1
|
Panagopoulou P, Roilides E. An update on pharmacotherapy for fungal infections in allogeneic stem cell transplant recipients. Expert Opin Pharmacother 2024. [PMID: 39096057 DOI: 10.1080/14656566.2024.2387686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Invasive fungal diseases (IFD) constitute a major cause of morbidity and mortality in hematopoietic stem cell transplantation (HSCT) recipients. AREAS COVERED We describe epidemiology, causes and risk factors of IFD in allogeneic HSCT discussing prophylaxis and treatment in various HSCT phases. We present the most recent studies on this thematic area, including novel data on currently available antifungals, i.e. formulations, dosing, safety, efficacy and therapeutic drug monitoring. Finally, we present the most recent relevant recommendations published. Literature search included PubMed, Scopus and clinicaltrials.gov between January 2014-April 2024. EXPERT OPINION The antifungal agents employed for prophylaxis and therapy should be predicated on local epidemiology of IFD. Fluconazole prophylaxis remains a first-line choice before engraftment when the main pathogen is Candida spp. After engraftment prophylaxis should be with mold-active agents (i.e. triazoles). For candidiasis echinocandins are suggested as first-line treatment, whereas aspergillosis responds well to mold-active azoles and liposomal amphotericin B (L-AmB). For mucormycosis treatment of choice includes L-AmB and isavuconazole. Choice between fever-driven and diagnostics-driven strategies remains equivocal. Open research topics remain: 1) optimization of tools to ensure prompt and accurate IFD diagnosis to avoid unnecessary exposure to antifungals, drug interactions and cost; 2) refinement of treatment for resistant/refractory strains.
Collapse
Affiliation(s)
- Paraskevi Panagopoulou
- Pediatric Hematology & Oncology, 4th Department of Pediatrics, Aristotle University School of Medicine and Papageorgiou General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University School of Medicine and Hippokration General Hospital, Thessaloniki, Greece
| |
Collapse
|
2
|
Kamel NA, Abdalla MS, Al Ali A, Alshahrani MY, Aboshanab KM, El Borhamy MI. Effectiveness of Pre-Transplant Screening for High-Priority Multidrug-Resistant Pathogens on Pre-Engraftment Infections After Hematopoietic Stem Cell Transplantation. Infect Drug Resist 2024; 17:2249-2260. [PMID: 38854781 PMCID: PMC11162205 DOI: 10.2147/idr.s463868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/26/2024] [Indexed: 06/11/2024] Open
Abstract
Objective Owing to the rising incidence of multidrug-resistant organisms (MDRO) and the high mortality rates associated with such bacterial infections post-hematopoietic stem cell transplantation (HSCT), we investigated the MDRO colonization rate prior to transplantation using an active surveillance approach and determined its impact on subsequent infection during the pre-engraftment period. Methods A single-center observational study was conducted, and surveillance cultures from multiple body sites, including the rectum, nasal cavity, and groin, were performed at admission to determine MDRO colonization. Serological tests were used to detect certain viruses and toxoplasmosis before HSCT. Results In the pre-transplant setting, 59 MDRO were recovered from the 40 HSCT recipients. Of the 59 isolates recovered from one or more body sites, 29 were positive for methicillin-resistant Staphylococcus aureus (MRSA), 7 for carbapenem-resistant Enterobacterales (CRE), and 23 were positive for extended-spectrum β-lactamase (ESBLs). Serological assessment before HSCT revealed active or reactivation of latent infection with cytomegalovirus (7.5%), Epstein-Barr virus (EBV; 5%), and Toxoplasma gondii (2.5%) among HSCT patients. In terms of factors associated with pre-engraftment infections, the type of transplant (p=0.04) was statistically significant, whereas other factors, such as age, sex, and underlying conditions, were not. In post-transplant settings, bloodstream infections (BSIs) were documented in 2 allogeneic HSCT patients (5%), and the isolated microorganisms were ESBL-producing E. coli and non-MDR Acinetobacter baumannii. Conclusion Active screening cultures are a helpful tool for identifying patients colonized by MDRO or relevant viruses before HSCT, and for predicting those at risk of developing subsequent pre-engraftment infections. Additionally, active screening may aid in predicting those who are likely to develop subsequent pre-engraftment infections Our findings highlight the importance of pre-transplant screening for high-priority multidrug-resistant pathogens and the application of infection control interventions after HSCT.
Collapse
Affiliation(s)
- Noha A Kamel
- Department of Microbiology, Faculty of Pharmacy, Misr International University (MIU), Cairo, Egypt
| | - Mahmoud S Abdalla
- Hematology and Bone Marrow Transportation (BMT) Unit, International Medical Center (IMC), Cairo, Egypt
| | - Amer Al Ali
- Department of Clinical Laboratory Sciences, Faculty of Applied Medical Sciences, University of Bisha, Bisha, 67714, Saudi Arabia
| | - Mohammad Y Alshahrani
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha, 9088, Saudi Arabia
| | - Khaled M Aboshanab
- Microbiology and Immunology Department, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
- Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, University Technology MARA (Uitm), Campus Puncak Alam, Bandar Puncak Alam, Selangor, 42300, Malaysia
| | - Mervat I El Borhamy
- Department of Microbiology, Faculty of Pharmacy, Misr International University (MIU), Cairo, Egypt
- International Medical Center, Clinical Microbiology Laboratory, Cairo, Egypt
| |
Collapse
|
3
|
Shahabudin S, Azmi NS, Lani MN, Mukhtar M, Hossain MS. Candida albicans skin infection in diabetic patients: An updated review of pathogenesis and management. Mycoses 2024; 67:e13753. [PMID: 38877612 DOI: 10.1111/myc.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 06/16/2024]
Abstract
Candida species, commensal residents of human skin, are recognized as the cause of cutaneous candidiasis across various body surfaces. Individuals with weakened immune systems, particularly those with immunosuppressive conditions, are significantly more susceptible to this infection. Diabetes mellitus, a major metabolic disorder, has emerged as a critical factor inducing immunosuppression, thereby facilitating Candida colonization and subsequent skin infections. This comprehensive review examines the prevalence of different types of Candida albicans-induced cutaneous candidiasis in diabetic patients. It explores the underlying mechanisms of pathogenicity and offers insights into recommended preventive measures and treatment strategies. Diabetes notably increases vulnerability to oral and oesophageal candidiasis. Additionally, it can precipitate vulvovaginal candidiasis in females, Candida balanitis in males, and diaper candidiasis in young children with diabetes. Diabetic individuals may also experience candidal infections on their nails, hands and feet. Notably, diabetes appears to be a risk factor for intertrigo syndrome in obese individuals and periodontal disorders in denture wearers. In conclusion, the intricate relationship between diabetes and cutaneous candidiasis necessitates a comprehensive understanding to strategize effective management planning. Further investigation and interdisciplinary collaborative efforts are crucial to address this multifaceted challenge and uncover novel approaches for the treatment, management and prevention of both health conditions, including the development of safer and more effective antifungal agents.
Collapse
Affiliation(s)
- Sakina Shahabudin
- Faculty of Industrial Sciences and Technology, Universiti Malaysia Pahang Al-Sultan Abdullah, Kuantan, Pahang, Malaysia
| | - Nina Suhaity Azmi
- Faculty of Industrial Sciences and Technology, Universiti Malaysia Pahang Al-Sultan Abdullah, Kuantan, Pahang, Malaysia
| | - Mohd Nizam Lani
- Faculty of Fisheries and Food Science, Universiti Malaysia Terengganu, Kuala Nerus, Terengganu, Malaysia
| | | | - Md Sanower Hossain
- Centre for Sustainability of Mineral and Resource Recovery Technology (Pusat SMaRRT), Universiti Malaysia Pahang Al-Sultan Abdullah, Kuantan, Pahang, Malaysia
| |
Collapse
|
4
|
Price EB, Dubey S, Sulaiman ZI, Samra H, Askar G. A Silent Threat Unveiled: Invasive Fungal Sinusitis in a High-Risk Hematologic Malignancy Patient. Cureus 2024; 16:e61232. [PMID: 38939236 PMCID: PMC11210428 DOI: 10.7759/cureus.61232] [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] [Accepted: 05/28/2024] [Indexed: 06/29/2024] Open
Abstract
Invasive fungal sinusitis (IFS) poses a fatal threat to patients with hematological malignancies or a history of allogeneic hematopoietic stem cell transplant (HSCT). While invasive aspergillosis, a subtype of IFS, remains rare in immunocompetent individuals, allogeneic HSCT recipients face a notable surge in incidence. Despite the rapid onset and progression of IFS, its clinical presentation is subtle, contributing to heightened mortality rates. Prompt surgical debridement and systemic antifungal therapy are required to yield positive results. Examining IFS cases in HSCT recipients is vital, providing insights into its clinical course, prevention strategies, and improved evaluation. We present a rare presentation of IFS with Aspergillus niger in a relapsed acute myeloid leukemia patient post-HSCT. Two weeks after chemotherapy, the patient developed headaches and blood-tinged sinus drainage in the setting of pancytopenia. Radiologic and pathological findings confirmed the diagnosis of IFS, necessitating weeks of intensive anti-fungal therapy. Despite the initial positive response, the disease ultimately progressed to a fatal outcome. This case emphasizes that early detection is required for a favorable treatment response. Furthermore, it underscores the importance of heightened clinical suspicion, risk stratification, multidisciplinary care, and ongoing research for optimal management of IFS in allogeneic HSCT recipients.
Collapse
Affiliation(s)
- Elexis B Price
- Infectious Disease, Medical College of Georgia at Augusta University, Augusta, USA
| | - Shresttha Dubey
- Infectious Disease, Medical College of Georgia at Augusta University, Augusta, USA
| | - Zoheb I Sulaiman
- Infectious Disease, Medical College of Georgia at WellStar MCG Health, Augusta, USA
| | - Hasan Samra
- Pathology, Medical College of Georgia at WellStar MCG Health, Augusta, USA
| | - Gina Askar
- Infectious Disease, Medical College of Georgia at WellStar MCG Health, Augusta, USA
| |
Collapse
|
5
|
Davies GE, Thornton CR. A Lateral-Flow Device for the Rapid Detection of Scedosporium Species. Diagnostics (Basel) 2024; 14:847. [PMID: 38667492 PMCID: PMC11048963 DOI: 10.3390/diagnostics14080847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Scedosporium species are human pathogenic fungi, responsible for chronic, localised, and life-threatening disseminated infections in both immunocompetent and immunocompromised individuals. The diagnosis of Scedosporium infections currently relies on non-specific CT, lengthy and insensitive culture from invasive biopsy, and the time-consuming histopathology of tissue samples. At present, there are no rapid antigen tests that detect Scedosporium-specific biomarkers. Here, we report the development of a rapid (30 min) and sensitive (pmol/L sensitivity) lateral-flow device (LFD) test, incorporating a Scedosporium-specific IgG1 monoclonal antibody (mAb), HG12, which binds to extracellular polysaccharide (EPS) antigens between ~15 kDa and 250 kDa secreted during the hyphal growth of the pathogens. The test is compatible with human serum and allows for the detection of the Scedosporium species most frequently reported as agents of human disease (Scedosporium apiospermum, Scedosporium aurantiacum, and Scedosporium boydii), with limits of detection (LODs) of the EPS biomarkers in human serum of ~0.81 ng/mL (S. apiospermum), ~0.94 ng/mL (S. aurantiacum), and ~1.95 ng/mL (S. boydii). The Scedosporium-specific LFD (ScedLFD) test therefore provides a potential novel opportunity for the detection of infections caused by different Scedosporium species.
Collapse
Affiliation(s)
- Genna E. Davies
- ISCA Diagnostics Ltd., B12A, Hatherly Laboratories, Prince of Wales Road, Exeter EX4 4PS, UK;
| | - Christopher R. Thornton
- ISCA Diagnostics Ltd., B12A, Hatherly Laboratories, Prince of Wales Road, Exeter EX4 4PS, UK;
- Biosciences, Faculty of Health and Life Sciences, Prince of Wales Road, Exeter EX4 4PS, UK
| |
Collapse
|
6
|
Niu X, Al-Hatmi AMS, Vitale RG, Lackner M, Ahmed SA, Verweij PE, Kang Y, de Hoog S. Evolutionary trends in antifungal resistance: a meta-analysis. Microbiol Spectr 2024; 12:e0212723. [PMID: 38445857 PMCID: PMC10986544 DOI: 10.1128/spectrum.02127-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024] Open
Abstract
The present paper includes a meta-analysis of literature data on 318 species of fungi belonging to 34 orders in their response to 8 antifungal agents (amphotericin B, caspofungin, fluconazole, itraconazole, ketoconazole, posaconazole, terbinafine, and voriconazole). Main trends of MIC results at the ordinal level were visualized. European Committee on Antimicrobial Susceptibility Testing and Clinical & Laboratory Standards Institute (CLSI) clinical breakpoints were used as the staff gauge to evaluate MIC values ranging from resistance to susceptibility, which were subsequently compared with a phylogenetic tree of the fungal kingdom. Several orders (Hypocreales, Microascales, and Mucorales) invariably showed resistance. Also the basidiomycetous orders Agaricales, Polyporales, Sporidiales, Tremellales, and Trichosporonales showed relatively high degrees of azole multi-resistance, while elsewhere in the fungal kingdom, including orders with numerous pathogenic and opportunistic species, that is, Onygenales, Chaetothyiales, Sordariales, and Malasseziales, in general were susceptible to azoles. In most cases, resistance vs susceptibility was consistently associated with phylogenetic distance, members of the same order showing similar behavior. IMPORTANCE A kingdom-wide the largest set of published wild-type antifungal data comparison were analyzed. Trends in resistance in taxonomic groups (monophyletic clades) can be compared with the phylogeny of the fungal kingdom, eventual relationships between fungus-drug interaction and evolution can be described.
Collapse
Affiliation(s)
- Xueke Niu
- Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education of Guizhou & Key Laboratory of Microbiology and Parasitology of Education Department of Guizhou, School of Basic Medical Sciences, Guizhou Medical University, Guiyang, China
- Center of Expertise in Mycology of Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - 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, Oman
| | - 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
| | - Michaela Lackner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sarah A. Ahmed
- Center of Expertise in Mycology of Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Paul E. Verweij
- Center of Expertise in Mycology of Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Yingqian Kang
- Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education of Guizhou & Key Laboratory of Microbiology and Parasitology of Education Department of Guizhou, School of Basic Medical Sciences, Guizhou Medical University, Guiyang, China
| | - Sybren de Hoog
- Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education of Guizhou & Key Laboratory of Microbiology and Parasitology of Education Department of Guizhou, School of Basic Medical Sciences, Guizhou Medical University, Guiyang, China
- Center of Expertise in Mycology of Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| |
Collapse
|
7
|
Oyama T, Fujiwara SI, Tominaga R, Yokoyama D, Noguchi A, Furuki S, Koyama S, Murahashi R, Nakashima H, Hyodo K, Ikeda T, Kawaguchi SI, Toda Y, Nagayama T, Umino K, Minakata D, Morita K, Ashizawa M, Yamamoto C, Hatano K, Sato K, Otsuki I, Ohmine K, Kanda Y. Effects of CD34 + cell dose on engraftment and long-term outcomes after allogeneic bone marrow transplantation. Clin Transplant 2024; 38:e15313. [PMID: 38581299 DOI: 10.1111/ctr.15313] [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: 02/19/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The number of CD34+ cells in the graft is generally associated with time to engraftment and survival in transplantation using cord blood or allogeneic peripheral blood stem cells. However, the significance of abundant CD34+ in bone marrow transplantation (BMT) remained unclear. METHODS We retrospectively reviewed 207 consecutive adult patients who underwent their first BMT at Jichi Medical University between January 2009 and June 2021. RESULTS The median nucleated cell count (NCC) and CD34+ cell dose were 2.17 × 108/kg (range .56-8.52) and 1.75 × 106/kg (.21-5.84), respectively. Compared with 104 patients in the low CD34+ group (below the median), 103 patients in the high CD34+ group (above the median) showed faster engraftment at day +28 in terms of neutrophil (84.6% vs. 94.2%; p = .001), reticulocyte (51.5% vs. 79.6%; p < .001), and platelet (39.4% vs. 72.8%; p < .001). There were no significant differences in overall survival, relapse, nonrelapse mortality, acute or chronic graft-versus-host disease, or infectious complications between the two groups in univariate and multivariate analyses. Low or high NCC had no significant effect on overall survival, nonrelapse mortality, cumulative incidence of relapse and graft-versus-host disease, either. While a positive correlation was observed between NCC and the CD34+ cell dose, a high CD34+ cell dose was associated with rapid hematopoietic recovery, even in patients with NCC below the median. CONCLUSION Measurement of CD34+ cell dose in addition to NCC was useful for predicting hematopoietic recovery, but seemed to have little influence on the long-term outcome in BMT.
Collapse
Affiliation(s)
- Takashi Oyama
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shin-Ichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
- Division of Cell Transplantation and Transfusion, Jichi Medical University, Tochigi, Japan
| | - Ryutaro Tominaga
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Daizo Yokoyama
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Atsuto Noguchi
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shuka Furuki
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shunsuke Koyama
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Rui Murahashi
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Hirotomo Nakashima
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kazuki Hyodo
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Takashi Ikeda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shin-Ichiro Kawaguchi
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yumiko Toda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Takashi Nagayama
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
- Division of Cell Transplantation and Transfusion, Jichi Medical University, Tochigi, Japan
| | - Kento Umino
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Daisuke Minakata
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kaoru Morita
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Masahiro Ashizawa
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Chihiro Yamamoto
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kaoru Hatano
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kazuya Sato
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ikuko Otsuki
- Division of Cell Transplantation and Transfusion, Jichi Medical University, Tochigi, Japan
| | - Ken Ohmine
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| |
Collapse
|
8
|
Zoowa R, Shah R, Pradhan D, Karmacharya S, Bhandari D. Candida krusei pneumonia in graft-versus-host disease after allogeneic hematopoietic stem cell transplant for paroxysmal nocturnal hemoglobinuria: a case report. Ann Med Surg (Lond) 2023; 85:6168-6172. [PMID: 38098551 PMCID: PMC10718395 DOI: 10.1097/ms9.0000000000001374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/24/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction and importance Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder caused by a somatic mutation of PIGA (phosphatidylinositol glycan anchor biosynthesis, class A) gene that leads to the destruction of blood cells. Allogeneic haematopoietic stem cell transplant (HSCT) is a treatment option for PHN, but it can cause graft-versus-host disease (GVHD). Long-term immunosuppression as a treatment of GVHD increases the risk for invasive fungal infections such as Candida krusei pneumonia. Case presentation We present the case of a 22-year-old male with C. krusei pneumonia in a known case of chronic GVHD following HSCT for PNH undergoing long-term immunosuppressive therapy. The patient presented with progressive shortness of breath, productive cough, palpitations, and difficulty swallowing. On examination, he had skin rashes and oral lesions, along with signs of severe malnutrition. Diagnosis was made on the basis of radiological imaging and fungal culture. Discussion The combination of PNH, GVHD, and HSCT created an immunocompromised state, making the patient susceptible to opportunistic infections, including fungal pneumonia. Early recognition of this condition is challenging due to its non-specific symptoms and potential overlap with other post-transplant complications. Timely diagnosis and appropriate treatment, including antifungal therapy and immunosuppression management, are crucial for optimising patient outcomes. Conclusion This case highlights the importance of early recognition and timely treatment of fungal infections in patients with severe conditions such as GVHD following HSCT for PNH. Timely treatment with appropriate antifungals is necessary for optimal outcomes. Additionally, more research with long-term follow-up and monitoring is necessary to address the necessary knowledge gaps in this field.
Collapse
Affiliation(s)
- Ronit Zoowa
- Nepalese Army Institute of Health Sciences, Sanobharyang
| | - Ravi Shah
- Nepalese Army Institute of Health Sciences, Sanobharyang
| | | | | | | |
Collapse
|
9
|
Heimlich FV, de Arruda JAA, Pereira NM, Faria LDS, Abreu LG, Ferreira MVL, Kakehasi FM, Travassos DV, Silva TA, Mesquita RA. Proposal of a prophylactic photobiomodulation protocol for chemotherapy-induced oral and oropharyngeal mucositis: a randomized clinical trial. Lasers Med Sci 2023; 38:245. [PMID: 37889325 DOI: 10.1007/s10103-023-03916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/19/2023] [Indexed: 10/28/2023]
Abstract
Photobiomodulation therapy (PBMT) is widely used in oncology settings, but lack of assessment standardization is the main barrier to optimization of clinical protocols. This study analyzed three PBMT protocols for preventing oral and oropharyngeal mucositis (OM) in patients undergoing chemotherapy (CT) and/or hematopoietic stem cell transplantation (HSCT). This is a preliminary randomized blind clinical trial. Group 1 received intraoral prophylactic PBMT, Group 2 received intraoral and oropharyngeal PBMT, and Group 3 received intraoral, oropharyngeal, and extraoral PBMT. The applications were from the first day of CT to day + 10. Clinicodemographic data, CT regimens, types of HSCT, hematological exams, occurrence/severity of OM, odynophagia, and OM-related opportunistic infections were assessed. Sixty participants (age range: 18-74 years) were included; 70% of them underwent CT and 30% HSCT. About 43.3% of patients had OM, while odynophagia was reported by 23.3%. Both Groups 1 and 2 revealed better results. Multivariate analysis showed that HSCT directly influenced the occurrence of OM. Individuals who had undergone allogeneic HSCT were 1.93 times more likely to develop OM (p < 0.001). Group 3 exhibited a higher frequency of OM, albeit of lower grades. This group consisted of half the population who had undergone HSCT, had the highest percentage of melphalan use, and had the lowest mean leukocyte count. The three proposed protocols were effective in preventing and reducing OM, with good tolerance and no reported adverse effects. PBMT is a safe and effective approach to OM prophylaxis in adults undergoing CT/HSCT.
Collapse
Affiliation(s)
- Fernanda Vieira Heimlich
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - José Alcides Almeida de Arruda
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Nickolas Mendes Pereira
- Multiprofessional Integrated Residency in Health, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Larissa Dos Santos Faria
- Multiprofessional Integrated Residency in Health, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Lucas Guimarães Abreu
- Department of Child and Adolescent Oral Health, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Marcus Vinícius Lucas Ferreira
- Department of Restorative Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Fabiana Maria Kakehasi
- Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Denise Vieira Travassos
- Multiprofessional Integrated Residency in Health, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Department of Social and Preventive Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Tarcília Aparecida Silva
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Multiprofessional Integrated Residency in Health, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Ricardo Alves Mesquita
- Department of Oral Surgery, Pathology and Clinical Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| |
Collapse
|
10
|
Cai W, Ruan Q, Li J, Lin L, Xi L, Sun J, Lu S. Fungal Spectrum and Susceptibility Against Nine Antifungal Agents in 525 Deep Fungal Infected Cases. Infect Drug Resist 2023; 16:4687-4696. [PMID: 37484904 PMCID: PMC10362860 DOI: 10.2147/idr.s403863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/30/2023] [Indexed: 07/25/2023] Open
Abstract
Background Deep fungal infection has become an important cause of infection and death in hospitalized patients, and this has worsened with increasing antifungal drug resistance. Objective A 3-year retrospective study was conducted to investigate the clinical characteristics, pathogen spectrum, and drug resistance of deep fungal infection in a regional hospital of Guangzhou, China. Methods Non-duplicate fungi isolates recovered from blood and other sterile body fluids of in-patients of the clinical department were identified using biochemical tests of pure culture with the API20C AUX and CHROMagar medium. Antifungal susceptibilities were determined by Sensititre YeastOne® panel trays. Results In this study, 525 patients (283 female, 242 male) with deep fungal infection were included, half of them were elderly patients (≥60 years) (54.67%, n=286). A total of 605 non-repetitive fungi were finally isolated from sterile samples, of which urine specimens accounted for 66.12% (n=400). Surgery, ICU, and internal medicine were the top three departments that fungi were frequently detected. The mainly isolated fungal species were Candida albicans (43.97%, n=266), Candida glabrata (20.00%, n=121), and Candida tropicalis (17.02%, n=103), which contributed to over 80% of fungal infection. The susceptibility of the Candida spp. to echinocandins, 5-fluorocytosine, and amphotericin B remained above 95%, while C. glabrata and C. tropicalis to itraconazole were about 95%, and the dose-dependent susceptibility of C. glabrata to fluconazole was more than 90%. The echinocandins had no antifungal activity against Trichosporon asahi in vitro (MIC90>8 μg/mL), but azole drugs were good, especially voriconazole and itraconazole (MIC90 = 0.25 μg/mL). Conclusion The main causative agents of fungal infection were still the genus of Candida. Echinocandins were the first choice for clinical therapy of Candida infection, followed with 5-fluorocytosine and amphotericin B. Azole antifungal agents should be used with caution in Candida glabrata and Candida tropicalis infections.
Collapse
Affiliation(s)
- Wenying Cai
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Qianqian Ruan
- Guangdong Provincial Institute of Public Health, Guangzhou, People’s Republic of China
- Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, People’s Republic of China
- School of Public Health, Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Jiahao Li
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Li Lin
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Liyan Xi
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
- Dermatology Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Jiufeng Sun
- Guangdong Provincial Institute of Public Health, Guangzhou, People’s Republic of China
- Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, People’s Republic of China
| | - Sha Lu
- Department of Dermatology and Venereology, Sun Yat-sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
| |
Collapse
|
11
|
McCrea JB, Menzel K, Fancourt C, Witter R, Zhao T, Robbins JA, Stoch SA, Iwamoto M. Evaluation of the inhibitory effects of itraconazole on letermovir. Br J Clin Pharmacol 2023; 89:2122-2130. [PMID: 36717270 DOI: 10.1111/bcp.15677] [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: 10/06/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 02/01/2023] Open
Abstract
AIMS Letermovir, a cytomegalovirus (CMV) DNA terminase complex inhibitor, is a substrate of ABCB1 (P-glycoprotein; P-gp), organic anion transporting polypeptide (OATP)1B1/3, UDP-glucuronosyltransferase (UGT)1A1, UGT1A3 and possibly ABCG2 (breast cancer resistance protein; BCRP). A study was conducted to evaluate the effects of itraconazole, a prototypic ABCB1/ABCG2 inhibitor, on letermovir pharmacokinetics (PK) and the effects of letermovir on itraconazole PK. METHODS In an open-label, fixed-sequence study in 14 healthy participants, 200 mg oral itraconazole was administered once daily for 4 days. Following a 10-day washout, 480 mg oral letermovir was administered once daily for 14 days (Days 1-14) and then coadministered with 200 mg itraconazole once daily for 4 days (Days 15-18). Intensive PK sampling was performed for letermovir and itraconazole. PK and safety were evaluated. RESULTS Letermovir geometric mean ratio (GMR; 90% confidence interval [CI]) for area under the concentration-time curve from time 0 to 24 h (AUC0-24 ) was 1.33 (1.17, 1.51) and for maximum concentration (Cmax ) was 1.21 (1.05, 1.39) following administration with/without itraconazole. Itraconazole GMR (90% CI) for AUC0-24 was 0.76 (0.71, 0.81) and for Cmax was 0.84 (0.76, 0.92) following administration with/without letermovir. Coadministration of letermovir with itraconazole was generally well tolerated. CONCLUSIONS The increase in letermovir exposure with coadministration of itraconazole is likely predominantly due to inhibition of intestinal ABCB1 and potentially ABCG2 transport. The mechanism for the decrease in itraconazole exposure is unknown. The modest changes in letermovir and itraconazole PK are not considered clinically meaningful.
Collapse
Affiliation(s)
| | | | | | | | - Tian Zhao
- Merck & Co., Inc., Rahway, New Jersey, USA
| | | | | | | |
Collapse
|
12
|
Calle-Miguel L, Garrido-Colino C, Santiago-García B, Moreno Santos MP, Gonzalo Pascual H, Ponce Salas B, Beléndez Bieler C, Navarro Gómez M, Guinea Ortega J, Rincón-López EM. Changes in the epidemiology of invasive fungal disease in a Pediatric Hematology and Oncology Unit: the relevance of breakthrough infections. BMC Infect Dis 2023; 23:348. [PMID: 37226103 DOI: 10.1186/s12879-023-08314-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/08/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Invasive fungal disease (IFD) is a significant cause of morbimortality in children under chemotherapy or hematopoietic stem cell transplant (HSCT). The purpose of this study is to describe the changes in the IFD epidemiology that occurred in a Pediatric Hematology-Oncology Unit (PHOU) with an increasing activity over time. METHODS Retrospective revision of the medical records of children (from 6 months to 18 years old) diagnosed with IFD in the PHOU of a tertiary hospital in Madrid (Spain), between 2006 and 2019. IFD definitions were performed according to the EORTC revised criteria. Prevalence, epidemiological, diagnostic and therapeutic parameters were described. Comparative analyses were conducted using Chi-square, Mann-Whitney and Kruskal-Wallis tests, according to three time periods, the type of infection (yeast vs mold infections) and the outcome. RESULTS Twenty-eight episodes of IFD occurred in 27 out of 471 children at risk (50% males; median age of 9.8 years old, [IQR 4.9-15.1]), resulting in an overall global prevalence of 5.9%. Five episodes of candidemia and 23 bronchopulmonary mold diseases were registered. Six (21.4%), eight (28.6%) and 14 (50%) episodes met criteria for proven, probable and possible IFD, respectively. 71.4% of patients had a breakthrough infection, 28.6% required intensive care and 21.4% died during treatment. Over time, bronchopulmonary mold infections and breakthrough IFD increased (p=0.002 and p=0.012, respectively), occurring in children with more IFD host factors (p=0.028) and high-risk underlying disorders (p=0.012). A 64% increase in the number of admissions in the PHOU (p<0.001) and a 277% increase in the number of HSCT (p=0.008) were not followed by rising rates of mortality or IFD/1000 admissions (p=0.674). CONCLUSIONS In this study, we found that yeast infections decreased, while mold infections increased over time, being most of them breakthrough infections. These changes are probably related to the rising activity in our PHOU and an increase in the complexity of the baseline pathologies of patients. Fortunately, these facts were not followed by an increase in IFD prevalence or mortality rates.
Collapse
Affiliation(s)
- Laura Calle-Miguel
- Pediatric Infectious Diseases Section. Pediatrics Department. Hospital Materno, Infantil Gregorio Marañón. C/ O', Donnell 48-50, 28009, Madrid, Spain.
| | - Carmen Garrido-Colino
- Hospital General Universitario Gregorio Marañón (Pediatric Hematology and Oncology Unit. Pediatrics Department), Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
| | - Begoña Santiago-García
- Hospital General Universitario Gregorio Marañón (Pediatric Infectious Diseases Unit. Pediatrics Department), CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Martha Patricia Moreno Santos
- Pediatric Infectious Diseases Section. Pediatrics Department. Hospital Materno, Infantil Gregorio Marañón. C/ O', Donnell 48-50, 28009, Madrid, Spain
| | - Henar Gonzalo Pascual
- Pediatric Infectious Diseases Section. Pediatrics Department. Hospital Materno, Infantil Gregorio Marañón. C/ O', Donnell 48-50, 28009, Madrid, Spain
| | - Beatriz Ponce Salas
- Hospital General Universitario Gregorio Marañón (Pediatric Hematology and Oncology Unit. Pediatrics Department), Madrid, Spain
| | - Cristina Beléndez Bieler
- Hospital General Universitario Gregorio Marañón (Pediatric Hematology and Oncology Unit. Pediatrics Department), Madrid, Spain
| | - Marisa Navarro Gómez
- Complutense University of Madrid, Madrid, Spain
- Hospital General Universitario Gregorio Marañón (Pediatric Infectious Diseases Unit. Pediatrics Department), CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Guinea Ortega
- Complutense University of Madrid, Madrid, Spain
- Hospital General Universitario Gregorio Marañón (Clinical Microbiology and Infectious Diseases Department), Madrid, Spain
| | - Elena María Rincón-López
- Hospital General Universitario Gregorio Marañón (Pediatric Infectious Diseases Unit. Pediatrics Department), CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
13
|
Bhatti H, Batbileg E, De S, Friedman G, Antony S. Acute Colonic Perforation with Septic Shock Secondary to Disseminated Histoplasmosis in an Autologous Bone Marrow Transplant Recipient. Infect Drug Resist 2023; 16:3029-3034. [PMID: 37215300 PMCID: PMC10199683 DOI: 10.2147/idr.s402228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
Histoplasma capsulatum is an opportunistic pathogen which can lead to a wide variety of clinical presentations in the immunocompromised host. Post-transplant histoplasmosis in hematopoietic cell transplant recipients is exceedingly rare, with an incidence of <1%. We present a case of acute caecal perforation resulting from disseminated histoplasmosis in a patient who had undergone autologous bone marrow transplant for plasma cell dyscrasia. This is a 71-year-old patient who initially presented due to progressive weakness associated with shortness of breath.
Collapse
Affiliation(s)
- Harsimrandeep Bhatti
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| | - Enkhbileg Batbileg
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| | - Srijisnu De
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| | - Glen Friedman
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| | - Suresh Antony
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| |
Collapse
|
14
|
Indications that the Antimycotic Drug Amphotericin B Enhances the Impact of Platelets on Aspergillus. Antimicrob Agents Chemother 2022; 66:e0068122. [PMID: 36190233 PMCID: PMC9578436 DOI: 10.1128/aac.00681-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Platelets are currently thought to harbor antimicrobial functions and might therefore play a crucial role in infections, e.g., those caused by Aspergillus or mucormycetes. The incidence of invasive fungal infections is increasing, particularly during the coronavirus disease 2019 (COVID-19) pandemic, and such infections continue to be life-threatening in immunocompromised patients. For this reason, the interaction of antimycotics with platelets is a key issue to evaluate modern therapeutic regimens. Amphotericin B (AmB) is widely used for the therapy of invasive fungal infections either as deoxycholate (AmB-D) or as a liposomal formulation (L-AmB). We showed that AmB strongly activates platelets within a few minutes. AmB concentrations commonly measured in the blood of patients were sufficient to stimulate platelets, indicating that this effect is highly relevant in vivo. The stimulating effect was corroborated by a broad spectrum of platelet activation parameters, including degranulation, aggregation, budding of microparticles, morphological changes, and enhanced adherence to fungal hyphae. Comparison between the deoxycholate and the liposomal formulation excluded the possibility that the liposomal part of L-Amb is responsible for these effects, as no difference was visible. The induction of platelet activation and alteration by L-AmB resulted in the activation of other parts of innate immunity, such as stimulation of the complement cascade and interaction with granulocytes. These mechanisms might substantially fuel the antifungal immune reaction in invasive mycoses. On the other hand, thrombosis and excessive inflammatory processes might occur via these mechanisms. Furthermore, the viability of L-AmB-activated platelets was consequently decreased, a process that might contribute to thrombocytopenia in patients.
Collapse
|
15
|
González-García P, Alonso-Sardón M, Rodríguez-Alonso B, Almeida H, Romero-Alegría Á, Vega-Rodríguez VJ, López-Bernús A, Muñoz-Bellido JL, Muro A, Pardo-Lledías J, Belhassen-García M. How Has the Aspergillosis Case Fatality Rate Changed over the Last Two Decades in Spain? J Fungi (Basel) 2022; 8:jof8060576. [PMID: 35736059 PMCID: PMC9225319 DOI: 10.3390/jof8060576] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 02/04/2023] Open
Abstract
(1) Background: Aspergillus produces high morbidity and mortality, especially in at-risk populations. In Spain, the evolution of mortality in recent years due to this fungus is not well established. The aim of this study was to estimate the case fatality rate of aspergillosis in inpatients from 1997 to 2017 in Spain. (2) Methodology: A retrospective descriptive study was conducted with records of inpatients admitted to the National Health System with a diagnosis of aspergillosis. (3) Principal findings: Of 32,960 aspergillosis inpatients, 24.5% of deaths were registered, and 71% of the patients who died were men. The percentage of deaths increased progressively with age. The case fatality rate progressively decreased over the period, from 25.4 and 27.8% in 1997–1998 to values of 20.6 and 20.8% in 2016 and 2017. Influenza and pneumonia occurrence/association significantly increased case fatality rates in all cases. (4) Conclusions: Our study shows that lethality significantly decreased in the last two decades despite the increase in cases. This highlights the fact that patients with solid and/or hematological cancer do not have a much higher mortality rate than the group of patients with pneumonia or influenza alone, these two factors being the ones that cause the highest CFRs. We also need studies that analyze the causes of mortality to decrease it and studies that evaluate the impact of COVID-19.
Collapse
Affiliation(s)
- Pablo González-García
- Servicio de Medicina Interna, Hospital Marqués de Valdecilla, IDIVAL, Universidad de Cantabria, 39008 Santander, Spain; (P.G.-G.); (J.P.-L.)
| | - Montserrat Alonso-Sardón
- Área de Medicina Preventiva, Epidemiología y Salud Pública, IBSAL, CIETUS, Universidad de Salamanca, 37007 Salamanca, Spain;
| | - Beatriz Rodríguez-Alonso
- Servicio de Medicina Interna, Unidad de Enfermedades Infecciosas CAUSA, IBSAL, CIETUS, 37007 Salamanca, Spain; (B.R.-A.); (Á.R.-A.); (A.L.-B.)
| | - Hugo Almeida
- Serviçio de Medicina Interna, Unidade Local de Saúde de Guarda, 6300 Guarda, Portugal;
| | - Ángela Romero-Alegría
- Servicio de Medicina Interna, Unidad de Enfermedades Infecciosas CAUSA, IBSAL, CIETUS, 37007 Salamanca, Spain; (B.R.-A.); (Á.R.-A.); (A.L.-B.)
| | | | - Amparo López-Bernús
- Servicio de Medicina Interna, Unidad de Enfermedades Infecciosas CAUSA, IBSAL, CIETUS, 37007 Salamanca, Spain; (B.R.-A.); (Á.R.-A.); (A.L.-B.)
| | - Juan Luis Muñoz-Bellido
- Servicio de Microbiología y Parasitología, CAUSA, CIETUS, IBSAL, Departamento de Ciencias Biomédicas y del Diagnóstico, Universidad de Salamanca, CSIC, 37007 Salamanca, Spain;
| | - Antonio Muro
- Infectious and Tropical Diseases Group (e-INTRO), IBSAL-CIETUS, Faculty of Pharmacy, University of Salamanca, 37007 Salamanca, Spain;
| | - Javier Pardo-Lledías
- Servicio de Medicina Interna, Hospital Marqués de Valdecilla, IDIVAL, Universidad de Cantabria, 39008 Santander, Spain; (P.G.-G.); (J.P.-L.)
| | - Moncef Belhassen-García
- Servicio de Medicina Interna, Unidad de Enfermedades Infecciosas CAUSA, IBSAL, CIETUS, 37007 Salamanca, Spain; (B.R.-A.); (Á.R.-A.); (A.L.-B.)
- Correspondence: ; Tel.: +34-923291100 (ext. 306)
| |
Collapse
|
16
|
Busca A, Cinatti N, Gill J, Passera R, Dellacasa CM, Giaccone L, Dogliotti I, Manetta S, Corcione S, De Rosa FG. Management of Invasive Fungal Infections in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation: The Turin Experience. Front Cell Infect Microbiol 2022; 11:805514. [PMID: 35071052 PMCID: PMC8782257 DOI: 10.3389/fcimb.2021.805514] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/13/2021] [Indexed: 02/03/2023] Open
Abstract
Background Allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients are exposed to an increased risk of invasive fungal infections (IFIs) due to neutropenia, immunosuppressive treatments, graft-versus-host disease (GvHD) and incomplete immune reconstitution. Although clinical benefit from antifungal prophylaxis has been demonstrated, IFIs remain a leading cause of morbidity and mortality in these patients. In the last decades, attention has also been focused on potential risk factors for IFI to tailor an antifungal prevention strategy based on risk stratification. Aim of the Study This retrospective single-center study aimed to assess the epidemiology and the prognostic factors of IFI in a large cohort of allo-HSCT patients. Methods Between January 2004 and December 2020, 563 patients with hematological malignancies received an allo-HSCT at the Stem Cell Transplant Unit in Turin: 191 patients (34%) received grafts from a matched sibling donor, 284 (50.5%) from a matched unrelated donor, and 87 (15.5%) from an haploidentical family member. The graft source was peripheral blood in 81.5% of the patients. Our policy for antifungal prophylaxis included fluconazole in matched related and unrelated donors, while micafungin was administered in patients receiving haploidentical transplant. According to this practice, fluconazole was administered in 441 patients (79.6%) and micafungin in 62 (11.2%), while only 9 patients received mold-active prophylaxis. Galactomannan testing was routinely performed twice a week; patients with persisting fever unresponsive to broad spectrum antibiotics were evaluated with lung high-resolution computed tomography (HRCT) scan. In case of imaging suggestive of IFI, bronchoalveolar lavage (BAL) was performed whenever feasible. Statistical Analysis Only probable/proven IFI (PP-IFI) occurring during the first 12 months after transplant have been evaluated. IFIs were classified as probable or proven according to the new revised European Organization for Research and Treatment of Cancer (EORTC)/Mycoses Study Group (MSG) consensus criteria. Multivariate competing risk regression, binary logistic, and proportional hazard models were performed to identify risk factors for PP-IFI. Results A total of 58 PP-IFIs (n = 47 probable; n = 11 proven) occurred in our patients resulting in a cumulative incidence of 4.1%, 8.1%, and 9.6% at 30, 180, and 365 days, respectively. Molds were the predominant agents (n = 50 Aspergillus; n = 1 Mucor), followed by invasive candidemia (n = 5 non-albicans Candida; n = 1 Candida albicans; n = 1 Trichosporon). Lung was the most frequent site involved in patients with mold infections (47/51, 92.2%). Median time from HSCT to IFI was 98.44 days (0–365 days). Only 34.5% of patients with IFI were neutropenic at the time of infection. The presence of IFI had a significant impact on overall survival at 1 year (IFI, 32.8% vs. non-IFI, 54.6%; p < 0.001). IFI-related mortality rate was 20.7% in the overall population, 17% in patients with probable IFI, and 36% in patients with proven IFI. Multivariate competing risk regression revealed that donor type was the factor significantly associated to the risk of IFI [subdistribution hazard ratio (SDHR), 1.91, IC 1.13–3.20; p = 0.015]. BAL was informative in a consistent number of cases (36/57, 63.2%) leading to the identification of fungal (21), bacterial (4), viral (3), and polymicrobial (8) infections. Overall, 79 patients (14%) received a diagnostic-driven treatment, and 63 patients (11.2%) received a fever-driven treatment. Liposomal amphoteric B was the drug used in the majority of patients receiving diagnostic-driven therapy (30/79, 38%), while caspofungin was administered more frequently in patients who received a fever-driven strategy (27/63, 42.9%). Conclusion According to our experience, a non-mold active prophylaxis in patients undergoing allo-HSCT is feasible when combined with an intensive diagnostic work-up including CT scan and BAL. BAL performed at the onset of the disease may provide informative results in most patients. A diagnostic-driven treatment strategy may contribute to limit the use of costly antifungal therapies.
Collapse
Affiliation(s)
- Alessandro Busca
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, Turin, Italy
| | - Natascia Cinatti
- Department of Medical Sciences, Division of Internal Medicine, University of Turin, Turin, Italy
| | - Jessica Gill
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Turin, Turin, Italy
| | - Roberto Passera
- Department of Medical Sciences, Division of Nuclear Medicine, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Maria Dellacasa
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luisa Giaccone
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Turin, Turin, Italy
| | - Irene Dogliotti
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, Turin, Italy
| | - Sara Manetta
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Division of Infectious Diseases, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Division of Infectious Diseases, Azienda Ospedaliera Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| |
Collapse
|