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Fochtmann A, Forstner C, Hagmann M, Keck M, Muschitz G, Presterl E, Ihra G, Rath T. Predisposing factors for candidemia in patients with major burns. Burns 2014; 41:326-32. [PMID: 25239850 DOI: 10.1016/j.burns.2014.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 07/03/2014] [Accepted: 07/05/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Despite advances in surgery and critical care, candidemia remains a significant cause of morbidity and mortality in patients with extensive burns. METHODS A retrospective single-center cohort study was performed on 174 patients admitted to the Burn Intensive Care Unit of the General Hospital of Vienna (2007-2013). An AIC based model selection procedure for logistic regression models was utilized to identify factors associated with the presence of candidemia. RESULTS Twenty (11%) patients developed candidemia on median day 16 after ICU admission associated with an increased overall mortality (30% versus 10%). Statistical analysis identified the following factors associated with proven candidemia: younger age (years) odds ratio (OR):0.96, 95% confidence interval (95% CI):0.92-1.0, female gender (reference male) OR:5.03, 95% CI:1.25-24.9, gastrointestinal (GI) complications requiring surgery (reference no GI complication) OR:20.37, 95% CI:4.25-125.8, non-gastrointestinal thromboembolic complications (reference no thromboembolic complication) OR:17.3, 95% CI:2.57-170.4 and inhalation trauma (reference no inhalation trauma) OR:7.96, 95% CI:1.4-48.4. CONCLUSIONS Above-mentioned patient groups are at considerably high risk for candidemia and might benefit from a prophylactic antifungal therapy. Younger age as associated risk factor is likely to be the result of the fact that older patients with a great extent of burn body surface have a lower chance of survival compared to younger patients with a comparable TBSA.
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Affiliation(s)
- Alexandra Fochtmann
- Medical University of Vienna, Clinical Division of Plastic and Reconstructive Surgery, Department of Surgery, Vienna, Austria.
| | - Christina Forstner
- Medical University of Vienna, Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Vienna, Austria.
| | - Michael Hagmann
- Medical University of Vienna, Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Vienna, Austria.
| | - Maike Keck
- Medical University of Vienna, Clinical Division of Plastic and Reconstructive Surgery, Department of Surgery, Vienna, Austria.
| | - Gabriela Muschitz
- Medical University of Vienna, Clinical Division of Plastic and Reconstructive Surgery, Department of Surgery, Vienna, Austria.
| | - Elisabeth Presterl
- Medical University of Vienna, Clinical Institute of Infection Control and Hospital Epidemiology, Vienna, Austria.
| | - Gerald Ihra
- Medical University of Vienna, Department of Anesthesiology and General Intensive Care, Vienna, Austria.
| | - Thomas Rath
- Medical University of Vienna, Clinical Division of Plastic and Reconstructive Surgery, Department of Surgery, Vienna, Austria.
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Winkler J, Müller U, Nenoff P, Seyfarth HJ, Vogtmann M, Borte G, Pönisch W, Kahn T, Wirtz H, Schauer J, Hoheisel G. Treatment of invasive pulmonary aspergillosis in neutropenic patients by additional bronchoscopic amphotericin B instillation. Respiration 2007; 74:663-73. [PMID: 17622755 DOI: 10.1159/000105385] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Accepted: 02/15/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Invasive pulmonary aspergillosis (IPA) remains a life-threatening condition despite systemic antifungal therapy. OBJECTIVES This retrospective analysis investigated whether additional bronchoscopic instillation of amphotericin B (amB) would improve efficacy of antifungal treatment in patients with haematological malignancies suffering from IPA. METHODS Twenty patients (40.6 +/- 14.2 years, 14 male) with preceding chemotherapy, bone marrow or stem cell transplantation complicated by severe IPA who did not respond sufficiently to systemic antifungal therapy were additionally treated by repeated bronchoscopic instillations of amB solution (91 instillations, on average 4.6 +/- 2.2 instillations per patient over a period of 24.1 +/- 21.0 days). Therapeutic response to this combined treatment regimen was monitored by chest X-ray and CT scan. RESULTS The mean infiltration sizes during systemic antifungal therapy alone (mean duration 11.9 +/- 9.9 days) did not change significantly. However, after additional bronchoscopic instillation of amB solution infiltration sizes were reduced significantly (p < 0.05). A total resolution of infiltrates was seen in 3 and a partial reduction in 13 of 20 patients. Mean duration of total antifungal treatment was 50.1 +/- 24.0 days. The mean follow-up period was 34.1 +/- 31.2 months. The IPA-related mortality rate was 18.8% (3 of 16 patients). CONCLUSIONS Additional bronchoscopic instillation of amB may improve the efficacy of systemic antifungal therapy in patients with haematological malignancies complicated by severe IPA. Bronchoscopic instillation of amB should be considered as an additional treatment option in cases with IPA unresponsive to systemic therapy.
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Affiliation(s)
- J Winkler
- Pulmonary Unit, Department of Internal Medicine, University of Leipzig, Leipzig, Germany.
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Rosen GP, Nielsen K, Glenn S, Abelson J, Deville J, Moore TB. Invasive fungal infections in pediatric oncology patients: 11-year experience at a single institution. J Pediatr Hematol Oncol 2005; 27:135-40. [PMID: 15750444 DOI: 10.1097/01.mph.0000155861.38641.ca] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to determine the incidence of fungal infections in pediatric hematology and oncology (PHO) patients and to describe variations regarding site of infection, organisms, and mortality. The records of 1,052 patients presenting to the UCLA PHO service with various malignancies from 1991 to 2001 were retrospectively reviewed. No patient received invasive antifungal prophylaxis. Transplant patients were excluded. The 11-year incidence of fungal infections in this pediatric oncology cohort was 4.9%. There was a linear increase in the incidence of fungal infections from 2.9% to 7.8% between 1996 and 2001 (P = 0.001). Patients with acute leukemia represented 36% of the population but had a disproportionate incidence (67%) of fungal infections. Adolescents had twice the expected incidence of infection (P < 0.0001). Overall, Candida sp. was the major pathogen. Over time, a trend of fewer infections caused by Candida and more due to Aspergillus was noted. Blood-borne infections decreased over time, while those in the urinary and respiratory tracts increased (P = 0.04). Sixty-two percent of infections occurred in neutropenic patients. PHO patients had an overall mortality of 21%, but those with fungal infections experienced a 2.6-fold higher mortality that was not attributable to infections alone. Empiric antifungal therapy had no effect on mortality rates. Concurrent nonfungal infections did not increase mortality rates. The incidence of fungal infections increased over time, possibly as a result of advances in antibacterial and chemotherapeutic regimens. Adolescents and patients with leukemia were especially at risk. Fungal infections are a poor prognostic factor, independent of fungal-related mortality. New diagnostic methods allowing for early detection and treatment as well as more effective therapies are needed.
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Affiliation(s)
- Galit P Rosen
- Department of Pediatrics, Mattel Children's Hospital at UCLA, Los Angeles, California, USA
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Sammassimo S, Mazzotta S, Tozzi M, Gentili S, Lenoci M, Santopietro R, Bucalossi A, Bocchia M, Lauria F. Disseminated mucormycosis in a patient with acute myeloblastic leukemia misdiagnosed as infection by Enterococcus faecium. J Clin Microbiol 2004; 42:487-9. [PMID: 14715813 PMCID: PMC321679 DOI: 10.1128/jcm.42.1.487-489.2004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Mucormycosis is a rare complication in cancer patients. This report presents the case of a acute myeloblastic leukemia patient who developed an ascending paralysis due to disseminated mucormycosis. The presentation was unusual because the early symptoms were fever and pain, and the disease was misdiagnosed because of a concomitant infection by Enterococcus faecium.
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Affiliation(s)
- S Sammassimo
- Department of Hematology and Hematopoietic Stem Cell Transplantation, University of Siena, Siena, Italy.
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Polak A. Antifungal therapy--state of the art at the beginning of the 21st century. PROGRESS IN DRUG RESEARCH. FORTSCHRITTE DER ARZNEIMITTELFORSCHUNG. PROGRES DES RECHERCHES PHARMACEUTIQUES 2003; Spec No:59-190. [PMID: 12675476 DOI: 10.1007/978-3-0348-7974-3_4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.
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Lee DG, Choi SM, Choi JH, Yoo JH, Park YH, Kim YJ, Lee S, Min CK, Kim HJ, Kim DW, Lee JW, Min WS, Shin WS, Kim CC. Selective bowel decontamination for the prevention of infection in acute myelogenous leukemia: a prospective randomized trial. Korean J Intern Med 2002; 17:38-44. [PMID: 12014211 PMCID: PMC4531660 DOI: 10.3904/kjim.2002.17.1.38] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Infection is still a frequent cause of morbidity and mortality in acute myelogenous leukemia (AML) patients receiving chemotherapy. Recently the main cause of infection has changed from gram-negative to gram-positive bacteria and the resistance to antibiotics has increased. This study aimed to access the effectiveness of antimicrobial prophylaxis (AP) with orally absorbable antibiotics. METHODS Ninety-five AML patients receiving chemotherapy at Catholic Hemopoietic Stem Cell Transplantation Center from March 1999 to July 1999 were randomly divided into the AP group (250 mg ciprofloxacin twice a day, 150 mg roxithromycin twice a day, 50 mg fluconazole once a day) and the control group for a prospective analysis. RESULTS The incidence of fever was 82.6% in the AP group and 91.6% in the control group (p = 0.15). Though classification and sites of infections showed no difference between the two groups, the catheter associated infection occurred more frequently in the AP group in significance. The time interval between initiation of chemotherapy and onset of fever, white blood cell (WBC) count at the onset of fever, duration of leukopenia (WBC < 1,000/mm3), duration of systemic antibiotic therapy, mortality due to infection and hospitalization period from the data starting chemotherapy showed no differences between the two groups. Infections due to gram negative bacteria decreased to 33.3% in the AP group (vs. 92% in the control group), but infections due to gram positive bacteria increased to 66.7% (vs. 8% in the control group). Gram negative bacteria showed 100% resistance to ciprofloxacin in the AP group and gram-positive bacteria showed 90-100% resistance to erythromycin, regardless of the presence of AP. CONCLUSION The AP could not reduce the occurrence of infection or infection associated death in AML patients receiving chemotherapy. On considering increased gram-positive infection and resistance to fluoroquinolone and macrolide, routine prescription of AP should be reconsidered. Further studies that assess the effectiveness of AP in other malignancies, aplastic anemia and bone marrow transplantation are required.
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Affiliation(s)
- Dong Gun Lee
- Department of Internal Medicine, Catholic University College of Medicine, Seoul, Korea
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Barber FD. MANAGEMENT OF FEVER IN NEUTROPENIC PATIENTS WITH CANCER. Nurs Clin North Am 2001. [DOI: 10.1016/s0029-6465(22)02662-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Fungal infections, particularly those in immunocompromised hosts, have been a major therapeutic challenge over recent decades. The difficulty in diagnosing invasive infections, together with the emergence of unusual opportunistic pathogens and a pathogen shift in the spectrum of the causative organisms, have greatly hampered the effectiveness of antifungal therapy. Knowledge of the immunoregulation of fungal infections may provide new insights for therapeutic interventions. The appreciation of the importance of T helper cells and cytokines in the overall coordination of the effector immune response to fungi has offered novel opportunities to manipulate these processes and to alter the outcome of fungal infections while improving the therapeutic efficacy of antifungal drugs. Cytokine and cytokine antagonists, alone or in combination with antifungals, have the potential to overcome the specific defects of host immune reactivity predisposing to fungal infections. The current challenge lies in translating much of the information obtained in experimental and preclinical studies into therapeutic strategies providing prospects for the ultimate treatment of fungal infections.
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Affiliation(s)
- L Romani
- Department of Experimental Medicine and Biochemical Sciences, University of Perugia, Italy.
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Rex JH, Sobel JD. Prophylactic antifungal therapy in the intensive care unit. Clin Infect Dis 2001; 32:1191-200. [PMID: 11283809 DOI: 10.1086/319763] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2000] [Revised: 11/29/2000] [Indexed: 11/03/2022] Open
Abstract
Antifungal prophylaxis is regularly used during treatment of patients with some cancers, as subgroups with high rates of invasive fungal infections are readily identified; for these patients, prophylaxis has been shown to be of value. High-risk liver transplant recipients also benefit from antifungal prophylaxis. Although the idea of extending this concept to the prevention of candidal infections in the larger population of critically ill patients who are seen in the intensive care unit (ICU) and who do not have neutropenia is attractive, implementation of this strategy is difficult because of the widely varying characteristics of patients in the ICU. Two studies have shown the benefit of such prophylaxis, but the benefit was shown only in selected groups of patients who had an unusually high risk for invasive candidiasis. Although the concept is sound, broad-scale implementation of antifungal prophylaxis would be premature and costly, both financially and with regard to resistance and toxicity. Investigations are needed to define and prove the utility of predictive tools for the identification of patients in the ICU who would benefit from prophylaxis.
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Affiliation(s)
- J H Rex
- Division of Infectious Diseases, Department of Internal Medicine, Center for the Study of Emerging and Re-Emerging Pathogens, University of Texas Medical School, Houston, TX 77030, USA.
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Binder C, Rüchel R. Case report. Mixed systemic mycosis with fatal outcome in a patient with acute myeloblastic leukaemia. Mycoses 2000; 43:59-63. [PMID: 10838849 DOI: 10.1046/j.1439-0507.2000.00537.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fungal infections represent an increasing problem in immunocompromised patients. The majority of cases are caused by one single fungal pathogen and infections with more than one fungus are very rare. Here we describe a case of combined infection with Aspergillus and a zygomycete species, involving the lungs, spleen and the brain and leading to fatal outcome in spite of early antimycotic therapy.
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Karthaus M, Doellmann T, Klimasch T, Elser C, Rosenthal C, Ganser A, Heil G. Intensive intravenous amphotericin B for prophylaxis of systemic fungal infections. Results of a prospective controlled pilot study in acute leukemia patients. Chemotherapy 2000; 46:293-302. [PMID: 10859435 DOI: 10.1159/000007301] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Invasive fungal infections are an increasing cause of morbidity in acute leukemia (AL) patients. METHODS In a prospective pilot trial, the safety and efficacy of antifungal prophylaxis with intravenous (i.v.) amphotericin B (AMB; 1 mg/kg every 48 h) was studied in 46 consecutive cycles. Prophylaxis with i.v. AMB was carried out in patients treated with intensive chemotherapy for AL and compared with a control of 49 cycles without prophylaxis. RESULTS Pulmonary infiltrates (5 vs. 23; p < 0.001) and fungal microabscesses in the liver or spleen (0 vs. 6; p = 0.014) occurred significantly less frequently in the prophylaxis group. While there were 3 deaths related to systemic fungal infections in the control group, there were none in the prophylaxis group. Escalation to conventional AMB (1.0 mg/kg/day) was significantly less frequent in the prophylaxis group (9 out of 46 cycles) compared with the control arm (29 out of 49 cycles; p = 0.001). A total of 695 mg of AMB per cycle was administered in the prophylaxis arm, compared with 634 mg/cycle for empirical treatment in the control group (p = 0.6). Infusion-related toxicity was documented in 29% of the cycles of prophylaxis compared with 55% of the cycles of empirical treatment with i.v. AMB in the control group. The nephrotoxicity of AMB prophylaxis was moderate, with >/= WHO degree II reported in 1 out of 46 cycles only. CONCLUSION Intensive i.v. AMB prophylaxis reduced invasive fungal infections and led to a reduction in fungal microabscesses in the liver or spleen, as well as pulmonary infiltrates, in patients treated for AL. The need for escalation to empirical i.v. AMB treatment was significantly reduced. Intensive AMB prophylaxis was feasible, with moderate adverse effects.
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Affiliation(s)
- M Karthaus
- Department of Hematology and Oncology, Medizinische Hochschule Hannover, Hannover, Germany
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