1
|
Kamel T, Janssen-Langenstein R, Quelven Q, Chelly J, Valette X, Le MP, Bourenne J, Garot D, Fillatre P, Labruyere M, Heming N, Lambiotte F, Lascarrou JB, Lesieur O, Bachoumas K, Ferre A, Maury E, Chalumeau-Lemoine L, Bougon D, Roux D, Guisset O, Coudroy R, Boulain T. Pneumocystis pneumonia in intensive care: clinical spectrum, prophylaxis patterns, antibiotic treatment delay impact, and role of corticosteroids. A French multicentre prospective cohort study. Intensive Care Med 2024:10.1007/s00134-024-07489-2. [PMID: 38829531 DOI: 10.1007/s00134-024-07489-2] [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: 02/29/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE Severe Pneumocystis jirovecii pneumonia (PJP) requiring intensive care has been the subject of few prospective studies. It is unclear whether delayed curative antibiotic therapy may impact survival in these severe forms of PJP. The impact of corticosteroid therapy combined with antibiotics is also unclear. METHODS This multicentre, prospective observational study involving 49 adult intensive care units (ICUs) in France was designed to evaluate the severity, the clinical spectrum, and outcomes of patients with severe PJP, and to assess the association between delayed curative antibiotic treatment and adjunctive corticosteroid therapy with mortality. RESULTS We included 158 patients with PJP from September 2020 to August 2022. Their main reason for admission was acute respiratory failure (n = 150, 94.9%). 12% of them received antibiotic prophylaxis for PJP before ICU admission. The ICU, hospital, and 6-month mortality were 31.6%, 35.4%, and 40.5%, respectively. Using time-to-event analysis with a propensity score-based inverse probability of treatment weighting, the initiation of curative antibiotic treatment after 96 h of ICU admission was associated with faster occurrence of death [time ratio: 6.75; 95% confidence interval (95% CI): 1.48-30.82; P = 0.014]. The use of corticosteroids for PJP was associated with faster occurrence of death (time ratio: 2.48; 95% CI 1.01-6.08; P = 0.048). CONCLUSION This study showed that few patients with PJP admitted to intensive care received prophylactic antibiotic therapy, that delay in curative antibiotic treatment was common and that both delay in curative antibiotic treatment and adjunctive corticosteroids for PJP were associated with accelerated mortality.
Collapse
Affiliation(s)
- Toufik Kamel
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orleans Cedex 2, France
| | - Ralf Janssen-Langenstein
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Centre Hospitalier Universitaire de Strasbourg, Avenue Molière, 67200, Strasbourg, France
| | - Quentin Quelven
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire Rennes, Pontchaillou, 2, Rue Henri Le Guilloux, 35000, Rennes, France
| | - Jonathan Chelly
- Réanimation Polyvalente, Centre Hospitalier Intercommunal Toulon La Seyne Sur Mer, 54 Rue Henri Sainte Claire Deville, 83100, Toulon, France
| | - Xavier Valette
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Caen Normandie, 14000, Caen, France
| | - Minh-Pierre Le
- Médecine Intensive-Réanimation, Hôpital Cochin, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Jeremy Bourenne
- Réanimation des Urgences et Dechocage Hôpital de La Timone, 264 Rue Saint-Pierre, 13005, Marseille, France
| | - Denis Garot
- Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire Bretonneau, Tours, 37044, Tours, France
| | - Pierre Fillatre
- Réanimation Polyvalente, Centre Hospitalier Yves-Le Foll, 10, Rue Marcel Proust, 22000, Saint Brieuc, France
| | - Marie Labruyere
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Dijon, 14 Rue Gaffarel, BP 77908, 21079, Dijon Cedex, France
| | - Nicholas Heming
- Médecine Intensive-Réanimation, Hôpital Raymond-Poincaré, 104, Boulevard Raymond-Poincaré, 92380, Garches, France
| | - Fabien Lambiotte
- Médecine Intensive-Réanimation, Centre Hospitalier de Valenciennes-CHV, Avenue Désandrouin CS 50479, 59322, Valenciennes Cedex, France
| | - Jean-Baptiste Lascarrou
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu-HME, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Olivier Lesieur
- Médecine Intensive-Réanimation, Hôpital Saint-Louis, Rue Du Dr Schweitzer, 17019, La Rochelle, France
| | - Konstantinos Bachoumas
- Médecine Intensive-Réanimation, Centre Hospitalier Départemental Vendée, Boulevard Stéphane Moreau, 85000, La Roche-Sur-Yon, France
| | - Alexis Ferre
- Intensive Care Unit, Versailles Hospital, 177 Rue De Versailles, 78157, Le Chesnay, France
| | - Eric Maury
- Médecine Intensive-Réanimation, Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Ludivine Chalumeau-Lemoine
- Service de Réanimation Médico-Chirurgicale, Hôpital Privé Claude Galien, 20 Route de Boussy, 91480, Quincy-Sous-Sénart, France
| | - David Bougon
- Médecine Intensive-Réanimation, CH Annecy-Genevois, Site Annecy, 1 Avenue De L'Hôpital, 74370, Annecy, France
| | - Damien Roux
- Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, France
| | - Olivier Guisset
- Médecine Intensive-Réanimation, Centre Hospitalier Universitaire-SAINT-ANDRE, Bordeaux, 1 Rue Jean Burguet, 33075, Bordeaux, France
| | - Remi Coudroy
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
- INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Thierry Boulain
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de l'Hôpital CS 86709, 45067, Orleans Cedex 2, France.
| |
Collapse
|
2
|
Kamel T, Boulain T. Pneumocystis pneumonia in French intensive care units in 2013-2019: mortality and immunocompromised conditions. Ann Intensive Care 2024; 14:80. [PMID: 38776012 PMCID: PMC11111439 DOI: 10.1186/s13613-024-01309-y] [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: 02/05/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE The recent epidemiology of Pneumocystis pneumonia (PCP) requiring intensive care unit (ICU) admission and the associated spectrum of immunocompromising conditions are poorly described. METHODS We analyzed all adult PCP cases admitted to French ICUs via the French medical database system (PMSI), over the period from 2013 to 2019. RESULTS French ICUs admitted a total of 4055 adult patients with PCP. Among all hospitalized PCP cases, the proportion requiring ICU admission increased from 17.8 in 2014 to 21.3% in 2019 (P < 0.001). The incidence of severe PCP rose from 0.85 in 2013 to 1.32/100,000 adult inhabitants in 2019 (P < 0.0001), primarily due to the proportion of HIV-negative patients that increased from 60.6% to 74.4% (P < 0.0001). Meanwhile, the annual number of severe PCP cases among patients with HIV infection remained stable over the years. In-hospital mortality of severe PCP cases was 28.5% in patients with HIV infection and 49.7% in patients without. Multivariable logistic analysis showed that patients with HIV infection had a lower adjusted risk of death than patients without HIV infection (Odds Ratio [OR]: 0.30, 95% confidence interval [95CI]: 0.17-0.55). Comorbidities or conditions strongly associated with hospital mortality included the patient's age, Simplified Acute Physiologic Score II, congestive heart failure, coagulopathy, solid organ cancer, and cirrhosis. A vast array of autoimmune inflammatory diseases affected 19.9% of HIV-negative patients. CONCLUSIONS The number of PCP cases requiring ICU admission in France has risen sharply. While the yearly count of severe PCP cases in HIV-infected patients has remained steady, this rise predominantly affects cancer patients, with a recent surge observed in patients with autoimmune inflammatory diseases, affecting one in five individuals.
Collapse
Affiliation(s)
- Toufik Kamel
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de L'Hôpital CS 86709, 45067, Orleans Cedex 2, France
| | - Thierry Boulain
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, 14 Avenue de L'Hôpital CS 86709, 45067, Orleans Cedex 2, France.
| |
Collapse
|
3
|
Chean D, Windsor C, Lafarge A, Dupont T, Nakaa S, Whiting L, Joseph A, Lemiale V, Azoulay E. Severe Community-Acquired Pneumonia in Immunocompromised Patients. Semin Respir Crit Care Med 2024; 45:255-265. [PMID: 38266998 DOI: 10.1055/s-0043-1778137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Due to higher survival rates with good quality of life, related to new treatments in the fields of oncology, hematology, and transplantation, the number of immunocompromised patients is increasing. But these patients are at high risk of intensive care unit admission because of numerous complications. Acute respiratory failure due to severe community-acquired pneumonia is one of the leading causes of admission. In this setting, the need for invasive mechanical ventilation is up to 60%, associated with a high hospital mortality rate of around 40 to 50%. A wide range of pathogens according to the reason of immunosuppression is associated with severe pneumonia in those patients: documented bacterial pneumonia represents a third of cases, viral and fungal pneumonia both account for up to 15% of cases. For patients with an undetermined etiology despite comprehensive diagnostic workup, the hospital mortality rate is very high. Thus, a standardized diagnosis strategy should be defined to increase the diagnosis rate and prescribe the appropriate treatment. This review focuses on the benefit-to-risk ratio of invasive or noninvasive strategies, in the era of omics, for the management of critically ill immunocompromised patients with severe pneumonia in terms of diagnosis and oxygenation.
Collapse
Affiliation(s)
- Dara Chean
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Camille Windsor
- Medical Intensive Care Unit, AP-HP Henri Mondor University Hospital, Créteil, France
| | - Antoine Lafarge
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Thibault Dupont
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Sabrine Nakaa
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Livia Whiting
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Adrien Joseph
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| |
Collapse
|
4
|
Saadatzadeh T, Angarone M, Stosor V. Pneumocystis jirovecii in solid organ transplant recipients: updates in epidemiology, diagnosis, treatment, and prevention. Curr Opin Infect Dis 2024; 37:121-128. [PMID: 38230604 DOI: 10.1097/qco.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
PURPOSE OF REVIEW This review highlights the epidemiology of Pneumocystis jirovecii pneumonia in solid organ transplant recipients, advancements in the diagnostic landscape, and updates in treatment and prevention. RECENT FINDINGS The increasing use of immune-depleting agents in the context of solid organ transplantation has given rise to P. jirovecii pneumonia in this population. The use of prophylaxis has dramatically reduced risk of infection; however, late-onset infections occur after cessation of prophylaxis and in the setting of lymphopenia, advancing patient age, acute allograft rejection, and cytomegalovirus infection. Diagnosis requires respiratory specimens, with PCR detection of Pneumocystis replacing traditional staining methods. Quantitative PCR may be a useful adjunct to differentiate between infection and colonization. Metagenomic next-generation sequencing is gaining attention as a noninvasive diagnostic tool. Trimethoprim-sulfamethoxazole remains the drug of choice for treatment and prevention of Pneumocystis pneumonia. Novel antifungal agents are under investigation. SUMMARY P. jirovecii is a fungal opportunistic pathogen that remains a cause of significant morbidity and mortality in solid organ transplant recipients. Early detection and timely treatment remain the pillars of management.
Collapse
Affiliation(s)
| | | | - Valentina Stosor
- Divisions of Infectious Diseases
- Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
5
|
Miyake K, Senoo S, Shiiba R, Itano J, Kimura G, Kawahara T, Tamura T, Kudo K, Kawamura T, Nakahara Y, Higo H, Himeji D, Takigawa N, Miyahara N. Pneumocystis jirovecii pneumonia mortality risk associated with preceding long-term steroid use for the underlying disease: A multicenter, retrospective cohort study. PLoS One 2024; 19:e0292507. [PMID: 38330061 PMCID: PMC10852346 DOI: 10.1371/journal.pone.0292507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVE Long-term steroid use increases the risk of developing Pneumocystis pneumonia (PcP), but there are limited reports on the relation of long-term steroid and PcP mortality. METHODS Retrospective multicenter study to identify risk factors for PcP mortality, including average steroid dose before the first visit for PcP in non-human immunodeficiency virus (HIV)-PcP patients. We generated receiver operating characteristic (ROC) curves for 90-day all-cause mortality and the mean daily steroid dose per unit body weight in the preceding 10 to 90 days in 10-day increments. Patients were dichotomized by 90-day mortality and propensity score-based stabilized inverse probability of treatment weighting (IPTW) adjusted covariates of age, sex, and underlying disease. Multivariate analysis with logistic regression assessed whether long-term corticosteroid use affected outcome. RESULTS Of 133 patients with non-HIV-PcP, 37 died within 90 days of initial diagnosis. The area under the ROC curve for 1-40 days was highest, and the optimal cutoff point of median adjunctive corticosteroid dosage was 0.34 mg/kg/day. Past steroid dose, underlying interstitial lung disease and emphysema, lower serum albumin and lower lymphocyte count, higher lactate dehydrogenase, use of therapeutic pentamidine and therapeutic high-dose steroids were all significantly associated with mortality. Underlying autoimmune disease, past immunosuppressant use, and a longer time from onset to start of treatment, were associated lower mortality. Logistic regression analysis after adjusting for age, sex, and underlying disease with IPTW revealed that steroid dose 1-40 days before the first visit for PcP (per 0.1 mg/kg/day increment, odds ratio 1.36 [95% confidence interval = 1.16-1.66], P<0.001), low lymphocyte counts, and high lactate dehydrogenase revel were independent mortality risk factor, while respiratory failure, early steroid, and sulfamethoxazole/trimethoprim for PcP treatment did not. CONCLUSION A steroid dose before PcP onset was strongly associated with 90-day mortality in non-HIV-PcP patients, emphasizing the importance of appropriate prophylaxis especially in this population.
Collapse
Affiliation(s)
- Kohei Miyake
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Satoru Senoo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Ritsuya Shiiba
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Junko Itano
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Goro Kimura
- Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, Japan
| | - Tatsuyuki Kawahara
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Tomoki Tamura
- Department of Respiratory Medicine, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Kenichiro Kudo
- Department of Respiratory Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Himeji, Japan
| | - Hisao Higo
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Daisuke Himeji
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Nagio Takigawa
- Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan
| | - Nobuaki Miyahara
- Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | | |
Collapse
|
6
|
Li H, Lu Y, Tian G, Wu Y, Chen T, Zhang J, Hu N, Wang X, Wang Y, Gao L, Yan J, Zhou L, Shi Q. A regimen based on the combination of trimethoprim/sulfamethoxazole with caspofungin and corticosteroids as a first-line therapy for patients with severe non-HIV-related pneumocystis jirovecii pneumonia: a retrospective study in a tertiary hospital. BMC Infect Dis 2024; 24:152. [PMID: 38297200 PMCID: PMC10829312 DOI: 10.1186/s12879-024-09031-7] [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: 07/08/2023] [Accepted: 01/18/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening and severe disease in immunocompromised hosts. A synergistic regimen based on the combination of sulfamethoxazole-trimethoprim (SMX-TMP) with caspofungin and glucocorticosteroids (GCSs) may be a potential first-line therapy for PJP. Therefore, it is important to explore the efficacy and safety of this synergistic therapy for treating non-HIV-related PJP patients. METHODS We retrospectively analysed the data of 38 patients with non-HIV-related PJP at the First Affiliated Hospital of Xi'an Jiaotong University. Patients were divided into two groups: the synergistic therapy group (ST group, n = 20) and the monotherapy group (MT group, n = 18). All patients were from the ICU and were diagnosed with severe PJP. In the ST group, all patients were treated with SMX-TMP (TMP 15-20 mg/kg per day) combined with caspofungin (70 mg as the loading dose and 50 mg/day as the maintenance dose) and a GCS (methylprednisolone 40-80 mg/day). Patients in the MT group were treated only with SMX-TMP (TMP 15-20 mg/kg per day). The clinical response, adverse events and mortality were compared between the two groups. RESULTS The percentage of patients with a positive clinical response in the ST group was significantly greater than that in the MT group (100.00% vs. 66.70%, P = 0.005). The incidence of adverse events in the MT group was greater than that in the ST group (50.00% vs. 15.00%, P = 0.022). Furthermore, the dose of TMP and duration of fever in the ST group were markedly lower than those in the MT group (15.71 mg/kg/day vs. 18.35 mg/kg/day (P = 0.001) and 7.00 days vs. 11.50 days (P = 0.029), respectively). However, there were no significant differences in all-cause mortality or duration of hospital stay between the MT group and the ST group. CONCLUSIONS Compared with SMZ/TMP monotherapy, synergistic therapy (SMZ-TMP combined with caspofungin and a GCS) for the treatment of non-HIV-related PJP can increase the clinical response rate, decrease the incidence of adverse events and shorten the duration of fever. These results indicate that synergistic therapy is effective and safe for treating severe non-HIV-related PJP.
Collapse
Affiliation(s)
- Hao Li
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
- Shaanxi Provincial Key Laboratory of Sepsis in Critical Care Medicine, Xi'an, Shaanxi, China
| | - Yihe Lu
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
- Shaanxi Provincial Key Laboratory of Sepsis in Critical Care Medicine, Xi'an, Shaanxi, China
| | - Guoxin Tian
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
- Shaanxi Provincial Key Laboratory of Sepsis in Critical Care Medicine, Xi'an, Shaanxi, China
| | - Yongxing Wu
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
- Shaanxi Provincial Key Laboratory of Sepsis in Critical Care Medicine, Xi'an, Shaanxi, China
| | - Tianjun Chen
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
| | - Jiangwei Zhang
- Department of Kideny Transplant, Hospital of Nephrology, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
| | - Nan Hu
- Department of Rheumatology, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
| | - Xiaoning Wang
- Department of Hematology, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
| | - Yang Wang
- Department of Cardiovascular Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
| | - Lan Gao
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
- Shaanxi Provincial Key Laboratory of Sepsis in Critical Care Medicine, Xi'an, Shaanxi, China
| | - Jinqi Yan
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
- Shaanxi Provincial Key Laboratory of Sepsis in Critical Care Medicine, Xi'an, Shaanxi, China
| | - Linjing Zhou
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China
- Shaanxi Provincial Key Laboratory of Sepsis in Critical Care Medicine, Xi'an, Shaanxi, China
| | - Qindong Shi
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, China.
- Shaanxi Provincial Key Laboratory of Sepsis in Critical Care Medicine, Xi'an, Shaanxi, China.
| |
Collapse
|
7
|
Xue T, Kong X, Ma L. Trends in the Epidemiology of Pneumocystis Pneumonia in Immunocompromised Patients without HIV Infection. J Fungi (Basel) 2023; 9:812. [PMID: 37623583 PMCID: PMC10455156 DOI: 10.3390/jof9080812] [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: 04/28/2023] [Revised: 06/19/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023] Open
Abstract
The increasing morbidity and mortality of life-threatening Pneumocystis pneumonia (PCP) in immunocompromised people poses a global concern, prompting the World Health Organization to list it as one of the 19 priority invasive fungal diseases, calling for increased research and public health action. In response to this initiative, we provide this review on the epidemiology of PCP in non-HIV patients with various immunodeficient conditions, including the use of immunosuppressive agents, cancer therapies, solid organ and stem cell transplantation, autoimmune and inflammatory diseases, inherited or primary immunodeficiencies, and COVID-19. Special attention is given to the molecular epidemiology of PCP outbreaks in solid organ transplant recipients; the risk of PCP associated with the increasing use of immunodepleting monoclonal antibodies and a wide range of genetic defects causing primary immunodeficiency; the trend of concurrent infection of PCP in COVID-19; the prevalence of colonization; and the rising evidence supporting de novo infection rather than reactivation of latent infection in the pathogenesis of PCP. Additionally, we provide a concise discussion of the varying effects of different immunodeficient conditions on distinct components of the immune system. The objective of this review is to increase awareness and knowledge of PCP in non-HIV patients, thereby improving the early identification and treatment of patients susceptible to PCP.
Collapse
Affiliation(s)
- Ting Xue
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Xiaomei Kong
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD 20892, USA
| |
Collapse
|
8
|
Huang J, Zeng F, Li J, Xu W, Shen M, Shu Q, Liu D. Case report: A HIV-negative hemodialysis patient positive for pANCA with severe pneumocystis pneumonia: A case report and review of literature. Medicine (Baltimore) 2023; 102:e33351. [PMID: 36961149 PMCID: PMC10035997 DOI: 10.1097/md.0000000000033351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/03/2023] [Indexed: 03/25/2023] Open
Abstract
RATIONALE Pneumocystis pneumonia (PCP) is an opportunistic fungal infection that occurs in people with impaired or suppressed immunity such as patients with human immunodeficiency virus or organ transplant. However, the incidence and characteristics of PCP in the population with long-term hemodialysis is poorly described in the literature. PATIENT CONCERNS We present a case of a 50-year-old female patient being transferred to our hospital in February 2022 with a 20-day history of cough and tight breath. She received amoxicillin and cephalosporin anti-infection treatment successively in local hospital but no significant improvement in symptoms. She had a 2-year history of hemodialysis and no relevant transplantation and human immunodeficiency virus infection. She was diagnosed as ANCA associated vasculitis (AAV) and given oral prednisone acetate (20 mg/day) and methotrexate (2.5 mg/week) half a year ago. DIAGNOSES Based on the patient's medical history, Lung computerized tomography image, the Next generation sequencing report, the patient was diagnosed with renal failure, anti-neutrophil cytoplasmic antibody associated vasculitis, and Pneumocystis pneumonia. INTERVENTIONS The dosage of immunosuppressant was reduced due to leucocyte dripping and fever, and antibiotic and antifungal treatment were also given. The patient's lung condition was getting worse and noninvasive ventilator was required to maintain blood oxygen. Blood filtration is used to remove toxins. Ganciclovir and trimethoprim-sulfamethoxazole was used based on the next generation sequencing report. OUTCOMES The patient died of respiratory failure. LESSONS The risk of PCP in hemodialysis patients may be higher than that in ordinary population, and the prognosis of patients with immunosuppression may be worse. Dynamic assessment of vasculitis activity is necessary for hemodialysis patients with AAV because infections may obscure lung symptoms of AAV. It is not recommended that hemodialysis patients with long-term immunosuppression should reduce or stop the dosage of immunosuppressive drugs during the treatment because it may aggravate the condition of PCP. There is still no clear conclusion on whether hemodialysis patients need preventive medicine, but the identification of risk factors and early diagnosis and treatment are important for the prognosis of PCP on hemodialysis population.
Collapse
Affiliation(s)
- Jingda Huang
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Fang Zeng
- Department of Nephrology, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Jiajie Li
- Department of Hepatobiliary and Pancreatic, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Wang Xu
- Department of Cardiovascular, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Meirong Shen
- Department of Critical Care Medicine, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Qiao Shu
- Department of Nephrology, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Dehui Liu
- Department of Nephrology, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| |
Collapse
|
9
|
Ibrahim A, Chattaraj A, Iqbal Q, Anjum A, Rehman MEU, Aijaz Z, Nasir F, Ansar S, Zangeneh TT, Iftikhar A. Pneumocystis jiroveci
Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised Patients. Avicenna J Med 2023; 13:23-34. [PMID: 36969352 PMCID: PMC10038753 DOI: 10.1055/s-0043-1764375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
Pneumocystis jirovecii
pneumonia is an opportunistic fungal infection that was mainly associated with pneumonia in patients with advanced human immunodeficiency virus (HIV) disease. There has been a decline in
Pneumocystis jirovecii
pneumonia incidence in HIV since the introduction of antiretroviral medications. However, its incidence is increasing in non-HIV immunocompromised patients including those with solid organ transplantation, hematopoietic stem cell transplantation, solid organ tumors, autoimmune deficiencies, and primary immunodeficiency disorders. We aim to review and summarize the etiology, epidemiology, clinical presentation, diagnosis, and management of
Pneumocystis jirovecii
pneumonia in HIV, and non-HIV patients. HIV patients usually have mild-to-severe symptoms, while non-HIV patients present with a rapidly progressing disease. Induced sputum or bronchoalveolar lavage fluid can be used to make a definitive diagnosis of
Pneumocystis jirovecii
pneumonia. Trimethoprim-sulfamethoxazole is considered to be the first-line drug for treatment and has proven to be highly effective for
Pneumocystis jirovecii
pneumonia prophylaxis in both HIV and non-HIV patients. Pentamidine, atovaquone, clindamycin, and primaquine are used as second-line agents. While several diagnostic tests, treatments, and prophylactic regimes are available at our disposal, there is need for more research to prevent and manage this disease more effectively.
Collapse
Affiliation(s)
- Atif Ibrahim
- North Mississippi Medical Center, Tupelo, Mississippi, United States
| | - Asmi Chattaraj
- University of Pittsburgh Medical Center, McKeesport, Pennsylvania, United States
| | - Qamar Iqbal
- TidalHealth, Salisbury, Maryland, United States
| | - Ali Anjum
- King Edward Medical University, Lahore, Pakistan
| | | | | | | | - Sadia Ansar
- Rawal Institute of Health Sciences, Islamabad, Pakistan
| | - Tirdad T. Zangeneh
- Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Ahmad Iftikhar
- Department of Internal Medicine, University of Arizona, Tucson, Arizona, United States
- Address for correspondence Ahmad Iftikhar, MD Department of Medicine, University of Arizona1525N. Campbell Avenue, PO Box 245212, Tucson, AZ 85724
| |
Collapse
|
10
|
See KC, Lau YH. Acute management of pneumonia in adult patients. Singapore Med J 2023; 64:209-216. [PMID: 36876626 PMCID: PMC10071852 DOI: 10.4103/singaporemedj.smj-2022-050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| |
Collapse
|
11
|
Song S, Zhang Y, Yu J, Xie C, Chen Y, Zhang X. Time to trimethoprim/sulfamethoxazole initiation among patients with rheumatic disease complicated by Pneumocystis jirovecii pneumonia: impact on 90-day mortality. BMC Infect Dis 2022; 22:961. [PMID: 36575406 PMCID: PMC9793549 DOI: 10.1186/s12879-022-07940-z] [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: 04/27/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a life-threatening disease with increasing prevalence in patients with rheumatic disease. Trimethoprim/sulfamethoxazole (TMP/SMX) is an effective treatment for patients with rheumatic disease hospitalized for PJP. This study aimed to describe the 90-day mortality of patients with rheumatic disease complicated by PJP and investigate whether the administration of TMP/SMX after 7 days from initial symptoms correlates with 90-day mortality. METHODS We enrolled consecutive patients with rheumatic disease complicated with PJP in our center from August 2018 to August 2021. The participants were classified into two groups according to when TMP/SMX was initiated: early (within the first 7 days) and late (after 7 days). The primary outcome was 90-day PJP-related mortality. Multivariate cox regression and Kaplan-Meier survival analyses were conducted to identify the risk factors for mortality and examine differences in survival between early and late use of TMP/SMX. RESULTS Thirty-seven patients with rheumatic disease (median age 50.1 years, 24.3% male) complicated by PJP were enrolled in our study, and 15 (40.5%) patients died at or before 90 days of follow-up. The most common comorbidity was systemic lupus erythematosus (14, 37.8%), followed by inflammatory myopathy (11, 27.9%). Patients in the early group were less likely to require mechanical ventilation (8/27, 29.6% vs. 9/10, 90.0%, P = 0.002), lower doses glucocorticoids (43.2 mg/d vs. 72.2 mg/d, P = 0.039) and had lower mortality (7/27, 25.9% vs. 8/10, 80.0%, P = 0.006) than those in the late group. In the Kaplan-Meier analysis, the survivor probability of the early group was notably higher than that of the late group (P = 0.007). Multivariate cox regression analysis showed that initiation of TMP/SMX after 7 days from admission (hazard ratio [HR]: 5.9, 95% confidence interval [CI]: 1.1-30.4; P = 0.034) and a higher level of lactate dehydrogenase (LDH; HR: 6.0, 95% CI: 1.1-31.8; P = 0.035) were associated with 90-day mortality in patients with rheumatic disease complicated by PJP. CONCLUSION Patients with rheumatic disease complicated by PJP had poor prognoses, with mortality rates as high as 40.5%. TMP/SMX initiation after 7 days from initial symptoms and a higher level of serum LDH were significantly associated with increased 90-day mortality.
Collapse
Affiliation(s)
- Siyang Song
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Yang Zhang
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Jie Yu
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Cuiying Xie
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Yi Chen
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| | - Xingyu Zhang
- grid.415869.7Department of Emergency, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, 2000 Jiangyue Road, Minhang District, Shanghai, China
| |
Collapse
|
12
|
Huang YM, Lu CH, Cheng CF, Shen CY, Hsieh SC, Li KJ, Chien JY, Hsueh PR. Clinical features and prognostic predictors in patients with rheumatic diseases complicated by Pneumocystis pneumonia. Int J Infect Dis 2022; 122:1018-1025. [DOI: 10.1016/j.ijid.2022.07.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/19/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022] Open
|
13
|
Amratia DA, Viola H, Ioachimescu OC. Glucocorticoid therapy in respiratory illness: bench to bedside. J Investig Med 2022; 70:1662-1680. [DOI: 10.1136/jim-2021-002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/07/2022]
Abstract
Each year, hundreds of millions of individuals are affected by respiratory disease leading to approximately 4 million deaths. Most respiratory pathologies involve substantially dysregulated immune processes that either fail to resolve the underlying process or actively exacerbate the disease. Therefore, clinicians have long considered immune-modulating corticosteroids (CSs), particularly glucocorticoids (GCs), as a critical tool for management of a wide spectrum of respiratory conditions. However, the complex interplay between effectiveness, risks and side effects can lead to different results, depending on the disease in consideration. In this comprehensive review, we present a summary of the bench and the bedside evidence regarding GC treatment in a spectrum of respiratory illnesses. We first describe here the experimental evidence of GC effects in the distal airways and/or parenchyma, both in vitro and in disease-specific animal studies, then we evaluate the recent clinical evidence regarding GC treatment in over 20 respiratory pathologies. Overall, CS remain a critical tool in the management of respiratory illness, but their benefits are dependent on the underlying pathology and should be weighed against patient-specific risks.
Collapse
|
14
|
Wang Y, Huang X, Sun T, Fan G, Zhan Q, Weng L. Non-HIV-infected patients with Pneumocystis pneumonia in the intensive care unit: A bicentric, retrospective study focused on predictive factors of in-hospital mortality. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:152-161. [PMID: 35001555 PMCID: PMC9060091 DOI: 10.1111/crj.13463] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/06/2021] [Accepted: 11/07/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The incidence of Pneumocystis pneumonia (PCP) among patients without human immunodeficiency virus (HIV) infection continues to increase. Here, we identified potential risk factors for in-hospital mortality among HIV-negative patients with PCP admitted to the intensive care unit (ICU). METHODS We retrospectively analyzed medical records of 154 non-HIV-infected PCP patients admitted to the ICU at Peking Union Medical College Hospital (PUMCH) and China-Japan Friendship Hospital (CJFH) from October 2012 to July 2020. Clinical characteristics were examined, and factors related to in-hospital mortality were analyzed. RESULTS A total of 154 patients were enrolled in our study. Overall, the in-hospital mortality rate was 65.6%. The univariate analysis indicated that nonsurvivors were older (58 vs. 52 years, P = 0.021), were more likely to use high-dose steroids (≥1 mg/kg/day prednisone equivalent, 39.62% vs. 55.34%, P = 0.047), receive caspofungin during hospitalization (44.6% vs. 28.3%, P = 0.049), require invasive ventilation (83.2% vs. 47.2%, P < 0.001), develop shock during hospitalization (61.4% vs. 20.8%, P < 0.001), and develop pneumomediastinum (21.8% vs. 47.2%, P = 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores on ICU admission (20.32 vs. 17.39, P = 0.003), lower lymphocyte counts (430 vs. 570 cells/μl, P = 0.014), and lower PaO2/FiO2 values (mmHg) on admission (108 vs. 147, P = 0.001). Multivariate analysis showed that age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.00-1.06; P = 0.024), use of high-dose steroids (≥1 mg/kg/day prednisone equivalent) during hospitalization (OR 2.29; 95% CI 1.07-4.90; P = 0.034), and a low oxygenation index on admission (OR 0.99; 95% CI 0.99-1.00; P = 0.014) were associated with in-hospital mortality. CONCLUSIONS The mortality rate of non-HIV-infected patients with PCP was high, and predictive factors of a poor prognosis were advanced age, use of high-dose steroids (≥1 mg/kg/day prednisone equivalent) during hospitalization, and a low oxygenation index on admission. The use of caspofungin during hospitalization might have no contribution to the prognosis of non-HIV-infected patients with PCP in the ICU.
Collapse
Affiliation(s)
- Yuqiong Wang
- China-Japan Friendship School of Clinical Medicine, Peking University, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Xu Huang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Ting Sun
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,China-Japan Friendship School of Clinical Medicine, Capital Medical University, Beijing, China
| | - Guohui Fan
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Disease, Beijing, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
15
|
Lécuyer R, Issa N, Tessoulin B, Lavergne RA, Morio F, Gabriel F, Canet E, Bressollette-Bodin C, Guillouzouic A, Boutoille D, Raffi F, Lecomte R, Le Turnier P, Deschanvres C, Camou F, Gaborit BJ. Epidemiology and clinical impact of respiratory co-infections at diagnosis of Pneumocystis jirovecii Pneumonia. J Infect Dis 2021; 225:868-880. [PMID: 34604908 DOI: 10.1093/infdis/jiab460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/09/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To describe the epidemiology and clinical impact of respiratory co-infections at diagnosis of Pneumocystis jirovecii Pneumonia (PcP). METHODS A retrospective observational study was conducted between January 2011 and April 2019 to evaluate respiratory co-infections at diagnosis of PcP patients, in two tertiary care hospitals. Respiratory co-infection was defined by the identification of pathogens from P. jirovecii-positive samples. RESULTS Of the 7 882 respiratory samples tested for P. jirovecii during the 8-year study period, 328 patients with final diagnosis of PcP were included in this study. Mean age was 56.7 ± 14.9 years, 193 (58.8%) were male, 74 (22.6%) had a positive HIV serology, 125 (38.1%) had a viral co-infections, 76 (23.2%) a bacterial co-infections and 90-day mortality was 25.3%. In overall population, 90-Day mortality was independently associated with a solid tumor underlying disease (OR 11.8, 1.90-78, p=0.008), SOFA score at admission (OR 1.62, 1.34-2.05; p<0.001) and CMV respiratory co-infection (OR 3.44, 1.24-2.90; p=0.02). Among HIV-negative patients, respiratory CMV co-infection was associated with a worse prognosis, especially when treated with adjunctive corticosteroid therapy. CONCLUSIONS Respiratory CMV co-infection at diagnosis of PcP was independently associated with increased 90-day mortality, specifically in HIV-negative patients.
Collapse
Affiliation(s)
- Romain Lécuyer
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France.,EA 1155, Laboratory of targets and drugs for infections and cancer, IRS2-Nantes Biotech, Nantes, France
| | - Nahema Issa
- Intensive Care and Infectious Disease Unit, Groupe Saint-André, University Hospital, Bordeaux, France
| | - Benoit Tessoulin
- INSERM, U1232, Université de Nantes, Service d'Hématologie, University Hospital, Nantes, France
| | - Rose-Anne Lavergne
- EA 1155, Laboratory of targets and drugs for infections and cancer, IRS2-Nantes Biotech, Nantes, France.,Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Florent Morio
- EA 1155, Laboratory of targets and drugs for infections and cancer, IRS2-Nantes Biotech, Nantes, France.,Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Frederic Gabriel
- Centre Hospitalier Universitaire de Bordeaux, Service de Parasitologie Mycologie, F-33000, Bordeaux, France
| | - Emmanuel Canet
- Medical Intensive Care, University Hospital, Nantes, France
| | | | | | - David Boutoille
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France.,EA 3826, Laboratory of clinical and experimental therapeutics of infections, IRS2-Nantes Biotech, Nantes, France
| | - François Raffi
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Raphael Lecomte
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Paul Le Turnier
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Colin Deschanvres
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Fabrice Camou
- Intensive Care and Infectious Disease Unit, Groupe Saint-André, University Hospital, Bordeaux, France
| | - Benjamin Jean Gaborit
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France.,EA 3826, Laboratory of clinical and experimental therapeutics of infections, IRS2-Nantes Biotech, Nantes, France
| | | |
Collapse
|
16
|
Wang Y, Zhou X, Saimi M, Huang X, Sun T, Fan G, Zhan Q. Risk Factors of Mortality From Pneumocystis Pneumonia in Non-HIV Patients: A Meta-Analysis. Front Public Health 2021; 9:680108. [PMID: 34222179 PMCID: PMC8244732 DOI: 10.3389/fpubh.2021.680108] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background: We performed a meta-analysis to systematically review the risk factors of mortality from non-HIV-related Pneumocystis pneumonia (PcP) and provide the theoretical basis for managing non-HIV-related PcP. Methods: PubMed, Embase, Web of Science, the Cochrane Library and CNKI databases were searched. A meta-analysis of the risk factors of mortality from non-HIV-related PcP was conducted. Results: A total of 19 studies and 1,310 subjects were retrieved and included in the meta-analysis, including 485 and 825 patients in the non-survivor and survivor groups, respectively. In the primary analysis, age, concomitant with other pulmonary diseases at diagnosis of PcP, solid tumors, cytomegalovirus(CMV) co-infection, lactate dehydrogenase (LDH), lymphocyte count, invasive ventilation during hospitalization, and pneumothorax were associated with mortality from non-HIV-related PcP, whereas sex, albumin, PcP prophylaxis, use of corticosteroids after admission, and time from onset of symptoms to treatment were not associated with mortality from non-HIV-related PcP. Conclusions: The mortality rate of non-HIV-infected patients with PcP was still high. Age, concomitant with other pulmonary diseases at diagnosis of PcP, solid tumors, CMV co-infection, LDH, lymphocyte count, invasive ventilation during hospitalization, and pneumothorax were risk factors of mortality from non-HIV-related PcP. Improved knowledge of prognostic factors is crucial to guide early treatment.
Collapse
Affiliation(s)
- Yuqiong Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaoyi Zhou
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Maidinuer Saimi
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing, China
| | - Xu Huang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China
| | - Ting Sun
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing, China
| | - Guohui Fan
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Disease, Beijing, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China
| |
Collapse
|
17
|
Lagrou K, Chen S, Masur H, Viscoli C, Decker CF, Pagano L, Groll AH. Pneumocystis jirovecii Disease: Basis for the Revised EORTC/MSGERC Invasive Fungal Disease Definitions in Individuals Without Human Immunodeficiency Virus. Clin Infect Dis 2021; 72:S114-S120. [PMID: 33709126 DOI: 10.1093/cid/ciaa1805] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) causes substantive morbidity in immunocompromised patients. The EORTC/MSGERC convened an expert group to elaborate consensus definitions for Pneumocystis disease for the purpose of interventional clinical trials and epidemiological studies and evaluation of diagnostic tests. METHODS Definitions were based on the triad of host factors, clinical-radiologic features, and mycologic tests with categorization into probable and proven Pneumocystis disease, and to be applicable to immunocompromised adults and children without human immunodeficiency virus (HIV). Definitions were formulated and their criteria debated and adjusted after public consultation. The definitions were published within the 2019 update of the EORTC/MSGERC Consensus Definitions of Invasive Fungal Disease. Here we detail the scientific rationale behind the disease definitions. RESULTS The diagnosis of proven PCP is based on clinical and radiologic criteria plus demonstration of P. jirovecii by microscopy using conventional or immunofluorescence staining in tissue or respiratory tract specimens. Probable PCP is defined by the presence of appropriate host factors and clinical-radiologic criteria, plus amplification of P. jirovecii DNA by quantitative real-time polymerase chain reaction (PCR) in respiratory specimens and/or detection of β-d-glucan in serum provided that another invasive fungal disease and a false-positive result can be ruled out. Extrapulmonary Pneumocystis disease requires demonstration of the organism in affected tissue by microscopy and, preferably, PCR. CONCLUSIONS These updated definitions of Pneumocystis diseases should prove applicable in clinical, diagnostic, and epidemiologic research in a broad range of immunocompromised patients without HIV.
Collapse
Affiliation(s)
- Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Laboratory Medicine and National Reference Centre for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Sharon Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital and the University of Sydney, Sydney, Australia
| | - Henry Masur
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Claudio Viscoli
- Division of Infectious Diseases, University of Genoa (DISSAL) and Ospedale Policlinico San Martino, Genoa, Italy
| | - Catherine F Decker
- Infectious Disease Division, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Livio Pagano
- Istituto di Ematologia, Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| |
Collapse
|
18
|
Assal M, Lambert J, Chow-Chine L, Bisbal M, Servan L, Gonzalez F, de Guibert JM, Faucher M, Vey N, Sannini A, Mokart D. Prognostic impact of early adjunctive corticosteroid therapy in non-HIV oncology or haematology patients with Pneumocystis jirovecii pneumonia: A propensity score analysis. PLoS One 2021; 16:e0250611. [PMID: 33886692 PMCID: PMC8061944 DOI: 10.1371/journal.pone.0250611] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 04/10/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose While early adjunctive corticosteroid therapy (EACST) has been proven effective in HIV patients with Pneumocystis Jirovecii Pneumonia (PJP), data remains controversial concerning non-HIV oncology or haematology patients. Methods This retrospective study included cancer patients without HIV and with diagnosis of PJP admitted in a cancer referral centre, from January-1-2010 to March-31-2017. We compared 30-day and 1-year mortality rate, change in the respiratory item of the Sequential Organ Failure Assessment score(SOFA-resp worsening), use of tracheal intubation between day-1 and day-5 of anti-pneumocystis therapy and occurrence of coinfections between patients with EACST and those with no or late corticosteroid therapy, using an inverse probability weighting propensity score-based (IPW) analysis. Results 133 non-HIV oncology or haematology PJP patients were included (EACST n = 58, others n = 75). The main underlying conditions were haematological malignancies (n = 107, 80,5%), solid tumour (n = 27, 20,3%) and allogeneic stem cell transplantation (n = 17, 12,8%). Overall 30-day and 1-year mortality rate was 24,1% and 56,4%, respectively. IPW analysis found no difference on 30-day (HR = 1.45, 95% CI [0.7–3.04], p = 0.321) and 1-year (HR = 1.25, CI 95% [0.75–2.09], p = 0.39) mortality rate between groups. Conclusion No difference in SOFA-resp worsening, tracheal intubation and coinfections was found between groups. Combination of EACST with anti-pneumocystis therapy in non-HIV onco-haematology PJP-patients was not associated with clinical improvement.
Collapse
Affiliation(s)
- Mehdi Assal
- Intensive Care Unit, Hôpital La Timone, Marseille, France
| | - Jérôme Lambert
- Biostatistics Department, Saint Louis Teaching Hospital, Paris, France
| | | | - Magali Bisbal
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Luca Servan
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | | | | | - Marion Faucher
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Norbert Vey
- Department of Haematology, Institut Paoli-Calmettes, Marseille, France
| | - Antoine Sannini
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Djamel Mokart
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
- * E-mail:
| |
Collapse
|
19
|
Weyant RB, Kabbani D, Doucette K, Lau C, Cervera C. Pneumocystis jirovecii: a review with a focus on prevention and treatment. Expert Opin Pharmacother 2021; 22:1579-1592. [PMID: 33870843 DOI: 10.1080/14656566.2021.1915989] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Pneumocystis jirovecii (PJ) is an opportunistic fungal pathogen that can cause severe pneumonia in immunocompromised hosts. Risk factors for Pneumocystis jirovecii pneumonia (PJP) include HIV, organ transplant, malignancy, certain inflammatory or rheumatologic conditions, and associated therapies and conditions that result in cell-mediated immune deficiency. Clinical signs of PJP are nonspecific and definitive diagnosis requires direct detection of the organism in lower respiratory secretions or tissue. First-line therapy for prophylaxis and treatment remains trimethoprim-sulfamethoxazole (TMP-SMX), though intolerance or allergy, and rarely treatment failure, may necessitate alternate therapeutics, such as dapsone, pentamidine, atovaquone, clindamycin, primaquine and most recently, echinocandins as adjunctive therapy. In people living with HIV (PLWH), adjunctive corticosteroid use in treatment has shown a mortality benefit.Areas covered: This review article covers the epidemiology, pathophysiology, diagnosis, microbiology, prophylaxis indications, prophylactic therapies, and treatments.Expert opinion: TMP-SMX has been first-line therapy for treating and preventing pneumocystis for decades. However, its adverse effects are not uncommon, particularly during treatment. Second-line therapies may be better tolerated, but often sacrifice efficacy. Echinocandins show some promise for new combination therapies; however, further studies are needed to define optimal antimicrobial therapy for PJP as well as the role of corticosteroids in those without HIV.
Collapse
Affiliation(s)
- R Benson Weyant
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Doucette
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cecilia Lau
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
20
|
Abstract
PURPOSE OF REVIEW This review aims to evaluate the evidence and recommendations for the prescription of corticosteroids as adjunctive therapy in patients with severe community-acquired pneumonia. RECENT FINDINGS Corticosteroids have been prescribed with the objective to attenuate the marked and persistent activation of the immune system. However, some causes of community-acquired pneumonia, namely viral, are associated with unexpected low levels of cytokines and depressed cellular immunity. As a result, several recent randomized controlled trials and large prospective observational studies repeatedly showed that corticosteroids had no impact on survival, and in some types of pneumonia like influenza, its use was associated with potential harmful effects like invasive aspergillosis. Apart from this, adverse effects, namely hyperglycemia, superinfections and increased length-of-stay, were frequent findings in the corticosteroid-treated patients. SUMMARY According to the current evidence, corticosteroids are recommended in Pneumocystis jiroveci pneumonia in HIV-infected patients and recommendations are against its use in influenza. In all other forms of severe community-acquired pneumonia, with the exclusion of SARS-CoV-2 pneumonia, the strength of the evidence does not support the safe and widespread use of corticosteroids as adjunctive therapy. Further studies are needed to identify subgroups of severe community-acquired pneumonia that can benefit or not from corticosteroids.
Collapse
|
21
|
Li L, Hsu SH, Gu X, Jiang S, Shang L, Sun G, Sun L, Zhang L, Wang C, Ren Y, Wang J, Pan J, Liu J, Bin C. Aetiology and prognostic risk factors of mortality in patients with pneumonia receiving glucocorticoids alone or glucocorticoids and other immunosuppressants: a retrospective cohort study. BMJ Open 2020; 10:e037419. [PMID: 33109645 PMCID: PMC7592294 DOI: 10.1136/bmjopen-2020-037419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Long-term use of high-dose glucocorticoids can lead to severe immunosuppression and increased risk of treatment-resistant pneumonia and mortality. We investigated the aetiology and prognostic risk factors of mortality in hospitalised patients who developed pneumonia while receiving glucocorticoid therapy alone or glucocorticoid and other immunosuppressant therapies. DESIGN Retrospective cohort study. SETTING Six secondary and tertiary academic hospitals in China. PARTICIPANTS Patients receiving glucocorticoids who were hospitalised with pneumonia between 1 January 2013 and 31 December 2019. MAIN OUTCOMES We analysed the prevalence of comorbidities, microbiology, antibiotic susceptibility patterns, 30-day and 90-day mortality and prognostic risk factors. RESULTS CONCLUSIONS: A total of 716 patients were included, with pneumonia pathogens identified in 69.8% of patients. Significant morbidities occurred, including respiratory failure (50.8%), intensive care unit transfer (40.8%) and mechanical ventilation (36%), with a 90-day mortality of 26.0%. Diagnosis of pneumonia occurred within 6 months of glucocorticoid initiation for 69.7% of patients with Cytomegalovirus (CMV) pneumonia and 79.0% of patients with Pneumocystis jirovecii pneumonia (PCP). Pathogens, including Pneumocystis, CMV and multidrug-resistant bacteria, were identified more frequently in patients with persistent lymphocytopenia and high-dose glucocorticoid treatment (≥30 mg/day of prednisolone or equivalent within 30 days before admission). The 90-day mortality was significantly lower for non-CMV viral pneumonias than for PCP (p<0.05), with a similar mortality as CMV pneumonias (24.2% vs 38.1% vs 27.4%, respectively). Cox regression analysis indicated several independent negative predictors for mortality in this patient population, including septic shock, respiratory failure, persistent lymphocytopenia, interstitial lung disease and high-dose glucocorticoid use.Patients who developed pneumonia while receiving glucocorticoid therapy experienced high rates of opportunistic infections, with significant morbidity and mortality. These findings should be carefully considered when determining treatment strategies for this patient population.
Collapse
Affiliation(s)
- Lijuan Li
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Steven H Hsu
- Department of Medical Intensive Care Unit, Houston Methodist Hospital, Houston, Texas, USA
| | - Xiaoying Gu
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Shan Jiang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lianhan Shang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Guolei Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lingxiao Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Li Zhang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Chuan Wang
- Department of Pulmonary and Critical Care Medicine, First Hospital of Shijiazhuang, Shijiazhuang, China
| | - Yali Ren
- Department of Pulmonary and Critical Care Medicine, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jinxiang Wang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jianliang Pan
- Department of Pulmonary and Critical Care Medicine, Second People's Hospital of Weifang, Weifang, China
| | - Jiangbo Liu
- Department of Pulmonary and Critical Care Medicine, Tianjin First Central Hospital, Tianjin, China
| | - Cao Bin
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Science; Tsinghua University-Peking University Joint Center for Life Sciences, China-Japan Friendship Hospital, Beijing, China
| |
Collapse
|
22
|
Edey MM, Gunasekera PN, Lobb M, Imran M. Intravenous immunoglobulin as adjunctive therapy in kidney transplant recipients with severe pneumocystis pneumonia. Transpl Infect Dis 2020; 23:e13454. [PMID: 32869412 DOI: 10.1111/tid.13454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 12/28/2022]
Abstract
Pneumocystis jirovecii is an opportunistic pathogen that may cause severe, life-threatening respiratory infections in immunocompromised patients such as those with kidney transplants. Although antimicrobial prophylaxis is now universally recommended in the early post-transplant period, Pneumocystis pneumonia (PCP) can occur later. If such infection occurs, mortality rates are high. Beyond standard therapy with trimethoprim-sulfamethoxazole, there is a lack of evidence-based options for intensifying treatment when initial therapy fails to show improvement. Moreover, it is usual to minimize immunosuppression in life-threatening infection, but graft damage may occur, particularly in kidney transplant recipients at above-average immunological risk. Here we present two cases of severe PCP in high immunological risk recipients who were managed with adjunctive intravenous immunoglobulin and withdrawal of immunosuppression. Both patients recovered and were discharged from hospital with functioning grafts.
Collapse
Affiliation(s)
- Matthew M Edey
- Department of Nephrology, Hull University Teaching Hospitals NHS Trust, Hull, UK.,Hull-York Medical School, Kingston-upon-Hull, UK
| | - Pumali N Gunasekera
- Department of Critical Care Medicine, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Mark Lobb
- Department of Transplant and Cellular Immunology, St James's University Hospital, Leeds, UK
| | - Muhammad Imran
- Department of Nephrology, Hull University Teaching Hospitals NHS Trust, Hull, UK.,Hull-York Medical School, Kingston-upon-Hull, UK
| |
Collapse
|
23
|
Ding L, Huang H, Wang H, He H. Adjunctive corticosteroids may be associated with better outcome for non-HIV Pneumocystis pneumonia with respiratory failure: a systemic review and meta-analysis of observational studies. Ann Intensive Care 2020; 10:34. [PMID: 32198645 PMCID: PMC7083987 DOI: 10.1186/s13613-020-00649-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/06/2020] [Indexed: 11/23/2022] Open
Abstract
Background Evidence supporting corticosteroids adjunctive treatment (CAT) for Pneumocystis jirovecii pneumonia (PCP) in non-HIV patients is highly controversial. We aimed to systematically review the literature and perform a meta-analysis of available data relating to the effect of CAT on mortality of PCP in non-HIV patients. Methods We searched Pubmed, Medline, Embase, and Cochrane database from 1989 through 2019. Data on clinical outcomes from non-HIV PCP were extracted with a standardized instrument. Heterogeneity was assessed with the I2 index. Pooled odds ratios and 95% confidence interval were calculated using a fixed effects model. We analyzed the impact of CAT on mortality of non-HIV PCP in the whole PCP population, those who had hypoxemia (PaO2 < 70 mmHg) and who had respiratory failure (PaO2 < 60 mmHg). Results In total, 259 articles were identified, and 2518 cases from 16 retrospective observational studies were included. In all non-HIV PCP cases included, there was an association between CAT and increased mortality (odds ratio, 1.37; 95% confidence interval 1.07–1.75; P = 0.01). CAT showed a probable benefit of decreasing mortality in hypoxemic non-HIV PCP patients (odds ratio, 0.69; 95% confidence interval 0.47–1.01; P = 0.05). Furthermore, in a subgroup analysis, CAT showed a significantly lower mortality in non-HIV PCP patients with respiratory failure compared to no CAT (odds ratio, 0.63; 95% confidence interval 0.41–0.95; P = 0.03). Conclusions Our meta-analysis suggests that among non-HIV PCP patients with respiratory failure, CAT use may be associated with better clinical outcomes, and it may be associated with increased mortality in unselected non-HIV PCP population. Clinical trials are needed to compare CAT vs no-CAT in non-HIV PCP patients with respiratory failure. Furthermore, CAT use should be withheld in non-HIV PCP patients without hypoxemia.
Collapse
Affiliation(s)
- Lin Ding
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Beijing, China
| | - Huixue Huang
- Department of Medicine, Beijing University of Technology Hospital, Beijing, China
| | - Heyan Wang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang, Guizhou, China
| | - Hangyong He
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China. .,Beijing Engineering Research Center for Diagnosis and Treatment of Pulmonary and Critical Care, Beijing, China. .,Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
| |
Collapse
|
24
|
Boniche C, Rossi SA, Kischkel B, Vieira Barbalho F, Nogueira D’Aurea Moura Á, Nosanchuk JD, Travassos LR, Pelleschi Taborda C. Immunotherapy against Systemic Fungal Infections Based on Monoclonal Antibodies. J Fungi (Basel) 2020; 6:jof6010031. [PMID: 32121415 PMCID: PMC7151209 DOI: 10.3390/jof6010031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/22/2020] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
The increasing incidence in systemic fungal infections in humans has increased focus for the development of fungal vaccines and use of monoclonal antibodies. Invasive mycoses are generally difficult to treat, as most occur in vulnerable individuals, with compromised innate and adaptive immune responses. Mortality rates in the setting of our current antifungal drugs remain excessively high. Moreover, systemic mycoses require prolonged durations of antifungal treatment and side effects frequently occur, particularly drug-induced liver and/or kidney injury. The use of monoclonal antibodies with or without concomitant administration of antifungal drugs emerges as a potentially efficient treatment modality to improve outcomes and reduce chemotherapy toxicities. In this review, we focus on the use of monoclonal antibodies with experimental evidence on the reduction of fungal burden and prolongation of survival in in vivo disease models. Presently, there are no licensed monoclonal antibodies for use in the treatment of systemic mycoses, although the potential of such a vaccine is very high as indicated by the substantial promising results from several experimental models.
Collapse
Affiliation(s)
- Camila Boniche
- Biomedical Sciences Institute, Department of Microbiology, University of São Paulo, Sao Paulo 05508-000, Brazil; (C.B.); (S.A.R.); (B.K.); (F.V.B.)
| | - Suélen Andreia Rossi
- Biomedical Sciences Institute, Department of Microbiology, University of São Paulo, Sao Paulo 05508-000, Brazil; (C.B.); (S.A.R.); (B.K.); (F.V.B.)
| | - Brenda Kischkel
- Biomedical Sciences Institute, Department of Microbiology, University of São Paulo, Sao Paulo 05508-000, Brazil; (C.B.); (S.A.R.); (B.K.); (F.V.B.)
| | - Filipe Vieira Barbalho
- Biomedical Sciences Institute, Department of Microbiology, University of São Paulo, Sao Paulo 05508-000, Brazil; (C.B.); (S.A.R.); (B.K.); (F.V.B.)
| | - Ágata Nogueira D’Aurea Moura
- Tropical Medicine Institute, Department of Dermatology, Faculty of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil;
| | - Joshua D. Nosanchuk
- Departments of Medicine (Division of Infectious Diseases) and Microbiology and Immunology, Albert Einstein College of Medicine, New York, NY 10461, USA;
| | - Luiz R. Travassos
- Department of Microbiology, Immunology and Parasitology, Federal University of São Paulo, Sao Paulo 04021-001, Brazil;
| | - Carlos Pelleschi Taborda
- Biomedical Sciences Institute, Department of Microbiology, University of São Paulo, Sao Paulo 05508-000, Brazil; (C.B.); (S.A.R.); (B.K.); (F.V.B.)
- Tropical Medicine Institute, Department of Dermatology, Faculty of Medicine, University of Sao Paulo, Sao Paulo 05403-000, Brazil;
- Correspondence:
| |
Collapse
|
25
|
Barbier F, Mer M, Szychowiak P, Miller RF, Mariotte É, Galicier L, Bouadma L, Tattevin P, Azoulay É. Management of HIV-infected patients in the intensive care unit. Intensive Care Med 2020; 46:329-342. [PMID: 32016535 PMCID: PMC7095039 DOI: 10.1007/s00134-020-05945-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
The widespread use of combination antiretroviral therapies (cART) has converted the prognosis of HIV infection from a rapidly progressive and ultimately fatal disease to a chronic condition with limited impact on life expectancy. Yet, HIV-infected patients remain at high risk for critical illness due to the occurrence of severe opportunistic infections in those with advanced immunosuppression (i.e., inaugural admissions or limited access to cART), a pronounced susceptibility to bacterial sepsis and tuberculosis at every stage of HIV infection, and a rising prevalence of underlying comorbidities such as chronic obstructive pulmonary diseases, atherosclerosis or non-AIDS-defining neoplasms in cART-treated patients aging with controlled viral replication. Several patterns of intensive care have markedly evolved in this patient population over the late cART era, including a steady decline in AIDS-related admissions, an opposite trend in admissions for exacerbated comorbidities, the emergence of additional drivers of immunosuppression (e.g., anti-neoplastic chemotherapy or solid organ transplantation), the management of cART in the acute phase of critical illness, and a dramatic progress in short-term survival that mainly results from general advances in intensive care practices. Besides, there is a lack of data regarding other features of ICU and post-ICU care in these patients, especially on the impact of sociological factors on clinical presentation and prognosis, the optimal timing of cART introduction in AIDS-related admissions, determinants of end-of-life decisions, long-term survival, and functional outcomes. In this narrative review, we sought to depict the current evidence regarding the management of HIV-infected patients admitted to the intensive care unit.
Collapse
Affiliation(s)
- François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France.
| | - Mervin Mer
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg University Hospital, Johannesburg, South Africa
| | - Piotr Szychowiak
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - Robert F Miller
- Research Department of Infection and Population Health, University College London, London, UK
| | - Éric Mariotte
- Medical Intensive Care Unit, Saint-Louis University Hospital, APHP, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Saint-Louis University Hospital, APHP, Paris, France
| | - Lila Bouadma
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, APHP, Paris, France.,Paris Diderot University, IAME-UMR 1137, INSERM, Paris, France
| | - Pierre Tattevin
- Infectious Diseases and Medical Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Élie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, APHP, Paris, France. .,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic, Sorbonne-Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France.
| |
Collapse
|
26
|
Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
|
27
|
Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti-inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.
Collapse
Affiliation(s)
- David Nora
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Wagner Nedel
- Intensive Care Unit, Hospital Nossa Senhora Da Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Hospital De Clínicas De Porto Alegre, Post-Graduation Program (PPG) Pneumology,Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Jorge Salluh
- D'or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
| |
Collapse
|
28
|
Hoy Z, Wright TW, Elliott M, Malone J, Bhagwat S, Wang J, Gigliotti F. Combination Immunotherapy with Passive Antibody and Sulfasalazine Accelerates Fungal Clearance and Promotes the Resolution of Pneumocystis-Associated Immunopathogenesis. Infect Immun 2020; 88:e00640-19. [PMID: 31611280 PMCID: PMC6977122 DOI: 10.1128/iai.00640-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/10/2019] [Indexed: 12/31/2022] Open
Abstract
The pulmonary immune response protects healthy individuals against Pneumocystis pneumonia (PcP). However, the immune response also drives immunopathogenesis in patients who develop severe PcP, and it is generally accepted that optimal treatment requires combination strategies that promote fungal killing and also provide effective immunomodulation. The anti-inflammatory drug sulfasalazine programs macrophages for enhanced Pneumocystis phagocytosis and also suppresses PcP-related immunopathogenesis. Anti-Pneumocystis antibody opsonizes Pneumocystis organisms for greater phagocytosis and may also mask antigens that drive immunopathogenesis. Thus, we hypothesized that combining antibody and sulfasalazine would have the dual benefit of enhancing fungal clearance while dampening immunopathogenesis and allow the rescue of severe PcP. To model a clinically relevant treatment scenario in mice, therapeutic interventions were withheld until clear symptoms of pneumonia were evident. When administered individually, both passive antibody and sulfasalazine improved pulmonary function and enhanced Pneumocystis clearance to similar degrees. However, combination treatment with antibody and sulfasalazine produced a more rapid improvement, with recovery of body weight, a dramatic improvement in pulmonary function, reduced lung inflammation, and the rapid clearance of the Pneumocystis organisms. Accelerated fungal clearance in the combination treatment group was associated with a significant increase in macrophage phagocytosis of Pneumocystis Both passive antibody and sulfasalazine resulted in the suppression of Th1 cytokines and a marked increase in lung macrophages displaying an alternatively activated phenotype, which were enhanced by combination treatment. Our data support the concept that passive antibody and sulfasalazine could be an effective and specific adjunctive therapy for PcP, with the potential to accelerate fungal clearance while attenuating PcP-associated immunopathogenesis.
Collapse
Affiliation(s)
- Zachary Hoy
- Department of Pediatrics, Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
| | - Terry W Wright
- Department of Pediatrics, Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York, USA
| | - Michael Elliott
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jane Malone
- Department of Pediatrics, Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
| | - Samir Bhagwat
- Department of Pediatrics, Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
| | - Jing Wang
- Department of Pediatrics, Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
| | - Francis Gigliotti
- Department of Pediatrics, Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York, USA
| |
Collapse
|
29
|
Gaborit BJ, Tessoulin B, Lavergne RA, Morio F, Sagan C, Canet E, Lecomte R, Leturnier P, Deschanvres C, Khatchatourian L, Asseray N, Garret C, Vourch M, Marest D, Raffi F, Boutoille D, Reignier J. Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study. Ann Intensive Care 2019; 9:131. [PMID: 31776705 PMCID: PMC6881486 DOI: 10.1186/s13613-019-0604-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/13/2019] [Indexed: 01/11/2023] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lavage fluid cytology profiles at diagnosis. Methods We prospectively enrolled all patients meeting pre-defined diagnostic criteria for PJP admitted at Nantes university hospital, France, from January 2012 to January 2017. Diagnostic criteria for PJP were typical clinical features with microbiological confirmation of P. jirovecii cysts by direct examination or a positive specific quantitative real-time polymerase chain reaction (PCR) assay. Severe PJP was defined as hypoxemic acute respiratory failure requiring high-flow nasal oxygen with at least 50% FiO2, non-invasive ventilation, or MV. Results Of 2446 respiratory samples investigated during the study period, 514 from 430 patients were positive for P. jirovecii. Of these 430 patients, 107 met criteria for PJP and were included in the study, 53 (49.5%) patients had severe PJP, including 30 who required MV. All patients were immunocompromised with haematological malignancy ranking first (n = 37, 35%), followed by solid organ transplantation (n = 27, 25%), HIV-infection (n = 21, 20%), systemic diseases (n = 13, 12%), solid tumors (n = 12, 11%) and primary immunodeficiency (n = 6, 8%). By multivariate analysis, factors independently associated with severity were older age (OR, 3.36; 95% CI 1.4–8.5; p < 0.05), a P. jirovecii microscopy-positive result from bronchoalveolar lavage (BAL) (OR, 1.3; 95% CI 1.54–9.3; p < 0.05); and absence of a BAL fluid alveolitis profile (OR, 3.2; 95% CI 1.27–8.8; p < 0.04). The 90-day mortality rate was 27%, increasing to 50% in the severe PJP group. Factors independently associated with 90-day mortality were worse SOFA score on day 1 (OR, 1.05; 95% CI 1.02–1.09; p < 0.001) whereas alveolitis at BAL was protective (OR, 0.79; 95% CI 0.65–0.96; p < 0.05). In the subgroup of HIV-negative patients, similar findings were obtained, then viral co-infection were independently associated with higher 90-day mortality (OR, 1.25; 95% CI 1.02–1.55; p < 0.05). Conclusions Older age and P. jirovecii oocysts at microscopic examination of BAL were independently associated with severe PJP. Both initial PJP severity as evaluated by the SOFA score and viral co-infection predicted 90-day mortality. Alveolitis at BAL examination was associated with less severe PJP. The pathophysiological mechanism underlying this observation deserves further investigation.
Collapse
Affiliation(s)
- Benjamin Jean Gaborit
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France. .,EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, Nantes, France.
| | - Benoit Tessoulin
- Service d'Hématologie, University Hospital, INSERM, U1232, Université de Nantes, Nantes, France
| | - Rose-Anne Lavergne
- Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Florent Morio
- Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | | | - Emmanuel Canet
- Medical Intensive Care, University Hospital, Nantes, France
| | - Raphael Lecomte
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Paul Leturnier
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Colin Deschanvres
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Lydie Khatchatourian
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Nathalie Asseray
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | | | - Michael Vourch
- Medical Intensive Care, University Hospital, Nantes, France
| | | | - François Raffi
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - David Boutoille
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France.,EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, Nantes, France
| | - Jean Reignier
- Medical Intensive Care, University Hospital, Nantes, France
| |
Collapse
|
30
|
White PL, Price JS, Backx M. Pneumocystis jirovecii Pneumonia: Epidemiology, Clinical Manifestation and Diagnosis. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-00349-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
31
|
Ando T, Abe Y, Endo Y, Tada K, Yamaji K, Tamura N. Rapid glucocorticoid tapering therapy to reduce mortality from pneumocystis pneumonia in patients with rheumatic disease. Mod Rheumatol 2019; 29:656-661. [PMID: 29972334 DOI: 10.1080/14397595.2018.1496873] [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: 10/28/2022]
Abstract
Objective: Pneumocystis pneumonia (PCP) is a serious complication in patients with rheumatic diseases who are receiving immunosuppressive therapy. These patients have a higher mortality from PCP than those with human immunodeficiency virus. We examined factors associated with poor prognosis in patients with rheumatic diseases and evaluated PCP treatment in this population. Methods: This retrospective, single-center, observational cohort study included 31 patients with rheumatic diseases who were admitted to Juntendo University Hospital for PCP treatment from June 2006 to December 2017. The primary outcome was non-disease-specific mortality at discharge. Results: The median age at PCP diagnosis was 64 years. The survival rate was 61.3% (19/31). Twelve patients died, in all cases due to respiratory failure due to PCP. Among variables at PCP diagnosis and those related to PCP treatment, the presence of coexisting pulmonary diseases and greater glucocorticoid dose at PCP diagnosis were associated with higher mortality. The mortality related to biological agents for PCP was low. Rapid tapering of glucocorticoids improved survivability. Conclusion: In the treatment of PCP in patients with rheumatic diseases, rapid tapering of glucocorticoids was associated with a higher survival rate than the use of conventional therapy.
Collapse
Affiliation(s)
- Taiki Ando
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Yoshiyuki Abe
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Yukari Endo
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Kurisu Tada
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Ken Yamaji
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Naoto Tamura
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| |
Collapse
|
32
|
Liu CJ, Lee TF, Ruan SY, Yu CJ, Chien JY, Hsueh PR. Clinical characteristics, treatment outcomes, and prognostic factors of Pneumocystis pneumonia in non-HIV-infected patients. Infect Drug Resist 2019; 12:1457-1467. [PMID: 31239724 PMCID: PMC6554003 DOI: 10.2147/idr.s199761] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/21/2019] [Indexed: 01/01/2023] Open
Abstract
Objectives: The incidence of Pneumocystis pneumonia (PCP) has been increasing among non-HIV-infected patients. Here, we investigated the clinical characteristics, treatment outcomes, and prognostic factors of PCP in non-HIV-infected patients. Patients and methods: Information on clinical characteristics, treatment outcomes, and prognostic factors of PCP patients who were treated at a medical center in northern Taiwan from October 2015 to October 2016 were retrieved from medical records and evaluated. Results: Among the patients with PCP included in the study, 84 were non-HIV-infected and 25 were HIV-infected. Non-HIV-infected patients with PCP had a longer duration between radiographic findings and treatment (P<0.001), and a higher rate of hospital-associated PCP (P<0.001), hypoxia (P=0.015), respiratory failure (P<0.001), and mortality (P=0.006) than HIV-infected patients with PCP. Among non-HIV-infected patients, non-survivors had a higher fungal burden (46.2% vs 22.2%, P=0.039), higher requirement for adjunctive steroid treatment (94.9% vs 71.1%, P=0.011), and higher rate of pneumothorax (17.9% vs 2.2%, P=0.038) than survivors. Multiple logistic regression revealed that lymphopenia (odds ratio [OR] =3.24, 95% confidence interval [CI] =1.07–9.79; P=0.037), adjunctive steroid use (OR =6.23, 95% CI =1.17–33.14; P=0.032), and pneumothorax (OR =10.68, 95% CI =1.00–113.93; P=0.050) were significantly associated with increased 60-day mortality among non-HIV-infected PCP patients. Conclusion: Lymphopenia, adjunctive steroid therapy, and pneumothorax were significantly associated with higher mortality in non-HIV-infected patients with PCP.
Collapse
Affiliation(s)
- Chia-Jung Liu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tai-Fen Lee
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sheng-Yuan Ruan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
33
|
Respiratory Infections. INFECTIONS IN NEUTROPENIC CANCER PATIENTS 2019. [PMCID: PMC7120562 DOI: 10.1007/978-3-030-21859-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pneumonia is defined as the presence of a new pulmonary infiltrate on radiologic imaging in the patient with appropriate clinical symptoms such as fever, cough, production of purulent sputum, shortness of breath and/or hypoxia, in the absence of pulmonary edema [1, 2].
Collapse
|
34
|
Therapy and Management of Pneumocystis jirovecii Infection. J Fungi (Basel) 2018; 4:jof4040127. [PMID: 30469526 PMCID: PMC6313306 DOI: 10.3390/jof4040127] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/08/2018] [Accepted: 11/11/2018] [Indexed: 12/21/2022] Open
Abstract
The rates of Pneumocystis pneumonia (PcP) are increasing in the HIV-negative susceptible population. Guidance for the prophylaxis and treatment of PcP in HIV, haematology, and solid-organ transplant (SOT) recipients is available, although for many other populations (e.g., auto-immune disorders) there remains an urgent need for recommendations. The main drug for both prophylaxis and treatment of PcP is trimethoprim/sulfamethoxazole, but resistance to this therapy is emerging, placing further emphasis on the need to make a mycological diagnosis using molecular based methods. Outbreaks in SOT recipients, particularly renal transplants, are increasingly described, and likely caused by human-to-human spread, highlighting the need for efficient infection control policies and sensitive diagnostic assays. Widespread prophylaxis is the best measure to gain control of outbreak situations. This review will summarize diagnostic options, cover prophylactic and therapeutic management in the main at risk populations, while also covering aspects of managing resistant disease, outbreak situations, and paediatric PcP.
Collapse
|
35
|
Early Corticosteroids for Pneumocystis Pneumonia in Adults Without HIV Are Not Associated With Better Outcome. Chest 2018; 154:636-644. [DOI: 10.1016/j.chest.2018.04.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 03/07/2018] [Accepted: 04/02/2018] [Indexed: 12/26/2022] Open
|
36
|
[Severe hypoxemic respiratory failure caused by Pneumocystis jirovecii in a late kidney transplant recipient]. BIOMEDICA 2018; 38:32-36. [PMID: 29668131 DOI: 10.7705/biomedica.v38i0.3589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 05/06/2017] [Indexed: 11/21/2022]
Abstract
Pneumonia caused by Pneumocystis jirovecii is an uncommon infection in kidney transplant patients that can have an acute and rapid progression to respiratory failure and death. The period of greatest risk occurs in the first six months after the transplant, and it relates to the high doses of immunosuppression drugs required by patients. However, it may occur late, associated with the suspension of prophylaxis with trimethoprim-sulfamethoxazole.We present two cases of renal transplant patients who had severe hypoxemic respiratory failure due to P. jirovecii six years after transplantation. In addition to steroids, they received treatment with trimethoprim-sulfamethoxazole. One patient died, while the other had clinical recovery, with preservation of the renal graft function.
Collapse
|
37
|
Epidemiology of fungal infections in China. Front Med 2018; 12:58-75. [DOI: 10.1007/s11684-017-0601-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 10/23/2017] [Indexed: 01/19/2023]
|
38
|
Adjuvant therapies in critical care: steroids to treat infectious diseases. Intensive Care Med 2017; 44:1306-1309. [DOI: 10.1007/s00134-017-5020-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
|
39
|
Liu Y, Su L, Jiang SJ, Qu H. Risk factors for mortality from pneumocystis carinii pneumonia (PCP) in non-HIV patients: a meta-analysis. Oncotarget 2017; 8:59729-59739. [PMID: 28938676 PMCID: PMC5601772 DOI: 10.18632/oncotarget.19927] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/26/2017] [Indexed: 01/23/2023] Open
Abstract
The number of patients with non-human immunodeficiency virus (HIV) related pneumocystis carinii pneumonia (PCP) is increasing with widespread immunosuppressive treatment. We performed a meta-analysis to describe the clinical characteristics and factors associated with outcomes of PCP in HIV-negative patients. A total of 13 studies including 867 patients with non-HIV related PCP was included. The overall mortality for non-HIV patients with PCP was 30.6%. The most common underlying disorder for the development of PCP is hematological malignancies (29.1%), followed by autoimmune disease (20.1%), organ or bone marrow transplantation (14.0%), and solid tumors (6.0%). Risk factors associated with increased mortality rate including old age, female sex, longer time from onset of symptoms to diagnosis, respiratory failure, solid tumors, high lactate dehydrogenase, low serum albumin, bacterial, and aspergillus co-infection, etc (P < 0.05). Adjunctive corticosteroid and PCP prophylaxis was not shown to improve the outcome of PCP in non-HIV patients (P > 0.05). Our findings indicate that mortality in non-HIV patients with PCP is high. Improved knowledge about the prognostic factors may guide the early treatment.
Collapse
Affiliation(s)
- Yao Liu
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Lili Su
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Shu-Juan Jiang
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Hui Qu
- Department of General Surgery, Shandong University Qilu Hospital, Jinan, Shandong, China
| |
Collapse
|
40
|
Huang YS, Yang JJ, Lee NY, Chen GJ, Ko WC, Sun HY, Hung CC. Treatment of Pneumocystis jirovecii pneumonia in HIV-infected patients: a review. Expert Rev Anti Infect Ther 2017; 15:873-892. [PMID: 28782390 DOI: 10.1080/14787210.2017.1364991] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Pneumocystis pneumonia is a potentially life-threatening pulmonary infection that occurs in immunocompromised individuals and HIV-infected patients with a low CD4 cell count. Trimethoprim-sulfamethoxazole has been used as the first-line agent for treatment, but mutations within dihydropteroate synthase gene render potential resistance to sulfamide. Despite advances of combination antiretroviral therapy (cART), Pneumocystis pneumonia continues to occur in HIV-infected patients with late presentation for cART or virological and immunological failure after receiving cART. Areas covered: This review summarizes the diagnosis and first-line and alternative treatment and prophylaxis for Pneumocystis pneumonia in HIV-infected patients. Articles for this review were identified through searching PubMed. Search terms included: 'Pneumocystis pneumonia', 'Pneumocystis jirovecii pneumonia', 'Pneumocystis carinii pneumonia', 'trimethoprim-sulfamethoxazole', 'primaquine', 'trimetrexate', 'dapsone', 'pentamidine', 'atovaquone', 'echinocandins', 'human immunodeficiency virus infection', 'acquired immunodeficiency syndrome', 'resistance to sulfamide' and combinations of these terms. We limited the search to English language papers that were published between 1981 and March 2017. We screened all identified articles and cross-referenced studies from retrieved articles. Expert commentary: Trimethoprim-sulfamethoxazole will continue to be the first-line agent for Pneumocystis pneumonia given its cost, availability of both oral and parenteral formulations, and effectiveness or efficacy in both treatment and prophylaxis. Whether resistance due to mutations within dihydropteroate synthase gene compromises treatment effectiveness remains controversial. Continued search for effective alternatives with better safety profiles for Pneumocystis pneumonia is warranted.
Collapse
Affiliation(s)
- Yu-Shan Huang
- a Department of Internal Medicine , National Taiwan University Hospital Hsin-Chu Branch , Hsin-Chu , Taiwan
| | - Jen-Jia Yang
- b Department of Internal Medicine , Po Jen General Hospital , Taipei , Taiwan
| | - Nan-Yao Lee
- c Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan.,d Department of Medicine , College of Medicine, National Cheng Kung University , Tainan , Taiwan
| | - Guan-Jhou Chen
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan
| | - Wen-Chien Ko
- c Department of Internal Medicine , National Cheng Kung University Hospital , Tainan , Taiwan.,d Department of Medicine , College of Medicine, National Cheng Kung University , Tainan , Taiwan
| | - Hsin-Yun Sun
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan
| | - Chien-Ching Hung
- e Department of Internal Medicine , National Taiwan University Hospital and National Taiwan University College of Medicine , Taipei , Taiwan.,f Department of Parasitology , National Taiwan University College of Medicine , Taipei , Taiwan.,g Department of Medical Research , China Medical University Hospital , Taichung , Taiwan.,h China Medical University , Taichung , Taiwan
| |
Collapse
|
41
|
A Systematic Review and Meta-Analysis of the Data Behind Current Recommendations for Corticosteroids in Non-HIV-Related PCP: Knowing When You Are on Shaky Foundations. Transplant Direct 2017; 3:e137. [PMID: 28361121 PMCID: PMC5367754 DOI: 10.1097/txd.0000000000000642] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/08/2016] [Indexed: 12/21/2022] Open
Abstract
Background Randomized trials show a mortality benefit to adjunctive corticosteroids for human immunodeficiency virus (HIV)-related Pneumocystis jiroveci pneumonia (HIV-PCP). Guidelines for non-HIV PCP (NH-PCP) recommend adjunctive corticosteroids based on expert opinion. We conducted a systematic review and meta-analysis characterizing adjunctive corticosteroids for NH-PCP. Methods We searched MEDLINE from 1966 through 2015. Data on clinical outcomes from NH-PCP were extracted with a standardized instrument. Heterogeneity was assessed with the I2 index. Pooled odds ratios and 95% confidence interval were calculated using a fixed effects model. Results Our search yielded 5044 abstracts, 277 articles were chosen for full review, and 6 articles described outcomes in moderate to severe NH-PCP. Studies were limited by variable definitions, treatment selection bias, concomitant infections and small sample size. Individual studies reported shorter intensive care unit stay and duration of mechanical ventilation of patients given adjunctive corticosteroids. There was no association between corticosteroids and survival in NH-PCP (odds ratio, 0.66; 95% confidence interval, 0.38-1.15; P = 0.14). Conclusions The literature does not support an association between adjunctive corticosteroids and survival from NH-PCP but data are limited and findings should not be considered conclusive. Further research with improved methodology is needed to better understand the role of adjunctive corticosteroids for NH-PCP.
Collapse
|
42
|
van Halem K, Vrolijk L, Pereira AM, de Boer MGJ. Characteristics and Mortality of Pneumocystis Pneumonia in Patients With Cushing's Syndrome: A Plea for Timely Initiation of Chemoprophylaxis. Open Forum Infect Dis 2017; 4:ofx002. [PMID: 28480275 PMCID: PMC5414011 DOI: 10.1093/ofid/ofx002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/07/2017] [Indexed: 11/13/2022] Open
Abstract
In patients with Cushing's syndrome, development of Pneumocystis pneumonia (PCP) is associated with extreme cortisol production levels. In this setting, immune reconstitution after abrogation of cortisol excess appears to induce development of symptomatic PCP. The high mortality rate warrants timely initiation of chemoprophylaxis or even preemptive treatment of PCP.
Collapse
Affiliation(s)
| | | | - Alberto Martin Pereira
- Department of Medicine, Division of Endocrinology, and Center for Endocrine Tumors, Leiden University Medical Center, The Netherlands
| | | |
Collapse
|
43
|
Weng L, Huang X, Chen L, Feng LQ, Jiang W, Hu XY, Peng JM, Wang CY, Zhan QY, Du B. Prognostic factors for severe Pneumocystis jiroveci pneumonia of non-HIV patients in intensive care unit: a bicentric retrospective study. BMC Infect Dis 2016; 16:528. [PMID: 27686235 PMCID: PMC5041573 DOI: 10.1186/s12879-016-1855-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/20/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PJP) in non-HIV patients is still a challenge for intensivists. The aim of our study was to evaluate mortality predictors of PJP patients requiring Intensive care unit (ICU) admission. METHODS Retrospectively review medical records of patients with diagnosis of PJP admitted to four ICUs of two academic medical centers from October 2012 to October 2015. RESULTS Eighty-two patients were enrolled in the study. Overall hospital mortality was 75.6 %. Compared with survivors, the non-survivors had older age (55 ± 16 vs. 45 ± 17, p = 0.014), higher APACHE II score (20 ± 5 vs. 17 ± 5, p = 0.01), lower white blood cell count (7.68 ± 3.44 vs. 10.48 ± 4.62, p = 0.005), less fever (80.6%vs. 100 %, p = 0.033), more hypotension (58.1 % vs. 20 %, p = 0.003), more pneumomediastinum (29 % vs. 5 %, p = 0.027). Logistic regression analysis demonstrated that age [odds ratio (OR)1.051; 95 % CI 1.007-1.097; p = 0.022], white blood cell count [OR 0.802; 95 % CI 0.670-0.960; p = 0.016], and pneumomediastinum [OR 16.514; 95 % CI 1.330-205.027; p = 0.029] were independently associated with hospital mortality. CONCLUSIONS Mortality rate for non-HIV PJP patients requiring ICU admission was still high. Poor prognostic factors included age, white blood cell count and pneumomediastinum.
Collapse
Affiliation(s)
- Li Weng
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng district, Beijing, 100730 China
| | - Xu Huang
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Hepingli, Beijing, 100029 China
| | - Lie Chen
- Department of General Internal Medicine, Shijingshan hospital, Capital Medical University, 24 Shijingshan street, Shijingshan district, Beijing, 100043 China
| | - Li-Qin Feng
- Intensive Care Unit, Fifth Hospital of Shi Jia Zhuang, 42 Tanan street, Yuhua district, Shijiazhuang, 050021 China
| | - Wei Jiang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng district, Beijing, 100730 China
| | - Xiao-Yun Hu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng district, Beijing, 100730 China
| | - Jin-Min Peng
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng district, Beijing, 100730 China
| | - Chun-Yao Wang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng district, Beijing, 100730 China
| | - Qing-Yuan Zhan
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Hepingli, Beijing, 100029 China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng district, Beijing, 100730 China
| |
Collapse
|
44
|
Kim KR, Kim JM, Kang JM, Kim YJ. Pneumocystis jirovecii pneumonia in pediatric patients: an analysis of 15 confirmed consecutive cases during 14 years. KOREAN JOURNAL OF PEDIATRICS 2016; 59:252-5. [PMID: 27462353 PMCID: PMC4958702 DOI: 10.3345/kjp.2016.59.6.252] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 12/25/2015] [Accepted: 12/29/2015] [Indexed: 11/27/2022]
Abstract
Purpose Pneumocystis jirovecii pneumonia occurs in various immunocompromised patients. Despite the prophylaxis strategies in clinical practice, certain patients develop P. jirovecii pneumonia. This study was performed to investigate pediatric cases with P. jirovecii pneumonia in a single center. Methods We identified pediatric patients younger than 19 years with microbiologically confirmed P. jirovecii pneumonia from January 2000 to February 2014. A retrospective chart review was performed. Results Fifteen episodes of P. jirovecii pneumonia in 14 patients were identified with median age of 8.3 years (range, 0.4–18.6 years). Among these patients, 11 patients had hematology-oncology diseases, 2 had primary immunodeficiency disorders (one with severe combined immunodeficiency and the other with Wiskott Aldrich syndrome), 1 had systemic lupus erythematosus and 1 received kidney transplant. Four patients were transplant recipients; 1 allogeneic and 2 autologous hematopoietic cell transplant and 1 with kidney transplant. The median absolute lymphocyte count at the diagnosis of P. jirovecii pneumonia was 5,156 cells/mm3 (range, 20–5,111 cells/mm3). In 13 episodes (13 of 15, 86.7%), patients were not receiving prophylaxis at the onset of P. jirovecii pneumonia. For treatment, trimethoprim/sulfamethoxazole was given as a main therapeutic agent in all 15 episodes. Steroid was given in 9 episodes (60%). Median treatment duration was 15 days (range, 4–33 days). Overall mortality at 60 days was 35.7% (5 of 14). Conclusion Majority of our patients developed P. jirovecii pneumonia while not on prophylaxis. Continuous efforts and more data are needed to identify high risk patients who may get benefit from P. jirovecii pneumonia prophylaxis.
Collapse
Affiliation(s)
- Kyung-Ran Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Min Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Man Kang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
45
|
Bouguerba A, Ayed S, Roux A, Bornstain C, Vincent F. Questions non résolues sur la pneumocystose pulmonaire chez les patients VIH négatifs. Rev Mal Respir 2016; 33:555-7. [DOI: 10.1016/j.rmr.2016.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 03/21/2016] [Indexed: 11/24/2022]
|
46
|
Maschmeyer G, Helweg-Larsen J, Pagano L, Robin C, Cordonnier C, Schellongowski P. ECIL guidelines for treatment of Pneumocystis jirovecii pneumonia in non-HIV-infected haematology patients. J Antimicrob Chemother 2016; 71:2405-13. [PMID: 27550993 DOI: 10.1093/jac/dkw158] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The initiation of systemic antimicrobial treatment of Pneumocystis jirovecii pneumonia (PCP) is triggered by clinical signs and symptoms, typical radiological and occasionally laboratory findings in patients at risk of this infection. Diagnostic proof by bronchoalveolar lavage should not delay the start of treatment. Most patients with haematological malignancies present with a severe PCP; therefore, antimicrobial therapy should be started intravenously. High-dose trimethoprim/sulfamethoxazole is the treatment of choice. In patients with documented intolerance to this regimen, the preferred alternative is the combination of primaquine plus clindamycin. Treatment success should be first evaluated after 1 week, and in case of clinical non-response, pulmonary CT scan and bronchoalveolar lavage should be repeated to look for secondary or co-infections. Treatment duration typically is 3 weeks and secondary anti-PCP prophylaxis is indicated in all patients thereafter. In patients with critical respiratory failure, non-invasive ventilation is not significantly superior to intubation and mechanical ventilation. The administration of glucocorticoids must be decided on a case-by-case basis.
Collapse
Affiliation(s)
- Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Livio Pagano
- Institute of Haematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Christine Robin
- Department of Haematology, Assistance Publique-hôpitaux de Paris (APHP), Henri Mondor Teaching Hospital, Créteil, France University Paris-Est Créteil (UPEC), Créteil, France
| | - Catherine Cordonnier
- Department of Haematology, Assistance Publique-hôpitaux de Paris (APHP), Henri Mondor Teaching Hospital, Créteil, France University Paris-Est Créteil (UPEC), Créteil, France
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria Intensive Care in Hematologic and Oncologic Patients (iCHOP)
| | | |
Collapse
|
47
|
Pneumocystose chez les patients immunodéprimés non infectés par le VIH. Rev Med Interne 2016; 37:327-36. [DOI: 10.1016/j.revmed.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/02/2015] [Indexed: 12/15/2022]
|
48
|
Canet E, Zafrani L, Azoulay É. The Critically Ill Kidney Transplant Recipient: A Narrative Review. Chest 2016; 149:1546-55. [PMID: 26836919 DOI: 10.1016/j.chest.2016.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/11/2015] [Accepted: 01/03/2016] [Indexed: 12/20/2022] Open
Abstract
Kidney transplantation is the most common solid organ transplantation performed worldwide. Up to 6% of kidney transplant recipients experience a life-threatening complication that requires ICU admission, chiefly in the late posttransplantation period (≥ 6 months). Acute respiratory failure and septic shock are the main reasons for ICU admission. Cardiac pulmonary edema, bacterial pneumonia, acute graft pyelonephritis, and bloodstream infections account for the vast majority of diagnoses in the ICU. Pneumocystis jirovecii pneumonia is the most common opportunistic infection, and one-half of the patients so infected require mechanical ventilation. The incidence of cytomegalovirus visceral infections in the era of preemptive therapy has dramatically decreased. Drug-related neutropenia, sirolimus-related pneumonitis, and posterior reversible encephalopathy syndrome are among the most common immunosuppression-associated toxic effects. Importantly, the impact of critical illness on graft function is worrisome. Throughout the ICU stay, acute kidney injury is common, and about 40% of the recipients require renal replacement therapy. One-half of the patients are discharged alive and free from dialysis. Hospital mortality can reach 30% and correlates with acute illness severity and reason for ICU admission. Transplant characteristics are not predictors of short-term survival. Graft survival depends on pre-ICU graft function, disease severity, and renal toxicity of ICU investigations and treatments.
Collapse
Affiliation(s)
- Emmanuel Canet
- Medical Intensive Care Unit Department, Saint-Louis University Hospital, Paris, France.
| | - Lara Zafrani
- Medical Intensive Care Unit Department, Saint-Louis University Hospital, Paris, France; Paris Diderot University, Sorbonne Paris Cité Paris, France
| | - Élie Azoulay
- Medical Intensive Care Unit Department, Saint-Louis University Hospital, Paris, France; Paris Diderot University, Sorbonne Paris Cité Paris, France
| |
Collapse
|
49
|
Maschmeyer G, Donnelly JP. How to manage lung infiltrates in adults suffering from haematological malignancies outside allogeneic haematopoietic stem cell transplantation. Br J Haematol 2016; 173:179-89. [PMID: 26729577 PMCID: PMC7161791 DOI: 10.1111/bjh.13934] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/13/2015] [Indexed: 12/20/2022]
Abstract
Pulmonary complications affect up to 40% of patients with severe neutropenia lasting for more than 10 d. As they are frequently associated with fever and elevation of C‐reactive protein or other signs of inflammation, they are mostly handled as pneumonia. However, the differential diagnosis is broad, and a causative microbial agent remains undetected in the majority of cases. Pulmonary side effects from cytotoxic treatment or pulmonary involvement by the underlying malignancy must always be taken into account and may provide grounds for invasive diagnostic procedures in selected patients. Pneumocystis jirovecii (in patients not receiving co‐trimoxazole as prophylaxis), multi‐resistant gram‐negative bacilli, mycobacteria or respiratory viruses may be involved. High‐risk patients may be infected by filamentous fungi, such as Aspergillus spp., but these infections are seldom proven when treatment is initiated. Microorganisms isolated from cultures of blood, bronchoalveolar lavage or respiratory secretions need careful interpretation as they may be irrelevant for determining the aetiology of pulmonary infiltrates, particularly when cultures yield coagulase‐negative staphylococci, enterococci or Candida species. Non‐culture based diagnostics for detecting Aspergillus galactomannan, beta‐D‐glucan or DNA from blood, bronchoalveolar lavage or tissue samples can facilitate the diagnosis, but must always be interpreted in the context of clinical and imaging findings. Systemic antifungal treatment with mould‐active agents, given in combination with broad‐spectrum antibiotics, improves clinical outcome when given pre‐emptively. Co‐trimoxazole remains the first‐line treatment for Pneumocystis pneumonia, while cytomegalovirus pneumonia will respond to ganciclovir or foscarnet in most cases. The clinical outcome of acute respiratory failure can also be successful with proper intensive care, when indicated.
Collapse
Affiliation(s)
- Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - J Peter Donnelly
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
50
|
Goto N, Futamura K, Okada M, Yamamoto T, Tsujita M, Hiramitsu T, Narumi S, Watarai Y. Management of Pneumocystis jirovecii Pneumonia in Kidney Transplantation to Prevent Further Outbreak. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:81-90. [PMID: 26609250 PMCID: PMC4648609 DOI: 10.4137/ccrpm.s23317] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/11/2015] [Accepted: 08/12/2015] [Indexed: 12/19/2022]
Abstract
The outbreak of Pneumocystis jirovecii pneumonia (PJP) among kidney transplant recipients is emerging worldwide. It is important to control nosocomial PJP infection. A delay in diagnosis and treatment increases the number of reservoir patients and the number of cases of respiratory failure and death. Owing to the large number of kidney transplant recipients compared to other types of organ transplantation, there are greater opportunities for them to share the same time and space. Although the use of trimethoprim-sulfamethoxazole (TMP-SMX) as first choice in PJP prophylaxis is valuable for PJP that develops from infections by trophic forms, it cannot prevent or clear colonization, in which cysts are dominant. Colonization of P. jirovecii is cleared by macrophages. While recent immunosuppressive therapies have decreased the rate of rejection, over-suppressed macrophages caused by the higher levels of immunosuppression may decrease the eradication rate of colonization. Once a PJP cluster enters these populations, which are gathered in one place and uniformly undergoing immunosuppressive therapy for kidney transplantation, an outbreak can occur easily. Quick actions for PJP patients, other recipients, and medical staff of transplant centers are required. In future, lifelong prophylaxis may be required even in kidney transplant recipients.
Collapse
Affiliation(s)
- Norihiko Goto
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takayuki Yamamoto
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Makoto Tsujita
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshihiko Watarai
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| |
Collapse
|