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Saber-Moghaddam N, Nodeh MM, Ghavami V, Rahimi H, Azimi SA, Seddigh-Shamsi M, Kamandi M, Allahyari A, Shariatmaghani SS, Elyasi S, Arasteh O. The evaluation of atorvastatin as an adjunct to fluconazole for the anti-fungal prophylaxis in acute myeloid leukemia: a multicenter, triple-blinded, randomized clinical trial. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:4355-4364. [PMID: 38095652 DOI: 10.1007/s00210-023-02892-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/04/2023] [Indexed: 05/23/2024]
Abstract
The development of invasive fungal infections (IFIs) is a serious complication in acute myeloid leukemia (AML) patients who undergo an induction to remission chemotherapy. Given the increased mortality in AML patients with IFI despite prophylaxis, we need to address this problem. Statins have traditionally been employed in clinical settings as agents for reducing lipid levels. Nonetheless, recent investigations have brought to light their antifungal properties in animals, as well as in vitro studies. The objective of this study was to assess the effectiveness of atorvastatin when added to the routine IFI prophylaxis regimen in patients diagnosed with AML. A randomized, multicenter, triple-blind study was conducted on 76 AML patients aged 18-70, who received either placebo or atorvastatin in addition to fluconazole. Patients were followed for 30 days in case of developing IFIs, patient survival, and atorvastatin- related adverse drug reactions. Data were analyzed with SPSS version 26.0. A level of significance of 0.05 was utilized as the threshold for all statistical tests. The data were analyzed by adjusting for the effect of age, regarding that there was a significant difference between the two groups, and showed that atorvastatin reduced the development of both probable and proven IFI (based on EORTC/MSGERC criteria) compared to placebo. IFI-free survival was also significantly better in the atorvastatin group. The incidence of developing aspergillosis did not differ between the two groups. No serious adverse events related to atorvastatin were observed. The present investigation has substantiated the antecedent in vitro and animal research on the fungicidal impact of statins and has suggested the need for additional research involving larger sample sizes and an extended duration of follow-up. Trial registration: This study was registered on the Iranian registry of clinical trials as IRCT20210503051166N1 (Date of confirmation 2021.05.03).
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Affiliation(s)
- Niloufar Saber-Moghaddam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Moeini Nodeh
- Department of Hematology-Oncology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vahid Ghavami
- Department of Epidemiology & Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Rahimi
- Department of Hematology-Oncology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajjad Ataei Azimi
- Department of Hematology-Oncology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Seddigh-Shamsi
- Department of Hematology-Oncology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mostafa Kamandi
- Department of Hematology-Oncology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abolghasem Allahyari
- Department of Hematology-Oncology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Sepideh Elyasi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Arasteh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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Pungprasert T, Dhirachaikulpanich D, Phutthasakda W, Tantai N, Maneeon S, Nganthavee V, Atipas K, Tanpong S, Krithin S, Tanglitanon S, Jutidamrongphan W, Chayakulkeeree M, Srinonprasert V, Phikulsod P. The cost-utility analysis of antifungal prophylaxis for invasive fungal infections in acute myeloid leukaemia patients receiving chemotherapy: a study from a middle-income country. J Hosp Infect 2024; 145:118-128. [PMID: 38219835 DOI: 10.1016/j.jhin.2023.12.013] [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: 08/05/2023] [Revised: 12/15/2023] [Accepted: 12/25/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Invasive fungal infections (IFIs) contribute to morbidity and mortality during acute myeloid leukaemia (AML) treatment. Without prophylaxis, IFI rate during AML treatment in Thailand is high and results in a high mortality rate and a prolonged hospital stay. AIM To evaluate the cost-utility of antifungal therapy (AFT) prophylaxis during AML treatment. METHODS We assessed the cost-utility of AFT available in Thailand, including posaconazole (solution), itraconazole (solution and capsule), and voriconazole. A hybrid model consisting of a decision tree and the Markov model was established. RESULTS The costs to prevent overall IFI using any AFT were all lower than the treatment cost of a non-prophylaxis group, resulting in a saving of 808-1507 USD per patient. Prevention with voriconazole prophylaxis showed the highest quality-adjusted life years (QALYs = 3.51, incremental QALYs = 0.23), followed by posaconazole (QALYs = 3.46, incremental QALY = 0.18) and itraconazole solution (QALYs = 3.45, incremental QALYs = 0.17). Itraconazole capsule reduced QALY in the model. For invasive aspergillosis prevention, posaconazole and voriconazole both resulted in better QALYs and life year savings compared with no prophylaxis. However, posaconazole prophylaxis was the only cost-saving option (976 USD per patient). CONCLUSION Posaconazole, itraconazole solution and voriconazole were all cost saving compared with no prophylaxis for overall IFI prophylaxis, with voriconazole being the most cost-effective option. Posaconazole and voriconazole were both cost effective for invasive aspergillosis prevention but only posaconazole was cost saving. A change in reimbursement policy for the use of AFT prophylaxis during intensive AML treatment could provide both clinical benefits to patients and substantial economic benefits to healthcare systems.
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Affiliation(s)
- T Pungprasert
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - W Phutthasakda
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - N Tantai
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Department of Pharmacy, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Maneeon
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Department of Pharmacy, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V Nganthavee
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - K Atipas
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Tanpong
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Krithin
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Tanglitanon
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - W Jutidamrongphan
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - M Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V Srinonprasert
- Siriaj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Phikulsod
- Division of Haematology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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3
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Tober R, Schnetzke U, Fleischmann M, Yomade O, Schrenk K, Hammersen J, Glaser A, Thiede C, Hochhaus A, Scholl S. Impact of treatment intensity on infectious complications in patients with acute myeloid leukemia. J Cancer Res Clin Oncol 2023; 149:1569-1583. [PMID: 35583829 PMCID: PMC10020242 DOI: 10.1007/s00432-022-03995-2] [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: 02/21/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Infectious complications reflect a major challenge in the treatment of patients with acute myeloid leukemia (AML). Both induction chemotherapy and epigenetic treatment with hypomethylating agents (HMA) are associated with severe infections, while neutropenia represents a common risk factor. Here, 220 consecutive and newly diagnosed AML patients were analyzed with respect to infectious complications dependent on treatment intensity and antifungal prophylaxis applied to these patients. PATIENTS AND METHODS We retrospectively analyzed 220 patients with newly diagnosed AML at a tertiary care hospital between August 2016 and December 2020. The median age of AML patients undergoing induction chemotherapy (n = 102) was 61 years (25-76 years). Patients receiving palliative AML treatment (n = 118) had a median age of 75 years (53-91 years). We assessed the occurrence of infectious complication including the classification of pulmonary invasive fungal disease (IFD) according to the EORTC/MSG criteria at diagnosis and until day 100 after initiation of AML treatment. Furthermore, admission to intensive care unit (ICU) and subsequent outcome was analyzed for both groups of AML patients, respectively. RESULTS AML patients subsequently allocated to palliative AML treatment have a significantly higher risk of pneumonia at diagnosis compared to patients undergoing induction chemotherapy (37.3% vs. 13.7%, P < 0.001) including a higher probability of atypical pneumonia (22.0% vs. 10.8%, P = 0.026). Furthermore, urinary tract infections are more frequent in the palliative subgroup at the time of AML diagnosis (5.1% vs. 0%, P = 0.021). Surprisingly, the incidence of pulmonary IFD is significantly lower after initiation of palliative AML treatment compared to the occurrence after induction chemotherapy (8.4% vs. 33.3%, P < 0.001) despite only few patients of the palliative treatment group received Aspergillus spp.-directed antifungal prophylaxis. The overall risk for infectious complications at AML diagnosis is significantly higher for palliative AML patients at diagnosis while patients undergoing induction chemotherapy have a significantly higher risk of infections after initiation of AML treatment. In addition, there is a strong correlation between the occurrence of pneumonia including atypical pneumonia and pulmonary IFD and the ECOG performance status at diagnosis in the palliative AML patient group. Analysis of intensive care unit (ICU) treatment (e.g. in case of sepsis or pneumonia) for both subgroups reveals a positive outcome in 10 of 15 patients (66.7%) with palliative AML treatment and in 15 of 18 patients (83.3%) receiving induction chemotherapy. Importantly, the presence of infections and the ECOG performance status at diagnosis significantly correlate with the overall survival (OS) of palliative AML patients (315 days w/o infection vs. 69 days with infection, P 0.0049 and 353 days for ECOG < 1 vs. 50 days for ECOG > 2, P < 0.001, respectively) in this intent-to-treat analysis. CONCLUSION The risk and the pattern of infectious complications at diagnosis and after initiation of AML therapy depends on age, ECOG performance status and subsequent treatment intensity. A comprehensive diagnostic work-up for identification of pulmonary IFD is indispensable for effective treatment of pneumonia in AML patients. The presence of infectious complications at diagnosis contributes to an inferior outcome in elderly AML patients.
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Affiliation(s)
- Romy Tober
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Ulf Schnetzke
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Maximilian Fleischmann
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Olaposi Yomade
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Karin Schrenk
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Jakob Hammersen
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Anita Glaser
- Institut Für Humangenetik, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Christian Thiede
- Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Andreas Hochhaus
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sebastian Scholl
- Klinik Für Innere Medizin II, Abteilung Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
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4
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Liu N, Tu J, Huang Y, Yang W, Wang Q, Li Z, Sheng C. Target- and prodrug-based design for fungal diseases and cancer-associated fungal infections. Adv Drug Deliv Rev 2023; 197:114819. [PMID: 37024014 DOI: 10.1016/j.addr.2023.114819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Abstract
Invasive fungal infections (IFIs) are emerging as a serious threat to public health and are associated with high incidence and mortality. IFIs also represent a frequent complication in patients with cancer who are undergoing chemotherapy. However, effective and safe antifungal agents remain limited, and the development of severe drug resistance further undermines the efficacy of antifungal therapy. Therefore, there is an urgent need for novel antifungal agents to treat life-threatening fungal diseases, especially those with new mode of action, favorable pharmacokinetic profiles, and anti-resistance activity. In this review, we summarize new antifungal targets and target-based inhibitor design, with a focus on their antifungal activity, selectivity, and mechanism. We also illustrate the prodrug design strategy used to improve the physicochemical and pharmacokinetic profiles of antifungal agents. Dual-targeting antifungal agents offer a new strategy for the treatment of resistant infections and cancer-associated fungal infections.
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Zhou J, Wei Z, Xu B, Liu M, Xu R, Wu X. Pharmacovigilance of triazole antifungal agents: Analysis of the FDA adverse event reporting system (FAERS) database. Front Pharmacol 2022; 13:1039867. [PMID: 36588707 PMCID: PMC9798094 DOI: 10.3389/fphar.2022.1039867] [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: 09/08/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
Triazole antifungal drugs (TAD) are widely used to treat invasive fungal infections due to their broad antifungal spectrum and low toxicity. Despite their preference in the clinic, multiple Adverse Events (AE) are still reported each year. OBJECTIVE We aimed to characterize the distribution of Adverse Events associated with Triazole antifungal drugs in different systems and to identify Important Medical Events (IME) signals for Triazole antifungal drugs. METHODS The U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) was queried for Adverse Events related to Triazole antifungal drugs from 2012 to 2022. The Adverse Events caused by all other drugs and non-TAD antifungal drugs were analyzed as references. Reporting odds ratio and Bayesian confidence propagation neural network of information components were used to evaluate the association between Triazole antifungal drugs and Important Medical Events. Visual signal spectrum is mapped to identify potential adverse reaction signals. RESULTS Overall, 10,262 Adverse Events were reported to be associated with Triazole antifungal drugs, of which 5,563 cases were defined as Important Medical Events. Common adverse drug reactions (ADR) mentioned in the instructions such as delirium and hypokalemia were detected, as well as unlabeled ADRs such as rhabdomyolysis and hepatitis fulminant. Cholestasis, drug-induced liver injury, QT interval prolongation and renal impairment have notable signals in all Triazole antifungal drugs, with 50 percent of patients developing a severe clinical outcome. Isavuconazole had the lowest signal intensity and demonstrated a superior safety profile. CONCLUSION Most results are generally consistent with previous studies and are documented in the prescribing instructions, but some IMEs are not included, such as hepatitis fulminant. Additional pharmaco-epidemiological or experimental studies are required to validate the small number of unlabeled ADRs. TAD-related Important Medical Eventshave a considerable potential to cause clinically serious outcomes. Clinical use of Triazole antifungal drugs requires more attention.
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Affiliation(s)
- Jianxing Zhou
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Zipeng Wei
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Baohua Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Ruichao Xu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,*Correspondence: Xuemei Wu,
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Lamoth F, Lewis RE, Kontoyiannis DP. Investigational Antifungal Agents for Invasive Mycoses: A Clinical Perspective. Clin Infect Dis 2022; 75:534-544. [PMID: 34986246 DOI: 10.1093/cid/ciab1070] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Indexed: 01/13/2023] Open
Abstract
Treatment of invasive fungal infections (IFIs) remains challenging, because of the limitations of the current antifungal agents (ie, mode of administration, toxicity, and drug-drug interactions) and the emergence of resistant fungal pathogens. Therefore, there is an urgent need to expand our antifungal armamentarium. Several compounds are reaching the stage of phase II or III clinical assessment. These include new drugs within the existing antifungal classes or displaying similar mechanism of activity with improved pharmacologic properties (rezafungin and ibrexafungerp) or first-in-class drugs with novel mechanisms of action (olorofim and fosmanogepix). Although critical information regarding the performance of these agents in heavily immunosuppressed patients is pending, they may provide useful additions to current therapies in some clinical scenarios, including IFIs caused by azole-resistant Aspergillus or multiresistant fungal pathogens (eg, Candida auris, Lomentospora prolificans). However, their limited activity against Mucorales and some other opportunistic molds (eg, some Fusarium spp.) persists as a major unmet need.
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Affiliation(s)
- Frederic Lamoth
- Infectious Diseases Service and Institute of Microbiology, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Russell E Lewis
- Clinic of Infectious Diseases, S'Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italyand
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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7
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Vitale RG, Giudicessi SL, Romero SM, Al-Hatmi AMS, Li Q, de Hoog GS. Recent developments in less known and multi-resistant fungal opportunists. Crit Rev Microbiol 2021; 47:762-780. [PMID: 34096817 DOI: 10.1080/1040841x.2021.1927978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Fungal infections have increased in recent years due to host factors, such as oncohaematological and transplant-related disorders, immunosuppressive therapy, and AIDS. Additionally, molecular and proteomic facilities have become available to identify previously unrecognizable opportunists. For these reasons, reports on less-known and recalcitrant mycoses, such as those caused by black fungi, hyaline filamentous fungi, coelomycetes, Mucorales, and non-Candida yeasts have emerged. In this review, novel taxonomy in these groups, which often are multi-resistant to one or several classes of antifungals, is discussed. Clinical presentations, diagnosis and current treatment of some major groups are summarised.
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Affiliation(s)
- Roxana G Vitale
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Buenos Aires, Argentina.,Unidad de Parasitología, Sector Micología, Hospital J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Silvana L Giudicessi
- Facultad de Farmacia y Bioquímica, Cátedra de Biotecnología, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Nanobiotecnología (NANOBIOTEC), UBA-CONICET, Buenos Aires, Argentina
| | - Stella M Romero
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Buenos Aires, Argentina.,Instituto Multidisciplinario de Biología Vegetal (IMBIV), CONICET, FCEFyN, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Abdullah M S Al-Hatmi
- Center of Expertise in Mycology of Radboud, University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Natural & Medical Science Research Center, University of Nizwa, Nizwa, Omán
| | - Qirui Li
- Department of Pharmacy, Guiyang Medical University, Guiyang, PR China
| | - G Sybren de Hoog
- Center of Expertise in Mycology of Radboud, University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Key Laboratory of Environmental Pollution Monitoring and Disease Control, School of Basic Medical Sciences, Guizhou Medical University, Guiyang, PR China.,Department of Medical Microbiology, People's Hospital of Suzhou, National New & Hi-Tech Industrial Development Zone, Suzhou, PR China
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8
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Barnes R, Rogers T, Maertens J. Defining standards of CARE for invasive fungal diseases in adult haematology patients: antifungal prophylaxis versus treatment. J Antimicrob Chemother 2020; 74:ii21-ii26. [PMID: 31222310 DOI: 10.1093/jac/dkz040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Despite the availability of four different classes of antifungal agents, invasive fungal infections, in particular mould diseases, continue to have a high crude mortality rate in adult haematology patients, especially when diagnosed late. Early diagnosis, resulting in prompt and adequate antifungal intervention, is of great importance when trying to improve the overall outcome of these infections, but depends on the availability of rapid and sensitive diagnostic tools. The medical community has developed and continues to evaluate a continuum of antifungal strategies (starting with prophylaxis followed by empirical therapy and more recently a diagnostic-driven or pre-emptive approach) to better tackle these life-threatening diseases. While the empirical approach seems to have lost some of its popularity, the jury is still out about the pros and cons of universal antifungal prophylaxis in at-risk adult haematology patients compared with an approach that uses radiological and mycological diagnostic methods with good to excellent negative predictive values (also erroneously called pre-emptive), trying to exclude the presence of an invasive fungal disease. Whilst awaiting the results of comparative clinical studies, believers and non-believers around the globe continue to argue about the advantages and shortcomings of both strategies. The debate presented here provides a rationale for both prophylaxis for 'high-risk' haematology patients as well as for a more targeted approach based on the appropriate use of mycological, radiological, immunological (and genetic) methods for the diagnosis of invasive fungal diseases.
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Affiliation(s)
- Rosemary Barnes
- Department of Medical Microbiology and Infectious Diseases, Cardiff University, Cardiff, UK
| | - Thomas Rogers
- Department of Clinical Microbiology, Trinity College Dublin & St. James's Hospital, Dublin, Ireland
| | - Johan Maertens
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Clinical Department of Haematology, UZ Leuven, Leuven, Belgium
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9
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Signorelli J, Lei M, Lam J, Jalbut M, Amrein PC, Fathi AT, Hobbs G, Hock H, McAfee SL, Letourneau AR, Narayan R, Brunner A. Incidence of Invasive Fungal Infections in Acute Myeloid Leukemia Without Antifungal Prophylaxis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e883-e889. [PMID: 32917574 DOI: 10.1016/j.clml.2020.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antifungal prophylaxis during induction for acute myeloid leukemia (AML) varies according to local rates of invasive fungal infections (IFIs). We evaluated fluconazole prophylaxis and no antifungal prophylaxis, as a natural interrupted time-series study to assess survival and infection complications. PATIENTS AND METHODS We identified patients with AML ≥ 18 years old undergoing induction chemotherapy during 2 time periods: period 1, fluconazole prophylaxis from August 1, 2013 to September 30, 2015, and period 2, no prophylaxis from October 1, 2015 to December 31, 2017. The primary outcome was incidence of proven or probable IFI. Secondary outcomes included types of IFIs and 60-day overall survival (OS). IFI was defined by the 2002 European Organization for Research and Treatment of Cancer/Mycoses Study Group Consensus criteria. RESULTS One hundred forty-four patients received induction chemotherapy over the 2 time periods. In the prophylaxis versus no-prophylaxis groups, the rate of proven or probable IFIs was 4 (5%) of 87 versus 12 (21%) of 57 (P = .01). The total number of proven IFIs was 3 (3%) of 87 versus 4 (7%) of 57 (P = .44), whereas probable IFIs were 1 (1%) of 87 versus 8 (14%) of 57 (P < .01). No difference was observed in fungemia. Incidence of IFIs was too low to detect resistance patterns. OS at 60 days was improved in with fluconazole prophylaxis compared with no prophylaxis (hazard ratio, 0.329; 95% confidence interval, 0.12-0.89; P = .028). CONCLUSION Observed rates of proven or probable IFI were lower in the fluconazole prophylaxis group versus the no-prophylaxis group. Sixty-day OS was higher with fluconazole prophylaxis. Further study is required to evaluate how fluconazole may impart the differences in survival seen in this analysis.
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Affiliation(s)
| | - Matthew Lei
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | - Jenna Lam
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | - Marla Jalbut
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Philip C Amrein
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Amir T Fathi
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Gabriela Hobbs
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Hanno Hock
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Steven Lawrence McAfee
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Alyssa R Letourneau
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Rupa Narayan
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Andrew Brunner
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
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10
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Mishra P, Agrawal N, Bhurani D, Agarwal NB. Invasive Fungal Infections in Patients with Acute Myeloid Leukemia Undergoing Intensive Chemotherapy. Indian J Hematol Blood Transfus 2020; 36:64-70. [PMID: 32174692 DOI: 10.1007/s12288-019-01165-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/25/2019] [Indexed: 01/13/2023] Open
Abstract
Patients with hematological malignancies are severely immunocompromised and are at high risk of invasive fungal infection (IFI), particularly those undergoing remission-induction chemotherapy for acute myeloid leukemia (AML). IFIs are a major cause of morbidity and mortality in such patients. We planned to study the incidence of IFI in patients with AML undergoing intensive chemotherapy and receiving antifungal prophylaxis. We retrospectively reviewed consecutive 46 patients with non-M3 AML, who received induction chemotherapy and systemic antifungal prophylaxis. None of the patients had IFI at the time of initiation of the chemotherapy. Patients were monitored for the occurrence of IFI using high-resolution computerized tomography of the chest or para-nasal sinus and test for galactomannan antigen on serum or broncho-alveolar lavage and were followed up for 90 days. Of the 46 patients on intensive chemotherapies, 41, 4 and 1 patients were started on posaconazole, amphotericin B and voriconazole prophylaxis, respectively. The occurrence of possible and probable IFI was observed in 16 and 4 patients respectively, in which 19 patients were on posaconazole and 1 patient was on amphotericin-B prophylaxis. Overall mortality in the study population was 11 (23.9%). Four out of 20 patients died with IFI but none of the death was attributable to IFI. IFI still remains a significant cause of morbidity and mortality in patients with AML despite universal use of antifungal prophylaxis. With effective pharmacotherapy, the mortality due to IFI is preventable. Appropriate antifungal prophylaxis strategy still needs to be developed through larger and prospective studies.
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Affiliation(s)
- Pinki Mishra
- 1Centre for Translational and Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062 India
| | - Narendra Agrawal
- 2Department of Hemato-Oncology and Bone Marrow Transplant, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Dinesh Bhurani
- 2Department of Hemato-Oncology and Bone Marrow Transplant, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Nidhi Bharal Agarwal
- 1Centre for Translational and Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062 India
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11
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Bui V, Walker SA, Elligsen M, Vyas A, Kiss A, Palmay L. Voriconazole prophylaxis in leukemic patients: A retrospective single-center study. J Oncol Pharm Pract 2019; 26:873-881. [PMID: 31566111 DOI: 10.1177/1078155219876683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Invasive fungal infections commonly occur in acute myeloid and lymphoblastic leukemia patients receiving chemotherapy. In these patients with acute leukemia, posaconazole prophylaxis is recommended; however, voriconazole may be a less costly alternative. OBJECTIVES The objective of this study was to evaluate the efficacy and safety of voriconazole prophylaxis in acute leukemia patients. METHODS A retrospective chart review of inpatients at Sunnybrook Health Sciences Centre between 2005 and 2017 was completed. Hospitalized adult acute leukemia patients who received voriconazole prophylaxis (cases) were compared to patients who received fluconazole or no prophylaxis during chemotherapy (controls). Statistical analyses comparing baseline characteristics, safety, and efficacy outcomes between the study cohorts were completed. A posaconazole literature-based weighted mean risk was compared to the voriconazole risk of invasive fungal infection identified in this study. RESULTS Of 490 acute myeloid leukemia or acute lymphoblastic leukemia patients, 83 controls and 92 cases were eligible. Case patients received an average of 24.4 ± 10.8 days of voriconazole prophylaxis. The incidence of proven or probable invasive fungal infections with voriconazole was 3.3% (3/92) versus 7.2% (6/83) in the control cohort (p > 0.05) and was comparable to the literature reported weighted incidence of invasive fungal infection with posaconazole (2.4 ± 2.1%; 95% CI 1.3%-3.4%; p > 0.05). Voriconazole was well tolerated by patients (91%; 84/91; seven discontinued due to asymptomatic elevated liver function tests). CONCLUSIONS Voriconazole prophylaxis was found to be safe, effective, and comparable to literature-based efficacy data for risk of invasive fungal infection with posaconazole antifungal prophylaxis in patients with acute leukemia undergoing chemotherapy and could represent a significant cost advantage.
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Affiliation(s)
- Vivian Bui
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sandra An Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anju Vyas
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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12
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George B, Menon H, Bhurani D, Damodar S, Apte S, Seth T, Sharma A, Shyam R, Malhotra P, Easow J, Lakshmi KM, Agrawal N, Sengar M, Nataraj KS, Ahmed R, Sharma S, Khadwal A, Prakash G, Abraham A, Devasia A, Korula A, Mathews V. A Prospective Observational Multi-institutional Study on Invasive Fungal Infections Following Chemotherapy for Acute Myeloid Leukemia (MISFIC Study): A Real World Scenario from India. Indian J Hematol Blood Transfus 2019; 36:97-103. [PMID: 32158091 DOI: 10.1007/s12288-019-01173-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/13/2019] [Indexed: 12/11/2022] Open
Abstract
We performed a prospective multi-centre observational study to understand the incidence of IFI in patients with AML in India with use of anti-fungal prophylaxis. All patients with AML receiving either induction chemotherapy or salvage chemotherapy between November 2014 and February 2016 were included in this prospective observational study from 10 Indian centres. IFI was defined as per the revised EORTC-MSG criteria. Data on type of chemotherapy used, type of anti-fungal prophylaxis used, time to neutrophil recovery, incidence of IFI and survival were collected. Two hundred patients (118 male and 82 females) with a median age of 35 years (range: 2-66) were recruited. One hundred and eighty-six (93%) had newly diagnosed acute myeloid leukemia (AML) while 14 (7%) had relapsed disease. IFI occurred in 53 patients (26.5%) with proven or probable IFI occurring in 17 (8.5%). Use of posaconazole prophylaxis (p = 0.027) was the only factor found to be associated with a reduced incidence of IFI. The overall survival (OS) at 6 weeks and 3 months respectively was similar among patients who had IFI (83.0 ± 5.2%; 81.0 ± 5.4%) as compared to those without IFI (84.4 + 3.0%; 81.4 ± 3.2%). This prospective study reveals a high incidence of IFI in patients undergoing chemotherapy for AML in India. The use of posaconazole prophylaxis was associated with a significantly lower incidence of IFI. Optimal strategies to prevent IFI need to be studied.
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Affiliation(s)
| | | | | | | | | | - Tulika Seth
- 6All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Pankaj Malhotra
- 9Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jose Easow
- Apollo Specialty Hospital, Chennai, India
| | | | | | | | | | - Rayaz Ahmed
- 3Rajiv Gandhi Cancer Institute, New Delhi, India
| | | | - Alka Khadwal
- 9Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Gaurav Prakash
- 9Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | | | - Anu Korula
- 1Christian Medical College, Vellore, India
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13
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Clinical considerations for the use of FLT3 inhibitors in acute myeloid leukemia. Crit Rev Oncol Hematol 2019; 141:125-138. [PMID: 31279288 DOI: 10.1016/j.critrevonc.2019.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 05/22/2019] [Accepted: 06/21/2019] [Indexed: 12/18/2022] Open
Abstract
Internal tandem duplications and tyrosine kinase mutations in the fms-like tyrosine kinase 3 (FLT3) receptor can occur in acute myeloid leukemia (AML) and portend a poor prognosis. Midostaurin, a multikinase inhibitor that targets FLT3, demonstrated a survival benefit in FLT3-mutated AML in combination with front-line chemotherapy. Despite this advancement, the use of FLT3 inhibitors in clinical practice is complicated by significant drug-drug interactions and uncertainty about optimal timing, duration, and sequencing of therapy. As monotherapy, the utility of FLT3 inhibitors was initially limited by incomplete and transient clinical responses and the development of acquired resistance. This led to the development of more potent and selective FLT3 inhibitors designed to overcome common resistance mechanisms. One of these second generation FLT3 inhibitors, gilteritinib, is now FDA-approved for the treatment of relapsed or refractory AML. Now that multiple FLT3 inhibitors are commercially available, it is important to further delineate the role of these agents in the AML population. This review aims to provide a comprehensive overview of the role of FLT3 inhibitors in AML and apply the current literature to clinical practice.
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14
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Breda GL, Tuon FF, Meis JF, Herkert PF, Hagen F, de Oliveira LZ, Dias VDC, da Cunha CA, Queiroz-Telles F. Breakthrough candidemia after the introduction of broad spectrum antifungal agents: A 5-year retrospective study. Med Mycol 2019; 56:406-415. [PMID: 29420820 DOI: 10.1093/mmy/myx077] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 08/21/2017] [Indexed: 01/05/2023] Open
Abstract
Candidemia is the main invasive fungal disease among hospitalized patients. Several breakthrough candidemia (BrC) cases have been reported, but few studies evaluate the epidemiology, risk factors, molecular characterization, antifungal susceptibility profile and outcome of those patients, especially in developing countries and including patients using broad spectrum antifungals. We conducted a retrospective study from 2011 to 2016, including patients aged 12 years or older with candidemia. Epidemiological characteristics and risk factors for candidemia were evaluated and compared with patients with BrC using univariate and multivariate analysis. Sequential Candida isolates from BrC were identified by internal transcribed spacer sequencing, genotyped with amplified fragment length polymorphism fingerprinting (AFLP), and tested for antifungal susceptibility. From 148 candidemia episodes, 27 breakthrough episodes (18%) were identified, with neutropenia and mucositis being independent risk factors for BrC. Candida non-albicans was more frequent in the BrC group (P < .001). AFLP showed high correlation with conventional methods of identification among breakthrough isolates and a high genetic similarity among isolates from the same patient was observed. C. albicans was the most susceptible species with low MIC values for all antifungal agents tested. In contrast, we found isolates of C. glabrata, C. parapsilosis and C. tropicalis resistant to triazoles and echinocandins. In conclusion, BrC occurred mainly in severely immunosuppressed patients, with neutropenia and mucositis. Mortality did not differ between the groups. Candida non-albicans species were more recovered from BrC, with C. albicans being the most susceptible to antifungals.
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Affiliation(s)
- Giovanni L Breda
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, 80060-900, Brazil
| | - Felipe F Tuon
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, 80060-900, Brazil.,Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, N ijmegen, The Netherlands
| | - Patricia F Herkert
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands.,Postgraduate Program in Microbiology, Parasitology and Pathology, Biological Sciences, Department of Basic Pathology, Universidade Federal do Paraná, Curitiba, PR Brazil.,CAPES Foundation, Ministry of Education of Brazil, Brasília - DF, 70.040-020
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | | | - Clóvis Arns da Cunha
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, 80060-900, Brazil.,Hospital Nossa Senhora das Graças, Curitiba, PR, 80810-040, Brazil
| | - Flávio Queiroz-Telles
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, 80060-900, Brazil.,Department of Public Health, Universidade Federal do Paraná, Curitiba, Brazil
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15
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Bui A, Nguyen V, Hsu C, Hyde B, Simms-Waldrip T. Invasive Fungal Infections While on Voriconazole, Liposomal Amphotericin B, or Micafungin for Antifungal Prophylaxis in Pediatric Stem Cell Transplant Patients. J Pediatr Pharmacol Ther 2019; 24:220-226. [PMID: 31093021 DOI: 10.5863/1551-6776-24.3.220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study aimed to report the incidence of invasive fungal infections (IFIs) in pediatric hematopoietic stem cell transplant (HSCT) patients who received voriconazole, liposomal amphotericin B (L-AMB), or micafungin for primary antifungal prophylaxis (PAP). METHODS Using data retrospectively collected from institution's electronic records, this study analyzed the incidence of IFIs in pediatric HSCT patients between November 2012 and November 2016. RESULTS A total of 103 patients were screened. Of the 84 patients who met inclusion criteria, 76.2%, 29.8%, and 19% patients received voriconazole, L-AMB, and micafungin, respectively. The incidence of overall IFIs was 2.08 per 1000 prophylaxis days. There were 2 mold infections identified in 2 patients. Among 3 antifungal agents, the rates of IFIs were 2.67 per 1000 prophylaxis days in L-AMB group, 2.08 per 1000 prophylaxis days in micafungin group, and 1.17 per 1000 prophylaxis days in voriconazole group. CONCLUSION Patients who received L-AMB or micafungin had higher rates of IFIs than those who received voriconazole for PAP.
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16
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Patel HP, Perissinotti AJ, Patel TS, Bixby DL, Marshall VD, Marini BL. Incidence and Risk Factors for Breakthrough Invasive Mold Infections in Acute Myeloid Leukemia Patients Receiving Remission Induction Chemotherapy. Open Forum Infect Dis 2019; 6:ofz176. [PMID: 31123689 PMCID: PMC6524834 DOI: 10.1093/ofid/ofz176] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/09/2019] [Indexed: 01/22/2023] Open
Abstract
Background Despite fungal prophylaxis, invasive mold infections (IMIs) are a significant cause of morbidity and mortality in patients with acute myeloid leukemia (AML) receiving remission induction chemotherapy. The choice of antifungal prophylaxis agent remains controversial, especially in the era of novel targeted therapies. We conducted a retrospective case–control study to determine the incidence of fungal infections and to identify risk factors associated with IMI. Methods Adult patients with AML receiving anti-Aspergillus prophylaxis were included to determine the incidence of IMI per 1000 prophylaxis-days. Patients without and with IMI were matched 2:1 based on the day of IMI diagnosis, and multivariable models using logistic regression were constructed to identify risk factors for IMI. Results Of the 162 included patients, 28 patients had a possible (n = 22), probable, or proven (n = 6) diagnosis of IMI. The incidence of proven or probable IMI per 1000 prophylaxis-days was not statistically different between anti-Aspergillus azoles and micafungin (1.6 vs 5.4, P = .11). The duration of prophylaxis with each agent did not predict IMI occurrence on regression analysis. Older age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.004–1.081; P = .03) and relapsed/refractory AML diagnosis (OR, 4.44; 95% CI, 1.56–12.64; P = .003) were associated with IMI on multivariable analysis. Conclusions In cases that preclude use of anti-Aspergillus azoles for prophylaxis, micafungin 100 mg once daily may be considered; however, in older patients and those with relapsed/refractory disease, diligent monitoring for IMI is required, irrespective of the agent used for antifungal prophylaxis.
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Affiliation(s)
- Heena P Patel
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Twisha S Patel
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Dale L Bixby
- Department of Internal Medicine, Division of Hematology & Oncology, Michigan Medicine, Ann Arbor, Michigan
| | - Vincent D Marshall
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, Michigan
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17
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Girmenia C, Busca A, Candoni A, Cesaro S, Luppi M, Nosari AM, Pagano L, Rossi G, Venditti A, Aversa F. Breakthrough invasive fungal diseases in acute myeloid leukemia patients receiving mould active triazole primary prophylaxis after intensive chemotherapy: An Italian consensus agreement on definitions and management. Med Mycol 2019; 57:S127-S137. [PMID: 30816979 DOI: 10.1093/mmy/myy091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 12/17/2022] Open
Abstract
In the attempt to establish definitions and provide shared approaches to breakthrough invasive fungal diseases (br-IFD) in acute myeloid leukemia (AML) patients submitted to intensive chemotherapy and receiving triazoles as mould active primary antifungal prophylaxis (MA-PAP), literature on br-IFD in AML patients receiving triazoles MA-PAP was reviewed and a Consensus Development Conference Project was convened. The following four candidate key-questions were generated and formed the set of questions of the present document: "definition of br-IFD," "diagnostic strategy during MA-PAP to detect br-IFD," "possible causes of MA-PAP failure," "management of br-IFD."
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Affiliation(s)
- Corrado Girmenia
- Dipartimento di Ematologia, Oncologia, e Dermatologia, Azienda Policlinico Umberto I, Rome
| | - Alessandro Busca
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, SSD Trapianto allogenico di cellule staminali, Turin, Italy
| | - Anna Candoni
- Clinica Ematologica-Centro trapianti e Terapie Cellulari, Azienda Ospedaliero-Universitaria di Udine
| | - Simone Cesaro
- Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Integrata, Verona
| | - Mario Luppi
- Cattedra ed UO Ematologia. Dipartimento di Scienze Mediche e Chirurgiche Materno Infantile e dell' Adulto. AOU Modena. UNIMORE. Modena
| | - Anna Maria Nosari
- Divisione di Ematologia e Centro Trapianti Midollo ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Livio Pagano
- Istituto di Ematologia, Fondazione Policlinico A. Gemelli- IRCCS - Università Cattolica del Sacro Cuore, Rome
| | - Giuseppe Rossi
- S.C. Ematologia e Dipartimento Oncologia Medica Spedali Civili, Brescia
| | | | - Franco Aversa
- Haematology and BMT Unit, University of Parma, Parma, Italy
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18
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Özkocaman V, Özkalemkaş F, Seyhan S, Ener B, Ursavaş A, Ersal T, Kazak E, Demirdöğen E, Mıstık R, Akalın H. The Outcome of Antifungal Prophylaxis with Posaconazole in Patients with Acute Myeloid Leukemia: A Single-Center Study. Turk J Haematol 2018; 35:277-282. [PMID: 30047484 PMCID: PMC6256813 DOI: 10.4274/tjh.2017.0430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective Invasive fungal infections (IFIs) are a significant cause of morbidity and mortality among neutropenic patients undergoing chemotherapy for acute myeloid leukemia (AML) and stem cell transplantation. The aim of this study was to evaluate the real-life impact of posaconazole prophylaxis. Materials and Methods Eighty-four adult patients were included with AML under remission induction chemotherapy and posaconazole prophylaxis. The 34 patients in the control group did not receive primary antifungal prophylaxis. The period between June 2006 and January 2009, when antifungal prophylaxis was not administered (control group), was retrospectively compared to the period between December 2010 and May 2012 when primary oral posaconazole prophylaxis was administered in similar conditions (posaconazole group) according to the use of antifungal agents for treatment, breakthrough infections, galactomannan performance, and the necessity for performing bronchoalveolar lavage (BAL) procedures. Results The two groups were compared according to the use of antifungal agents; progression to a different antifungal agent was found in 34/34 patients (100%) in the control group and in 9/84 patients (11%) in the posaconazole group (p<0.001). There were four breakthrough IFIs (4/84, 4.8%) in the posaconazole group and 34 IFIs in the control group (p<0.001). In addition, 15/34 patients (44%) in the control group required BAL compared to 11/84 patients (13%) in the posaconazole group (p<0.001). Posaconazole treatment was discontinued within 7-14 days in 7/84 patients (8.3%) due to poor oral compliance related to mucositis after chemotherapy. Conclusion Posaconazole appears to be effective and well-tolerated protection against IFIs for AML patients.
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Affiliation(s)
- Vildan Özkocaman
- Uludağ University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Bursa, Turkey
| | - Fahir Özkalemkaş
- Uludağ University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Bursa, Turkey
| | - Serdar Seyhan
- Uludağ University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Bursa, Turkey
| | - Beyza Ener
- Uludağ University Faculty of Medicine, Department of Medical Microbiology, Bursa, Turkey
| | - Ahmet Ursavaş
- Uludağ University Faculty of Medicine, Department of Chest Disease and Tuberculosis, Bursa, Turkey
| | - Tuba Ersal
- Uludağ University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Bursa, Turkey
| | - Esra Kazak
- Uludağ University Faculty of Medicine, Department of Infectious Disease and Clinical Microbiology, Bursa, Turkey
| | - Ezgi Demirdöğen
- Uludağ University Faculty of Medicine, Department of Chest Disease and Tuberculosis, Bursa, Turkey
| | - Reşit Mıstık
- Uludağ University Faculty of Medicine, Department of Infectious Disease and Clinical Microbiology, Bursa, Turkey
| | - Halis Akalın
- Uludağ University Faculty of Medicine, Department of Infectious Disease and Clinical Microbiology, Bursa, Turkey
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19
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Invasive fungal infections in high-risk patients: report from TIMM-8 2017. Future Sci OA 2018; 4:FSO307. [PMID: 30057784 PMCID: PMC6060393 DOI: 10.4155/fsoa-2018-0019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/08/2018] [Indexed: 02/08/2023] Open
Abstract
Trends in Medical Mycology (TIMM) is the biennial meeting of the Infectious Disease Group of the European Organisation for Research and Treatment of Cancer (EORTC) and the European Confederation of Medical Mycology (ECMM). It brings together clinicians and researchers from across the world to share the latest R&Ds in medical mycology. Despite advances in treatment, invasive fungal infections remain a major cause of morbidity and mortality in certain high-risk groups of patients, particularly in immunocompromised patients, including those undergoing solid organ transplantation and those with acute leukemia. The challenges for clinicians are now compounded by the rapid development of multidrug resistance. The latest data and approaches to identifying patients at high risk for invasive fungal infections, ensuring early diagnosis and achieving effective treatment, including when and how to use therapeutic drug monitoring with azoles, were shared with >1000 clinicians and researchers from around the world attending the eighth TIMM, held in Belgrade, Serbia, in October 2017 (TIMM-8 2017).
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20
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Buege MJ, DiPippo AJ, DiNardo CD. Evolving Treatment Strategies for Elderly Leukemia Patients with IDH Mutations. Cancers (Basel) 2018; 10:E187. [PMID: 29882807 PMCID: PMC6025071 DOI: 10.3390/cancers10060187] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 05/23/2018] [Accepted: 06/04/2018] [Indexed: 12/17/2022] Open
Abstract
Acute myeloid leukemia (AML) is a debilitating and life-threatening condition, especially for elderly patients who account for over 50% of diagnoses. For over four decades, standard induction therapy with intensive cytotoxic chemotherapy for AML had remained unchanged. However, for most patients, standard therapy continues to have its shortcomings, especially for elderly patients who may not be able to tolerate the complications from intensive cytotoxic chemotherapy. New research into the development of targeted and alternative therapies has led to a new era in AML therapy. For the nearly 20% of diagnoses harboring a mutation in isocitrate dehydrogenase 1 or 2 (IDH1/2), potential treatment options have undergone a paradigm shift away from intensive cytotoxic chemotherapy and towards targeted therapy alone or in combination with lower intensity chemotherapy. The first FDA approved IDH2 inhibitor was enasidenib in 2017. In addition, IDH1 inhibitors are in ongoing clinical studies, and the oral BCL-2 inhibitor venetoclax shows preliminary efficacy in this subset of patients. These new tools aim to improve outcomes and change the treatment paradigm for elderly patients with IDH mutant AML. However, the challenge of how to best incorporate these agents into standard practice remains.
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Affiliation(s)
- Michael J Buege
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Adam J DiPippo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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21
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Vulaj V, Perissinotti AJ, Uebel JR, Nachar VR, Scappaticci GB, Crouch A, Bixby DL, Burke PW, Maillard I, Talpaz M, Marini BL. The FOSSIL Study: FLAG or standard 7+3 induction therapy in secondary acute myeloid leukemia. Leuk Res 2018; 70:91-96. [PMID: 29908418 DOI: 10.1016/j.leukres.2018.05.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/23/2018] [Accepted: 05/30/2018] [Indexed: 12/18/2022]
Abstract
Patients with secondary acute myeloid leukemia (sAML) have poor outcomes, with CR/CRi rates of 25-35% with standard 7 + 3 induction chemotherapy, while single center non-comparative analyses suggest promising outcomes with FLAG. We conducted a single-center, retrospective cohort study assessing outcomes in treatment-naïve patients with sAML treated with fludarabine, high-dose cytarabine, and granulocyte colony-stimulating factor (FLAG, n = 40) compared with 7 + 3 (n = 66). Median patient age was 63 years (range: 27-82) in the FLAG group and 60 years (range: 21-76) in the 7 + 3 group (P = 0.968). Patients treated with FLAG achieved higher overall response rates (CR + CRi + MLFS) compared to 7 + 3 (70% vs. 48%, P = 0.043). FLAG was well tolerated, with only one induction death (30-day mortality rate, 3% vs. 8%, P = 0.405) and no cases of cerebellar toxicity. Duration of neutropenia was significantly shorter with FLAG (median 16 vs. 23 days, P < 0.001). Half of the FLAG-treated patients proceeded to consolidative therapy compared with only 27% of those who received 7 + 3 (P = 0.022). Overall survival was comparable between groups (8.5 mos, FLAG vs. 9.1 mos, 7 + 3; P = 0.798). Thus, FLAG may represent a low-cost treatment strategy in sAML that produces higher response rates and promising survival outcomes with minimal treatment-related toxicity. Further studies are required to prospectively compare FLAG to the newly FDA-approved CPX-351 in sAML.
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Affiliation(s)
- Vera Vulaj
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| | - James R Uebel
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Victoria R Nachar
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| | - Gianni B Scappaticci
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| | - Ashley Crouch
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Dale L Bixby
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Patrick W Burke
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Ivan Maillard
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Moshe Talpaz
- Department of Internal Medicine, Division of Hematology and Oncology, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine and University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
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The burden of Invasive Aspergillosis in patients with haematological malignancy: A meta-analysis and systematic review. J Infect 2018; 76:550-562. [PMID: 29727605 DOI: 10.1016/j.jinf.2018.02.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/13/2018] [Accepted: 02/16/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Successful treatment of haematological malignancies is frequently complicated by Invasive Aspergillosis (IA), a life-threatening fungal infection that occurs in at least 10% of haemato-oncological patients. Case fatality rates (CFR) may fluctuate over time, depending on host pathogen interactions as well as on treatment and quality of patient care. We conducted a systematic review and metaanalysis of current - i.e. 2008-revised EORTC-MSG criteria era - incidence and case fatality rates (CFR) of IA in patients with haematological malignancy. METHODS A systematic search according to PRISMA guidelines was performed to identify all literature reporting populations with a haematological malignancy and the incidence of IA, defined according to the EORTC/MSG 2008 criteria. Pooled cumulative incidences and CFR within 100 days were estimated using a random effects model for predefined patient populations and stratified by use of prophylaxis. RESULTS The systematic literature search yielded 1285 publications of which n = 49 met the inclusion criteria. Overall, 16.815 patients were involved of which 1056 (6.3%) developed IA. IA risk ranged from 4% (during remission-induction, with prophylaxis) to 11% (during remission-induction, without prophylaxis). Antifungal prophylaxis was associated with a lower rate of IA, especially in the pre-HSCT population. The pooled CFR within 100 days was 29% (95% CI: 20-38%). DISCUSSION This study confirms that IA is a relevant threat in the treatment of haematological cancer despite the universal use of antifungal prophylaxis. These outcomes inform scientists and other stakeholders about the current burden of IA and may be used to direct, implement and improve antifungal stewardship programs.
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Outcomes of previously untreated elderly patients with AML: a propensity score-matched comparison of clofarabine vs. FLAG. Ann Hematol 2017; 97:573-584. [PMID: 29288428 DOI: 10.1007/s00277-017-3217-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 12/19/2017] [Indexed: 12/11/2022]
Abstract
The 5-year overall survival (OS) in patients ≥ 60 years old with acute myeloid leukemia (AML) remains < 10%. Clofarabine-based induction (CLO) provides an alternative to low-intensity therapy (LIT) and palliative care for this population, but supporting data are conflicted. Recently, our institution adopted the FLAG regimen (fludarabine, cytarabine, and granulocyte colony-stimulating factor) based on data reporting similar outcomes to CLO in elderly patients with AML unable to tolerate anthracycline-based induction. We retrospectively analyzed the efficacy and safety of patients ≥ 60 years old with AML treated with FLAG or CLO over the past 10 years. We performed a propensity score match that provided 32 patients in each group. Patients treated with FLAG had a higher CR/CRi rate (65.6 vs. 37.5%, P = 0.045) and OS (7.9 vs. 2.8 months, P = 0.085) compared to CLO. Furthermore, FLAG was better tolerated with significantly less grade 3/4 toxicities and a shorter duration of neutropenia (18.5 vs. 30 days, P = 0.002). Finally, we performed a cost analysis that estimated savings to be $30,000-45,000 per induction with FLAG. Our study supports the use of FLAG both financially and as an effective, well-tolerated high-dose treatment regimen for elderly patients with AML. No cases of cerebellar neurotoxicity occurred.
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Real-Life Challenges to the Use of Antifungal Agents in Hematology Patients. CURRENT FUNGAL INFECTION REPORTS 2017. [DOI: 10.1007/s12281-017-0303-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Pergam SA. Fungal Pneumonia in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:279-294. [PMID: 28477639 DOI: 10.1016/j.ccm.2016.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Invasive fungal infections, which occur primarily as a consequence of prolonged neutropenia and immunosuppression, are a life-threatening complication seen among patients with hematologic malignancies. The routine use of triazole antifungal prophylaxis, enhanced diagnostics, and newer antifungal agents have led to improvements in the care of fungal pneumonias, but invasive fungal infections remain a major cause of morbidity and mortality. This article covers risk factors for major fungal infections, diagnostic approaches, and treatment options for specific fungal pathogens, including Aspergillus and Mucorales species, and discusses current approved strategies for prevention of common and uncommon fungal pneumonias.
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Affiliation(s)
- Steven A Pergam
- Vaccine & Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Infection Prevention, Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA 98109, USA.
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Korula A, Abraham A, Abubacker FN, Viswabandya A, Lakshmi KM, Abraham OC, Rupali P, Varghese GM, Michael JS, Srivastava A, Mathews V, George B. Invasive fungal infection following chemotherapy for acute myeloid leukaemia-Experience from a developing country. Mycoses 2017; 60:686-691. [PMID: 28736936 DOI: 10.1111/myc.12646] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/19/2017] [Accepted: 05/24/2017] [Indexed: 12/28/2022]
Abstract
The incidence of invasive fungal infections (IFI) is believed to be higher in patients with acute myeloid leukaemia (AML) undergoing chemotherapy in non-HEPA-filtered rooms. The aim of this study is to review the incidence of IFI in a large cohort of patients with AML treated at a single centre in India. Two hundred and twenty-two patients with AML treated with either induction chemotherapy or salvage chemotherapy between 2008 and 2013 were studied retrospectively. IFI was defined as per the revised EORTC-MSG criteria. Data on type of chemotherapy, prophylactic strategies, engraftment (ANC>500), the presence of IFI and survival were collected. IFI was diagnosed in 86 patients (38.7%) with proven IFI in 12 (5.4%). Use of posaconazole prophylaxis (P=.001) was the only factor associated with reduced incidence of IFI. Survival in patients with proven IFI was lower than those without proven IFI, but not statistically significant (59.4% vs 78.5%; P=.139). There is a high incidence of IFI during induction chemotherapy for acute myeloid leukaemia in developing countries. Posaconazole prophylaxis was associated with a significantly lower incidence of IFI. Optimal yet cost-effective strategies for prevention and early diagnosis of IFI are required to improve survival in patients undergoing chemotherapy for AML.
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Affiliation(s)
- Anu Korula
- Department of Haematology, Christian Medical College, Vellore, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Auro Viswabandya
- Department of Haematology, Christian Medical College, Vellore, India
| | - Kavitha M Lakshmi
- Department of Haematology, Christian Medical College, Vellore, India
| | - O C Abraham
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Priscilla Rupali
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Joy S Michael
- Department of Microbiology and Mycology, Christian Medical College, Vellore, India
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, India
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Berking S, Doedens D, Horns H, Fiegl M, Ostermann H, Rieger CT. Antifungal prophylaxis in newly diagnosed AML patients-Adherence to guidelines and feasibility in a real life setting. Mycoses 2017; 60:600-606. [DOI: 10.1111/myc.12635] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 02/14/2017] [Accepted: 04/13/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Sophie Berking
- Department of Internal Medicine III; Hospital of the University of Munich; Munich Germany
| | - Daphne Doedens
- Department of Internal Medicine III; Hospital of the University of Munich; Munich Germany
| | - Heidi Horns
- Department of Internal Medicine III; Hospital of the University of Munich; Munich Germany
| | - Michael Fiegl
- Haematology and Oncology Teaching Practice; Ludwig-Maximilians-University of Munich; Germering Germany
| | - Helmut Ostermann
- Department of Internal Medicine III; Hospital of the University of Munich; Munich Germany
| | - Christina T. Rieger
- Department of Internal Medicine III; Hospital of the University of Munich; Munich Germany
- Haematology and Oncology Teaching Practice; Ludwig-Maximilians-University of Munich; Germering Germany
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28
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Zhang R, Chen J, Huang H, Ma J, Meng F, Tang Y, Hu J, Zhang X, Ji Y, Ai H, Liang Y, Wu D, Huang X, Han M. Primary fungal prophylaxis in acute leukemia patients with different risk factors: retrospective analysis from the CAESAR study. Int J Hematol 2017; 106:221-228. [DOI: 10.1007/s12185-017-2224-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/22/2017] [Accepted: 03/24/2017] [Indexed: 11/28/2022]
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Heo ST, Aitken SL, Tverdek FP, Kontoyiannis DP. How common is subsequent central nervous system toxicity in asymptomatic patients with haematologic malignancy and supratherapeutic voriconazole serum levels? Clin Microbiol Infect 2017; 23:387-390. [PMID: 28082193 DOI: 10.1016/j.cmi.2016.12.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/27/2016] [Accepted: 12/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES We sought to determine the frequency at which patients with elevated voriconazole (VRC) levels but no clinically evident central nervous system (CNS) toxicity subsequently develop CNS toxicity. METHODS We retrospectively reviewed the records of adult patients with haematolologic malignancy who had a VRC serum level >5.5 μg/mL at MD Anderson Cancer Center (January 2010 to December 2015). Patients with any documented CNS toxicity at the time the VRC level was obtained or patients whose VRC was discontinued as a response to high VRC level were excluded. Neurologic status was assessed using standard grading scales. Demographic and clinical characteristics, including potentially interacting medications, were correlated with the development of toxicity. RESULTS We identified 320 such patients (mean age, 57 ± 15 years; 202 male (63%)). Subsequent CNS toxicity was documented in only 16 patients (5%). The most common CNS toxicities were visual disturbances (9/16, 56%), depressed consciousness (5/16, 31%) and cognitive disturbance (4/16, 19%). Patients with CNS toxicity tended to be older than those without (64 ± 8 vs 57 ± 15 y, p 0.08). The use of one or more neurotoxic drugs was common in patients with subsequent CNS toxicity (14/16, 88%). Reduction of VRC dose associated with the high VRC level did not correlate with less subsequent CNS toxicity. CONCLUSIONS Development of subsequent CNS toxicity is uncommon in haematolologic malignancy patients with elevated VRC levels who had no evidence of toxicity at the time the level was obtained. Automatic reduction of VRC dose out of concern for impending CNS toxicity might not be warranted.
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Affiliation(s)
- S T Heo
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Infectious Diseases, Jeju National University School of Medicine, Jeju, South Korea
| | - S L Aitken
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - F P Tverdek
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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30
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Douglas AP, Slavin MA. Risk factors and prophylaxis against invasive fungal disease for haematology and stem cell transplant recipients: an evolving field. Expert Rev Anti Infect Ther 2016; 14:1165-1177. [PMID: 27710140 DOI: 10.1080/14787210.2016.1245613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Due to increasing intensity and complexity of therapies and longer survivorship, many patients with haematologic malignancy (HM) are at risk of invasive fungal disease (IFD). Mortality from IFD is high and treatment of an episode of IFD results in an excess length of hospital stay and costs and delays delivery of curative therapy of the underlying haematologic condition. Therefore, prevention and early recognition and treatment of IFD are crucial. Areas covered: Risk factors particular to certain HMs and haematopoietic stem cell transplantation, as well as those risk factors universal to all HM groups are examined. Expert commentary: Risk stratification identifies those patients who would benefit most from mould active versus yeast active prophylaxis and those who can be safely managed with monitoring and clinically driven interventions for IFD. This approach aids in antifungal stewardship.
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Affiliation(s)
- Abby P Douglas
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , Melbourne , VIC , Australia.,b Victorian Infectious Diseases Service , Royal Melbourne Hospital , Melbourne , VIC , Australia.,c Department of Medicine , University of Melbourne , Melbourne , VIC , Australia
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de Almeida Júnior JN, Hennequin C. Invasive Trichosporon Infection: a Systematic Review on a Re-emerging Fungal Pathogen. Front Microbiol 2016; 7:1629. [PMID: 27799926 PMCID: PMC5065970 DOI: 10.3389/fmicb.2016.01629] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 09/29/2016] [Indexed: 12/11/2022] Open
Abstract
Objectives: This review aimed to better depict the clinical features and address the issue of therapeutic management of Trichosporon deep-seated infections. Methods: We comprehensively reviewed the cases of invasive Trichosporon infection reported in the literature from 1994 (date of taxonomic modification) to 2015. Data from antifungal susceptibility testing (AST) studies were also analyzed. Results: Two hundred and three cases were retained and split into four groups: homeopathy (n = 79), other immunodeficiency conditions (n = 41), miscellaneous (n = 58) and newborns (n = 25). Trichosporon asahii was the main causative species (46.7%) and may exhibit cross-resistance to different antifungal classes. The unfavorable outcome rate was at 44.3%. By multivariate analysis, breakthrough infection (OR 2.45) was associated with unfavorable outcome, whilst the use of an azole-based therapy improved the prognosis (OR 0.16). Voriconazole-based treatment was associated with favorable outcome in hematological patients (73.6 vs. 41.8%; p = 0.016). Compiled data from AST demonstrated that (i) T. asahii exhibits the highest MICs to amphotericin B and (ii) voriconazole has the best in vitro efficacy against clinical isolates of Trichosporon spp. Conclusions:Trichosporon infection is not only restricted to hematological patients. Analysis of compiled data from AST and clinical outcome support the use of voriconazole as first line therapy.
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Affiliation(s)
- João N de Almeida Júnior
- Central Laboratory Division-LIM03, Faculdade de Medicina da Universidade de São PauloSão Paulo, Brazil; Laboratory of Medical Mycology-LIM53, Instituto de Medicina Tropical da Universidade de São PauloSão Paulo, Brazil
| | - Christophe Hennequin
- Service de Parasitologie-Mycologie-AP-HP, Hôpital St AntoineParis, France; Institut National de la Santé et de la Recherche Médicale UMR 1135, Centre National de la Recherche Scientifique ERL 8255, Sorbonne Universités, University Pierre and Marie Curie (UPMC)Paris, France; Centre d'Immunologie et des Maladies Infectieuses, Bd de l'hôpitalParis, France
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Douglas AP, Thursky KA, Slavin MA. Invasive fungal infections in ALL: a new 'growth' area. Leuk Lymphoma 2016; 57:1985-7. [PMID: 27124301 DOI: 10.1080/10428194.2016.1177775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Abby P Douglas
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Victoria , Australia
| | - Karin A Thursky
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Victoria , Australia ;,b Victorian Infectious Diseases Service , Royal Melbourne Hospital , Melbourne , Victoria , Australia ;,c The Peter Doherty Institute for Infection and Immunity , Melbourne , Victoria , Australia ;,d Department of Medicine, University of Melbourne , Melbourne , Victoria , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Victoria , Australia ;,b Victorian Infectious Diseases Service , Royal Melbourne Hospital , Melbourne , Victoria , Australia ;,c The Peter Doherty Institute for Infection and Immunity , Melbourne , Victoria , Australia ;,d Department of Medicine, University of Melbourne , Melbourne , Victoria , Australia
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Shah A, Ganesan P, Radhakrishnan V, Kannan K, Rajendranath R, Mahajan V, Vijayakumar V, Ganesan T, Sagar TG. Voriconazole is a safe and effective anti-fungal prophylactic agent during induction therapy of acute myeloid leukemia. Indian J Med Paediatr Oncol 2016; 37:53-8. [PMID: 27051159 PMCID: PMC4795377 DOI: 10.4103/0971-5851.177032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Antifungal prophylaxis (AFP) reduces the incidence of invasive fungal infections (IFIs) during induction therapy of acute myeloid leukemia (AML). Posaconazole is considered the standard of care. Voriconazole, a generic cheaper alternative is a newer generation azole with broad anti-fungal activity. There is limited data on the use of voriconazole as a prophylactic drug. Materials and Methods: A single-center, prospective study was performed during which patients with AML undergoing induction chemotherapy received voriconazole as AFP (April 2012 to February 2014). Outcomes were compared with historical patients who received fluconazole as AFP (January 2011-March 2012, n = 66). Results: Seventy-five patients with AML (median age: 17 years [range: 1-75]; male:female 1.6:1) received voriconazole as AFP. The incidence of proven/probable/possible (ppp) IFI was 6.6% (5/75). Voriconazole and fluconazole cohorts were well-matched with respect to baseline characteristics. Voriconazole (when compared to fluconazole) reduced the incidence of pppIFI (5/75, 6.6% vs. 19/66, 29%; P < 0.001), need to start therapeutic (empiric + pppIFI) antifungals (26/75, 34% vs. 51/66, 48%; P < 0.001) and delayed the start of therapeutic antifungals in those who needed it (day 16 vs. day 10; P < 0.001). Mortality due to IFI was also reduced with the use of voriconazole (1/75, 1.3% vs. 6/66, 9%; P = 0.0507), but this was not significant. Three patients discontinued voriconazole due to side-effects. Conclusion: Voriconazole is an effective and safe oral agent for IFI prophylaxis during induction therapy of AML. Availability of generic equivalents makes this a more economical alternative to posaconazole.
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Affiliation(s)
- Akash Shah
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | | | - Krishnarathinam Kannan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Rejiv Rajendranath
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Vandana Mahajan
- Department of Radiodiagnosis, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | | | - Trivadi Ganesan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Tenali Gnana Sagar
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
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Gedik H. The expenditures related to the use of antifungal drugs in patients with hematological cancers: a cost analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:537-43. [PMID: 26622185 PMCID: PMC4639477 DOI: 10.2147/ceor.s92455] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Objective The aim of this study is to analyze the expenditures related to the use of antifungal drugs in patients with hematological malignancies. Methods In this retrospective study, the expenditures related to use of antifungal drugs for treatment of invasive fungal infections in patients with hematological malignancies between November 2010 and November 2012 were analyzed. Expenditures of antifungal drugs were calculated by converting the price billed to the Republic of Turkey Social Security Institution per patient using the US dollar ($) exchange rate. Results We retrospectively analyzed the expenditures related to the use of antifungal drugs in 282 febrile episodes of 126 neutropenic patients. Voriconazole (VOR), caspofungin, and liposomal amphotericin B (L-AmB) were administered as a first-line antifungal therapy to treat 72 febrile episodes of 65 neutropenic patients, 45 febrile episodes of 37 neutropenic patients, and 34 febrile episodes of 32 neutropenic patients, respectively. The expenditures related to the use of antifungal drugs per febrile neutropenic episode were $3,857.85 for VOR; $15,783.34 for caspofungin, and $21,561.02 for L-AmB, respectively. The expenditure related to the use of posaconazole (POS) was $32,167.39 per patient for primary or secondary prophylaxis. Conclusion Improving conditions in the patient’s room, choosing pre-emptive antifungal treatment instead of empirical antifungal treatment, switching to tablet form of VOR after initiation of its intravenous form, secondary prophylaxis with VOR against invasive aspergillosis, primary prophylaxis with POS in high-risk patients, and choosing less L-AmB as being an alternative to other antifungal drugs, may reduce expenditures related to the use of antifungal drugs in the treatment of invasive fungal infections during febrile neutropenic episodes of patients with hematological malignancies.
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Affiliation(s)
- Habip Gedik
- Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Okmeydanı Training and Research Hospital, Istanbul, Turkey
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Doan TN, Kirkpatrick CMJ, Walker P, Slavin MA, Ananda-Rajah MR, Morrissey CO, Urbancic KF, Grigg A, Spencer A, Szer J, Seymour JF, Kong DCM. Primary antifungal prophylaxis in adult patients with acute lymphoblastic leukaemia: a multicentre audit. J Antimicrob Chemother 2015; 71:497-505. [DOI: 10.1093/jac/dkv343] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/22/2015] [Indexed: 11/12/2022] Open
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36
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Cho SY, Lee DG, Choi SM, Choi JK, Lee HJ, Kim SH, Park SH, Choi JH, Yoo JH, Kim YJ, Kim HJ, Min WS. Posaconazole for primary antifungal prophylaxis in patients with acute myeloid leukaemia or myelodysplastic syndrome during remission induction chemotherapy: a single-centre retrospective study in Korea and clinical considerations. Mycoses 2015. [PMID: 26214656 DOI: 10.1111/myc.12357] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Posaconazole was introduced as the primary antifungal prophylaxis (PAP) in acute myeloid leukaemia (AML) or myelodysplastic syndrome (MDS) patients during remission induction chemotherapy. Data on breakthrough invasive fungal infections (IFIs) from various centres are essential, as there are several considerations in treating IFIs in the posaconazole era. The aim of this study was to evaluate the effectiveness of posaconazole PAP and identify characteristics of IFIs at a single centre in Korea. We retrospectively reviewed consecutive patients with AML/MDS undergoing remission induction chemotherapy between December 2010 and November 2013. Of the 424 patients, 140 received posaconazole and 284 received fluconazole prophylaxis. The incidence of breakthrough proven/probable IFIs (15.5% vs. 2.9%, P < 0.001) and empirical antifungal treatment (EAFT) (45.8% vs. 12.9%, P < 0.001) decreased in the posaconazole group compared to the fluconazole group. In the posaconazole PAP group, two cases of breakthrough mucormycosis were noted among 13 proven/probable/possible IFI cases (15.4%). Overall and IFI-related mortality was 12.1% and 1.9% respectively. Fungus-free survival was significantly higher in the posaconazole group (74.7% vs. 87.1%, P = 0.028). Breakthrough IFIs and EAFT decreased significantly after posaconazole PAP. The benefit in fungus-free survival was noted with posaconazole PAP. Clinicians should be vigilant to identify non-Aspergillus IFIs with active diagnostic effort.
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Affiliation(s)
- Sung-Yeon Cho
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su-Mi Choi
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ki Choi
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo-Jin Lee
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Si-Hyun Kim
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Hee Park
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hyun Choi
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Hong Yoo
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woo-Sung Min
- The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
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37
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Tang JL, Kung HC, Lei WC, Yao M, Wu UI, Hsu SC, Lin CT, Li CC, Wu SJ, Hou HA, Chou WC, Huang SY, Tsay W, Chen YC, Chen YC, Chang SC, Ko BS, Tien HF. High Incidences of Invasive Fungal Infections in Acute Myeloid Leukemia Patients Receiving Induction Chemotherapy without Systemic Antifungal Prophylaxis: A Prospective Observational Study in Taiwan. PLoS One 2015; 10:e0128410. [PMID: 26061179 PMCID: PMC4462587 DOI: 10.1371/journal.pone.0128410] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/28/2015] [Indexed: 11/18/2022] Open
Abstract
Invasive fungal infections (IFIs) is an important complication for acute myeloid leukemia (AML) patients receiving induction chemotherapy. However, the epidemiological information is not clear in Southeastern Asia, an area of potential high incidences of IFIs. To clarify it, we enrolled 298 non-M3 adult AML patients receiving induction chemotherapy without systemic anti-fungal prophylaxis from Jan 2004 to Dec 2009, when we applied a prospective diagnostic and treatment algorithm for IFIs. Their demographic parameters, IFI characters, and treatment outcome were collected for analysis. The median age of these patients was 51 years. Standard induction chemotherapy was used for 246 (82.6%) patients, and 66.8% of patients achieved complete remission (CR) or partial remission. The incidence of all-category IFIs was 34.6% (5.7% proven IFIs, 5.0% probable IFIs and 23.8% possible IFIs). Candida tropicalis was the leading pathogen among yeast, and lower respiratory tract was the most common site for IFIs (75.4%, 80/106). Standard induction chemotherapy and failure to CR were identified as risk factors for IFIs. The presence of IFI in induction independently predicted worse survival (hazard ratio 1.536 (1.100–2.141), p value = 0.012). Even in those who survived from the initial IFI insults after 3 months, the presence of IFIs in induction still predicted a poor long-term survival. This study confirms high incidences of IFIs in Southeastern Asia, and illustrates potential risk factors; poor short-term and long-term outcomes are also demonstrated. This epidemiological information will provide useful perspectives for anti-fungal prophylaxis and treatment for AML patients during induction, so that best chances of cure and survival can be provided.
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Affiliation(s)
- Jih-Luh Tang
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
- Tai-Cheng Stem Cell Therapy Center, National Taiwan University, Taipei, Taiwan
| | - Hsiang-Chi Kung
- Division of Infection, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Weng-Chi Lei
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming Yao
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Un-In Wu
- Clinical Trial Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Chun Hsu
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Ting Lin
- Tai-Cheng Stem Cell Therapy Center, National Taiwan University, Taipei, Taiwan
| | - Chi-Cheng Li
- Tai-Cheng Stem Cell Therapy Center, National Taiwan University, Taipei, Taiwan
| | - Shang-Ju Wu
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsin-An Hou
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Chien Chou
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shang-Yi Huang
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Woei Tsay
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Yao-Chang Chen
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Chun Chen
- Division of Infection, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
- National Institute of Infectious Diseases and Vaccinology, National health Research Institute, Miaoli, Taiwan
| | - Shan-Chwen Chang
- Division of Infection, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | - Bor-Sheng Ko
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
| | - Hwei-Fang Tien
- Division of Hematology, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
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38
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Risk for invasive fungal infections during acute myeloid leukemia induction therapy: a true association with echinocandins? Antimicrob Agents Chemother 2015; 58:4988-9. [PMID: 25028730 DOI: 10.1128/aac.03044-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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39
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Philip C, George B, Ganapule A, Korula A, Jain P, Alex AA, Lakshmi KM, Sitaram U, Abubacker FN, Abraham A, Viswabandya A, Srivastava VM, Srivastava A, Balasubramanian P, Mathews V. Acute myeloid leukaemia: challenges and real world data from India. Br J Haematol 2015; 170:110-7. [PMID: 25858293 PMCID: PMC4864448 DOI: 10.1111/bjh.13406] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 01/26/2015] [Indexed: 01/25/2023]
Abstract
The management of acute myeloid leukaemia (AML) in India remains a challenge. In a two-year prospective study at our centre there were 380 newly diagnosed AML (excluding acute promyelocytic leukaemia, AML-M3) patients. The median age of newly diagnosed patients was 40 years (range: 1-79; 12.3% were ≤ 15 years, 16.3% were ≥ 60 years old) and there were 244 (64.2%) males. The median duration of symptoms prior to first presentation at our hospital was 4 weeks (range: 1-52). The median distance from home to hospital was 580 km (range: 6-3200 km). 109 (29%) opted for standard of care and were admitted for induction chemotherapy. Of the 271 that did not take treatment the major reason was lack of financial resources in 219 (81%). There were 27 (24.7%) inductions deaths and of these, 12 (44.5%) were due to multidrug-resistant gram-negative bacilli and 12 (44.5%) showed evidence of a fungal infection. The overall survival at 1 year was 70.4% ± 10.7%, 55.6% ± 6.8% and 42.4% ± 15.6% in patients aged ≤ 15 years, 15 - 60 years and ≥ 60 years, respectively. In conclusion, the biggest constraint is the cost of treatment and the absence of a health security net to treat all patients with this diagnosis.
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Affiliation(s)
- Chepsy Philip
- Department of Haematology, Christian Medical College, Vellore, India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, India
| | - Abhijeet Ganapule
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Vellore, India
| | - Punit Jain
- Department of Haematology, Christian Medical College, Vellore, India
| | - Ansu Abu Alex
- Department of Haematology, Christian Medical College, Vellore, India
| | - Kavitha M Lakshmi
- Department of Haematology, Christian Medical College, Vellore, India
| | - Usha Sitaram
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, India
| | | | - Aby Abraham
- Department of Haematology, Christian Medical College, Vellore, India
| | - Auro Viswabandya
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, India
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40
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Fleming S, Yannakou CK, Haeusler GM, Clark J, Grigg A, Heath CH, Bajel A, van Hal SJ, Chen SC, Milliken ST, Morrissey CO, Tam CS, Szer J, Weinkove R, Slavin MA. Consensus guidelines for antifungal prophylaxis in haematological malignancy and haemopoietic stem cell transplantation, 2014. Intern Med J 2014; 44:1283-97. [DOI: 10.1111/imj.12595] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- S. Fleming
- Malignant Haematology and Stem Cell Transplantation Service; Alfred Health; Prahran Victoria
| | - C. K. Yannakou
- Department of Clinical Haematology and Bone Marrow Transplant Service; The Royal Melbourne Hospital; Parkville Victoria
| | - G. M. Haeusler
- Department of Infectious Diseases and Infection Control; Peter MacCallum Cancer Centre; East Melbourne Victoria
- Department of Paediatric Infectious Diseases; Monash Children's Hospital; Monash Health; Clayton Victoria
- Paediatric Integrated Cancer Service; Parkville Victoria
| | - J. Clark
- Infection Management and Prevention Service; The Royal Children's Hospital Brisbane; Queensland Health; Herston Queensland
| | - A. Grigg
- Department of Clinical Haematology; Austin Health; Heidelberg Victoria
- School of Medicine; The University of Melbourne; Melbourne Victoria
| | - C. H. Heath
- Department of Microbiology and Infectious Diseases; Royal Perth Hospital; Perth Western Australia
- School of Medicine and Pharmacology (RPH Unit); University of Western Australia; Perth Western Australia
| | - A. Bajel
- Department of Clinical Haematology and Bone Marrow Transplant Service; The Royal Melbourne Hospital; Parkville Victoria
| | - S. J. van Hal
- Department of Microbiology and Infectious Diseases; Royal Prince Alfred Hospital; Camperdown New South Wales
| | - S. C. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services; ICPMR - Pathology West; Westmead New South Wales
- Department of Infectious Diseases; Westmead Hospital; Westmead New South Wales
- Sydney Medical School; The University of Sydney; Sydney New South Wales
| | - S. T. Milliken
- Department of Haematology; St Vincent's Hospital; Darlinghurst New South Wales
- Faculties of Medicine and Pathology; The University of NSW; Kensington New South Wales
| | - C. O. Morrissey
- Department of Infectious Diseases; Alfred Health and Monash University; Prahran Victoria
- Department of Clinical Haematology; Alfred Health; Prahran Victoria
| | - C. S. Tam
- School of Medicine; The University of Melbourne; Melbourne Victoria
- Department of Haematology; Peter MacCallum Cancer Centre; East Melbourne Victoria
| | - J. Szer
- Department of Clinical Haematology and Bone Marrow Transplant Service; The Royal Melbourne Hospital; Parkville Victoria
- School of Medicine; The University of Melbourne; Melbourne Victoria
| | - R. Weinkove
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
- Vaccine Research Group; Malaghan Institute of Medical Research; Wellington New Zealand
| | - M. A. Slavin
- Department of Infectious Diseases and Infection Control; Peter MacCallum Cancer Centre; East Melbourne Victoria
- School of Medicine; The University of Melbourne; Melbourne Victoria
- Victorian Infectious Diseases Service; The Doherty Institute for Infection and Immunity; Parkville Victoria
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41
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Reply to "Risk for invasive fungal infections during acute myeloid leukemia induction therapy: a true association with echinocandins?". Antimicrob Agents Chemother 2014; 58:4990-1. [PMID: 25028731 DOI: 10.1128/aac.03224-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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42
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Effectiveness of primary anti-Aspergillus prophylaxis during remission induction chemotherapy of acute myeloid leukemia. Antimicrob Agents Chemother 2014; 58:2775-80. [PMID: 24590477 DOI: 10.1128/aac.01527-13] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Although antifungal prophylaxis is frequently administered to patients with acute myeloid leukemia (AML) during remission-induction chemotherapy (RIC), its impact on reducing invasive fungal infections (IFIs) outside clinical trials is rarely reported. We performed a retrospective observational study to identify risk factors for development of IFIs (definite or probable, using revised European Organization for Research and Treatment of Cancer [EORTC] criteria) and all-cause mortality in a cohort of 152 AML patients receiving RIC (2009 to 2011). We also compared rates of IFI and mortality in patients who received echinocandin versus anti-Aspergillus azole (voriconazole or posaconazole) prophylaxis during the first 120 days of RIC. In multivariate analysis, clofarabine-based RIC (hazard ratio [HR], 3.5; 95% confidence interval [CI], 1.5 to 8.3; P = 0.004) and echinocandin prophylaxis (HR, 4.6; 95% CI, 1.8 to 11.9; P = 0.002) were independently associated with higher rates of IFI rates during RIC. Subsequent analysis failed to identify any malignancy- or chemotherapy-related covariates linked to echinocandin prophylaxis that accounted for the higher rates of breakthrough IFI. Although the possibility of other confounding variables cannot be excluded, our findings suggest that echinocandin-based prophylaxis during RIC for AML may be associated with a higher risk of breakthrough IFI.
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