologiche con interesse Trapiantologico, Oncologico e di Medicina Rigenerativa, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Rossella Manfredini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Tagliafico
- Diagnostic Hematology and Clinical Genomics, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, Modena, Italy
| | - Mario Sarti
- Diagnostic Hematology and Clinical Genomics, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, Modena, Italy
| | - Tommaso Trenti
- Diagnostic Hematology and Clinical Genomics, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, Modena, Italy
| | - Russell Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology Unit and Cell Factory, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Albino Eccher
- Section of Pathology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Leonardo Potenza
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
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Portillo V, Neofytos D. An Update on Breakthrough Invasive Mold Infections. Mycopathologia 2024; 189:56. [PMID: 38869662 PMCID: PMC11176211 DOI: 10.1007/s11046-024-00864-z] [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: 04/22/2024] [Accepted: 05/21/2024] [Indexed: 06/14/2024]
Abstract
The incidence of breakthrough mold infections (bIMI) has been increasing, due to routine administration of broad-spectrum antifungal prophylaxis and an increasing pool of high-risk patient populations, with fungi more challenging to treat, resulting in a sustained high mortality, despite progress in diagnostic and therapeutic options. Pharmacokinetics of antifungal drugs, fungal, and host, including genetic, factors play a role in the emergence of bIMI. Suggested therapeutic approaches have included change of antifungal class treatment, with amphotericin-B products predominating as first-line empirical treatment and switching from one broad-spectrum azole to another remaining the most frequently used treatment modalities. Future perspectives include determining individual susceptibility to IMI to tailor prophylaxis and treatment strategies, improved diagnostic tests, and the introduction of new antifungal agents that may reduce morbidity and mortality caused by bIMI.
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Affiliation(s)
- Vera Portillo
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
- Internal Medecine, Ensemble Hospitalier de la Côte, Hôpital de Moges, Chemin de la Crêt 2, Morges, Vaud, Switzerland.
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
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Portillo V, Ragozzino S, Stavropoulou E, El-Khoury C, Bochud PY, Lamoth F, Khanna N, Neofytos D. Antifungal Treatment Duration in Hematology Patients With Invasive Mold Infections: A Real-life Update. Open Forum Infect Dis 2024; 11:ofae201. [PMID: 38756760 PMCID: PMC11097115 DOI: 10.1093/ofid/ofae201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024] Open
Abstract
Background Limited data exist on when and how to stop antifungal treatment (AFT) in patients with invasive mold infections (IMIs) who are immunocompromised. Methods This retrospective multicenter study included adult patients with acute myelogenous leukemia and proven/probable IMI (1 January 2010-31 December 2022) in 3 university hospitals. The primary objective was to describe AFT duration and adaptation. Secondary objectives were to investigate the reasons for AFT adjustments and prolongation. Results In total 71 patients with 73 IMIs were identified; 51 (71.8%) had an allogeneic hematopoietic cell transplant. Most infections were invasive aspergillosis (IA; 49/71, 69%), followed by mucormycosis (12, 16.9%) and other (12, 16.9%); there were 2 mixed infections. Median treatment duration was 227 days (IQR, 115.5-348.5). There was no difference in AFT duration between patients with IA and non-IA IMI (P = .85) or by center (P = .92). Treatment was longer in patients with an allogeneic hematopoietic cell transplant vs not (P = .004). Sixteen patients (22.5%) had no therapy modifications. In 55 patients (77.5%), a median 2 changes (IQR, 1-3; range, 1-8) were observed. There were 182 reasons leading to 165 changes, associated with clinical efficacy (82/182, 44.5%), toxicity (47, 25.8%), and logistical reasons (22, 12.1%); no reason was documented in 32 changes (18.8%). AFT was continued beyond days 90 and 180 in 59 (83%) and 39 (54.9%) patients, respectively, mostly due to persistence of immunosuppression. Conclusions AFT in patients with acute myelogenous leukemia and IMI is longer than that recommended by guidelines and is frequently associated with treatment adjustments due to variable reasons. More data and better guidance are required to optimize AFT duration and secondary prophylaxis administration according to immunosuppression.
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Affiliation(s)
- Vera Portillo
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Silvio Ragozzino
- Division of Infectious Diseases, University Hospital of Basel, Basel, Switzerland
| | - Elisavet Stavropoulou
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Celine El-Khoury
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre-Yves Bochud
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Frederic Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Microbiology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases, University Hospital of Basel, Basel, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
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Portillo V, Neofytos D. Duration of antifungal treatment in mold infection: when is enough? Curr Opin Infect Dis 2023; 36:443-449. [PMID: 37729658 DOI: 10.1097/qco.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
PURPOSE OF REVIEW Although invasive mold infections (IMI) are a major complication in high-risk populations, treatment duration has not yet been well defined. RECENT FINDINGS Guidelines suggest documenting clinical/radiological resolution and immunological recovery before stopping antifungal treatment, after a minimum duration of treatment of 3 months for invasive pulmonary aspergillosis, while longer (up to 6 months) duration is proposed for the treatment of invasive mucormycosis. However, data on and definitions of clinical/radiological resolution and immune recovery remain scarce. Limited real-life data suggest that often much longer courses of treatment are given, generally in the context of continuous immunosuppression, occasionally defined as secondary prophylaxis. However, clearcut definition and distinction of secondary prophylaxis from antifungal treatment remain to be defined. SUMMARY Decisions to stop antifungal treatment are based on poorly defined treatment responses and immune reconstitution and experts' opinions. More evidence is needed to determine the optimal duration of treatment of IMI. Well designed, easy to use, and realistic algorithms to help clinicians decide when to stop antifungal treatment are urgently needed.
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Affiliation(s)
- Vera Portillo
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
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Chen Y, Huang X, Qiu H, Cheng L, Yu Y, Ma X, Feng S, Li Q, Wu D, Huang W, Chen D, Lv X, Hu J, Wang J, Li J, Yang W, Zhan Q, Sun B, Wang M. Physicians' knowledge of invasive fungal disease in China. Mycoses 2023. [PMID: 37059587 DOI: 10.1111/myc.13590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/02/2023] [Accepted: 04/04/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Invasive fungal disease (IFD) is associated with high morbidity and mortality. Data are lacking regarding physicians' perspectives on the diagnosis and management of IFD in China. OBJECTIVES To evaluate physicians' perspectives on the diagnosis and management of IFD. METHODS Based on current guidelines, a questionnaire was designed and administered to 294 physicians working in haematology departments, intensive care units, respiratory departments and infectious diseases departments in 18 hospitals in China. RESULTS The total score and subsection scores for invasive candidiasis, invasive aspergillosis (IA), cryptococcosis and invasive mucormycosis (IM) were 72.0 ± 12.2 (maximum = 100), 11.1 ± 2.7 (maximum = 19), 43.0 ± 7.8 (maximum = 57), 8.1 ± 2.0 (maximum = 11) and 9.8 ± 2.3 (maximum = 13), respectively. Although the perspectives of the Chinese physicians were in good overall agreement with guideline recommendations, some knowledge gaps were identified. Specific areas in which the physicians' perspectives and guideline recommendations differed included use of the β-D-glucan test to facilitate the diagnosis of IFD, relative utility of the serum galactomannan test and bronchoalveolar lavage fluid galactomannan test in patients with agranulocytosis, use of imaging in the diagnosis of mucormycosis, risk factors for mucormycosis, indications for initiating antifungal therapy in patients with haematological malignancies, when to start empirical therapy in mechanically ventilated patients, first-line drugs for mucormycosis and treatment courses for IA and IM. CONCLUSION This study highlights the main areas that could be targeted by training programs to improve the knowledge of physicians treating patients with IFD in China.
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Affiliation(s)
- Yijian Chen
- Institute of Antibiotics, Huashan Hospital, Fudan University & Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai, China
| | - Xiaojun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Beijing, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Linling Cheng
- Department of Respiratory, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Sizhou Feng
- Department of Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Qi Li
- Department of Respiratory, The Second Affiliated Hospital of Military Medical University, Chongqing, China
| | - Depei Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wenxiang Huang
- Department of Infectious Disease, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoju Lv
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Jianda Hu
- Department of Hematology, Union Hospital of Fujian Medical University, Fujian, China
| | - Jingbo Wang
- Department of Hematology, Aerospace Central Hospital, Beijing, China
| | - Jiabin Li
- Department of Infectious Disease, The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Wenjie Yang
- Department of Infectious Diseases, Tianjin First Center Hospital, Tianjin, China
| | - Qingyuan Zhan
- Department of Respiratory, Intensive Care Unit, Sino-Japanese Friendship Hospital, Beijing, China
| | - Bing Sun
- Intensive Care Unit, Beijing Chaoyang Hospital of Capital Medical University, Beijing, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University & Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai, China
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Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
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Mikulska M, Balletto E, Castagnola E, Mularoni A. Beta-D-Glucan in Patients with Haematological Malignancies. J Fungi (Basel) 2021; 7:jof7121046. [PMID: 34947028 PMCID: PMC8706797 DOI: 10.3390/jof7121046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
(1-3)-beta-D-glucan (BDG) is an almost panfungal marker (absent in zygomycetes and most cryptococci), which can be successfully used in screening and diagnostic testing in patients with haematological malignancies if its advantages and limitations are known. The aim of this review is to report the data, particularly from the last 5 years, on the use of BDG in haematological population. Published data report mainly on the performance of the Fungitell™ assay, although several others are currently available, and they vary in method and cut-off of positivity. The sensitivity of BDG for invasive fungal disease (IFD) in haematology patients seems lower than in other populations, possibly because of the type of IFD (lower sensitivity was found in case of aspergillosis compared to candidiasis and pneumocystosis) or the use of prophylaxis. The specificity of the test can be improved by using two consecutive positive assays and avoiding testing in the case of the concomitant presence of factors associated with false positive results. BDG should be used in combination with clinical assessment and other diagnostic tests, both radiological and mycological, to provide maximum information. Good performance of BDG in cerebrospinal fluid (CSF) has been reported. BDG is a useful diagnostic method in haematology patients, particularly for pneumocystosis or initial diagnosis of invasive fungal infections.
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Affiliation(s)
- Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genoa, 16132 Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
- Correspondence: ; Tel.: +39-010-555-4649
| | - Elisa Balletto
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, Istituto Giannina Gaslini, 16147 Genova, Italy;
| | - Alessandra Mularoni
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy;
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Coussement J, Lindsay J, Teh BW, Slavin M. Choice and duration of antifungal prophylaxis and treatment in high-risk haematology patients. Curr Opin Infect Dis 2021; 34:297-306. [PMID: 34039878 DOI: 10.1097/qco.0000000000000737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize available guidelines as well as the emerging evidence for the prevention and treatment of invasive fungal diseases in high-risk haematology patients. RECENT FINDINGS Primary mould-active prophylaxis is the strategy used in many centres to manage the risk of invasive fungal disease in high-risk haematology patients, and posaconazole remains the antifungal of choice for most of these patients. Data on the use of other antifungals for primary prophylaxis, including isavuconazole, are limited. There is considerable interest in identifying a strategy that would limit the use of mould-active agents to the patients who are the most likely to benefit from them. In this regard, a recent trial demonstrated that the preemptive strategy is noninferior to the empiric strategy. For primary treatment of invasive aspergillosis, two randomized trials found isavuconazole and posaconazole to be noninferior to voriconazole. Isavuconazole does not appear to require therapeutic drug monitoring. SUMMARY Prophylaxis and treatment of invasive fungal diseases in high-risk haematology patients is a rapidly evolving field. Critical clinical questions remain unanswered, especially regarding the management of suspected invasive fungal diseases breaking through mould-active prophylaxis, and the duration of antifungal therapy for invasive mould infections.
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Affiliation(s)
- Julien Coussement
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne
| | - Julian Lindsay
- National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia.,Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Benjamin W Teh
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
| | - Monica Slavin
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
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Martino R, Garrido A, Santaliestra M, García-Cadenas I, Novelli S, Saavedra SD, Esquirol A, Granell M, Briones J, Moreno C, Brunet S, Giménez A, Hidalgo A, Sánchez F, Sierra J. Low Rate of Invasive Fungal Infections During Induction and Consolidation Chemotherapy for Adults with De Novo Acute Myeloid Leukemia Without Anti-mold Prophylaxis: Single-Center 2002-2018 Empirical/Pre-emptive Approach. Mycopathologia 2020; 185:639-652. [PMID: 32564177 DOI: 10.1007/s11046-020-00461-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/25/2020] [Indexed: 11/30/2022]
Abstract
Broad-spectrum antifungal prophylaxis is currently considered the standard of care for adults with de novo AML for the prevention of invasive fungal infections (IFIs), especially invasive pulmonary aspergillosis (IPA). Because fluconazole has been used in our center as anti-yeast prophylaxis, we sought to analyze in detail the incidence of IFIs over a 17-year period, as well as their impact on outcome. A standardized protocol of patient management, including serum galactomannan screening and thoracic CT-guided diagnostic-driven antifungal therapy, was used in all patients. A total of 214 consecutive adults with de novo AML who were treated in 3 CETLAM (Grupo Cooperativo para el Estudio y Tratamiento de las Leucemias Agudas y Mielodisplasias) protocols from 2002 to 2018 were included. The 90-day incidence of any IFI (including possible cases) was 11% (95% CI 4-15%), most cases occurred during induction chemotherapy (8%, 95% CI 4-12%), and most cases were probable/proven IPA (8%, 95% CI 3-13%). Developing an IFI during induction and consolidation had no impact on 1-year survival. A case-control study with 23 cases of IPA and 69 controls identified induction/re-induction chemotherapy, chronic pulmonary disease and age > 60 years/poor baseline performance status as potential pretreatment risk factors. The current study proves that inpatient induction and consolidation chemotherapy for de novo AML can be given in areas with "a priori" high-burden of airborne molds with fluconazole prophylaxis, while the selective use of anti-mold prophylaxis in patients at very high risk may further reduce the incidence of IFI in this specific clinical scenario.
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Affiliation(s)
- Rodrigo Martino
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain.
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain.
| | - Ana Garrido
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Marta Santaliestra
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Irene García-Cadenas
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Silvana Novelli
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Silvanna Daniella Saavedra
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Albert Esquirol
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Miquel Granell
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Javier Briones
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Carolina Moreno
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Salut Brunet
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Ana Giménez
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Alberto Hidalgo
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Fernando Sánchez
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Jorge Sierra
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
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