Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group

Antifungal prophylaxis with micafungin in patients treated for childhood cancer

BACKGROUND

Invasive fungal infections (IFIs) remain a major cause of infectious morality in neutropenic patients receiving chemotherapy or hematopoietic stem cell transplantation (HSCT). Micafungin exhibits broad antifungal activity against both Aspergillus and Candida species. We performed a retrospective study to determine the efficacy and safety of prophylactic micafungin against IFI in pediatric neutropenic patients during chemotherapy or HSCT.

PROCEDURE

Forty patients were given micafungin (3 mg/kg/day) intravenously for neutropenia: 131 patient-cycles (39 patients) after chemotherapy and 15 patient-cycles (14 patients) after HSCT. Median duration of neutropenia and micafungin prophylaxis was 13 and 23 days after chemotherapy and HSCT, respectively.

RESULTS

Treatment success rate, defined as absence of proven, probable, possible, or suspected IFIs, was 93.9% (121/131) and 80.0% (12/15) for chemotherapy and HSCT, respectively. Proven or probable IFI was documented in only one patient after HSCT. No adverse events were observed that could be related to micafungin prophylaxis.

CONCLUSIONS

These results suggest that prophylactic micafungin is well tolerated and may prevent IFIs in pediatric patients with neutropenia receiving chemotherapy or HSCT.

The clinical importance of bronchoalveolar lavage in allogeneic SCT patients with pneumonia

Patients who undergo allogeneic hematopoietic SCT (HSCT) are prone to pulmonary infections. Between 1998 and 2004, a total of 450 patients underwent HSCT at Karolinska University Hospital, Huddinge. Pneumonia was diagnosed in 167 patients (37%), including 42 children. Bronchoalveolar lavage (BAL) was performed on 68 occasions in 57 patients (six children). In 110 patients (36 children) with pneumonia, BAL was not performed. BAL contributed to the diagnosis in 43 cases (63%) and to relevant findings in 53 cases: bacteria (n=13, 24%), viruses (n=28, 53%) and fungi (n=12, 23%). In 25 cases BAL was negative. In 15 of these cases, BAL was performed >or=4 days after chest X-ray, and in four cases not in the same segment as the infiltrations. The median time between radiographic findings and positive BAL was 2 (0-15) days, and a negative BAL 6 (1-30) days (P<0.001). Antimicrobial treatment was administered to 79% patients with positive findings, and to 92% with negative findings at the time of BAL. No serious complications due to the procedure were reported. BAL resulted in a changed treatment in 32/68 (47%) episodes of pneumonia. To conclude, BAL is a safe and useful diagnostic procedure that should be performed early after the onset of pneumonia following allogeneic HSCT.

Therapeutic drug monitoring of posaconazole: a monocentric study with 54 adults

Posaconazole is a potent broad-spectrum triazole antifungal. Little is known about the prevalence and risk factors for low plasma posaconazole concentrations (PPCs). We retrospectively reviewed all adult patients whose PPCs were measured after at least 5 days of treatment between April 2006 and July 2008 at the Hôpital Necker Enfants Malades. A low PPC was defined as a concentration lower than 500 ng/ml. Fifty-four patients were included: 36 receiving prophylactic (200 mg three times a day) and 18 receiving curative (400 mg twice a day) posaconazole therapy. The prevalence of low PPCs was 44% (16/36) in the prophylaxis group and 22% (4/18) in the curative-treatment group. In the prophylaxis group, low PPCs tended to be more frequent in cases of digestive disease (62.5% versus 30%; P = 0.051) and were significantly more frequent among patients with diarrhea (71.4% versus 27%; P = 0.009) or mucositis (100% versus 33%; P = 0.004). In the curative-treatment group, low PPCs were significantly more frequent in cases of diarrhea (75% versus 7%; P = 0.018). In the prophylaxis group, the only two patients who subsequently developed invasive fungal infections exhibited low PPCs. The only adverse event was hepatotoxicity for 2/54 patients (3.7%), which was not related to high plasma drug concentrations. In conclusion, low PPC is common, significantly more frequent in cases of diarrhea or mucositis, and potentially associated with subsequent invasive fungal infection. Therapeutic drug monitoring of posaconazole is therefore mandatory for immunosuppressed adults, at least for those with gastrointestinal disorders.

Zygomycosis in Italy: a survey of FIMUA-ECMM (Federazione Italiana di Micopatologia Umana ed Animale and European Confederation of Medical Mycology)

The aims of the study were to analyze the clinical and epidemiological characteristics and treatments for patients who developed zygomycosis enrolled in Italy during the European Confederation of Medical Mycology of medical mycology survey. This prospective multicenter study was performed between 2004 and 2007 at 49 italian Departments. 60 cases of zygomycosis were enrolled: the median age was 59.5 years (range 1-87), with a prevalence of males (70%). The majority of cases were immunocompromised patients (42 cases, 70%), mainly hematological malignancies (37). Among non-immunocompromised (18 cases, 30%), the main category was represented by patients with penetrating trauma (7/18, 39%). The most common sites of infection were sinus (35%) with/without CNS involvement, lung alone (25%), skin (20%), but in 11 cases (18%) dissemination was observed. According to EORTC criteria, the diagnosis of zygomycosis was proven in 46 patients (77%) and in most of them it was made in vivo (40/46 patients, 87%); in the remaining 14 cases (23%) the diagnosis was probable. 51 patients received antifungal therapy and in 30 of them surgical debridement was also performed. The most commonly used antifungal drug was liposomal amphotericin B (L-AmB), administered in 44 patients: 36 of these patients (82%) responded to therapy. Altogether an attributable mortality rate of 32% (19/60) was registered, which was reduced to 18% in patients treated with L-AmB (8/44). Zygomycosis is a rare and aggressive filamentous fungal infection, still associated with a high mortality rate. This study indicates an inversion of this trend, with a better prognosis and significantly lower mortality than that reported in the literature. It is possible that new extensive, aggressive diagnostic and therapeutic procedures, such as the use of L-AmB and surgery, have improved the prognosis of these patients.

Predicting survival in adults with invasive aspergillosis during therapy for hematological malignancies or after hematopoietic stem cell transplantation: Single-center analysis and validation of the Seattle, French, and Strasbourg prognostic indexes

In this retrospective monocenter study, we analyzed the outcomes of 130 adult hematological patients who developed a proven (n = 23), probable (n = 71), and possible (n = 36) invasive aspergillosis (IA) in a 13-year period. Forty-nine patients (38%) were recipients of an allogeneic hematopoietic stem cell transplantation (AlloHSCT). The main goal of the study was the identification of prognostic factors for 4-month aspergillosis free survival (AFS) and overall survival (OS). IA was identified as the main cause of death in 27/49 recipients of an AlloHSCT (55%) and 28/81 nontransplanted patients (35%). Diagnosis of IA at or before 2000 had a negative impact in both 4-month AFS and 4-month OS in the entire group. In multivariate analysis performed separately for nontransplanted and allo-HSCT patients, five variables (excluding the year of diagnosis) decreased 4-month AFS: (i) impairment of one organ function (OF), (ii) impairment of two or more OFs (two points), (iii) disseminated IA, (iv) neutropenia lasting more than 10 days (non-AlloHSCT group only) or monocytopenia (<0.1 x 10(9)/l) [AlloHSCT group only], and (v) high-dose steroids (non-AlloHSCT group only) or an alternative donor (AlloHSCT group only). According to the number of adverse risk factors, three prognostic subgroups were defined in non-transplanted and alloHSCT patients with good (97% and 78% AFS), intermediate (73% and 32% AFS) and poor prognosis (20% and 11% AFS) of IA [P < 0.01]. In addition, we validated the French and Seattle prognostic indexes for allo-HSCT recipients and the Strasbourg model for all hematological patients with IA.

Recent advances in antifungal prevention and treatment

Invasive fungal infections are important causes of morbidity and mortality in patients with bone marrow failure syndromes and hematological malignancies, or who are undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Current epidemiological trends indicate a shift toward infections by Aspergillus spp., non-albicans Candida spp., and previously uncommon fungal pathogens that have decreased susceptibility to the available antifungal agents. The last two decades have seen substantial improvements in the clinical, laboratory, and radiological diagnosis of these infections and the development of new antifungal compounds. Progress has been made in establishing disease definitions and paradigms for antifungal intervention and in the design and conduct of interventional clinical trials. Collectively, these advances have led to major but ongoing changes in the management of patients at risk of or being affected by invasive fungal infections. This article reviews current approaches to prevention and treatment of opportunistic fungal infections in immunocompromised patients with hematological disorders and discusses novel approaches to antifungal chemotherapy and adjunctive treatments.

Prevention and treatment of invasive fungal diseases in neutropenic patients

PURPOSE OF REVIEW

Despite advances in the diagnosis and management, invasive fungal diseases contribute substantially to the morbidity and mortality of patients with prolonged neutropenia.

RECENT FINDINGS

Major advances in the prevention, diagnosis, and treatment of invasive fungal diseases have occurred with the introduction of fungal markers and new antifungal agents over the past decade. The newer broad-spectrum azoles and echinocandins, due to their acceptable safety profiles and efficacy, have emerged as valuable options as antifungal prophylaxis and therapy. Empirical antifungal therapy, a strategy in which persistent neutropenic fever triggers the addition of an antifungal agent, remains a common practice. However, the development of fungal diagnostic markers (e.g. galactomannan and beta-glucan assays) combined with radiologic imaging has given potential to more targeted preemptive antifungal strategies.

SUMMARY

With the validation of preemptive strategies in clinical trials, we will likely have evidence-based targeted use of antifungals. PCR-based techniques are also promising tools for preemptive strategies and are undergoing evaluation. Knowledge of host genetic factors may be important in stratifying the risk for fungal disease during periods of high risk.

Invasive mould infections in the setting of hematopoietic cell transplantation: current trends and new challenges

PURPOSE OF REVIEW

Invasive mould infections remain major causes of infection-related mortality following hematopoietic stem cell transplantation (HSCT). In this review, we summarize the recent advances in the diagnosis, prevention, and management of invasive mould infections in HSCT recipients.

RECENT FINDINGS

The evolving epidemiologic characteristics of post-HSCT invasive mould infections, specifically the rising incidence of Aspergillus and non-Aspergillus mould infections in the postengraftment period, necessitate the development of preventive strategies. The efficacy of prophylactic broad-spectrum triazoles against invasive mould infections in HSCT recipients has now been demonstrated in two large prospective studies. However, concerns over drug absorption, interactions, and costs may shift attention from universal prophylaxis to risk stratification and preemptive strategies. In this regard, recent studies have highlighted the potential of genetic polymorphism analysis to identify HSCT recipients at risk for invasive aspergillosis, and efforts are underway to improve the predictive values of antigen and nucleic acid detection assays. Emerging data on risk factors for invasive aspergillosis relapse after HSCT, antifungal drug monitoring, and the use of galactomannan testing to monitor treatment response may help inform therapeutic decisions for HSCT recipients.

SUMMARY

Evidence-driven management of invasive mould infections in HSCT recipients is becoming increasingly individualized, integrating host factors and pharmacologic and epidemiologic considerations. However, the optimal approach to invasive mould infection prevention in HSCT recipients remains to be resolved by prospective clinical studies.

Late infectious complications after cord blood stem cell transplantation

The slower engraftment kinetics and impaired immune reconstitution of cord blood stem cell transplant recipients increase the risk of infectious complications. We retrospectively reviewed patients who underwent cord blood stem cell transplantation at Roswell Park Cancer Institute for hematological malignancies and who survived beyond day 100 for late infectious events. Among 15 patients who were included in the study, there were 18 episodes of bacteremia, 5 cases of bacterial pneumonia, 9 viral, 4 fungal, and 1 nontuberculous mycobacterial infection. Overall mortality was 60%, with infections contributing in 44% of cases. In conclusion, survival beyond day 100 following cord bloodstem cell transplantation is associated with a considerable risk of infections in our single center experience.

Index to Predict Invasive Mold Infection in High-Risk Neutropenic Patients Based on the Area Over the Neutrophil Curve

Purpose

Patients with prolonged and profound neutropenia are at high risk to develop invasive mold infections (IMIs). We developed an index (D-index) that combines duration and severity of neutropenia. The aim of this study was to test the D-index as a predictor of IMI.

Patients and Methods

The D-index was based on a graph plotting the absolute neutrophil counts during neutropenia and was the area over the neutrophil curve. We tested the D-index in 11 patients with acute myeloid leukemia (AML) who developed IMI during neutropenia and 33 AML patients without IMI (controls). We also calculated a cumulative D-index (c-D-index), defined as the cumulative D-index from the start of neutropenia until the date of the first clinical manifestation of IMI in patient cases. We compared the D-index and c-D-index with duration of neutropenia and defined a cutoff for IMI using the receiver operating characteristic (ROC) curve.

Results

The median duration of neutropenia and profound neutropenia of patient cases were significantly higher compared with controls (P = .002 and P = .001, respectively), as were the D-index (P < .001) and c-D-index (P = .02). The D-index and c-D-index performed better than duration of neutropenia in ROC curve analysis. For a cutoff point of 5,800 of the c-D-index, the sensitivity and specificity were 91% and 58%, respectively, and for a prevalence of IMI of 5%, 10%, and 15%, the negative predictive values were 99%, 98%, and 97%, respectively.

Conclusion

The high negative predictive value of the c-D-index may be of help in defining different risks for IMI in febrile neutropenic patients.

Colitis as a manifestation of infliximab-associated disseminated cryptococcosis

The ability of tumor necrosis factor (TNF)-alpha inhibitors to impair pivotal pro-inflammatory host defenses may facilitate the development of disseminated cryptococcosis. Gastrointestinal (GI) tract disease is an unusual presentation of this yeast infection. We describe a unique case of disseminated cryptococcosis presenting as colitis that mimicked an exacerbation of Crohn's disease in a TNF-alpha inhibitor recipient. Review of existing literature shows that in immunocompromised patients, GI cryptococcosis invariably coexists with disseminated cryptococcosis, often lacks prominent GI symptomatology, and is primarily diagnosed postmortem. In cases with opportunistic infections, discontinuation of TNF-alpha inhibitors is a common practice, however rapid rebound of inflammatory responses may incur the risk of immune reconstitution syndrome.

Trichosporon mycotoxinivorans, a novel respiratory pathogen in patients with cystic fibrosis

This report describes the molecular epidemiology, in vitro susceptibility, colonial and microscopic morphologies, and biochemical features of Trichosporon mycotoxinivorans, a newly recognized pathogen that appears to have a propensity for patients with cystic fibrosis. The index patient died with histologically documented Trichosporon pneumonia complicating cystic fibrosis. This is also the first report of disease caused by a Trichosporon species in a nontransplant patient with cystic fibrosis. As T. mycotoxinivorans has not previously been recognized as a respiratory pathogen, the significance of its recovery from sputum samples was not initially appreciated. Genetic analysis of archived clinical samples found three additional cases of T. mycotoxinivorans infection which had previously been identified as other members of the genus. An additional isolate of T. mycotoxinivorans was identified from a clinical sample on initial testing. Three of these four cases were also patients with cystic fibrosis. All isolates had MICs at 48 h of amphotericin B of > or = 1 microg/ml and of echinocandins of > or = 16 microg/ml, but they displayed various susceptibilities to the triazoles. In summary, Trichosporon mycotoxinivorans is a newly recognized human pathogen that is associated with cystic fibrosis.

Three-day treatment with imipenem for unexplained fever during prolonged neutropaenia in haematology patients receiving fluoroquinolone and fluconazole prophylaxis: a prospective observational safety study

BACKGROUND

Guidelines advocate >7d of broad-spectrum antibiotics for unexplained fever (UF) during neutropaenia. However, effective antimicrobial prophylaxis reduces the incidence of gram-negative infections, which may allow shorter treatment. This study evaluates the safety of discontinuing empirical broad-spectrum antibiotics if no microbial source is documented after an initial work-up of 72 h.

METHODS

Prospective observational study at a tertiary-care haematology-unit in patients suffering from haematologic malignancies and treatment-induced prolonged neutropaenia of 10d. Oral fluoroquinolone and fluconazole prophylaxis was given from day 1. Fever was empirically treated with imipenem which was discontinued after 72 h if, following a standardised protocol, no infectious aetiology was documented. Duration of fever, antimicrobial therapy and overall mortality were registered.

RESULTS

One hundred and sixty six patients were evaluated during 276 neutropaenic episodes. One hundred and thirty six patients (82.5%) experienced 1 febrile episode. A total of 317 febrile episodes were observed, of which 177 (56%) were diagnosed as UF. In 135 febrile episodes (43%), a probable/definite infectious origin was documented. Mean duration of fever in neutropaenic periods with 1 febrile episode was 5d, and mean time of treatment with imipenem was 4.7d. In patients without documented infection, mean time of imipenem treatment was only 3.7d. Overall mortality 30 d after neutrophil recovery was 3.6% (6/166); no patient died from untreated bacterial infection.

CONCLUSION

Discontinuation of broad-spectrum antibiotics during neutropaenia in haematology patients on fluoroquinolone and fluconazole prophylaxis is safe, provided that no infectious aetiology is established after 72 h.

Management of invasive aspergillosis in patients with COPD: rational use of voriconazole

Invasive pulmonary aspergillosis (IPA) is an important cause of mortality in patients with hematologic malignancies. The reported incidence of IPA in the context of chronic obstructive pulmonary disease (COPD) seems to increase. Approximately 1%-2% of overall fatal cases of IPA occur in COPD patients. The combination of factors such as lung immune imbalance, long-term corticosteroid use, increasing rate of bacterial exacerbations over time, and malnutrition are responsible for the emergence of IPA in these patients. The diagnosis of IPA is difficult to establish, which explains the delay in implementing accurate antifungal therapy and the high mortality rate. Persistent pneumonia nonresponsive to appropriate antibiotic treatment raises the concern of an invasive fungal infection. Definite diagnosis is obtained from tissue biopsy evidencing Aspergillus spp. on microscopic examination or in culture. Culture and microscopy of respiratory tract samples have a sensitivity and specificity of around 50%. Other diagnostic tools can be useful in documenting IPA: computed tomography (CT) scan, nonculture-based tests in serum and/or in bronchoalveolar lavage such as antibody/antigen tests for Aspergillus spp. More recent tools such as polymerase chain reaction or [1-->3]-beta-D-glucan have predictive values that need to be further investigated in COPD patients. Antifungal monotherapy using azole voriconazole is recommended as a first-line treatment of IPA. This review assesses the use of voriconazole in COPD patients.

Antifungal prophylaxis in liver transplant recipients

Although the overall incidence of fungal infections in liver transplant recipients has declined, these infections still contribute significantly to the morbidity and mortality of patients with risk factors for infection. Although antifungal prophylaxis has been widely studied and practiced, no consensus exists on which patients should receive prophylaxis, with which agent, and for what duration. Numerous studies have attempted to ascertain independent risk factors for invasive fungal infections in liver transplant patients, and these data, in addition to clinical trials, identify several patient groups at exceedingly high risk of fungal infection. These include retransplant patients, patients with renal failure requiring hemodialysis or renal replacement therapy, and those requiring reoperations after transplant. Because the majority of infections occur in the first month after transplantation, prophylaxis should be continued for 4-6 weeks. However, local epidemiology and research should guide decisions regarding choice of agent as well as overall development of interinstitutional guidelines, because the incidence and spectrum of infection may differ dramatically among institutions. Liver Transpl 15:842-858, 2009. (c) 2009 AASLD.

Aspergillus colonization of the lung allograft is a risk factor for bronchiolitis obliterans syndrome

Multiple infections have been linked with the development of bronchiolitis obliterans syndrome (BOS) post-lung transplantation. Lung allograft airway colonization by Aspergillus species is common among lung transplant recipients. We hypothesized that Aspergillus colonization may promote the development of BOS and may decrease survival post-lung transplantation. We reviewed all lung transplant recipients transplanted in our center between January 2000 and June 2006. Bronchoscopy was performed according to a surveillance protocol and when clinically indicated. Aspergillus colonization was defined as a positive culture from bronchoalveolar lavage or two sputum cultures positive for the same Aspergillus species, in the absence of invasive pulmonary Aspergillosis. We found that Aspergillus colonization was strongly associated with BOS and BOS related mortality in Cox regression analyses. Aspergillus colonization typically preceded the development of BOS by a median of 261 days (95% CI 87-520). Furthermore, in a multivariate Cox regression model, Aspergillus colonization was a distinct risk factor for BOS, independent of acute rejection. These data suggest a potential causative role for Aspergillus colonization in the development of BOS post-lung transplantation and raise the possibility that strategies aimed to prevent Aspergillus colonization may help delay or reduce the incidence of BOS.

Prospective evaluation of mannan and anti-mannan antibodies for diagnosis of invasive Candida infections in patients with neutropenic fever

The diagnostic performance and usefulness of the Platelia antigen and antibody test (Bio-Rad) was investigated in a prospective study of haematological patients at risk for invasive Candida infections. Among 100 patients, 86 were eligible, of whom invasive candidiasis (IC) occurred in 12 (14%), according to the criteria of the European Organization for Research and Treatment of Cancer/Mycoses Study Group. These included candidaemia due to Candida albicans (one patient) or Candida tropicalis (four patients), and hepatosplenic candidiasis (seven patients). The comparator group of 74 patients included 50 with febrile neutropenia alone and 24 with mould infections. A strategy was developed to determine diagnostic cut-offs from receiver operating characteristic curves with maximal sensitivity and, given this sensitivity, maximal specificity, both being greater than 0. In this patient population, these values were 0.25 ng ml(-1) for mannan (M) and 2.6 arbitrary units ml(-1) for anti-mannan (AM), which are lower than those recommended by the manufacturer. All patients developed at least one positive diagnostic M or AM result during the 10 days of persistent febrile neutropenia (PFN). The optimal overall performance was found when two consecutive positive tests for both M and AM were used [sensitivity, specificity, positive predictive value and negative predictive value (NPV) (95 % confidence intervals) of 0.73 (0.39-0.94), 0.80 (0.69-0.89), 0.36 (0.17-0.59) and 0.95 (0.86-0.99), respectively]. There was a positive correlation of M with beta-D-glucan (r=0.28, P=0.01). The first positive M test was found up to a mean+/-sd of 8.8+/-8.5 (range 2-23) days prior to a clinical/mycological diagnosis of IC. Day-to-day variation in quantitative M levels was high. High-level AM responses were delayed until leucopenia resolved. The low specificities of the test performance may have been due to some of the comparator patients having subclinical Candida infections as evidenced by the high incidence of colonization among them (60% had a colonization index of >or=0.5). The high NPVs suggest that the tests may be particularly useful in excluding IC. It is feasible to explore the use of serial measurements of M and AM as part of a broader diagnostic strategy for selecting PFN patients to receive antifungal drug therapy.

Candida in the ICU

Invasive Candida infections are becoming increasingly recognized in critically ill patients. These infections result in serious morbidity, can be life threatening, and are expensive to manage. Early suspicion of Candida infection and the use of timely and proper antifungal treatment can improve outcome. Although treatment of documented, deep-seated Candida infections in nonneutropenic patients has been studied extensively, guidelines for the management of suspected but undocumented cases of invasive Candida infections in critically ill patients have not been clearly established. Future work should focus on better delineation of the sector of critically ill patients who have suspected invasive Candida infection and who could benefit from the use of empiric antifungal therapy, and on the investigation of novel approaches for the potential salvage of devices infected with Candida species.

Invasive Aspergillus infections in allo-SCT recipients: environmental sampling, nasal and oral colonization and galactomannan testing

A study was performed to investigate the air quality of a haematopoietic SCT ward, colonization of the upper airways with Aspergillus spp. and the role of galactomannan (GM) ELISA testing in serum in the diagnosis of invasive aspergillosis (IA). In 102 allo-SCT recipients, two cases of IA (one proven and one probable) were seen. Of 2071 serum samples, 12 were positive, two in a patient with proven IA and 10 in patients without IA. Of the 2059 negative samples, 22 were taken from the patient with probable IA. Of the 245 environmental samples, 20 (8.2%) were positive for filamentous fungi. Aspergillus fumigatus was seen in 14 samples. A total of 657 oral and nasal swabs were taken. Seven nasal samples and one oral sample were positive for Aspergillus species (A. fumigatus 4, A. niger 4) in four patients, one of whom had probable IA. In summary, most environmental samples were negative, colonization of the oral and nasal cavities was rare and IA was diagnosed in only 2% of patients. The GM ELISA test remained negative in one of two patients with IA and does not seem useful in a population of patients with a low incidence of IA.

A safety and feasibility study comparing an intermittent high dose with a daily standard dose of liposomal amphotericin B for persistent neutropenic fever

A high intermittent dose regimen (group A: 10 mg kg(-1) on day 1, 5 mg kg(-1) on days 3 and 6) was compared with standard dosing (group B: 3 mg kg(-1) per day for 14 days) of liposomal amphotericin B (LAB) for empirical treatment of persistent febrile neutropenia. A total cumulative dose of 1275 mg (group A) and 2800 mg (group B) was administered. Infusion-related adverse drug events, mainly rigors/chills, occurred more frequently with group A (11/45, 24 % infusions) than with group B (12/201, 6 % infusions) (P=0.002), which extended the mean infusion time by 20 min (P=0.001). Creatinine levels were similar in the two regimens: the A : B ratio of the area under the curve for creatinine (AUC(CREATININE)) for days 2-7 was 1.09 (P=0.27) and for days 2-14 was 1.05 (P=0.51). Rises in creatinine were mild (clinical toxicity criteria 1) in all patients with elevations. Hypokalaemia tended to be less severe in group A with a lower proportion of hypokalaemic days [57/143 (39 %) vs 80/137 (58 %), P=0.21], a higher AUC(POTASSIUM) (A : B ratio of 1.06, P=0.12), a lower proportion of patients with hypokalaemia at the end of study (10 vs 61 %, P=0.01) and fewer potassium-supplemented days [12/210 (6 %) vs 41/210 (19.5 %), P<0.1]. There were mildly elevated median levels of serum bilirubin, alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase, which were similar for the two regimens and were usually associated with other co-existing co-morbid conditions. The AUC for these enzymes was also similar in the two groups. No patient had discontinuation of the study drug due to toxicity. Composite success was identical for each regimen (11/15 patients, 73 %). Three of the fifteen patients in group B and none in group A developed invasive fungal infections (IFIs). Beta-D-Glucan levels were similar in both groups for patients without an IFI [AUC(GLUCAN) of 362 and 683 (P=0.36) for groups A and B, respectively]. The rate of defervescence was similar for each regimen (P=0.75). This feasibility study suggests that a short intermittent high-dose course of 10/5/5 mg LAB kg(-1) on days 1, 3 and 6 may be as safe and effective as a standard 14 day course of 3 mg kg(-1) per day, with drug-acquisition cost savings and reduced drug exposure. A larger study is indicated for confirmation of this.

A regulator of Aspergillus fumigatus extracellular proteolytic activity is dispensable for virulence

Virulence of the fungal pathogen Aspergillus fumigatus is in part based on the saprophytic lifestyle that this mold has evolved. A crucial function for saprophytism resides in secreted proteases that allow assimilation of proteinaceous substrates. The impact of extracellular proteolytic activities on the pathogenesis of aspergillosis, however, remains controversial. In order to address this issue, characterization of a conserved regulatory factor, PrtT, that acts on expression of secreted proteases was pursued. Expression of PrtT appears to be regulated posttranscriptionally, and the existence of an mRNA leader sequence implies translational control via eIF2alpha kinase signaling. Phenotypic classification of a prtTDelta deletion mutant revealed that expression of several major extracellular proteases is PrtT dependent, resulting in the inability to utilize protein as a nutritional source. Certain genes encoding secreted proteases are not regulated by PrtT. Most strikingly, the deletant strain is not attenuated in virulence when tested in a leukopenic mouse model, which makes a strong case for reconsidering any impact of secreted proteases in pulmonary aspergillosis.

Polymorphisms in Toll-like receptor genes and susceptibility to infections in allogeneic stem cell transplantation

OBJECTIVE

Discovery of genetic variations in the genes encoding for Toll-like receptors (TLRs) has highlighted a potential link between genomic variation of the host and susceptibility to infections.

MATERIALS AND METHODS

We investigated the association between polymorphisms in the TLR2, TLR4, and TLR9 genes in recipients of allogeneic hematopoietic stem cell transplant and susceptibility to infections caused by cytomegalovirus and filamentous fungi.

RESULTS

A significant association was observed between the presence of the T-1237C polymorphism (TLR9) and susceptibility to viral pneumonia (p=0.04; odds ratio [OR]: 1.73). For fungi, a significant association was observed between the presence of the cosegregating Asp299Gly/Thr399Ile polymorphisms (TLR4) and fungal colonization (p=0.003; OR: 10.6). However, susceptibility to fungal infections, predominantly fungal pneumonia, was instead significantly decreased in the presence of the same polymorphisms (p=0.03; OR: 0.23).

CONCLUSION

Thus, fungal colonization may not predict susceptibility to infection in the presence of these single nucleotide polymorphisms. The finding that defective viral but not fungal sensing may predict susceptibility to infection highlights the divergent function of TLRs in the pathogenesis of opportunistic infections.

Defining responses to therapy and study outcomes in clinical trials of invasive fungal diseases: Mycoses Study Group and European Organization for Research and Treatment of Cancer consensus criteria

Invasive fungal diseases (IFDs) have become major causes of morbidity and mortality among highly immunocompromised patients. Authoritative consensus criteria to diagnose IFD have been useful in establishing eligibility criteria for antifungal trials. There is an important need for generation of consensus definitions of outcomes of IFD that will form a standard for evaluating treatment success and failure in clinical trials. Therefore, an expert international panel consisting of the Mycoses Study Group and the European Organization for Research and Treatment of Cancer was convened to propose guidelines for assessing treatment responses in clinical trials of IFDs and for defining study outcomes. Major fungal diseases that are discussed include invasive disease due to Candida species, Aspergillus species and other molds, Cryptococcus neoformans, Histoplasma capsulatum, and Coccidioides immitis. We also discuss potential pitfalls in assessing outcome, such as conflicting clinical, radiological, and/or mycological data and gaps in knowledge.

The changing face of febrile neutropenia-from monotherapy to moulds to mucositis. Management of mycoses in neutropenic patients: a brief history, 1960-2008

The career that this symposium honours, that of Ben E. de Pauw, MD, PhD, could be said to have begun in 1970 upon his graduation from the University of Amsterdam. However, it was his move to Nijmegen in 1975 to finish his PhD studies that really began the career in which he forged expertise in haematology, oncology, immunology and infectious diseases into one spectacular career that resulted in more than 200 publications.

Hemagglutination test for rapid serodiagnosis of human pythiosis

Human pythiosis is an emerging, life-threatening infectious disease, caused by the oomycete Pythium insidiosum. Thailand is an area where human pythiosis is endemic and the genetic blood disorder thalassemia is a predisposing factor. Patients with pythiosis present with arterial occlusions of the lower extremities, corneal ulcers, or chronic cutaneous infections. Diagnosis relies on time-consuming, relatively insensitive tests such as culture identification and immunodiffusion assay. Most patients undergo surgical removal of infected organs, and many die from the infection. Delayed diagnosis results in a poor prognosis. Here, we describe a hemagglutination (HA) test for rapid diagnosis of human pythiosis. Sheep red blood cells were coated with P. insidiosum protein extract and used in duplicated detection assays using serum samples from 33 patients with vascular (n = 27), cutaneous (n = 2), or ocular (n = 4) pythiosis and serum samples from 289 control patients with other infectious diseases (n = 77), with highly positive antinuclear antibody (n = 5), with thalassemia (n = 21), or with no known disorder (i.e., healthy blood donors) (n = 186). Based on receiver-operating characteristic analysis, a serum titer of 1:160 was selected as the cutoff point for the HA test. Serum samples that generated HA at the cutoff titer were read as positive, while samples that did not were read as negative. Positive results were obtained with the serum samples of all patients with vascular and cutaneous pythiosis and with two serum samples from the control group. Negative results were obtained with serum samples from all ocular pythiosis patients and the 287 remaining serum samples from the control group. Sensitivity and specificity of the HA were 88% and 99%, respectively. In conclusion, the HA test for detection of anti-Pythium antibodies is a simple, rapid, and reliable test for serodiagnosis of vascular and cutaneous pythiosis.

Surgical management of invasive pulmonary fungal infection in hematology patients

BACKGROUND

The purpose of this study was to analyze our institutional results with pulmonary resection in neutropenic patients with hematologic malignancies and suspected invasive pulmonary fungal infections.

METHODS

We performed a retrospective medical record review of 25 immunocompromised patients with hematologic malignancies who underwent pulmonary resection between 2000 and 2007. We analyzed preoperative diagnostic technique, degree of pulmonary resection, and postoperative morbidity and mortality to determine whether surgery is a viable treatment option in this subset of patients.

RESULTS

Twenty-three of 25 patients had a minithoracotomy compared with 2 who had video-assisted thorascopic surgery resection only. Thirteen had wedge resections, 9 had lobectomies, and 3 had segmentectomies. Early surgical morbidity was 2 of 25, involving 1 pneumothorax and 1 empyema. In-hospital mortality was 2, with 1 death primarily related to surgery. Median survival was 342 days, and survival was significantly better in patients with only one lesion. No patient experienced late recurrence of invasive pulmonary fungal infection. Resected pulmonary tissue also provided the best chance for a proven diagnosis in 19 of 25 (76%).

CONCLUSIONS

This study confirms that pulmonary resection in high-risk immunocompromised patients with suspected invasive fungal infection can be carried out with excellent operative morbidity and mortality.

Safety and outcomes of open-label deferasirox iron chelation therapy for mucormycosis

We sought to describe the safety profile of open-label, adjunctive deferasirox iron chelation therapy in eight patients with biopsy-proven mucormycosis. Deferasirox was administered for an average of 14 days (range, 7 to 21) at 5 to 20 mg/kg of body weight/day. The only adverse effects attributable to deferasirox were rashes in two patients. Deferasirox treatment was not associated with changes in renal or liver function, complete blood count, or transplant immunosuppressive levels. Thus, deferasirox appears safe as an adjunctive therapy for mucormycosis.

[Clinical use of micafungin for the treatment of invasive candidiasis in critical ill patients]

BACKGROUND

Over the last 30 years a significant increase of Candida spp. invasive disease has been observed in non-neutropenic critical ill patients. Both fluconazole and amphotericin B have been considered first line treatment for invasive (proven and probable) Candida spp. disease, although the mortality rate is still high.

OBJECTIVES

To review the current data on the use of micafungin for the treatment of Candida invasive disease in critical ill patients.

METHODS

The pharmacologic, mycological and clinical properties of micafungin are reviewed based on current published data. The use and efficacy of micafungin for the treatment of Candida invasive disease in critical ill patients is discussed.

RESULTS AND CONCLUSIONS

To reduce the rate of mortality more effective antifungals and pre-emptive treatment strategies are currently warranted. Candins achieve better results for the treatment of invasive Candida disease in non-neutropenic critical ill patients. Micafungin has a good safety profile (similar to fluconazole). Micafungin is a first line drug for the treatment of invasive Candida disease and may be used as a pre- emptive approach followed by a de-escalating strategy with azoles.

Indicators for steroid response in biopsy proven acute graft rejection after lung transplantation

OBJECTIVE

Acute rejection (AR) after lung transplantation (LTx) requires prompt intervention. Most episodes respond to steroid pulse therapy. The aim of this study was to evaluate clinical indicators for non-response to steroid treatment in biopsy proven AR after the early postoperative period.

METHODS

We prospectively analysed 85 patients more than 6 months after LTx with symptomatic biopsy proven AR (>or=grade A1) from Jan. 2005 until Nov. 2007 in a single centre. In 47 patients, AR was steroid-sensitive (group 1), 38 patients did not respond to steroid pulse therapy (group 2). All AR episodes were associated with clinical symptoms. Fifty-seven (67%) were low-grade rejections (ISHLT A1).

RESULTS

Independent clinical predictors for steroid response vs. non-steroid response in biopsy proven AR were "days after transplantation" (p=0.01, adjusted hazard ratio (HR) 1.2), "decline in home spirometry slope" (p=0.03, HR 0.97), "adherence to home spirometry" (p=0.05, HR 0.98) and "serum CRP" (p=0.02, HR 0.87). Eight patients (21%) of group 2 developed BOS during the following 6 months.

CONCLUSIONS

Early detection of deterioration in graft function seems to be crucial for effective treatment of AR. Home spirometry seems to be useful in detecting early changes in graft function and surveillance protocols could be potentially helpful in predicting patients likely to demonstrate a steroid response.

Monitoring trough concentration of voriconazole is important to ensure successful antifungal therapy and to avoid hepatic damage in patients with hematological disorders

We investigated the role of therapeutic dose monitoring (TDM) in the treatment of fungal infections with voriconazole through 49 analyses of 34 patients who received treatment for hematologic diseases. Voriconazole concentration was highly variable among patients regardless of renal, liver functions, or age, and the effect of dose enhancement was not constant. This indicates the difficulty of predicting voriconazole concentration without TDM. We evaluated the outcome with the composite assessment system where patients were assumed non-responders when they failed to show improvement in at least 2 of the following 3 criteria: clinical, radiologic, and mycologic. We showed that concentration-response relationship depended on the status of underlying hematologic diseases; this relationship was observed only in cases without refractory hematologic diseases, but not in those with refractory diseases. In the former group, cases with >2 mg/L of concentration were associated with good response to voriconazole. On the other hand, elevation of hepatic enzyme was frequently observed when voriconazole concentration was >6 mg/L. From these results, we concluded that TDM should be executed and targeted to 2-6 mg/L to improve efficacy and to avoid side effects.

The role of bronchoalveolar lavage galactomannan in the diagnosis of pediatric invasive aspergillosis

BACKGROUND

: Molecular biomarkers such as the galactomannan assay are of increasing interest in clinical settings for diagnosis of invasive aspergillosis (IA). The use of bronchoalveolar lavage galactomannan (BAL GM) is being validated in adult populations, but has not been systematically evaluated in pediatric patients.

METHODS

: A retrospective analysis was performed of patients for whom GM assays from BAL were submitted between November 1, 2006 and November14, 2007 at Childrens Hospital Los Angeles. Medical charts were reviewed and patients were categorized as having no, possible, probable, and proven IA, per established definitions.

RESULTS

: Of 85 pediatric patients who had a BAL GM submitted during the study, 59 were immunocompromised. Three patients were identified as having proven IA, 6 had probable IA, 37 had possible IA, and 39 had no evidence of IA; 38 had a concurrent serum GM performed. A positive, linear correlation was established between BAL and serum GM, using OD index values (rho = 0.48, P = 0.002). Among immunocompromised patients, receiver operating characteristic curves demonstrated an optimal BAL GM OD cut-off value of 0.87, that yielded a sensitivity for probable/proven IA of 78% and a specificity of 100%. At 0.87, the positive and negative predictive values among immunocompromised patients were 58% and 96%, respectively.

CONCLUSIONS

: We found a correlation between BAL GM values and a diagnosis of IA. We also noted a linear relationship between serum and BAL GM values. Receiver operating characteristic curves obtained from our pediatric data validate the current cut off for serum and suggest a possible cut off for BAL specimens.

Phenotypic and genotypic characterization of Aspergillus lentulus and Aspergillus fumigatus isolates in a patient with probable invasive aspergillosis

Characteristic morphological and phylogenetic analyses demonstrated the presence of Aspergillus fumigatus and Aspergillus lentulus as the aetiological agents in a case of probable invasive aspergillosis (IA). This is believed to be the first report of an A. lentulus strain isolated from a patient with probable IA in Argentina.