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Poth JM, Schmandt M, Schewe JC, Lehmann F, Kreyer S, Kohistani Z, Bakhtiary F, Hischebeth G, Putensen C, Weller J, Ehrentraut SF. Prevalence and prognostic relevance of invasive fungal disease during veno-arterial ECMO: A retrospective single-center study. J Crit Care 2024; 83:154831. [PMID: 38797056 DOI: 10.1016/j.jcrc.2024.154831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE To assess the prevalence and relevance of invasive fungal disease (IFD) during veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO). METHODS Retrospective analysis from January 2013 to November 2023 of adult V-A ECMO cases at a German University Hospital. Parameters relating to IFD, demographics, length of stay (LoS), days on ECMO and mechanical ventilation, prognostic scores and survival were assessed. Multivariable logistic regression analyses with IFD and death as dependent variables were performed. Outcome was assessed after propensity score matching IFD-patients to non-IFD-controls. RESULTS 421 patients received V-A ECMO. 392 patients with full electronic datasets were included. The prevalence of IFD, invasive candidiasis and probable invasive pulmonary aspergillosis was 4.6%, 3.8% and 1.0%. Severity of acute disease, pre-existing moderate-to-severe renal disease and continuous kidney replacement therapy were predictive of IFD. In-hospital mortality (94% (17/18) compared to 67% (252/374) in non-IFD patients (p = 0.0156)) was predicted by female sex, SOFA score at admission, SAVE score and IFD (for IFD: OR: 8.31; CI: 1.60-153.18; p: 0.044). There was no difference in outcome after matching IFD-cases to non-IFD-controls. CONCLUSIONS IFD are detected in about one in 20 patients on V-A ECMO, indicating mortality >90%. However, IFD do not contribute to prognosis in this population.
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Affiliation(s)
- Jens M Poth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Mathias Schmandt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Rostock, 18057 Rostock, Germany
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Zaki Kohistani
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, 53127 Bonn, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, 53127 Bonn, Germany
| | - Gunnar Hischebeth
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, 53127 Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Johannes Weller
- Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan F Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany.
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la Garza PRD, Cruz-de la Cruz CDL, Bejarano JIC, Romo AEL, Delgado JV, Ramos BA, Neira MNM, Rodríguez DS, Rodríguez HMS, Selvera OAR. A multicentric outbreak of Candida auris in Mexico: 2020 to 2023. Am J Infect Control 2024:S0196-6553(24)00611-4. [PMID: 39059713 DOI: 10.1016/j.ajic.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/17/2024] [Accepted: 07/20/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Candida auris, an emerging multidrug-resistant yeast, has become a global concern due to its association with nosocomial outbreaks and resistance to antifungal medications. The COVID-19 pandemic has exacerbated the situation, with several outbreaks reported worldwide, including in Mexico. We describe the clinical and microbiological characteristics of a multicentric outbreak in private institutions in Mexico. METHODS A retrospective observational study was conducted across 4 Christus Muguerza Hospital Health Care System facilities in Monterrey, Mexico, where simultaneous outbreaks of C auris occurred. Patients with colonization or infection with C auris between September 2020 and December 2023 were included. RESULTS Analysis revealed 37 cases, predominantly male (median age, 55.8years). While most cases were initially colonization, a significant proportion progressed to infection (32.4%). Patients with documented infection had longer intensive care unit and hospital stays, often requiring mechanical ventilation. Antifungal treatment varied, with empirical fluconazole being the first drug in most cases, followed by anidulafungin and caspofungin. Resistance to fluconazole was widespread, but susceptibility to other antifungals varied. The overall mortality rates were high (40.5%), with no significant difference in median survival between colonized and infected patients. CONCLUSIONS We reported a high rate of infection in previously colonized cases associated with longer hospital lenght stay, and a high susceptibility to echinocandins.
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Affiliation(s)
- Patricia Rodríguez-de la Garza
- Department of Internal Medicine; Christus Muguerza Hospital Alta Especialidad, Universidad de Monterrey, Monterrey, Mexico
| | - Carlos de la Cruz-de la Cruz
- Department of Internal Medicine; Christus Muguerza Hospital Alta Especialidad, Universidad de Monterrey, Monterrey, Mexico
| | | | - Alicia Estela López Romo
- Hospital Epidemiology and Surveillance Unit, Sistemas de Salud Christus Muguerza, Monterrey, Mexico
| | - Jorge Vera Delgado
- Department of Microbiology; Christus Muguerza Hospital Alta Especialidad, Universidad de Monterrey, Monterrey, Mexico
| | - Beatriz Aguilar Ramos
- Department of Microbiology; Christus Muguerza Hospital Alta Especialidad, Universidad de Monterrey, Monterrey, Mexico
| | - Mirna Natalia Martínez Neira
- Department of Microbiology; Christus Muguerza Hospital Alta Especialidad, Universidad de Monterrey, Monterrey, Mexico
| | - Daniel Siller Rodríguez
- Hospital Epidemiology and Surveillance Unit, Sistemas de Salud Christus Muguerza, Monterrey, Mexico
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Aslam S, Cowger J, Shah P, Stosor V, Copeland H, Reed A, Morales D, Giblin G, Mathew J, Morrissey O, Morejon P, Nicoara A, Molina E. The International Society for Heart and Lung Transplantation (ISHLT): 2024 infection definitions for durable and acute mechanical circulatory support devices. J Heart Lung Transplant 2024; 43:1039-1050. [PMID: 38691077 DOI: 10.1016/j.healun.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 05/03/2024] Open
Abstract
Infections remain a significant concern in patients receiving mechanical circulatory support (MCS), encompassing both durable and acute devices. This consensus manuscript provides updated definitions for infections associated with durable MCS devices and new definitions for infections in acute MCS, integrating a comprehensive review of existing literature and collaborative discussions among multidisciplinary specialists. By establishing consensus definitions, we seek to enhance clinical care, facilitate consistent reporting in research studies, and ultimately improve outcomes for patients receiving MCS.
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Affiliation(s)
- Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California.
| | - Jennifer Cowger
- Division of Cardiology, Henry Ford Health, Detroit, Michigan
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Valentina Stosor
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hannah Copeland
- Department of Surgery, Lutheran Hospital of Indiana/Indiana School of Medicine, Fort Wayne, Indiana
| | - Anna Reed
- Respiratory & Transplant Medicine, Royal Brompton and Harefield Hospitals, Harefield, United Kingdom
| | - David Morales
- Division of Cardiothoracic Surgery, Department of Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Gerard Giblin
- Cardiology Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jacob Mathew
- Cardiology Department, Royal Children's Hospital, Melbourne, Australia
| | - Orla Morrissey
- Department of Infectious Diseases, Monash University and Physician at Alfred Health, Melbourne, Australia
| | | | - Alina Nicoara
- Division of Cardiothoracic Anesthesia, Duke University, Durham, North Carolina
| | - Ezequiel Molina
- Samsky Heart Failure Center, Piedmont Heart Institute, Atlanta, Georgia
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4
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Kriegl L, Hatzl S, Schilcher G, Zollner-Schwetz I, Boyer J, Geiger C, Hoenigl M, Krause R. Antifungals in Patients With Extracorporeal Membrane Oxygenation: Clinical Implications. Open Forum Infect Dis 2024; 11:ofae270. [PMID: 38887481 PMCID: PMC11181180 DOI: 10.1093/ofid/ofae270] [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: 12/31/2023] [Accepted: 05/05/2024] [Indexed: 06/20/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving technique used in critical care medicine for patients with severe respiratory or cardiac failure. This review examines the treatment and prophylaxis of fungal infections in ECMO patients, proposing specific regimens based on available data for different antifungals (azoles, echinocandins, amphotericin B/liposomal amphotericin B) and invasive fungal infections. Currently, isavuconazole and posaconazole have the most supported data, while modified dosages of isavuconazole are recommended in ECMO. Echinocandins are preferred for invasive candidiasis. However, choosing echinocandins is challenging due to limited and varied data on concentration loss in the ECMO circuit. Caution is likewise advised when using liposomal amphotericin B due to uncertain concentrations and potential ECMO dysfunction based on scarce data. We further conclude with the importance of further research on the impact of ECMO on antifungal drug concentrations to optimize dosing regimens in critically ill patients.
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Affiliation(s)
- Lisa Kriegl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Stefan Hatzl
- BioTechMed-Graz, Graz, Austria
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Ines Zollner-Schwetz
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christina Geiger
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
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5
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Dobry P, Edwin SB, Ng TH, Dutcheshen K, Kaki A, Schreiber TL. Treatment of Candida auris during extracorporeal life support: A case report. Int J Artif Organs 2024; 47:223-226. [PMID: 38281934 DOI: 10.1177/03913988231226357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
With rates of ECMO utilization on the rise, prevention of nosocomial infections is of paramount importance. Candida auris, an emerging highly pathogenic multidrug resistant fungus, is of particular concern as it is associated with persistent colonization of environmental surfaces, inability to be recognized by many diagnostic platforms, inconsistent laboratory susceptibility results, and high mortality rates. We describe a case of C. auris in a VV-ECMO patient successfully managed with a combination of anidulafungin, amphotericin B, and flucytosine.
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Affiliation(s)
- Paul Dobry
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
- Eugene Applebaum College of Pharmacy, Wayne State University, Detroit, MI, USA
| | - Stephanie B Edwin
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | - Tsz Hin Ng
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | - Karey Dutcheshen
- Department of Cardiology, Ascension St. John Hospital, Detroit, MI, USA
| | - Amir Kaki
- Department of Cardiology, Ascension St. John Hospital, Detroit, MI, USA
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Moyon Q, Triboulet F, Reuter J, Lebreton G, Dorget A, Para M, Chommeloux J, Stern J, Pineton de Chambrun M, Hékimian G, Luyt CE, Combes A, Sonneville R, Schmidt M. Venoarterial extracorporeal membrane oxygenation in immunocompromised patients with cardiogenic shock: a cohort study and propensity-weighted analysis. Intensive Care Med 2024; 50:406-417. [PMID: 38436727 DOI: 10.1007/s00134-024-07354-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/11/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The outcomes of immunocompromised patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are seldom documented, making ECMO candidacy decisions challenging. This study aims (1) to report outcomes of immunocompromised patients treated with VA-ECMO, (2) to identify pre-ECMO predictors of 90-day mortality, (3) to assess the impact of immunodepression on 90-day mortality, and (4) to describe the main ECMO-related complications. METHODS This is a retrospective, propensity-weighted study conducted in two French experienced ECMO centers. RESULTS From January 2006 to January 2022, 177 critically ill immunocompromised patients (median (interquartile range, IQR) age 49 (32-60) years) received VA-ECMO. The main causes of immunosuppression were long-term corticosteroids/immunosuppressant treatment (29%), hematological malignancy (26%), solid organ transplant (20%), and solid tumor (13%). Overall 90-day and 1-year mortality were 70% (95% confidence interval (CI) 63-77%) and 75% (95% CI 65-79%), respectively. Older age and higher pre-ECMO lactate were independently associated with 90-day mortality. Across immunodepression causes, 1-year mortality ranged from 58% for patients with infection by human immunodeficiency virus (HIV) or asplenia, to 89% for solid organ transplant recipients. Hemorrhagic and infectious complications affected 39% and 54% of patients, while more than half the stay in intensive care unit (ICU) was spent on antibiotics. In a propensity score-weighted model comparing the 177 patients with 942 non-immunocompromised patients experiencing cardiogenic shock on VA-ECMO, immunocompromised status was independently associated with a higher 90-day mortality (odds ratio 2.53, 95% CI 1.72-3.79). CONCLUSION Immunocompromised patients undergoing VA-ECMO treatment face an unfavorable prognosis, with higher 90-day mortality compared to non-immunocompromised patients. This underscores the necessity for thorough evaluation and careful selection of ECMO candidates within this frail population.
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Affiliation(s)
- Quentin Moyon
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Félicien Triboulet
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jean Reuter
- Assistance Publique des Hopitaux de Paris, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Guillaume Lebreton
- Assistance Publique des Hopitaux de Paris, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Amandine Dorget
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Marylou Para
- Assistance Publique Des Hopitaux de Paris, Bichat Hospital, Service de Chirurgie Cardiaque, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Juliette Chommeloux
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Jules Stern
- Assistance Publique Des Hopitaux de Paris, Department of Anesthesiology and Critical Care Medicine, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Marc Pineton de Chambrun
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
| | - Guillaume Hékimian
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Charles-Edouard Luyt
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, GRC 30, RESPIRE, Paris, France
| | - Alain Combes
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France
- Sorbonne Université, GRC 30, RESPIRE, Paris, France
| | - Romain Sonneville
- Assistance Publique des Hopitaux de Paris, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Matthieu Schmidt
- Assistance Publique des Hopitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 75013, Paris, France.
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France.
- Sorbonne Université, GRC 30, RESPIRE, Paris, France.
- Service de Médecine Intensive-Réanimation Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition 47, Boulevard de L'Hôpital, 75013, Paris, France.
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Jendoubi A, Pressiat C, De Roux Q, Hulin A, Ghaleh B, Tissier R, Kohlhauer M, Mongardon N. The impact of extracorporeal membrane oxygenation on antifungal pharmacokinetics: A systematic review. Int J Antimicrob Agents 2024; 63:107078. [PMID: 38161046 DOI: 10.1016/j.ijantimicag.2023.107078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/09/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND OBJECTIVE The use of extracorporeal membrane oxygenation (ECMO) as a cardiocirculatory or respiratory support has tremendously increased in critically ill patients. In the setting of ECMO support, invasive fungal infections are a severe cause of morbidity and mortality. This vulnerable population is at risk of suboptimal antifungal exposure due to an increased volume of distribution (Vd), drug sequestration and decreased clearance. Here, we aimed to summarize ex-vivo and clinical studies on the potential impact of ECMO on the pharmacokinetics (PK) of antifungal agents and dosing requirements. METHODS A systematic search of the literature within electronic databases PubMed and EMBASE was conducted from database inception to 30 April 2023. Inclusion criteria were as follows: critically ill patients receiving ECMO regardless of age and reporting at least one PK parameter. RESULTS Thirty-six studies met inclusion criteria, including seven ex-vivo experiments and 29 clinical studies evaluating three classes of antifungals: polyenes, triazoles and echinocandins. Based on the available ex-vivo PK data, we found a significant sequestration of highly lipophilic and protein-bound antifungals within the ECMO circuit such as voriconazole, posaconazole and micafungin but the PK of several antifungals remains to be addressed such as amphotericin B, isavuconazole and anidulafungin. Most clinical studies have shown increased Vd of some antifungals like fluconazole and micafungin, particularly in the pediatric population. Conflicting data exist about caspofungin exposure. CONCLUSIONS The available literature on the antifungal PK changes in ECMO setting is scarce. Whenever possible, therapeutic drug monitoring is highly advised to personalize antifungal therapy.
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Affiliation(s)
- Ali Jendoubi
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Claire Pressiat
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Quentin De Roux
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Anne Hulin
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Bijan Ghaleh
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Renaud Tissier
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France
| | - Matthias Kohlhauer
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France
| | - Nicolas Mongardon
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France.
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Novy E, Abdul-Aziz MH, Cheng V, Burrows F, Buscher H, Corley A, Diehl A, Gilder E, Levkovich BJ, McGuinness S, Ordonez J, Parke R, Parker S, Pellegrino V, Reynolds C, Rudham S, Wallis SC, Welch SA, Fraser JF, Shekar K, Roberts JA. Population pharmacokinetics of fluconazole in critically ill patients receiving extracorporeal membrane oxygenation and continuous renal replacement therapy: an ASAP ECMO study. Antimicrob Agents Chemother 2024; 68:e0120123. [PMID: 38063399 PMCID: PMC10777822 DOI: 10.1128/aac.01201-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/07/2023] [Indexed: 01/11/2024] Open
Abstract
This multicenter study describes the population pharmacokinetics (PK) of fluconazole in critically ill patients receiving concomitant extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) and includes an evaluation of different fluconazole dosing regimens for achievement of target exposure associated with maximal efficacy. Serial blood samples were obtained from critically ill patients on ECMO and CRRT receiving fluconazole. Total fluconazole concentrations were measured in plasma using a validated chromatographic assay. A population PK model was developed and Monte Carlo dosing simulations were performed using Pmetrics in R. The probability of target attainment (PTA) of various dosing regimens to achieve fluconazole area under the curve to minimal inhibitory concentration ratio (AUC0-24/MIC) >100 was estimated. Eight critically ill patients receiving concomitant ECMO and CRRT were included. A two-compartment model including total body weight as a covariate on clearance adequately described the data. The mean (±standard deviation, SD) clearance and volume of distribution were 2.87 ± 0.63 L/h and 15.90 ± 13.29 L, respectively. Dosing simulations showed that current guidelines (initial loading dose of 12 mg/kg then 6 mg/kg q24h) achieved >90% of PTA for a MIC up to 1 mg/L. None of the tested dosing regimens achieved 90% of PTA for MIC above 2 mg/L. Current fluconazole dosing regimen guidelines achieved >90% PTA only for Candida species with MIC <1 mg/L and thus should be only used for Candida-documented infections in critically ill patients receiving concomitant ECMO and CRRT. Total body weight should be considered for fluconazole dose.
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Affiliation(s)
- Emmanuel Novy
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
- Université de Lorraine, SIMPA, Nancy, France
- Departement of anesthesiology, Critical care and peri-operative medicine, University hospital of Nancy, Nancy, France
| | - Mohd H. Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Vesa Cheng
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Fay Burrows
- Department of Pharmacy, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
- University of New South Wales, St Vincent’s Centre for Applied Medical Research, Sydney, New South Wales, Australia
| | - Amanda Corley
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eileen Gilder
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Bianca J. Levkovich
- Experiential Development and Graduate Education and Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shay McGuinness
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Jenny Ordonez
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The University of Auckland, School of Nursing, Auckland, New Zealand
| | - Suzanne Parker
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Claire Reynolds
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Sam Rudham
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Steven C. Wallis
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Susan A. Welch
- Department of Pharmacy, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - John F. Fraser
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kiran Shekar
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Jason A. Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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9
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Wang J, Wang S, Song Y, Huang M, Cao W, Liu S, Chen S, Li X, Liu M, He Y. Analysis of 24-hour Death Risk Factors in Circulatory Failure Patients Treated with Venoarterial Extracorporeal Membrane Oxygenation. Braz J Cardiovasc Surg 2023; 38:e20220398. [PMID: 37801399 PMCID: PMC10550103 DOI: 10.21470/1678-9741-2022-0398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 12/27/2022] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVE To explore the factors affecting short-term prognosis of circulatory failure patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) treatment. METHODS A total of 136 patients undergoing VA-ECMO were enrolled in this study and subsequently divided into the death group (n=35) and the survival group (n=101) based on whether death occurred during hospitalisation. Extracorporeal membrane oxygenation (ECMO) running time, length of intensive care unit stay, length of hospital stay, costs, and ECMO complications were then compared between the two groups. RESULTS The average age of all patients undergoing ECMO was 47.64±16.78 years (53.2±16.20 years in the death group and 45.713±16.62 years in the survival group) (P=0.022). Patients in the survival group exhibited a clear downward trend in lactic acid value following ECMO treatment compared to those in the death group. Total hospitalisation stay was longer in the survival group (35 days) than in the death group (15.5 days) (P<0.001). In the analysis of ECMO complications, the incidence of neurological complications, renal failure, limb complications, and infection were higher in the death group than in the survival group (P<0.05 for all). Specifically, as a risk factor for patient survival and discharge, the occurrence of infection will lead to increased hospitalisation stays and costs (P<0.05 for both). CONCLUSION Complications such as kidney failure and infection are associated with in-hospital death, and ECMO-related complications should be actively prevented to improve the survival rate of VA-ECMO treatment.
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Affiliation(s)
- Jianwei Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
- Department of Critical Care Medicine, Puyang People’s Hospital,
Henan, People’s Republic of China
| | - Shengshu Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
| | - Yang Song
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - MingJun Huang
- Department of Extracorporeal Support Center, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Wenzhe Cao
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Shaohua Liu
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Shimin Chen
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Xuehang Li
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Miao Liu
- Department of Statistics and Epidemiology, Graduate School, Chinese
People’s Liberation Army General Hospital, Beijing, People’s Republic of China
| | - Yao He
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- State Key Laboratory of Kidney Diseases, Beijing, People’s Republic
of China
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10
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Hanks J, Unai S, Bribriesco A, Insler S, Yu E, Banzon J, Mireles-Cabodevila E, Adi A, Elgharably H, Yun J, Krishnan S. Successful treatment of pulmonary mucormycosis ( Lichtheimia spp.) in a post-partum patient with COVID-19 ARDS requiring extra-corporeal membrane oxygenation using salvage therapy. Perfusion 2023; 38:1315-1318. [PMID: 35979585 PMCID: PMC9389274 DOI: 10.1177/02676591221111031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Case Summary: A 31-year-old female presented to a regional hospital at 27 weeks pregnant and was found to have COVID-19 ARDS. She underwent intubation and caesarian section for worsening hypoxia and non-reassuring fetal heart tones. Hypoxemia was refractory to proning requiring ECMO and transfer to a tertiary care center. Admission chest radiography showed a new right lower lobe cavitating lesion with computed tomography scan revealing a large multi-loculated cavity in the right lung and extensive bilateral ground-glass opacities. The patient was started on amphotericin and posaconazole, with final respiratory cultures growing Lichtheimia spp. Source control was discussed via possible open thoracostomy, but medical management alone was continued. Total ECMO support was 3 weeks. At the time of discharge to acute rehab, 1 month of amphotericin and posaconazole had been completed, with continuation of posaconazole. At last update, she had been discharged from rehab and was back home with her infant. Conclusion: Pulmonary mucormycosis, even in the non-ECLS population, carries a high mortality. Treatment in pulmonary disease with surgery improves mortality but is not always feasible. Salvage therapy with extended course antifungal medications may be an option for those not amendable.
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Affiliation(s)
- Justin Hanks
- Department of Internal Medicine, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Shinya Unai
- Department of Thoracic and
Cardiovascular Surgery, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Alejandro Bribriesco
- Department of Thoracic and
Cardiovascular Surgery, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Steven Insler
- Department of Intensive Care and
Resuscitation, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Eileen Yu
- Case Western Reserve
University, Cleveland OH, USA
| | - Jona Banzon
- Department of Infectious Disease, Cleveland Clinic
Foundation, Cleveland OH, USA
| | | | - Ahmad Adi
- Department of Intensive Care and
Resuscitation, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Haytham Elgharably
- Department of Thoracic and
Cardiovascular Surgery, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - James Yun
- Case Western Reserve
University, Cleveland OH, USA
| | - Sudhir Krishnan
- Department of Critical Care
Medicine, Cleveland Clinic
Foundation, Cleveland OH, USA
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11
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Poth JM, Schewe JC, Lehmann F, Weller J, Schmandt MW, Kreyer S, Muenster S, Putensen C, Ehrentraut SF. COVID-19 Is an Independent Risk Factor for Detrimental Invasive Fungal Disease in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: A Retrospective Study. J Fungi (Basel) 2023; 9:751. [PMID: 37504739 PMCID: PMC10381551 DOI: 10.3390/jof9070751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
Invasive fungal disease (IFD) is associated with the mortality of patients on extracorporeal membrane oxygenation (ECMO). Several risk factors for IFD have been identified in patients with or without ECMO. Here, we assessed the relevance of coronavirus disease (COVID-19) for the occurrence of IFD in patients on veno-venous (V-V) ECMO for respiratory failure. In a retrospective analysis of all ECMO cases between January 2013 and December 2022 (2020-2022 for COVID-19 patients), active COVID-19 and the type, timing and duration of IFD were investigated. Demographics, hospital, ICU length of stay (LoS), duration of ECMO, days on invasive mechanical ventilation, prognostic scores (Respiratory ECMO Survival Prediction (RESP) score, Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS)-10, Sequential Organ Failure Assessment (SOFA) score and Simplified Acute Physiology Score (SAPS)-II) and length of survival were assessed. The association of COVID-19 with IFD was investigated using propensity score matching and uni- and multivariable logistic regression analyses. We identified 814 patients supported with ECMO, and 452 patients were included in further analyses. The incidence of IFD was 4.8% and 11.0% in patients without and with COVID-19, respectively. COVID-19 status represented an independent risk factor for IFD (OR 4.30; CI 1.72-10.85; p: 0.002; multivariable regression analysis). In patients with COVID-19, 84.6% of IFD was candidemia and 15.4% represented invasive aspergillosis (IA). All of these patients died. In patients on V-V ECMO, we report that COVID-19 is an independent risk factor for IFD, which is associated with a detrimental prognosis. Further studies are needed to investigate strategies of antifungal therapy or prophylaxis in these patients.
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Affiliation(s)
- Jens Martin Poth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Rostock, 18057 Rostock, Germany
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Johannes Weller
- Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Mathias Willem Schmandt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Muenster
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Felix Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
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12
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Marcus JE, Ford MB, Sattler LA, Iqbal S, Garner CL, Sobieszczyk MJ, Barsoumian AE. Treatment and outcome of gram-positive bacteremia in patients receiving extracorporeal membrane oxygenation. Heart Lung 2023; 60:15-19. [PMID: 36871407 DOI: 10.1016/j.hrtlng.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND While guidance exists for management of blood stream infections with various invasive devices, there are currently limited data to guide antibiotic selection and duration for bacteremia in patients receiving extracorporeal membrane oxygenation (ECMO). OBJECTIVE To evaluate the treatment and outcomes of thirty-six patients with Staphylococcus aureus and Enterococcus bacteremia on ECMO support. METHODS Blood culture data was retrospectively analyzed from patients with Staphylococcus aureus bacteremia (SAB) or Enterococcus bacteremia who underwent ECMO support between March 2012 and September 2021 at Brooke Army Medical Center. RESULTS Of the 282 patients who received ECMO during this study period, there 25 (9%) patients developed Enterococcus bacteremia and 16 (6%) developed SAB. SAB occurred earlier in ECMO as compared to Enterococcus (median day 2 IQR (1-5) vs. 22 (12-51), p = 0.01). The most common duration of antibiotics was 28 days after clearance for SAB and 14 days after clearance for Enterococcus. 2 (5%) patients underwent cannula exchange with primary bacteremia, and 7 (17%) underwent circuit exchange. 1/3 (33%) patients with SAB and 3/10 (30%) patients with Enterococcus bacteremia who remained cannulated after completion of antibiotics had a second episode of SAB or Enterococcus bacteremia. CONCLUSION This single center case series is the first to describe the specific treatment and outcomes of patients receiving ECMO complicated by SAB and Enterococcus bacteremia. For patients who remain on ECMO after completion of antibiotics, there is a risk of a second episode of Enterococcus bacteremia or SAB.
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Affiliation(s)
- Joseph E Marcus
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center 3551 Roger Brooke Drive, Joint Base San Antonio, TX 78234 United States; Department of Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 United States.
| | - Mary B Ford
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center 3551 Roger Brooke Drive, Joint Base San Antonio, TX 78234 United States; Department of Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 United States
| | - Lauren A Sattler
- Department of Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 United States; Pulmonary and Critical Care Section, Washington University in St. Louis, 660 Euclid Avenue, St. Louis, MO 63110 United States
| | - Sonia Iqbal
- Department of Medicine, Andrews Air Force Base, 1050 West Perimeter Road, Joint Base Andrew AFB, MD 20762 United States
| | - Chelsea L Garner
- Pulmonary and Critical Care Service, Department of Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, Joint Base San Antonio, TX 78234 United States
| | - Michal J Sobieszczyk
- Department of Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 United States; Pulmonary and Critical Care Service, Department of Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, Joint Base San Antonio, TX 78234 United States
| | - Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center 3551 Roger Brooke Drive, Joint Base San Antonio, TX 78234 United States; Department of Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 United States
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13
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Lyster H, Shekar K, Watt K, Reed A, Roberts JA, Abdul-Aziz MH. Antifungal Dosing in Critically Ill Patients on Extracorporeal Membrane Oxygenation. Clin Pharmacokinet 2023; 62:931-942. [PMID: 37300631 PMCID: PMC10338597 DOI: 10.1007/s40262-023-01264-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 06/12/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an established advanced life support system, providing temporary cardiac and/or respiratory support in critically ill patients. Fungal infections are associated with increased mortality in patients on ECMO. Antifungal drug dosing for critically ill patients is highly challenging because of altered pharmacokinetics (PK). PK changes during critical illness; in particular, the drug volume of distribution (Vd) and clearance can be exacerbated by ECMO. This article discusses the available literature to inform adequate dosing of antifungals in this patient population. The number of antifungal PK studies in critically ill patients on ECMO is growing; currently available literature consists of case reports and studies with small sample sizes providing inconsistent findings, with scant or no data for some antifungals. Current data are insufficient to provide definitive empirical drug dosing guidance and use of dosing strategies derived from critically patients not on ECMO is reasonable. However, due to high PK variability, therapeutic drug monitoring should be considered where available in critically ill patients receiving ECMO to prevent subtherapeutic or toxic antifungal exposures.
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Affiliation(s)
- Haifa Lyster
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- University of Portsmouth, Portsmouth, UK
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Kevin Watt
- School of Pharmacy, University of Waterloo, 10 Victoria St S. Kitchener, Waterloo, ON, N2G 1C5, Canada
- Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Anna Reed
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- Imperial College London, London, SW3 6NP, UK
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
- Herston Infectious Diseases (HeIDI), Metro North Health, Brisbane, QLD, Australia.
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
| | - Mohd-Hafiz Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
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14
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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15
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Peitz GJ, Murry DJ. The Influence of Extracorporeal Membrane Oxygenation on Antibiotic Pharmacokinetics. Antibiotics (Basel) 2023; 12:500. [PMID: 36978367 PMCID: PMC10044059 DOI: 10.3390/antibiotics12030500] [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: 02/04/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is becoming increasingly utilized to support critically ill patients who experience life-threatening cardiac or pulmonary compromise. The provision of this intervention poses challenges related to its complications and the optimization of medication therapy. ECMO's mechanical circulatory support is facilitated via various devices and equipment that have been shown to sequester lipophilic- and protein-bound medications, including anti-infectives. Since infectious outcomes are dependent on achieving specific anti-infectives' pharmacodynamic targets, the understanding of these medications' pharmacokinetic parameters in the setting of ECMO is important to clinicians. This narrative, non-systematic review evaluated the findings of the most recent and robust pharmacokinetic analyses for commonly utilized anti-infectives in the setting of ECMO. The data from available literature indicates that anti-infective pharmacokinetic parameters are similar to those observed in other non-ECMO critically ill populations, but considerable variability in the findings was observed between patients, thus prompting further evaluation of therapeutic drug monitoring in this complex population.
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Affiliation(s)
- Gregory J. Peitz
- Nebraska Medicine, Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Daryl J. Murry
- Clinical Pharmacology Laboratory, Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198, USA
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16
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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17
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Abstract
Fungal infections are common and frequently associated with clinical failure in patients receiving extracorporeal membrane oxygenation (ECMO). Antifungal drugs have physicochemical characteristics associated with a higher likelihood of sequestration onto ECMO circuitry potentially leading to a subtherapeutic drug concentration. The percentage of sequestration of the antifungal drugs-caspofungin, posaconazole, and voriconazole-was determined using an ex vivo ECMO model. The circuits were primed with whole human blood, sodium chloride 0.9%, and human albumin solution. Serial 2 ml samples were taken at baseline, 0.5, 1, 2, 6, 12, and 24 hours after drug addition, paired with non-ECMO controls stored in a water bath at 37°C. Mean loss from the blood-primed ECMO circuits and controls at 24 hours relative to baseline were 80% and 61% for caspofungin ( p = ns), 64% and 11% for posaconazole ( p < 0.005), and 27% and 19% for voriconazole ( p < 0.05). Calculated AUC 0-24 showed a 44% for caspofungin ( p = ns), 30.6% posaconazole ( p < 0.005), and 9% loss for voriconazole ( p = 0.003) compared with the controls, suggesting therapeutic concentrations of these antifungal agents cannot be guaranteed with standard dosing in patients on ECMO. Posaconazole exhibited the greatest loss to the ECMO circuit correlating with both high lipophilicity and protein binding of the drug.
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18
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Recurrent Candidemia Due to Extracorporeal Membrane Oxygenation Circuit Seeding in Acute Respiratory Distress Syndrome From COVID-19. ASAIO J 2022; 69:e163-e164. [PMID: 36730944 PMCID: PMC10044584 DOI: 10.1097/mat.0000000000001840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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19
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Lee EH, Lee KH, Lee SJ, Kim J, Baek YJ, Ahn JY, Jeong SJ, Ku NS, Choi JY, Yeom JS, Song YG, Kim JH. Clinical and microbiological characteristics of and risk factors for bloodstream infections among patients with extracorporeal membrane oxygenation: a single-center retrospective cohort study. Sci Rep 2022; 12:15059. [PMID: 36064957 PMCID: PMC9445101 DOI: 10.1038/s41598-022-19405-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) provides hemodynamic and oxygenation support to critically ill patients. Due to multiple catheter cannulations, patients on ECMO are vulnerable to bloodstream infections (BSIs). We aimed to investigate the incidence, clinical characteristics, risk factors, and microorganisms associated with BSIs during ECMO. This single-center retrospective cohort study was conducted between January 2015 and May 2021. Patients aged 18 years or older with an ECMO duration of > 48 h for cardiogenic or respiratory support were included in the study. Patients who developed bacteremia or candidemia from 12 h after ECMO cannulation to 7 days after de-cannulation were included. The clinical factors between non-BSI and BSI were compared, along with an analysis of the risk factors associated with BSI during ECMO. A total of 480 patients underwent ECMO for cardiogenic shock (n = 267, 55.6%) or respiratory failure (n = 213, 44.4%) during the study period. The incidence was 20.0 episodes per 1000 ECMO-days. Approximately 20.2% (97/480) and 5.4% (26/480) of the patients developed bacteremia and candidemia, respectively. The median numbers of days of BSI development were 8.00 days for bacteremia and 11.0 days for candidemia. The most common pathogens were methicillin-resistant coagulase-negative staphylococci (n = 24), followed by vancomycin-resistant Enterococcus (n = 21). Multivariable logistic analysis demonstrated that hemodialysis (odds ratio [OR] 2.647, p < 0.001), veno-arterial-venous mode (OR 1.911, p = 0.030), and total ECMO duration (OR 1.030, p = 0.007) were significant risk factors for bacteremia. The total ECMO duration was the only risk factor associated with candidemia (OR 1.035, p = 0.010). The mortality rate was significantly higher in the bacteremia (57.7%) and candidemia (69.2%) groups than that in the non-BSI group (43.6%). BSI is a common complication of patients receiving ECMO support and is associated with poor clinical outcomes. Determining the type of frequently isolated organisms and the median onset time of BSI would help in the selection of appropriate prophylactic antibiotics or antifungal agents.
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Affiliation(s)
- Eun Hwa Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Ki Hyun Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Se Ju Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Jinnam Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Yae Jee Baek
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Jin Young Ahn
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Nam Su Ku
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Joon-Sup Yeom
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Young Goo Song
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722
| | - Jung Ho Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea, 50-1, Yonsei-ro, Seodaemun-gu, 03722.
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20
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Ye Q, Yu X, Chen W, Li M, Gu S, Huang L, Zhan Q, Wang C. Impact of extracorporeal membrane oxygenation on voriconazole plasma concentrations: A retrospective study. Front Pharmacol 2022; 13:972585. [PMID: 36059951 PMCID: PMC9428491 DOI: 10.3389/fphar.2022.972585] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/19/2022] [Indexed: 12/03/2022] Open
Abstract
Aims: We aimed to assess the impact of extracorporeal membrane oxygenation (ECMO) on voriconazole exposure. Methods: Adult critically ill patients with or without ECMO support receiving intravenous voriconazole therapy were included in this retrospective study conducted in a tertiary referral intensive care unit. The first therapeutic drug monitoring (TDM) results of voriconazole in ECMO patients and non-ECMO patients were collected, and the prevalence of subtherapeutic concentrations was analyzed. Multivariate analyses were performed to evaluate the effect of ECMO on voriconazole exposure. Results: A total of 132 patients (including 66 patients with ECMO support) were enrolled and their respective first voriconazole trough concentrations (Cmin) were recorded. The median Cmin of the ECMO group and the non-ECMO group was 1.9 (1.4–4.4) and 4.4 (3.2–6.9) mg/L, respectively (p = 0.000), and the proportion of the two groups in subtherapeutic concentrations range (<2 mg/L) was 51.5% and 7.6%, respectively (p = 0.000). Multiple linear regression analysis of voriconazole Cmin identified that the use of ECMO and coadministration of glucocorticoids were associated with significantly reduced concentrations, while increasing SOFA score and increasing daily dose were associated with significantly increased concentrations. The model accounted for 32.2% of the variability of voriconazole Cmin. Furthermore, binary logistic regression demonstrated that the use of ECMO was an independent risk factor (OR = 7.78, p = 0.012) for insufficient voriconazole exposure. Conclusion: Our findings showed that, in addition to the known drug interactions, ECMO is a significant covariable affecting voriconazole exposure. In addition, SOFA score was identified as a factor associated with increased voriconazole concentration.
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Affiliation(s)
- Qinghua Ye
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Xin Yu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Sichao Gu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Linna Huang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Qingyuan Zhan
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
- *Correspondence: Qingyuan Zhan,
| | - Chen Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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21
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Rosas MM, Sobieszczyk MJ, Warren W, Mason P, Walter RJ, Marcus JE. Outcomes of Fungemia in Patients Receiving Extracorporeal Membrane Oxygenation. Open Forum Infect Dis 2022; 9:ofac374. [PMID: 35949400 PMCID: PMC9356672 DOI: 10.1093/ofid/ofac374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/22/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
There are limited data on the treatment of fungal infections complicating extracorporeal membrane oxygenation (ECMO). In 14 patients who developed fungal bloodstream infections on ECMO, eight (57%) survived to discharge. Of the 5 patients completing treatment prior to decannulation, two (40%) developed recurrent fungal infections.
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Affiliation(s)
- Melissa M Rosas
- Pulmonary and Critical Care Division, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Michal J Sobieszczyk
- Pulmonary and Critical Care Division, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Whittney Warren
- Pulmonary and Critical Care Division, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Phillip Mason
- Critical Care Division, Emergency Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Robert J Walter
- Pulmonary and Critical Care Division, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Joseph E Marcus
- Correspondence: Joseph E. Marcus, MD, 3551 Roger Brooke Drive, Joint Base San Antonio–Fort Sam Houston, TX 78234, USA ()
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22
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Recent Advances in the Application of Essential Oils as Potential Therapeutic Candidates for Candida-Related Infections. Appl Microbiol 2022. [DOI: 10.3390/applmicrobiol2020030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Candidiasis (oral, vulvovaginal, or systemic bloodstream infections) are important human fungal infections associated with a high global prevalence in otherwise healthy adults but are also opportunistic infections in immunocompromised patients. With the recent discovery of the multidrug resistant—and often difficult to treat—Candida auris, as well as the rising costs associated with hospitalisations and the treatment of infections caused by Candida species, there is an urgent need to develop effective therapeutics against these pathogenic yeasts. Essential oils have been documented for many years as treatments for different ailments and are widely known and utilised in alternative and complementary therapies, including treating microbial infections. This review highlights knowledge from research on the effects of medicinal plants, and in particular, essential oils, as potential treatments against different Candida species. Studies have been evaluated that describe the experimental approaches used in investigating the anticandidal effects of essential oils (in vivo and in vitro), the established mode of action of the different compounds against different Candida species, the effect of a combination of essential oils with other compounds as potential therapies, and the evidence from clinical trial studies.
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Kundu R, Singla N. COVID-19 and Plethora of Fungal Infections. CURRENT FUNGAL INFECTION REPORTS 2022; 16:47-54. [PMID: 35432691 PMCID: PMC8994097 DOI: 10.1007/s12281-022-00432-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review Severe-acute respiratory coronavirus 2 (SARS-CoV-2) causing corona virus disease 2019 (COVID-19) has been the single most important pathogen driving health care delivery system for the last one and half years. Now, as the time is passing, many issues related to co-infections/secondary infections/superinfections in COVID-19 patients are emerging. The literature is getting enriched everyday by addition of reports from all over the world for the same. The purpose of this review is to decipher the plethora of fungal infections in COVID-19. Recent Findings COVID-19 infection along with it brought many risk factors namely lung injury, immunosuppression, need for oxygen therapy, monoclonal antibodies, steroid therapy, etc. which are known predisposing factors for fungal infections. Rather the extent and severity of fungal pathogens has been so much that it has led to new terminologies like CAC (COVID-19-associated Candida), CAPA (COVID-19-associated pulmonary aspergillosis) and CAM (COVID-19-associated mucormycosis). There is increase in invasiveness of Candida, prevalence of aspergillosis in COVID-19 damaged lung and outbreak of mucormycosis in COVID-19 patients resulting in “double trouble,” keeping laboratory personnel, clinicians, and intensivists on their toes in managing these patients. Summary Awareness and understanding regarding these possible complications is necessary to decrease the morbidity and mortality among patients. The COVID-19 and fungal coinfections may bring more insight into ways of pathogenesis of fungal infections, need for better antifungal agents, quick diagnostic modalities, and better management policies in the near future.
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Affiliation(s)
- Reetu Kundu
- Department of Cytology and Gynecological Pathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nidhi Singla
- Department of Microbiology, Government Medical College Hospital, Chandigarh, India
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24
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Impact of Invasive Fungal Diseases on Survival under Veno-Venous Extracorporeal Membrane Oxygenation for ARDS. J Clin Med 2022; 11:jcm11071940. [PMID: 35407548 PMCID: PMC8999842 DOI: 10.3390/jcm11071940] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To assess the incidence and significance of invasive fungal diseases (IFD) during veno-venous (VV) ECMO support for acute respiratory distress syndrome (ARDS). METHODS Retrospective analysis from January 2013 to April 2021 of all ECMO cases for ARDS at a German University Hospital. In patients with IFD (IFD patients), type of IFD, time of IFD, choice of antifungal agent, duration, and success of therapy were investigated. For comparison, patients without IFD (non-IFD patients) were selected by propensity score matching using treatment-independent variables (age, gender, height, weight, and the Sequential Organ Failure Assessment (SOFA) score at ICU admission). Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, prognostic scores (Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS), and length of survival were assessed. RESULTS A total of 646 patients received ECMO, 368 patients received VV ECMO. The incidence of IFD on VV ECMO was 5.98%, with 5.43% for Candida bloodstream infections (CBSI) and 0.54% for invasive aspergillosis (IA). In IFD patients, in-hospital mortality was 81.8% versus 40.9% in non-IFD patients. The hazard ratio for death was 2.5 (CI 1.1-5.4; p: 0.023) with IFD. CONCLUSIONS In patients on VV ECMO for ARDS, about one in 17 contracts an IFD, with a detrimental impact on prognosis. Further studies are needed to address challenges in the diagnosis and treatment of IFD in this population.
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Kluge S, Strauß R, Kochanek M, Weigand MA, Rohde H, Lahmer T. Aspergillosis: Emerging risk groups in critically ill patients. Med Mycol 2021; 60:6408468. [PMID: 34677613 DOI: 10.1093/mmy/myab064] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/23/2021] [Accepted: 10/19/2021] [Indexed: 02/06/2023] Open
Abstract
Information on invasive aspergillosis (IA) and other invasive filamentous fungal infections is limited in non-neutropenic patients admitted to the intensive care unit (ICU) and presenting with no classic IA risk factors. This review is based on the critical appraisal of relevant literature, on the authors' own experience and on discussions that took place at a consensus conference. It aims to review risk factors favoring aspergillosis in ICU patients, with a special emphasis on often overlooked or neglected conditions. In the ICU patients, corticosteroid use to treat underlying conditions such as chronic obstructive pulmonary disease (COPD), sepsis, or severe COVID-19, represents a cardinal risk factor for IA. Important additional host risk factors are COPD, decompensated cirrhosis, liver failure, and severe viral pneumonia (influenza, COVID-19). Clinical observations indicate that patients admitted to the ICU because of sepsis or acute respiratory distress syndrome are more likely to develop probable or proven IA, suggesting that sepsis could also be a possible direct risk factor for IA, as could small molecule inhibitors used in oncology. There are no recommendations for prophylaxis in ICU patients; posaconazole mold-active primary prophylaxis is used in some centers according to guidelines for other patient populations and IA treatment in critically ill patients is basically the same as in other patient populations. A combined evaluation of clinical signs and imaging, classical biomarkers such as the GM assay, and fungal cultures examination, remain the best option to assess response to treatment. LAY SUMMARY The use of corticosteroids and the presence of co-morbidities such as chronic obstructive pulmonary disease, acute or chronic advanced liver disease, or severe viral pneumonia caused by influenza or Covid-19, may increase the risk of invasive aspergillosis in intensive care unit patients.
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Affiliation(s)
- Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg - Eppendorf, Hamburg, D-20246, Germany
| | - Richard Strauß
- Department of Medicine 1, Medizinische Klinik 1, University Hospital Erlangen, Erlangen, D-91054, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, D-50937, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, D-69120, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, D-20246, Germany
| | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität Munich, Munich, D-81675, Germany
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Monk EJM, Rautemaa-Richardson R, Felton T, Montalti A, Parkes M, Templeton R, Ashworth A, Garcia M, Barker J, Thomas S. Candidaemia incidence in prolonged veno-venous extracorporeal membrane oxygenation. J Hosp Infect 2021; 119:49-53. [PMID: 34562545 DOI: 10.1016/j.jhin.2021.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 11/25/2022]
Abstract
This single-centre retrospective study reports the dynamics of candida bloodstream infection (CBSI) incidence in 145 patients receiving venovenous ECMO for respiratory support, between January 2014 and December 2018. Incidence rate and odds ratio (OR) of CBSI were calculated, stratified by week of ECMO exposure. Weekly incidence increased throughout the ECMO run, with a rising trend in OR (P = 0.005), and a window of continued risk after decannulation was observed. Of the 13 patients that developed CBSI, five (38%) received empirical micafungin treatment before positive culture due to clinical suspicion. Prospective studies, aiming to improve ECMO diagnostic stewardship practices and discourage antifungal prophylaxis or empiric management where unnecessary, are needed.
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Affiliation(s)
- Edward J M Monk
- Department of Microbiology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Infectious Diseases Service, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom.
| | - Riina Rautemaa-Richardson
- Infectious Diseases Service, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Mycology Reference Centre Manchester (ECMM Centre of Excellence), Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Timothy Felton
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom; Acute Intensive Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Department of Respiratory Medicine, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Alice Montalti
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Matthew Parkes
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Richard Templeton
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Alan Ashworth
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Miguel Garcia
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Julian Barker
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Stephanie Thomas
- Department of Microbiology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
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Mendoza-Palomar N, Melendo-Pérez S, Balcells J, Izquierdo-Blasco J, Martín-Gómez MT, Velasco-Nuño M, Rivière JG, Soler-Palacin P. Influenza-Associated Disseminated Aspergillosis in a 9-Year-Old Girl Requiring ECMO Support. J Fungi (Basel) 2021; 7:jof7090726. [PMID: 34575764 PMCID: PMC8465228 DOI: 10.3390/jof7090726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 12/12/2022] Open
Abstract
A previously healthy 9-year-old girl developed fulminant myocarditis due to severe influenza A infection complicated with methicillin-resistant Staphylococcus aureus pneumonia, requiring extracorporeal membrane oxygenation (ECMO) support. Twelve days after admission, Aspergillus fumigatus was isolated in tracheal aspirate, and 12 h later she suddenly developed anisocoria. Computed tomography (CT) of the head showed fungal brain lesions. Urgent decompressive craniectomy with lesion drainage was performed; histopathology found hyphae in surgical samples, culture-positive for Aspergillus fumigatus (susceptible to azoles, echinocandins, and amphotericin B). Extension workup showed disseminated aspergillosis. After multiple surgeries and combined antifungal therapy (isavuconazole plus liposomal amphotericin B), her clinical course was favorable. Isavuconazole therapeutic drug monitoring was performed weekly. Extensive immunological study ruled out primary immunodeficiencies. Fluorine-18 fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) follow-up showed a gradual decrease in fungal lesions. Influenza-associated pulmonary aspergillosis is well-recognized in critically ill adult patients, but pediatric data are scant. Clinical features described in adults concur with those of our case. Isavuconazole, an off-label drug in children, was chosen because our patient had severe renal failure. To conclude, influenza-associated pulmonary aspergillosis is uncommon in children admitted to intensive care for severe influenza, but pediatricians should be highly aware of this condition to enable prompt diagnosis and treatment.
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Affiliation(s)
- Natalia Mendoza-Palomar
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (S.M.-P.); (J.G.R.); (P.S.-P.)
- Infection in the Immunosuppressed Paediatric Patient Research Group, Vall d’Hebron Research Institute, 08035 Barcelona, Spain
- Correspondence: ; Tel.: +34-93-489-30-77
| | - Susana Melendo-Pérez
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (S.M.-P.); (J.G.R.); (P.S.-P.)
- Infection in the Immunosuppressed Paediatric Patient Research Group, Vall d’Hebron Research Institute, 08035 Barcelona, Spain
| | - Joan Balcells
- Paediatric Intensive Care Unit, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (J.B.); (J.I.-B.)
- Clinical Research/Innovation in Pneumonia and Sepsis (CRIPS) Research Group, Vall d’Hebron Research Institute, 08035 Barcelona, Spain
| | - Jaume Izquierdo-Blasco
- Paediatric Intensive Care Unit, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (J.B.); (J.I.-B.)
| | - Maria Teresa Martín-Gómez
- Microbiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain;
- Microbiology Research Group, Vall d’Hebron Research Institute, 08035 Barcelona, Spain
| | - Monica Velasco-Nuño
- Nuclear Medicine Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain;
- Molecular Medical Imaging Research Group, Vall d’Hebron Research Institute, 08035 Barcelona, Spain
| | - Jacques G. Rivière
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (S.M.-P.); (J.G.R.); (P.S.-P.)
- Infection in the Immunosuppressed Paediatric Patient Research Group, Vall d’Hebron Research Institute, 08035 Barcelona, Spain
| | - Pere Soler-Palacin
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain; (S.M.-P.); (J.G.R.); (P.S.-P.)
- Infection in the Immunosuppressed Paediatric Patient Research Group, Vall d’Hebron Research Institute, 08035 Barcelona, Spain
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Van Daele R, Bekkers B, Lindfors M, Broman LM, Schauwvlieghe A, Rijnders B, Hunfeld NGM, Juffermans NP, Taccone FS, Coimbra Sousa CA, Jacquet LM, Laterre PF, Nulens E, Grootaert V, Lyster H, Reed A, Patel B, Meersseman P, Debaveye Y, Wauters J, Vandenbriele C, Spriet I. A Large Retrospective Assessment of Voriconazole Exposure in Patients Treated with Extracorporeal Membrane Oxygenation. Microorganisms 2021; 9:microorganisms9071543. [PMID: 34361978 PMCID: PMC8303158 DOI: 10.3390/microorganisms9071543] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Voriconazole is one of the first-line therapies for invasive pulmonary aspergillosis. Drug concentrations might be significantly influenced by the use of extracorporeal membrane oxygenation (ECMO). We aimed to assess the effect of ECMO on voriconazole exposure in a large patient population. METHODS Critically ill patients from eight centers in four countries treated with voriconazole during ECMO support were included in this retrospective study. Voriconazole concentrations were collected in a period on ECMO and before/after ECMO treatment. Multivariate analyses were performed to evaluate the effect of ECMO on voriconazole exposure and to assess the impact of possible saturation of the circuit's binding sites over time. RESULTS Sixty-nine patients and 337 samples (190 during and 147 before/after ECMO) were analyzed. Subtherapeutic concentrations (<2 mg/L) were observed in 56% of the samples during ECMO and 39% without ECMO (p = 0.80). The median trough concentration, for a similar daily dose, was 2.4 (1.2-4.7) mg/L under ECMO and 2.5 (1.4-3.9) mg/L without ECMO (p = 0.58). Extensive inter-and intrasubject variability were observed. Neither ECMO nor squared day of ECMO (saturation) were retained as significant covariates on voriconazole exposure. CONCLUSIONS No significant ECMO-effect was observed on voriconazole exposure. A large proportion of patients had voriconazole subtherapeutic concentrations.
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Affiliation(s)
- Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium;
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
- Correspondence:
| | - Britt Bekkers
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Mattias Lindfors
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17177 Stockholm, Sweden; (M.L.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17177 Stockholm, Sweden; (M.L.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Alexander Schauwvlieghe
- Department of Hematology, Ghent University Hospital, 9000 Ghent, Belgium;
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, 3015 CP Rotterdam, The Netherlands;
| | - Bart Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, 3015 CP Rotterdam, The Netherlands;
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 3015 CP Rotterdam, The Netherlands
| | - Nicole G. M. Hunfeld
- Department of Intensive Care and Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 CP Rotterdam, The Netherlands;
| | - Nicole P. Juffermans
- Department of Intensive Care, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (F.S.T.); (C.A.C.S.)
| | - Carlos Antônio Coimbra Sousa
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (F.S.T.); (C.A.C.S.)
| | - Luc-Marie Jacquet
- Cardiovascular Intensive Care, Cliniques Universitaires Saint-Luc, 1050 Brussels, Belgium;
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques Universitaires St-Luc, Université Catholique de Louvain, 1050 Brussels, Belgium;
| | - Eric Nulens
- Laboratory Medicine, Medical Microbiology, Algemeen Ziekenhuis Sint-Jan, Brugge-Oostende, 8000 Brugge, Belgium;
| | - Veerle Grootaert
- Pharmacy Department, Algemeen Ziekenhuis Sint-Jan Brugge-Oostende AV, 8000 Brugge, Belgium;
| | - Haifa Lyster
- Pharmacy Department, Royal Brompton & Harefield Hospitals, London SW3 6NP, UK;
- Cardiothoracic Transplant Unit, Royal Brompton & Harefield Hospitals, London SW3 6NP, UK;
| | - Anna Reed
- Cardiothoracic Transplant Unit, Royal Brompton & Harefield Hospitals, London SW3 6NP, UK;
- Imperial College London, London SW3 6NP, UK
| | - Brijesh Patel
- Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London SW3 6NP, UK;
- Department of Adult Intensive Care, The Royal Brompton and Harefield Hospitals, London SW3 6NP, UK;
| | - Philippe Meersseman
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, 3000 Leuven, Belgium;
- Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Joost Wauters
- Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium;
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Adult Intensive Care, The Royal Brompton and Harefield Hospitals, London SW3 6NP, UK;
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium;
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
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Epelbaum O, Carmona EM, Evans SE, Hage CA, Jarrett B, Knox KS, Limper AH, Pennington KM. Antifungal Prophylaxis for Adult Recipients of Veno-Venous Extracorporeal Membrane Oxygenation: A Cautionary Stance During the COVID-19 Pandemic. ASAIO J 2021; 67:611-613. [PMID: 33769344 PMCID: PMC8153986 DOI: 10.1097/mat.0000000000001456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Oleg Epelbaum
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, New York
| | - Eva M. Carmona
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Scott E. Evans
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chadi A. Hage
- Division of Pulmonary, Critical Care, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Benjamin Jarrett
- Division of Pulmonary and Critical Care Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Kenneth S. Knox
- Division of Pulmonary and Critical Care Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Andrew H. Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kelly M. Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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Selçuk ÜN, Sargın M, Baştopçu M, Mete EMT, Erdoğan SB, Öcalmaz Ş, Orhan G, Aka SA. Microbiological Spectrum of Nosocomial ECMO Infections in a Tertiary Care Center. Braz J Cardiovasc Surg 2021; 36:338-345. [PMID: 33355788 PMCID: PMC8357375 DOI: 10.21470/1678-9741-2020-0077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment in cardiogenic and respiratory shock. It is prone to various complications, infection being among the most frequent. This study aims to define the prevalence and characteristics of infections in ECMO patients in a tertiary care center for cardiac diseases. METHODS All ECMO patients between 2012 and 2016 in a single cardiac center were retrospectively included. Demographic data, ECMO indications, type, site, duration, and infection-related data were recorded. Data were analyzed among all patients and separately between pediatric and adult patient groups. RESULTS One hundred and twenty-six patients, 66 (53.4%) pediatric and 60 (47.6%) adult, received ECMO within the study period. Mean age was 3.54±4.27 years in the pediatric group and 54.92±15.57 years in the adult group. The main indication for ECMO was postcardiotomy shock (77.8%). Forty-six (36.5%) of all cases developed a culture-proven nosocomial infection with a rate of 49/1000 ECMO days. Infection was associated with > 5 days of ECMO duration and hemodialysis requirement in all patients and lower age in the pediatric group. The most frequent infection site was the lower respiratory tract (14.3%), while the most common isolated organisms were Klebsiella (8.7%) and Streptococcus (4.8%) species. CONCLUSION The respiratory tract is the most common site of infection, however, all sites impose a threat to recovery, with longer treatment durations required for patients with culture-proven infections. A better understanding of the infectious spectrum and its effect on the mortality and morbidity is required for more successful treatment of ECMO patients.
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Affiliation(s)
- Ümmühan Nehir Selçuk
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Sargın
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Baştopçu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Evren Müge Taşdemir Mete
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinç Bayer Erdoğan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Şeyda Öcalmaz
- Department of Infectious Diseases and Clinical Microbiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gökçen Orhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serap Aykut Aka
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Kim HS, Park S, Ko HH, Ha SO, Lee SH, Kim YK. Different characteristics of bloodstream infection during venoarterial and venovenous extracorporeal membrane oxygenation in adult patients. Sci Rep 2021; 11:9498. [PMID: 33947970 PMCID: PMC8097062 DOI: 10.1038/s41598-021-89108-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/21/2021] [Indexed: 01/05/2023] Open
Abstract
Currently, there is scarcity of data on whether differences exist in clinical characteristics and outcomes of bloodstream infection (BSI) between venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) and whether they differ between Candida BSI and bacteremia in adult ECMO patients. We retrospectively reviewed data of patients who required ECMO for > 48 h and had BSIs while receiving ECMO between January 2015 and June 2020. Cases with a positive blood culture result within 24 h of ECMO implantation were excluded. We identified 94 (from 64 of 194 patients) and 38 (from 17 of 56 patients) BSI episodes under VA and VV ECMO, respectively. Fifty nine BSIs of VA ECMO (59/94, 62.8%) occurred in the first 2 weeks after ECMO implantation, whereas 24 BSIs of VV ECMO (24/38, 63.2%) occurred after 3 weeks of ECMO implantation. Gram-negative bacteremia (39/59, 66.1%) and gram-positive bacteremia (10/24, 41.7%) were the most commonly identified BSI types in the first 2 weeks after VA ECMO implantation and after 3 weeks of VV implantation, respectively. Timing of Candida BSI was early (6/11, 54.5% during the first 2 weeks) in VA ECMO and late (6/9, 66.7% after 3 weeks of initiation) in VV ECMO. Compared with bacteremia, Candida BSI showed no differences in clinical characteristics and outcomes during VA and VV ECMO, except the significant association with prior exposure to carbapenem in VA ECMO (vs. gram-negative bacteremia [P = 0.006], vs. gram-positive bacteremia [P = 0.03]). Our results suggest that ECMO modes may affect BSI clinical features and timing. In particular, Candida BSI occurrence during the early course of VA ECMO is not uncommon, especially in patients with prior carbapenem exposure; however, it usually occurs during the prolonged course of VV ECMO. Consequently, routine blood culture surveillance and empiric antifungal therapy might be warranted in targeted populations of adult ECMO patients, regardless of levels of inflammatory markers and severity scores.
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Affiliation(s)
- Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ho Hyun Ko
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Yong Kyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea.
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Neofytos D, Garcia-Vidal C, Lamoth F, Lichtenstern C, Perrella A, Vehreschild JJ. Invasive aspergillosis in solid organ transplant patients: diagnosis, prophylaxis, treatment, and assessment of response. BMC Infect Dis 2021; 21:296. [PMID: 33761875 PMCID: PMC7989085 DOI: 10.1186/s12879-021-05958-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients. Although IA has significant implications on graft and patient survival, data on diagnosis and management of this infection in SOT recipients are still limited. METHODS Discussion of current practices and limitations in the diagnosis, prophylaxis, and treatment of IA and proposal of means of assessing treatment response in SOT recipients. RESULTS Liver, lung, heart or kidney transplant recipients have common as well as different risk factors to the development of IA, thus each category needs a separate evaluation. Diagnosis of IA in SOT recipients requires a high degree of awareness, because established diagnostic tools may not provide the same sensitivity and specificity observed in the neutropenic population. IA treatment relies primarily on mold-active triazoles, but potential interactions with immunosuppressants and other concomitant therapies need special attention. CONCLUSIONS Criteria to assess response have not been sufficiently evaluated in the SOT population and CT lesion dynamics, and serologic markers may be influenced by the underlying disease and type and severity of immunosuppression. There is a need for well-orchestrated efforts to study IA diagnosis and management in SOT recipients and to develop comprehensive guidelines for this population.
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Affiliation(s)
- Dionysios Neofytos
- Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland.
| | - Carolina Garcia-Vidal
- Servicio de Enfermedades Infecciosas, Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, FungiCLINIC Research group (AGAUR), Barcelona, Spain
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
- Department of Laboratories, Institute of Microbiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Christoph Lichtenstern
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg, Germany
| | - Alessandro Perrella
- VII Department of Infectious Disease and Immunology, Hospital D. Cotugno, Naples, Italy
- CLSE-Liver Transplant Unit, Hospital A. Cardarelli, Naples, Italy
| | - Jörg Janne Vehreschild
- Medical Department II, Hematology and Oncology, University Hospital of Frankfurt, Frankfurt, Germany
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany
- German Centre for Infection Research, partner site Bonn-Cologne, University of Cologne, Cologne, Germany
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The Extent of Aspergillosis in Critically Ill Patients With Severe Influenza Pneumonia: A Multicenter Cohort Study. Crit Care Med 2021; 49:934-942. [PMID: 33591000 DOI: 10.1097/ccm.0000000000004861] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine the frequency and prognosis of invasive pulmonary aspergillosis in critically ill patients with severe influenza pneumonia. DESIGN Retrospective multicenter cohort study. SETTING Five French ICUs. PATIENTS Patients with influenza admitted to ICU between 2009 and 2018. MEASUREMENTS AND MAIN RESULTS Of the 524 patients admitted for severe influenza diagnosed with a positive airway reverse-transcriptase polymerase chain reaction test, 450 (86%) required mechanical ventilation. A lower respiratory tract sample yielded with Aspergillus (Asp+) in 28 patients (5.3%). Ten patients (1.9%) were diagnosed with putative or proven invasive pulmonary aspergillosis, based on the validated AspICU algorithm. A multivariate model was built to identify independent risk factors for Aspergillus-positive pulmonary culture. Factors independently associated with Aspergillus-positive culture were liver cirrhosis (odds ratio = 6.7 [2.1-19.4]; p < 0.01), hematologic malignancy (odds ratio = 3.3 [1.2-8.5]; p = 0.02), Influenza A(H1N1)pdm09 subtype (odds ratio = 3.9 [1.6-9.1]; p < 0.01), and vasopressor requirement (odds ratio = 4.1 [1.6-12.7]; p < 0.01). In-hospital mortality of Asp+ patients was 36% versus 21% in patients without Aspergillus-positive pulmonary culture (p = 0.09). CONCLUSIONS In this large retrospective multicenter cohort of critically ill patients, putative invasive pulmonary aspergillosis according to AspICU algorithm was a relatively rare complication of influenza. Patients at higher risk of Aspergillus pulmonary colonization included those with liver cirrhosis, hematologic malignancy, H1N1pdm09 influenza A virus, and requiring vasopressors. Our results provide additional data on the controversial association between severe influenza and invasive pulmonary aspergillosis. Reaching a consensual definition of invasive pulmonary aspergillosis becomes mandatory and confers further prospective research.
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Arastehfar A, Carvalho A, Nguyen MH, Hedayati MT, Netea MG, Perlin DS, Hoenigl M. COVID-19-Associated Candidiasis (CAC): An Underestimated Complication in the Absence of Immunological Predispositions? J Fungi (Basel) 2020; 6:jof6040211. [PMID: 33050019 PMCID: PMC7712987 DOI: 10.3390/jof6040211] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 12/20/2022] Open
Abstract
The recent global pandemic of COVID-19 has predisposed a relatively high number of patients to acute respiratory distress syndrome (ARDS), which carries a risk of developing super-infections. Candida species are major constituents of the human mycobiome and the main cause of invasive fungal infections, with a high mortality rate. Invasive yeast infections (IYIs) are increasingly recognized as s complication of severe COVID-19. Despite the marked immune dysregulation in COVID-19, no prominent defects have been reported in immune cells that are critically required for immunity to Candida. This suggests that relevant clinical factors, including prolonged ICU stays, central venous catheters, and broad-spectrum antibiotic use, may be key factors causing COVID-19 patients to develop IYIs. Although data on the comparative performance of diagnostic tools are often lacking in COVID-19 patients, a combination of serological and molecular techniques may present a promising option for the identification of IYIs. Clinical awareness and screening are needed, as IYIs are difficult to diagnose, particularly in the setting of severe COVID-19. Echinocandins and azoles are the primary antifungal used to treat IYIs, yet the therapeutic failures exerted by multidrug-resistant Candida spp. such as C. auris and C. glabrata call for the development of new antifungal drugs with novel mechanisms of action.
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Affiliation(s)
- Amir Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA;
- Correspondence: (A.A.); (A.C.); (M.H.); Tel./Fax: +1-201-880-3100 (A.A.); +351-253-604811 (A.C.); +1-619-543-5605 (M.H.)
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s—PT Government Associate Laboratory, 4710-057 Guimarães/Braga, Portugal
- Correspondence: (A.A.); (A.C.); (M.H.); Tel./Fax: +1-201-880-3100 (A.A.); +351-253-604811 (A.C.); +1-619-543-5605 (M.H.)
| | - M. Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA;
| | - Mohammad Taghi Hedayati
- Invasive Fungi Research Center, Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 4815733971, Iran;
| | - Mihai G. Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Centre, 6500HB Nijmegen, The Netherlands;
- Department of Genomics & Immunoregulation, Life and Medical Sciences Institute, University of Bonn, 53115 Bonn, Germany
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - David S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA;
| | - Martin Hoenigl
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA 92093, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, CA 92093, USA
- Correspondence: (A.A.); (A.C.); (M.H.); Tel./Fax: +1-201-880-3100 (A.A.); +351-253-604811 (A.C.); +1-619-543-5605 (M.H.)
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Sharma A, Mishra T, Kumar N, Soubani AO. Influenza-Associated Aspergillosis: Nationwide Trends, Predictors and Outcomes From 2005 to 2014. Chest 2020; 158:1857-1866. [PMID: 32565269 DOI: 10.1016/j.chest.2020.06.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/29/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Influenza-associated aspergillosis (IAA) has been increasingly reported in the literature in recent years, but contemporary large-scale data on the morbidity and mortality burden of IAA are lacking. RESEARCH QUESTION The goal of this study was to estimate the predictors, associations, and outcomes of IAA in the United States. STUDY DESIGN AND METHODS This retrospective cohort study was performed by using the National (Nationwide) Inpatient Sample database from 2005 to 2014 to identify influenza and IAA hospitalizations. Baseline variables and outcomes were compared between influenza hospitalizations without IAA and those with IAA. These variables were then used to perform an adjusted analysis for obtaining predictors and associations of the diagnosis and in-hospital mortality of IAA. RESULTS Of the 477,556 hospitalizations identified with the principal diagnosis of influenza, IAA was identified in 823 (0.17%) hospitalizations. The IAA cohort consisted more commonly of 45- to 65-year-olds in urban teaching hospitals with substance abuse. Yearly trends revealed that both influenza and IAA hospitalizations have increased over time, with a peak observed in 2009, the year of the influenza A(H1N1) pandemic. Mortality was higher (20.58% vs 1.36%), average length of stay was longer (17.94 vs 4.05 days), and mean cost per hospitalization was higher ($194,932 vs $24,286) in the IAA cohort compared with the influenza cohort without IAA (P < .005). Solid-organ transplantation, hematologic malignancies, and use of invasive mechanical ventilation were associated with higher odds of IAA, among other factors. Use of invasive mechanical ventilation (adjusted OR, 13.43; P < .005), longer length of stay (adjusted OR, 5.47; P < .005), utilization of extracorporeal membrane oxygenation (adjusted OR, 4.99; P = .014), and the group aged 45 to 64 years (adjusted OR, 3.03; P = .012) were associated with higher in-hospital mortality in the IAA cohort. INTERPRETATION Although IAA is a rare complication of influenza hospitalizations, it is associated with increased all-cause mortality, more extended hospital stays, and higher hospital charges compared with influenza without IAA.
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Affiliation(s)
- Aditi Sharma
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI
| | - Tushar Mishra
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI
| | - Narender Kumar
- Institute of Experimental Endocrinology and Oncology, National Research Council, Naples, Italy
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI.
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Lim JKB, Qadri SK, Toh TSW, Lin CB, Mok YH, Lee JH. Extracorporeal Membrane Oxygenation for Severe Respiratory Failure During Respiratory Epidemics and Pandemics: A Narrative Review. ANNALS ACADEMY OF MEDICINE SINGAPORE 2020. [DOI: 10.47102/annals-acadmed.sg.202046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Epidemics and pandemics from zoonotic respiratory viruses, such as the 2019 novel coronavirus, can lead to significant global intensive care burden as patients progress to acute respiratory distress syndrome (ARDS). A subset of these patients develops refractory hypoxaemia despite maximal conventional mechanical ventilation and require extracorporeal membrane oxygenation (ECMO). This review focuses on considerations for ventilatory strategies, infection control and patient selection related to ECMO for ARDS in a pandemic. We also summarise the experiences with ECMO in previous respiratory pandemics. Materials and Methods: A review of pertinent studies was conducted via a search using MEDLINE, EMBASE and Google Scholar. References of articles were also examined to identify other relevant publications. Results: Since the H1N1 Influenza pandemic in 2009, the use of ECMO for ARDS continues to grow despite limitations in evidence for survival benefit. There is emerging evidence to suggest that lung protective ventilation for ARDS can be further optimised while receiving ECMO so as to minimise ventilator-induced lung injury and subsequent contributions to multi-organ failure. Efforts to improve outcomes should also encompass appropriate infection control measures to reduce co-infections and prevent nosocomial transmission of novel respiratory viruses. Patient selection for ECMO in a pandemic can be challenging. We discuss important ethical considerations and predictive scoring systems that may assist clinical decision-making to optimise resource allocation. Conclusion: The role of ECMO in managing ARDS during respiratory pandemics continues to grow. This is supported by efforts to redefine optimal ventilatory strategies, reinforce infection control measures and enhance patient selection. Ann Acad Med Singapore 2020;49:199–214 Key words: Acute Respiratory Distress Syndrome, Coronavirus disease 2019, ECMO, Infection control, Mechanical ventilation
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Affiliation(s)
- Joel KB Lim
- KK Women’s and Children’s Hospital, Singapore
| | | | | | | | - Yee Hui Mok
- KK Women’s and Children’s Hospital, Singapore
| | - Jan Hau Lee
- KK Women’s and Children’s Hospital, Singapore
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Biomarkers for Point-of-Care Diagnosis of Sepsis. MICROMACHINES 2020; 11:mi11030286. [PMID: 32164268 PMCID: PMC7143187 DOI: 10.3390/mi11030286] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/06/2020] [Accepted: 03/07/2020] [Indexed: 12/18/2022]
Abstract
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. In 2017, almost 50 million cases of sepsis were recorded worldwide and 11 million sepsis-related deaths were reported. Therefore, sepsis is the focus of intense research to better understand the complexities of sepsis response, particularly the twin underlying concepts of an initial hyper-immune response and a counter-immunological state of immunosuppression triggered by an invading pathogen. Diagnosis of sepsis remains a significant challenge. Prompt diagnosis is essential so that treatment can be instigated as early as possible to ensure the best outcome, as delay in treatment is associated with higher mortality. In order to address this diagnostic problem, use of a panel of biomarkers has been proposed as, due to the complexity of the sepsis response, no single marker is sufficient. This review provides background on the current understanding of sepsis in terms of its epidemiology, the evolution of the definition of sepsis, pathobiology and diagnosis and management. Candidate biomarkers of interest and how current and developing point-of-care testing approaches could be used to measure such biomarkers is discussed.
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Nosocomial Infections During Extracorporeal Membrane Oxygenation in Neonatal, Pediatric, and Adult Patients: A Comprehensive Narrative Review. Pediatr Crit Care Med 2020; 21:283-290. [PMID: 31688809 DOI: 10.1097/pcc.0000000000002190] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation is increasingly used in critically ill patients with refractory cardiopulmonary failure. Nosocomial infection acquired during extracorporeal membrane oxygenation represents one of the most frequent complications but the available evidence on the risk of infection and its association with outcomes has not been comprehensively analyzed. We performed a narrative review examining the epidemiology of nosocomial infection during extracorporeal membrane oxygenation, association with clinical outcomes, and preventive strategies. DATA SOURCES We searched PubMed, Web of Science, EMBASE, and the Cochrane Library between 1972 and June 2018. STUDY SELECTION We included any article which detailed nosocomial infection during extracorporeal membrane oxygenation. Articles were excluded if they were not written in English, detailed extracorporeal membrane oxygenation use for infections acquired prior to extracorporeal membrane oxygenation, or used other forms of extracorporeal support such as ventricular assist devices. DATA EXTRACTION Two reviewers independently assessed eligibility and extracted data. We screened 984 abstracts and included 59 articles in the final review. DATA SYNTHESIS The reported risk of nosocomial infection among patients receiving extracorporeal membrane oxygenation ranged from 3.5% to 64% per extracorporeal membrane oxygenation run, while the incidence of infection ranged from 10.1 to 116.2/1,000 extracorporeal membrane oxygenation days. Nosocomial infections during extracorporeal membrane oxygenation were consistently associated with longer duration of extracorporeal membrane oxygenation and, in several large multicenter studies, with increased mortality. Risk factors for nosocomial infection included duration of extracorporeal membrane oxygenation, mechanical and hemorrhagic complications on extracorporeal membrane oxygenation, and use of venoarterial and central extracorporeal membrane oxygenation. Biomarkers had low specificity for infection in this population. Few studies examined strategies on how to prevent nosocomial infection on extracorporeal membrane oxygenation. CONCLUSIONS Nosocomial infections in extracorporeal membrane oxygenation patients are common and associated with worse outcomes. There is substantial variation in the rates of reported infection, and thus, it is possible that some may be preventable. The evidence for current diagnostic, preventive, and therapeutic strategies for infection during extracorporeal membrane oxygenation is limited and requires further investigation.
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Ribeiro F, Rossoni R, Barros P, Santos J, Fugisaki L, Leão M, Junqueira J. Action mechanisms of probiotics on
Candida
spp. and candidiasis prevention: an update. J Appl Microbiol 2019; 129:175-185. [DOI: 10.1111/jam.14511] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 10/18/2019] [Accepted: 10/30/2019] [Indexed: 12/19/2022]
Affiliation(s)
- F.C. Ribeiro
- Department of Biosciences and Oral Diagnosis Institute of Science and Technology São Paulo State University/UNESP Sao Jose dos Campos Brazil
| | - R.D. Rossoni
- Department of Biosciences and Oral Diagnosis Institute of Science and Technology São Paulo State University/UNESP Sao Jose dos Campos Brazil
| | - P.P. Barros
- Department of Biosciences and Oral Diagnosis Institute of Science and Technology São Paulo State University/UNESP Sao Jose dos Campos Brazil
| | - J.D. Santos
- Department of Biosciences and Oral Diagnosis Institute of Science and Technology São Paulo State University/UNESP Sao Jose dos Campos Brazil
| | - L.R.O. Fugisaki
- Department of Biosciences and Oral Diagnosis Institute of Science and Technology São Paulo State University/UNESP Sao Jose dos Campos Brazil
| | - M.P.V. Leão
- Bioscience Basic Institute University of Taubaté Bom Conselho Taubaté SP Brazil
| | - J.C. Junqueira
- Department of Biosciences and Oral Diagnosis Institute of Science and Technology São Paulo State University/UNESP Sao Jose dos Campos Brazil
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Invasive pulmonary aspergillosis complicating severe influenza: epidemiology, diagnosis and treatment. Curr Opin Infect Dis 2019; 31:471-480. [PMID: 30299367 DOI: 10.1097/qco.0000000000000504] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Bacterial super-infection of critically ill influenza patients is well known, but in recent years, more and more reports describe invasive aspergillosis as a frequent complication as well. This review summarizes the available literature on the association of invasive pulmonary aspergillosis (IPA) with severe influenza [influenza-associated aspergillosis (IAA)], including epidemiology, diagnostic approaches and treatment options. RECENT FINDINGS Though IPA typically develops in immunodeficient patients, non-classically immunocompromised patients such as critically ill influenza patients are at high-risk for IPA as well. The morbidity and mortality of IPA in these patients is high, and in the majority of them, the onset occurs early after ICU admission. At present, standard of care (SOC) consists of close follow-up of these critically ill influenza patients with high diagnostic awareness for IPA. As soon as there is clinical, mycological or radiological suspicion for IAA, antifungal azole-based therapy (e.g. voriconazole) is initiated, in combination with therapeutic drug monitoring (TDM). Antifungal treatment regimens should reflect local epidemiology of azole-resistant Aspergillus species and should be adjusted to clinical evolution. TDM is necessary as azoles like voriconazole are characterized by nonlinear pharmacokinetics, especially in critically ill patients. SUMMARY In light of the frequency, morbidity and mortality associated with influenza-associated aspergillosis in the ICU, a high awareness of the diagnosis and prompt initiation of antifungal therapy is required. Further studies are needed to evaluate the incidence of IAA in a prospective multicentric manner, to elucidate contributing host-derived factors to the pathogenesis of this super-infection, to further delineate the population at risk, and to identify the preferred diagnostic and management strategy, and also the role of prophylaxis.
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de Roux Q, Botterel F, Lepeule R, Taccone FS, Langeron O, Mongardon N. Candida bloodstream infection under veno-arterial ECMO therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:314. [PMID: 31530278 PMCID: PMC6747746 DOI: 10.1186/s13054-019-2593-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Quentin de Roux
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale cardio-vasculaire, DMU CARE, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France.,U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
| | - Françoise Botterel
- Unité de Parasitologie-Mycologie, Département des agents infectieux, Assistance Publique des Hôpitaux de Paris (APHP), Centre Hospitalier Universitaire Henri Mondor, Créteil, France.,Université Paris Est Créteil, Faculté de Médecine, Créteil, France
| | - Raphaël Lepeule
- Unité transversale de traitement des infections, Département des agents infectieux, Assistance Publique des Hôpitaux de Paris (APHP), Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Clinique Universitaire de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Olivier Langeron
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale cardio-vasculaire, DMU CARE, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France.,Université Paris Est Créteil, Faculté de Médecine, Créteil, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation chirurgicale, réanimation chirurgicale cardio-vasculaire, DMU CARE, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France. .,U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France. .,Université Paris Est Créteil, Faculté de Médecine, Créteil, France.
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Al-Abbasi FA, Sadath S, Mushtaq G, Anwar F. Vitamin B combination reduces fluconazole toxicity in Wistar rats. Daru 2019; 27:525-531. [DOI: 10.1007/s40199-019-00252-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 02/18/2019] [Indexed: 10/27/2022] Open
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Koerner MM, Harper MD, Gordon CK, Horstmanshof D, Long JW, Sasevich MJ, Neel JD, El Banayosy A. Adult cardiac veno-arterial extracorporeal life support (VA-ECMO): prevention and management of acute complications. Ann Cardiothorac Surg 2019; 8:66-75. [PMID: 30854314 DOI: 10.21037/acs.2018.12.09] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been shown to be a viable and effective treatment for patients suffering from refractory cardiogenic shock (rCS), which is associated with high mortality rates. Although ECMO therapy used as short-term mechanical circulatory support (MCS) has shown tremendous growth in its application over the past decade, the complication and mortality rates remain high. This retrospective study analyzes complications associated with VA-ECMO support, evaluates the use of defined protocols at a single center, and examines factors that may contribute to patient complication and mortality. Methods This retrospective analysis included 184 patients who were supported with ECMO from September 2014 through March 2018 at Integris Baptist Medical Center (IBMC). Descriptive statistics were generated to analyze baseline characteristics, demographics, complications, and outcomes. Results Acute myocardial infarct (AMI) was the primary etiology of this cohort (N=40; 22%). The mean age was 55±15 (median 56, range 15-84) years. All patients were inotrope and/or vasopressor dependent prior to ECMO initiation. Mean time on ECMO support was 7.8±7.9 days with median time of 6 days. Total patient days on support were 1,430. Most ECMO cannulations, 97 (52%) were performed within Integris Baptist Medical Center, with 48% done outside the hospital; 38% were performed outside of the hospital by the IBMC ECMO team, and 10.5% were performed by an outside team. Bleeding was noted to be the most common VA ECMO complication [N=41; 22.3%; 0.028 events per patient day (EPPD)]. Conclusions A dedicated 24/7 ECMO service using a multidisciplinary team (MDT) and defined protocols in a single center is able to effectively reduce complications due to VA-ECMO support in the sickest of the sick VA-ECMO patients.
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Affiliation(s)
- Michael M Koerner
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Michael D Harper
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Christopher K Gordon
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Douglas Horstmanshof
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - James W Long
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Michael J Sasevich
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - James D Neel
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
| | - Aly El Banayosy
- Advanced Cardiac Care and Transplant Institute, Integris Baptist Medical Center, Oklahoma City, OK, USA
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Khan Z, Ahmad S, Jeragh A, Alfouzan W, Al Foudri H, Hassan N, Asadzadeh M, Joseph L, Varghese S. First isolation of Ascotricha chartarum from bronchoalveolar lavage of two patients with pulmonary infections. New Microbes New Infect 2018; 28:11-16. [PMID: 30766685 PMCID: PMC6363919 DOI: 10.1016/j.nmni.2018.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 11/12/2022] Open
Abstract
Ascotricha chartarum is a rare human pathogen. We describe the isolation and characterization of A. chartarum from bronchoalveolar lavage samples of two patients with underlying pulmonary infections. The identity of both isolates was established by typical phenotypic characteristics and by sequencing of the internal transcribed spacer region and D1/D2 domains of recombinant DNA and β-tubulin gene fragment. The demonstration of branched, septate hyphae in direct microscopic examination of both the specimens and isolation of the fungus in pure cultures suggest its aetiologic role in the disease process. Because of phenotypic similarities of A. chartarum with Chaetomium spp. and other Chaetomium-like fungi, the application of molecular methods is needed for its accurate identification. Although in the absence of histopathologic evidence the aetiologic role of A. chartarum could not be established unequivocally, nonetheless, in view of the rarity of its isolation from clinical specimens and demonstration of hyphal elements in bronchoalveolar lavage sample, this report assumes considerable significance. It serves to create awareness about environmental fungi that previously have missed attention but may play a role in respiratory infections.
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Affiliation(s)
- Z Khan
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| | - S Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| | - A Jeragh
- Department of Microbiology, , Al Adan Hospital, Kuwait
| | - W Alfouzan
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| | - H Al Foudri
- Critical Care and ECMO Unit, Anesthesia Department, Al Adan Hospital, Kuwait
| | - N Hassan
- Department of Microbiology, , Al Adan Hospital, Kuwait
| | - M Asadzadeh
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| | - L Joseph
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| | - S Varghese
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
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Schauwvlieghe AFAD, Rijnders BJA, Philips N, Verwijs R, Vanderbeke L, Van Tienen C, Lagrou K, Verweij PE, Van de Veerdonk FL, Gommers D, Spronk P, Bergmans DCJJ, Hoedemaekers A, Andrinopoulou ER, van den Berg CHSB, Juffermans NP, Hodiamont CJ, Vonk AG, Depuydt P, Boelens J, Wauters J. Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study. THE LANCET RESPIRATORY MEDICINE 2018; 6:782-792. [DOI: 10.1016/s2213-2600(18)30274-1] [Citation(s) in RCA: 468] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/11/2018] [Accepted: 06/15/2018] [Indexed: 12/11/2022]
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Appraisal of fungal infections during ECMO therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:145. [PMID: 29871652 PMCID: PMC5989422 DOI: 10.1186/s13054-018-2082-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/24/2018] [Indexed: 01/06/2023]
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