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Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, Hagen F, Spec A, Oladele R, Govender NP, Chen SC, Mody CH, Groll AH, Chen YC, Lionakis MS, Alanio A, Castañeda E, Lizarazo J, Vidal JE, Takazono T, Hoenigl M, Alffenaar JW, Gangneux JP, Soman R, Zhu LP, Bonifaz A, Jarvis JN, Day JN, Klimko N, Salmanton-García J, Jouvion G, Meya DB, Lawrence D, Rahn S, Bongomin F, McMullan BJ, Sprute R, Nyazika TK, Beardsley J, Carlesse F, Heath CH, Ayanlowo OO, Mashedi OM, Queiroz-Telles Filho F, Hosseinipour MC, Patel AK, Temfack E, Singh N, Cornely OA, Boulware DR, Lortholary O, Pappas PG, Perfect JR. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. THE LANCET. INFECTIOUS DISEASES 2024; 24:e495-e512. [PMID: 38346436 PMCID: PMC11526416 DOI: 10.1016/s1473-3099(23)00731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/13/2023] [Indexed: 03/21/2024]
Abstract
Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.
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Soman R, Veeraraghavan B, Hegde A, Varma S, Todi S, Singh RK, Nagavekar V, Rodrigues C, Swaminathan S, Ramsubramanian V, Ansari A, Chaudhry D, Pednekar A, Bhagat S, Patil S, Barkate H. Indian consensus on the managemeNt of carbapenem-resistant enterobacterales infection in critically ill patients II (ICONIC II). Expert Rev Anti Infect Ther 2024; 22:453-468. [PMID: 38790080 DOI: 10.1080/14787210.2024.2360116] [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: 04/03/2024] [Accepted: 05/22/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION The rising challenge of carbapenem-resistant Enterobacterales (CRE) infections in Indian healthcare settings calls for clear clinical guidance on the management of these infections. The Indian consensus on the management of CRE infection in critically ill patients (ICONIC-II) is a follow-up of the ICONIC-I study, which was undertaken in 2019. AREAS COVERED A modified Delphi method was used to build expert consensus on CRE management in India, involving online surveys, face-to - face expert meetings, and a literature review. A panel of 12 experts was formed to develop potential clinical consensus statements (CCSs), which were rated through two survey rounds. The CCSs were finalized in a final face-to - face discussion. The finalized CCSs were categorized as consensus, near consensus, and no consensus. EXPERT OPINION The outcomes included 46 CCSs (consensus: 40; near consensus: 3; and no consensus: 3). The expert panel discussed and achieved consensus on various strategies for managing CRE infections, emphasizing the significance of existing and emerging resistance mechanisms, prompt and tailored empiric therapy, and use of combination therapies. The consensus statements based on the collective expertise of the panel can potentially assist clinicians in the management of CRE infections that lack high-level evidence.
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Rizvi M, Malhotra S, Agarwal J, Siddiqui AH, Devi S, Poojary A, Thakuria B, Princess I, Sami H, Gupta A, Sultan A, Jitendranath A, Mohan B, Banashankari GS, Khan F, Kalita JB, Jain M, Singh NP, Gur R, Mohapatra S, Farooq S, Purwar S, Jankhwala MS, Yamunadevi VR, Masters K, Goyal N, Sen M, Zadjali RA, Jaju S, Rugma R, Meena S, Dutta S, Langford B, Brown KA, Dougherty KM, Kanungo R, Jabri ZA, Singh S, Singh S, Taneja N, John KHS, Sardana R, Kapoor P, Jardani AA, Soman R, Balkhair A, Livermore DM. Regional variations in antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli in India: Findings of a multicentric study highlighting the importance of local antibiograms. IJID REGIONS 2024; 11:100370. [PMID: 38812702 PMCID: PMC11134879 DOI: 10.1016/j.ijregi.2024.100370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 05/31/2024]
Abstract
Objectives Evidence-based prescribing is essential to optimize patient outcomes in cystitis. This requires knowledge of local antibiotic resistance rates. Diagnostic and Antimicrobial Stewardship (DASH) to Protect Antibiotics (https://dashuti.com/) is a multicentric mentorship program guiding centers in preparing, analyzing and disseminating local antibiograms to promote antimicrobial stewardship in community urinary tract infection. Here, we mapped the susceptibility profile of Escherichia coli from 22 Indian centers. Methods These centers spanned 10 Indian states and three union territories. Antibiograms for urinary E. coli from the outpatient departments were collated. Standardization was achieved by regional online training; anomalies were resolved via consultation with study experts. Data were collated and analyzed. Results Nationally, fosfomycin, with 94% susceptibility (inter-center range 83-97%), and nitrofurantoin, with 85% susceptibility (61-97%), retained the widest activity. The susceptibility rates were lower for co-trimoxazole (49%), fluoroquinolones (31%), and oral cephalosporins (26%). The rates for third- and fourth-generation cephalosporins were 46% and 52%, respectively, with 54% (33-58%) extended-spectrum β-lactamase prevalence. Piperacillin-tazobactam (81%), amikacin (88%), and meropenem (88%) retained better activity; however, one center in Delhi recorded only 42% meropenem susceptibility. Susceptibility rates were mostly higher in South, West, and Northeast India; centers in the heavily populated Gangetic plains, across north and northwest India, had greater resistance. These findings highlight the importance of local antibiograms in guiding appropriate antimicrobial choices. Conclusions Fosfomycin and nitrofurantoin are the preferred oral empirical choices for uncomplicated E. coli cystitis in India, although elevated resistance in some areas is concerning. Empiric use of fluoroquinolones and third-generation cephalosporins is discouraged, whereas piperacillin/tazobactam and aminoglycosides remain carbapenem-sparing parenteral agents.
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Agarwal R, Sehgal IS, Muthu V, Denning DW, Chakrabarti A, Soundappan K, Garg M, Rudramurthy SM, Dhooria S, Armstrong-James D, Asano K, Gangneux JP, Chotirmall SH, Salzer HJF, Chalmers JD, Godet C, Joest M, Page I, Nair P, Arjun P, Dhar R, Jat KR, Joe G, Krishnaswamy UM, Mathew JL, Maturu VN, Mohan A, Nath A, Patel D, Savio J, Saxena P, Soman R, Thangakunam B, Baxter CG, Bongomin F, Calhoun WJ, Cornely OA, Douglass JA, Kosmidis C, Meis JF, Moss R, Pasqualotto AC, Seidel D, Sprute R, Prasad KT, Aggarwal AN. Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses. Eur Respir J 2024; 63:2400061. [PMID: 38423624 PMCID: PMC10991853 DOI: 10.1183/13993003.00061-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics. METHODS An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively. RESULTS We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL-1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus-IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response. CONCLUSION We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research.
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Soman R, Sirsat R, Sunavala A, Punatar N, Mehta J, Rodrigues C, Veeraraghavan B. Successful treatment of sino-pulmonary infection & skull base osteomyelitis caused by New Delhi metallo-β-lactamase-producing Pseudomonas aeruginosa in a renal transplant recipient by using an investigational antibiotic cefepime/zidebactam (WCK 5222). Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04791-1. [PMID: 38416290 DOI: 10.1007/s10096-024-04791-1] [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: 12/08/2023] [Accepted: 02/21/2024] [Indexed: 02/29/2024]
Abstract
A case of sino-pulmonary infection with skull base osteomyelitis due to XDR-Pseudomonas aeruginosa in renal transplant recipient was successfully treated with investigational antibiotic, cefepime/zidebactam (WCK 5222). This case highlights challenges in managing XDR-pseudomonal infection where source control was infeasible, antibiotic options were extremely limited and individualized dose adjustments were needed.
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Bansal SB, Ramasubramanian V, Prasad N, Saraf N, Soman R, Makharia G, Varughese S, Sahay M, Deswal V, Jeloka T, Gang S, Sharma A, Rupali P, Shah DS, Jha V, Kotton CN. South Asian Transplant Infectious Disease Guidelines for Solid Organ Transplant Candidates, Recipients, and Donors. Transplantation 2023; 107:1910-1934. [PMID: 36749281 DOI: 10.1097/tp.0000000000004521] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
These guidelines discuss the epidemiology, screening, diagnosis, posttransplant prophylaxis, monitoring, and management of endemic infections in solid organ transplant (SOT) candidates, recipients, and donors in South Asia. The guidelines also provide recommendations for SOT recipients traveling to this region. These guidelines are based on literature review and expert opinion by transplant physicians, surgeons, and infectious diseases specialists, mostly from South Asian countries (India, Pakistan, Bangladesh, Nepal, and Sri Lanka) as well as transplant experts from other countries. These guidelines cover relevant endemic bacterial infections (tuberculosis, leptospirosis, melioidosis, typhoid, scrub typhus), viral infections (hepatitis A, B, C, D, and E; rabies; and the arboviruses including dengue, chikungunya, Zika, Japanese encephalitis), endemic fungal infections (mucormycosis, histoplasmosis, talaromycosis, sporotrichosis), and endemic parasitic infections (malaria, leishmaniasis, toxoplasmosis, cryptosporidiosis, strongyloidiasis, and filariasis) as well as travelers' diarrhea and vaccination for SOT candidates and recipients including travelers visiting this region. These guidelines are intended to be an overview of each topic; more detailed reviews are being published as a special supplement in the Indian Journal of Transplantation .
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Chakrabarti A, Patel AK, Soman R, Todi S. Overcoming clinical challenges in the management of invasive fungal infections in low- and middle-income countries (LMIC). Expert Rev Anti Infect Ther 2023; 21:1057-1070. [PMID: 37698201 DOI: 10.1080/14787210.2023.2257895] [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: 06/09/2023] [Accepted: 09/07/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION The management of invasive fungal infections (IFIs) in low- and middle-income countries (LMIC) is a serious challenge due to limited epidemiology studies, sub-optimal laboratory facilities, gap in antifungal management training and resources. Limited studies highlighted distinctive epidemiology of IFIs in those countries, and difficulty in distinguishing from closely related infections. To overcome the gaps for appropriate management of IFIs, innovative approaches are required. AREAS COVERED Extensive literature search and discussion with experts have helped us to summarize the epidemiology, diagnostic and management difficulties in managing IFIs in LMIC, and recommend certain solutions to overcome the challenges. EXPERT OPINION The strategies to overcome the challenges in diagnosis may include local epidemiology study, training of healthcare workers, association of fungal infections with already existing budgeted national programs, development and incorporation of point-of-care test (POCT) for prompt diagnosis, simplifying clinical diagnostic criteria suitable for LMIC, judicious use of available expertise, and diagnostic stewardship. For management strategies judicious use of antifungal, partnering with industry for inexpensive antifungal agents, development of LMIC specific guidelines for cost-effective management of IFIs and fungal outbreaks, improvement of infection control practices, advocacy for implementation of WHO recommended antifungal use, and integration of IFIs with public health.
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Chakraborty S, Rao V, Joe G, Thatte S, Soman R. A middle-aged patient with a pustular dermatosis with inguinal lymphadenopathy. Trop Doct 2023; 53:196-198. [PMID: 36380605 DOI: 10.1177/00494755221137627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Soman R, Chakraborty S, Joe G, Purandare B, Panchakshari S, Patwardhan S. P168 Metastatic mo ld infections after COVID-19: the mo ld time -bomb. Med Mycol 2022. [PMCID: PMC9494460 DOI: 10.1093/mmy/myac072.p168] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM
Objective
COVID-19-positive patients are at risk of invasive mold infection. The portal of entry is presumably the lungs, but infection may disseminate to involve other organs as described in this case series.
Patients and Methods
Patients who presented with de novo mold infection (6 proven and 1 probable) involving kidney, spine, eye, knee joint, subcutaneous tissue within 10-180 days of COVID-19 infection were included in this series (Table 1).
Conclusion
These cases suggest that metastatic infection by molds involving various organs could result from a presumed primary source in the lungs. However, the precise connection between pulmonary and metastatic infection is difficult to establish.
COVID-19 patients should be carefully followed for such metastatic mold infections which need proper diagnosis and management.
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Koparkar V, Soman R, Shetty A, Purandare B, Sunavala A, Doshi A. P011 Antifungal lock therapy. Med Mycol 2022. [PMCID: PMC9515820 DOI: 10.1093/mmy/myac072.p011] [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] [Indexed: 11/12/2022] Open
Abstract
Abstract
Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM
Objective
Candida spp is the fourth leading cause of catheter-related blood stream infection (CRBSI). The standard treatment is prompt removal of the device (central venous catheter, CVC, or port or hemodialysis catheter) along with administration of systemic antifungal therapy. However, in patients with a lack of alternative intravenous access and in some critically ill patients, this standard of care is challenging. Our success with antibiotic lock solution in MDR GNB CRBSI, prompted us to consider similar therapy in Candida spp CRBSI.
Methods
Catheter salvage using antifungal lock therapy was tried in a total of 15 cases in two centers. In 10 cases echinocandin (9 anidulafungin, 1 micafungin) and in 5 cases amphotericin b deoxycholate (AmB-d) were used to obtain an antifungal concentration of ∼ 1000 mcg/ml in the lock solutions. All these formulations had additional NAC, heparin, and normal saline. Systemic antifungal therapy was also administered concurrently.
Success was defined as clearance of candidemia at 48 h and 14 days and/or till the use of the device was needed. Some of these patients had prior/co-infections with bacterial pathogens and they were managed with appropriate systemic antibiotics with antibiotic lock therapy.
Results
In 11/15 episodes of CRBSI due to Candida species, catheter salvage was achieved. One case could not be assessed at 14 days as a port was removed in view of megaprosthesis in situ. In two cases this therapy failed and one patient lost to follow-up.
See Figures 1 and 2 for details of all cases.
Conclusions
Antifungal lock therapy using echinocandins and AmB-d appears to be a promising therapy in patients where catheter removal is difficult. However, this success neither means that this can become standard practice, nor should it make clinicians and hospital staff complacent about infection control practices.
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Rege S, Soman R, Chavan D, Dadke M. P146 Penicillium-like mo ld: caught red-handed, but remained unidentified. Med Mycol 2022. [PMCID: PMC9516125 DOI: 10.1093/mmy/myac072.p146] [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] [Indexed: 11/12/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objective This case highlights the presence of a self-limited respiratory mycosis in an immunocompetent host and need for fungal sequencing in diagnosis of such rare cases. Methods and Results Ms X, a 25-year-old, apparently healthy software engineer, had an overnight journey in an air-conditioned bus from Hyderabad to Pune. The next day, she developed throat irritation followed 3 days later by fever and cough without dyspnea nor wheezing. Her chest X-ray was found to be normal at the time. Three days later she was admitted to our hospital, wherein X-ray chest and CT chest showed bilateral randomly scattered nodular shadows (Fig. 1). She was referred to ID as a case of suspected tuberculosis, but her presenting symptom being sore throat, the acuteness of symptoms, presence of nodular lung shadows which were absent on the X-ray chest done just 3 days earlier were against the diagnosis of TB. Inhalational fungal or viral pneumonitis were hence considered. Transbronchial biopsy showed an intense alveolar inflammatory exudate, but GMS staining did not reveal any fungal hyphae. BAL Galactomannan, Xpert MTB/RIF were negative. Both BAL and CT guided lung nodule biopsy samples grew a mold. Red pigment formation in culture and its morphological appearance on LPCB mount (Fig. 2) led to a diagnosis of Penicillium species infection. MALDI TOF MS, which had only a few Penicillium spp in its 2018 database, failed to identify the organism, leading us to believe that it could be a different Penicillium species. Since the patient was showing clinical improvement, a self-limited infection was thought of and therapy was withheld with cautious follow-up. The patient was completely asymptomatic after 10 days and CT chest done 20 days later showed complete resolution of the nodules. We believe that this illness was due to inhalation of spores from the air-conditioning vent, eliciting a brisk inflammatory response in the alveoli. The organism grew from BAL and CT guided biopsy from viable spores, but it failed to germinate into hyphae in the human host and hence was not seen on histopathology and did not produce galactomannan which is only released from the tips of growing hyphae. Conclusion Fungi are often isolated from poorly maintained air conditioning vents. In this case, the Penicillium like organism failed to produce progressive disease in the immunocompetent host. If the same organism could be cultured from the AC vent, showed genetic relatedness with the clinical isolate; the source, transmission, and disease linkage could have been established in this case.
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Rege S, Soman R. P268 Laryngeal Mucormycosis: does mucor take the voice away? Med Mycol 2022. [PMCID: PMC9510005 DOI: 10.1093/mmy/myac072.p268] [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] [Indexed: 11/12/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objective This case aims to highlight a unique presentation of Mucormycosis. Methods and Results A 57-year-old retired office supervisor, presented to the ENT department with complaints of hoarseness of voice ending with almost complete dysphonia over 6 months. There were no complaints of stridor, dyspnea or dysphagia. He had no history of prior surgery or tracheal intubation. On examination, a lesion over his right vocal cord was noted (Fig. 1) and underwent surgical excision of the lesion. HPE of the lesion (Fig. 2) showed hyperplastic stratified squamous epithelium which was partly ulcerated and covered by thick bands of necro-inflammatory material. Within the necrotic material were seen broad aseptate fungal hyphae. Beneath the necrotic material was inflamed granulation tissue with fibrosis. No tissue or vascular invasion was noted as per the report, however there was a recurrence of the lesion after 15 days. ID team opinion was sought in view of need for antifungals. Owing to financial constraints, CT chest could not be done, but his chest X-ray was normal. His HbA1c was 7.5%, which was suggestive of newly detected diabetes mellitus (DM). In this case, even though no angioinvasion or tissue invasion was reported, the presence of hyphae in the area of necrosis, the presence of inflammatory local tissue reaction, coupled with newly detected DM, prompted the ID team to advise treatment with amphotericin B followed by suspension posaconazole (GR was not available at the that time). The patient was not willing for treatment at the time. However, local recurrence of the lesion occurred 2 weeks later. Surgical resection along with posaconazole, TDM and close follow-up was advised. However, the patient was lost to follow-up, possibly due to loss of confidence in us? Conclusion The importance of sending every surgically excised tissue for histopathology and culture has been highlighted by this case. Early ID opinion and AF therapy could have averted recurrence and loss of patient confidence. Chronic Granulomatous form of mucormycosis though rare, needs timely diagnosis and treatment in the form of surgical resection as well as systemic antifungal therapy.
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Chakraborty S, Soman R, Joe G. P171 Pneumocystis Jirovecii Pneumonia in non-HIV immunosuppressed patients: Acase series. Med Mycol 2022. [PMCID: PMC9509781 DOI: 10.1093/mmy/myac072.p171] [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] [Indexed: 11/16/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objective Increased usage of immunosuppressive medications and lack of guidance about when to initiate primary Pneumocystis Jirovecii Pneumonia (PCP) prophylaxis has led to a rising incidence of PCP in non-HIV immunosuppressed patients. The objective of this case series is to review clinical challenges in diagnosis and management of these patients. Patients, methods, and results This is a retrospective case series of all 6 cases which were seen at Jupiter Hospital from January 2020 to October 2021 (Table 1). Conclusion The presence of the above-mentioned predisposing factors should raise the suspicion of PCP. Non-invasive investigations like serum LDH, BDG, PET CT scan/HRCT scan of chest can help in the diagnosis. This can be confirmed by BAL PCR, which is both, more sensitive and specific than immunofluorescence microscopy. Trimethoprim- sulfamethoxazole (TMP- SMX), the standard treatment, cannot be used in some circumstances and alternate treatment may have to be used. Guidance about prophylaxis, antimicrobial therapy for PCP, and adjuvant steroid therapy in non-HIV patients is unavailable, which is an unmet clinical need.
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Joe G, Soman R, Chakraborty S, Kothawade H, Ramchandani N, Chakrabarti A. P169 Systemic Pythiosis: presumably, the first human case in India. Med Mycol 2022. [PMCID: PMC9515889 DOI: 10.1093/mmy/myac072.p169] [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] [Indexed: 11/14/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives This is the first human case of systemic disease due to Pythium insidiosum reported from India. The case highlights difficulty in diagnosis and management. Methods A 44-year-old male patient had a peri-esophageal and peri-gastric inflammatory lesion which showed inflammation along with sparsely septate hyphae (Fig. 1), and partially responded to voriconazole (VCZ). After 1.5 years, he developed a massive liver lesion (Fig. 2), and hepatic venous thrombosis which was refractory despite restarting therapy with posaconazole (PCZ). As a desperate measure, surgical excision of the large liver lesion was undertaken. Results Serum BDG was positive and Serum Galactomannan was negative. There was no tidy explanation for the insidious clinical course of the illness over 1.5 years, partial response to VCZ for the esophageal lesion and inadequate response of the subsequent lesion to PCZ. The liver biopsy specimen showed a flat, feathery growth on SDA which was identified at PGI, Chandigarh by ITS as P. insidiosum. P. insidiosum and additionally Rhizopus microsporus were identified by molecular sequencing from the surgical specimen as well. The patient succumbed to carbapenem-resistant Klebsiella bacteremia in the postoperative stage. Conclusion The case underscores the insidious course of systemic pythiosis, diagnostic, and management challenges.
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Soman R, Chakraborty S, Jeloka T, Joe G, Ramchandani N, Kaur H. P137 Remote inoculation mycosis: Rip Van Winkle wakes up. Med Mycol 2022. [PMCID: PMC9515896 DOI: 10.1093/mmy/myac072.p137] [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] [Indexed: 12/04/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objective After immunosuppression, a remotely inoculated organism may be activated to produce clinical disease. We describe such a case with infection due to Medicopsis romeroi, a rare mold. Patient and Methods A 54-year-old male, diabetic, hypertensive, status post-live related donor renal transplantation, done in February 2021. The patient was on standard triple immunosuppressant regimen. He developed a painless nodule on his thumb over 5 months which did not respond to multiple courses of antibiotics. The swelling was excised and sent for various tests. Review of USG after infectious disease referral, showed a small foreign body, like a wooden splinter in the wall of the lesion (Fig. 1). On inquiry, a 3 mm wooden splinter in the lesion was noted during surgery and there was an injury at the same site, 20 years ago when the patient used to work on a farm. Organisms derived from soil or thorn injury including bacterial and fungal organisms were considered in the differential diagnosis. Bacterial organisms were considered less likely as there was no response to antibiotics. Results Histopathology showed brownish septate hyphae with constrictions at the areas of septations (Fig. 2). The excised tissue grew a dematiaceous mold. In Lactophenol Cotton Blue (LPCB) mount branched, septate hyphae with sparse conidia were seen. MALDI- TOF MS was unable to identify the mold. Sequencing identified it as M. romeroi. There are no ECOFFs or break points (BP) available for M. romeroi. Minimum inhibitory concentration (MIC) of Voriconazole (VCZ) is reportedly low and hence was chosen for treatment with an appropriate dose adjustment of Tacrolimus. Conclusion This case underscores that remote inoculation, when the patient was immunocompetent, could have introduced a mold, which remained latent and reactivated after immunosuppression. Sending excised tissue for appropriate tests is rewarding. Medicopsis romeroi is a rare mold with only 12 cases reported so far. It is difficult to identify except with sequencing. There is no standard guidance on treatment. Surgical excision along with prolonged treatment with one of the new azoles is beneficial.
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Soman R, Chakraborty S, Rao V, Rohit S, Joe G. P170 Life threatening hemoptysis in COVID-19 associated Pulmonary Aspergillosis (CAPA). Med Mycol 2022. [PMCID: PMC9494468 DOI: 10.1093/mmy/myac072.p170] [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] [Indexed: 11/13/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objective We report a case of large pulmonary mycotic aneurysms with massive hemorrhage as an unusual complication of CAPA which required vascular radiological interventions along with appropriate antifungal treatment. Method and Results A 71-year-old female patient had COVID-19 and was admitted elsewhere and she received steroids, aspirin, antibiotics, and fluconazole. Cough, dyspnea, and hemoptysis started 3 weeks later which markedly worsened over 4 days, requiring emergency hospitalization due to shock, and she received a large number of packed RBCs. The chest CT scan revealed two large nodular opacities with central breakdown and CT pulmonary angiography revealed large mycotic aneurysms within the nodular opacities (Fig. 1). The important task at the moment of presentation was pulmonary artery embolization to arrest hemoptysis; which took precedence over the diagnosis and treatment of the likely infectious process. Both aneurysms were embolized using coils and vascular plugs resulting in their obliteration. Common causes of such nodules with central necrotic cavitation and formation of pseudoaneurysms are angioinvasive molds like Aspergillus and Mucorales. In the post-COVID-19 and post steroid setting in India, invasive Mucormycosis (IM) is thought to be more common than invasive Aspergillosis (IA). A mixed infection with these molds appears to be present in about 15% of the cases. Absence of DM or hyperglycemia was somewhat against a diagnosis of Mucormycosis. TB was considered less likely due to the imaging features and Nocardia was considered less likely due to the tempo of the illness and the severity of hemoptysis. Since the clinical distinction between Aspergillosis and Mucormycosis was not possible and posaconazole can be potentially useful for both, it was chosen for treatment in preference to voriconazole. Both amphotericin B and isavuconazole were in short supply at that time. Posaconazole was used for the patient intravenously followed by gastroresistant tablets. Expectorated sputum revealed narrow, septate, acute angle branching fungal hyphae. Therapeutic drug monitoring was used later to assure an adequate drug exposure. Serum galactomannan and BDG reports were received soon after and were 2.49 ODI (Optical density Index) and >523pg/ml respectively. The mold grew in culture as shown in and was identified by morphological features and by MALDI TOF MS as Aspergillus fumigatus (Fig. 2). Sensititre MIC to posaconazole was found to be 0.12 which is considered in the susceptible range. Despite these findings indicating IA, posaconazole was not replaced by voriconazole as IM could not be ruled out as part of a mixed infection. The patient showed clinical improvement, had no further hemoptysis, serum galactomannan turned negative and CT showed obliteration of the aneurysms. Conclusion Posaconazole and isavuconazole may indeed emerge as good contemporary choices over voriconazole for IA and over amphotericin B for IM. This case adds to the clinical experience of using medical treatment with posaconazole as the sole drug and not undertaking surgery in cases such as these, due to certain extenuating circumstances.
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Dalvi M, Patwardhan S, Prayag P, Purandhare B, Soman R. P417 Evaluation of matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS)-Bruker Biotyper Sirius for identification of invasive molds. Med Mycol 2022. [PMCID: PMC9515934 DOI: 10.1093/mmy/myac072.p417] [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] [Indexed: 11/22/2022] Open
Abstract
Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM Objectives Susceptibility to various antifungal drugs varies between different species and subspecies within the same genus. Phenotypic identification of fungi has limitations for species-level identification. Correct identification of species and subspecies in invasive mold infections is important to initiate the appropriate antifungal therapy. Matrix Assisted Laser Desorption Ionization Time-of-Flight mass spectrometry (MALDI-TOF MS) with its proteomic analysis overcomes this limitation and helps in administering the correct anti-fungal therapy. A total of seven mold isolates from invasive fungal infections were evaluated for identification by MALDI-TOF MS and conventional morphological methods. Methods Total of seven isolates from invasive mold infections were identified by the conventional method of culturing specimens on Sabouraud's dextrose agar and Potato Dextrose agar with incubation at room temperature and 37°C in Biological oxygen demand (BOD) incubator. Micro-morphological identification of the fungus was done by Lacto Phenol Cotton Blue (LPCB) mount. Same isolates were processed on MALDI-TOF MS Bruker Biotyper Sirius (Bruker Daltonics, Bremen Germany) following recommended extraction protocol using ethanol absolute, acetonitrile, and 70% formic acid. Results As per the below Figure. Conclusion In four out of seven isolates phenotypic identification upto species level based on LPCB micromorphology was confirmed on MALDI-TOF MS. In the remaining three isolates we could only give a genus level identification based on LPCB mount. These three isolates were further identified upto the level of species after processing on MALDI as Aspergillus tamarii, Phaeoacremonium cinerum, and Fusarium equiseti. All mold isolates were identified with good quality mass spectra. In our experience, mold identification by MALDI-TOF MS using the Bruker Biotyper Sirius platform definitely has an edge over conventional phenotypic methods in species-level differentiation of various molds, impacting targeted antifungal management.
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Rege S, Soman R, Shetty A. P269 Managing prosthetic valve endocarditis due to Sarocladium kiliense: Finding a way through uncertainties. Med Mycol 2022. [PMCID: PMC9516254 DOI: 10.1093/mmy/myac072.p269] [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] [Indexed: 12/01/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objective To discuss the challenges in a case of recurrent/refractory prosthetic valve endocarditis due to Sarocladium kiliense. Methods and Results Timeline of events (Fig. 1). AUC/MIC is associated with efficacy. Recent clinical studies have incorporated the MIC into targets for TDM, wherein Trough/MIC target of 2-5 may be usedR. In this case Voriconazole trough—3.1/MIC-0.25 = 12.5 Usual posaconazole trough—1.2/MIC 0.5 = 2.4, which is at the lower limit of the PKPD index Hence voriconazole was used. Drug interactions of voriconazole with acenocoumarol, clopidogrel were considered. Beta D-Glucan was used to assess infection of the newly implanted valve as well as improvement and need for continuing treatment. Since it is difficult to be certain of a cure, the patient was advised voriconazole as lifelong chronic suppressive therapy with periodic follow-up. R: reference available. Conclusions The patient's status of the third mitral prosthetic valve necessitated all efforts to avoid further surgery. Therefore, the most efficacious agent had to be selected based on PK PD considerations and the likelihood of major long-term adverse effects. Careful management of DDI was needed. BDG may help to assess recurrence and response to treatment.
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Rege S, Soman R, Chavan D, Hanchanale P. P267 Candida in the biliary tract: extrapolative PK PD considerations. Med Mycol 2022. [PMCID: PMC9509882 DOI: 10.1093/mmy/myac072.p267] [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] [Indexed: 11/15/2022] Open
Abstract
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM
Objective
Candida norvegensis is an uncommon Candida species causing infection in immunocompromised hosts. It is intrinsically resistant to Fluconazole, which is commonly the empiric choice for therapy. A strong association with post-liver transplant status, as in this case and near-100% mortality, likely due to inappropriate antifungal therapy and lack of source control has been reported in the literature.
Methods and Results
Mr. AK, a 32-year-old gentleman, 10 months post-liver transplant recipient, had stenting done for biliary stricture. A month later, he developed ESBL E. coli cholangitis and bacteremia for which he was treated with Meropenem. Flaky pus was seen during stent exchange which grew Candida norvegensis on culture with 97% probability of identification (Fig. 1). Suspecting cholangitic abscesses, patient would require at least 3 weeks of antifungals and Meropenem.
Since there is limited data about antifungal susceptibilities of C. norvegensis, MICs were generated on VITEK by using names of other Candida species. Micafungin was found to show an MIC of 0.12 and voriconazole of 0.25. EUCAST breakpoints are only provided for certain species and for others treatment is based on PK/PD considerations. The PK PD indices for efficacy of voriconazole is AUC/MIC of 30 and of Echinocandins is Cmax/MIC of 1R, which prompted extrapolation in this case.
The extrapolative PK PD considerations were as follows (Table 1).
Micafungin dose of 150 mg generates a biliary trough level of 1.9 mcg/mlR, which will lead to Cmax/MIC (1.9/0.12) of 15.83, exceeding the required target Cmax/MIC for cidal therapy of echinocandins which is 1R. Micafungin and Meropenem were administered for 3 weeks and the patient responded well to treatment.
Conclusion
This case highlights the importance of speciation of Candida spp, extrapolating MICs and breakpoints for species where data are not available, early source control and use of PK/PD considerations in choosing the appropriate antifungal agent on a case-by-case basis.
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Sahu M, Chakraborty S, Joe G, Doshi R, Soman R. P172 First report of Aspergillus tamarii producing influenza associated invasive pulmonary Aspergillosis. Med Mycol 2022. [PMCID: PMC9494464 DOI: 10.1093/mmy/myac072.p172] [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] [Indexed: 11/14/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objective Multiple infections can occur after 2009, pandemic influenza, including fungal and bacterial infections, but data from India are limited. To our knowledge, this is the first reported case of influenza-associated invasive pulmonary aspergillosis (IAPA), caused by Aspergillus tamarii, after infection with pandemic (H1N1) 2009 which was preceded by COVID-19, 20 months before. Methods and Results A 33-year-old male, known asthmatic, had been hospitalized elsewhere in August 2020 with COVID-19 pneumonia for 50 days and had been on mechanical ventilation for 37 days. He had no residual respiratory symptoms 3 months after recovery from COVID-19. He was admitted to Jupiter Hospital in April 2022 with fever, cough, and dyspnea for 8 days, which developed after a cold bath in a temple. HRCT (chest) showed ground glass opacities (GGOs), crazy paving, nodules, and traction bronchiectasis. Review of previous HRCT showed that only GGOs were present (Fig. 1). At admission, the nasopharyngeal swab was positive for pandemic (H1N1) 2009 in the filmarray respiratory panel and no other pathogen was detected. He was treated with oseltamivir. Expectorated sputum examination showed a heavy load of thin septate hyphae, with acute angle branching, resembling Aspergilllus species (Fig. 2). Serum galactomannan was positive (1.8). Based on these features he was diagnosed as a case of probable IAPA and initiated posaconazole (PCZ) treatment. Sputum fungal culture was positive and was identified by MALDI TOF MS as A. tamarii. A. tamarii has been rarely encountered as a human pathogen. Case reports of its involvement in eyelid infection, keratitis, invasive sinonasal infection, and onychomycosis exist. Sensititre MICs were 0.0625 mcg/ml, 0.125 mcg/ml, 0.0625 mcg/ml, and 0.125 mcg/mL for itraconazole, voriconazole, PCZ, and for isavuconazole (ISVCZ) respectively. The usually obtained PCZ trough level with standard dose is 1.2 mg/l which generates AUC of 200R. The usually obtained ISVC) trough level with standard dose is 3 mg/l which generates AUC of 100R. The PKPD index, AUC/MIC of 100, is needed with both these azoles for a therapeutic effectR. Therefore, it would be possible to treat this infection with any of these azoles. PCZ was continued in view of the easy availability of therapeutic drug monitoring (TDM) to assure adequate drug exposure, lower cost, and clinical improvement which had already occurred. Conclusion An infection due to a rare Aspergillus species needs correct identification, MIC determination, and PKPD consideration for appropriate drug selection and management.
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Singhal T, Sonawane R, Kulkarni B, Raut A, Soman R. The mystery behind a 1000 day fever in a young male. Indian J Med Microbiol 2022; 40:596-598. [PMID: 36008195 DOI: 10.1016/j.ijmmb.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/26/2022] [Accepted: 08/01/2022] [Indexed: 11/05/2022]
Abstract
This case is of a 23 year old diabetic male who presented with fever and splenic lesions. He continued to have fever off and on over the next 3 years despite empirical antibiotics and anti-tubercular therapy. No definitive diagnosis could be made despite exhaustive investigations. Finally, a splenectomy resulted in sustained defervescence. The splenic histopathology showed caseating granulomas but aerobic cultures, Xpert MTB/Rif ULTRA, TB and fungal cultures were negative. A final diagnosis of splenic melioidosis was made based on the clinical features, radiology, histopathology, literature review and absence of an alternative diagnosis.
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Kulkarni S, Menon A, Rodrigues C, Soman R, Agashe VM. Rare Case of Non-tuberculous Mycobacterial Infection following Repair of Pectoralis Major Avulsion: Case Report and Review of Literature. J Orthop Case Rep 2022; 12:9-13. [PMID: 36687488 PMCID: PMC9831221 DOI: 10.13107/jocr.2022.v12.i08.2944] [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: 04/15/2022] [Revised: 06/25/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Non-tuberculous mycobacteria (NTM) infections of the musculoskeletal system are commonly missed due to their rarity and the absence of systemic symptoms. Here, we present a rare case of NTM infection following repair of an avulsed pectoralis major tendon in an immunocompetent host managed by a multi-disciplinary team specializing in musculoskeletal infections. Case Report A 23-year-old male patient presented with discharging sinus in the right axilla for 6 months. He sustained the right pectoralis major muscle avulsion following an accident which was surgically repaired using FiberWire® and endo buttons. He developed a discharging sinus 4-month post-surgery. He presented with persistent infection in spite of empirical antibiotics elsewhere. Radiographs and MRI sonogram showed intra-medullar endo buttons in the proximal humerus with marginal pus collection in the axillary region with minimal medial extension into pectoralis major and minor muscles along the superior aspect. A detailed plan was made with inputs from a multidisciplinary bone infection team. Wound was radically debrided, implants and sutures removed, humerus scraped, and tissues sent for microbiology and histopathology. Extended incubation of deep tissue culture as suggested by ID specialists grew Rapidly growing mycobacteria, a type of NTM 3 weeks after surgery. Patient was started on intravenous amikacin along with oral clarithromycin and linezolid based on antibiotic susceptibility. Wound discharge persisted for almost 5-week post-surgery and stopped 2 weeks after initiation of appropriate antibiotics. Amikacin was given for 1 month and oral antibiotics were continued for 6 months. The pectoralis major function was unaffected after surgery and patient returned to normal activities 3 months after debridement. Patient has an infection free follow-up of 4 years. Conclusion This case outlines the importance of having a high degree of suspicion for the diagnosing orthopedic NTM infections. In addition, it showcases the advantages of having good communication between surgeons, infectious disease specialist, and microbiologist for achieving good functional outcomes.
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Soman R, Chakraborty S, Joe G. Posaconazole or isavuconazole as sole or predominant antifungal therapy for COVID-19-associated mucormycosis. A retrospective observational case series. Int J Infect Dis 2022; 120:177-178. [PMID: 35405351 PMCID: PMC8993494 DOI: 10.1016/j.ijid.2022.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/05/2022] [Indexed: 12/03/2022] Open
Abstract
The surge of COVID-19 associated Mucormycosis (CAM) in India during the second wave of COVID-19 led to lack of availability of amphotericin B(AmB). We retrospectively evaluated the outcome in 28 consecutive patients with CAM who received posaconazole (PCZ) or isavuconazole (ISVCZ) as sole or predominant therapy, based on factors like availability, affordability, site of infection or lack of treatment response. Therapeutic drug monitoring was used for PCZ in all cases & for ISVCZ in some cases. Higher trough levels were aimed to ensure therapeutic effect. Overall, 16 patients were cured, 5 patients improved, 6 patients died, of which 2 deaths were attributable to mucormycosis and 1 patient was lost to follow-up. The outcomes and survival were comparable to those reported in the literature. Although wider applicability of these results cannot be assumed, it leads to a speculation that treatment of mucormycosis with PCZ or ISVCZ, without AmB, is possible.
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Gandhi A, Joe G, Soman R. Enteric Fever Still haunts us with New Challenges. THE NATIONAL MEDICAL JOURNAL OF INDIA 2022; 35:65-67. [PMID: 36461847 DOI: 10.25259/nmji_725_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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Soman R, Rege S. Omicron: Is its Bark Worse than its Bite? THE JOURNAL OF THE ASSOCIATION OF PHYSICIANS OF INDIA 2022; 70:11-12. [PMID: 35438273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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