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Özkan SG, Kimiaei A, Safaei S, Sönmezoğlu M, Özkan HA. Granulocyte Transfusions in Neutropenic Infections: Insights From a Single-Center Study. Cureus 2024; 16:e55953. [PMID: 38601410 PMCID: PMC11005880 DOI: 10.7759/cureus.55953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/12/2024] Open
Abstract
Introduction Despite the development of modern antibiotic and antifungal therapies, neutropenic infections remain life-threatening. Granulocyte transfusion (GTX) is a less frequently used treatment modality in patients with refractory neutropenic infections. The role of donor GTX remains controversial, partly because of the lack of proper clinical trials. This study aimed to contribute to the literature by evaluating the efficacy and side effects of granulocyte transfusions in our center. Methods Eight febrile neutropenic patients with confirmed infections received granulocyte transfusions from ABO-compatible related and unrelated donors. Donors received filgrastim and dexamethasone stimulation, and granulocyte suspensions were irradiated and administered within six hours. Monitoring, antibiotic therapy, and granulocyte colony-stimulating factor (G-CSF) support were maintained. Results Our study observed a 28-day survival rate of 25%, which was lower than that reported in previous literature. The median number of transfusions was 3, with an average eight-day duration post-infection diagnosis, and no side effects were observed. Conclusion While some patients benefited from GTX, overall survival rates remained modest, indicating the need for further research. Prospective, well-powered randomized controlled trials are essential to address patient selection, dosing, and duration to determine the clinical utility of GTX. This study underscores the complexity of GTX in real-world clinical practice and provides insight into the ongoing debate regarding its efficacy in treating severe neutropenic infections.
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Affiliation(s)
| | - Ali Kimiaei
- Hematology, Bahçeşehir University, Istanbul, TUR
| | | | - Meral Sönmezoğlu
- Infectious Diseases, Yeditepe University Hospital, Istanbul, TUR
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2
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Neofytos D, Steinbach WJ, Hanson K, Carpenter PA, Papanicolaou GA, Slavin MA. American Society for Transplantation and Cellular Therapy Series, #6: Management of Invasive Candidiasis in Hematopoietic Cell Transplantation Recipients. Transplant Cell Ther 2023; 29:222-227. [PMID: 36649748 DOI: 10.1016/j.jtct.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy (ASTCT) partnered with its Transplant Infectious Disease Special Interest Group (TID-SIG) to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A completely new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and then answered FAQs and finalized topics with harmonized recommendations made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. This sixth guideline in the series focuses on invasive candidiasis (IC) with FAQs to address epidemiology, clinical diagnosis, prophylaxis, and treatment of IC, plus special considerations for pediatric, cord blood, haploidentical, and T cell-depleted HCT recipients and chimeric antigen receptor T cell recipients, as well as future research directions.
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Affiliation(s)
- Dionysios Neofytos
- Division of Infectious Diseases, Transplant Infectious Disease Service, University Hospital of Geneva, Geneva, Switzerland.
| | - William J Steinbach
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kimberly Hanson
- Transplant Infectious Diseases and Immunocompromised Host Service, Clinical Microbiology, University of Utah, Salt Lake City, Utah
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica A Slavin
- Department of Infectious Disease Peter MacCallum Cancer Centre, Melbourne, Australia
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3
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Klinkmann G, Wild T, Heskamp B, Doss F, Doss S, Arseniev L, Aleksandrova K, Sauer M, Reuter DA, Mitzner S, Altrichter J. Extracorporeal immune cell therapy of sepsis: ex vivo results. Intensive Care Med Exp 2022; 10:26. [PMID: 35708856 PMCID: PMC9202321 DOI: 10.1186/s40635-022-00453-8] [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: 03/19/2022] [Accepted: 05/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immune cell dysfunction plays a central role in sepsis-associated immune paralysis. The transfusion of healthy donor immune cells, i.e., granulocyte concentrates (GC) potentially induces tissue damage via local effects of neutrophils. Initial clinical trials using standard donor GC in a strictly extracorporeal bioreactor system for treatment of septic shock patients already provided evidence for beneficial effects with fewer side effects, by separating patient and donor immune cells using plasma filters. In this ex vivo study, we demonstrate the functional characteristics of a simplified extracorporeal therapy system using purified granulocyte preparations. METHODS Purified GC were used in an immune cell perfusion model prefilled with human donor plasma simulating a 6-h treatment. The extracorporeal circuit consisted of a blood circuit and a plasma circuit with 3 plasma filters (PF). PF1 is separating the plasma from the patient's blood. Plasma is then perfused through PF2 containing donor immune cells and used in a dead-end mode. The filtrated plasma is finally retransfused to the blood circuit. PF3 is included in the plasma backflow as a redundant safety measure. The donor immune cells are retained in the extracorporeal system and discarded after treatment. Phagocytosis activity, oxidative burst and cell viability as well as cytokine release and metabolic parameters of purified GCs were assessed. RESULTS Cells were viable throughout the study period and exhibited well-preserved functionality and efficient metabolic activity. Course of lactate dehydrogenase and free hemoglobin concentration yielded no indication of cell impairment. The capability of the cells to secret various cytokines was preserved. Of particular interest is equivalence in performance of the cells on day 1 and day 3, demonstrating the sustained shelf life and performance of the immune cells in the purified GCs. CONCLUSION Results demonstrate the suitability of a simplified extracorporeal system. Furthermore, granulocytes remain viable and highly active during a 6-h treatment even after storage for 3 days supporting the treatment of septic patients with this system in advanced clinical trials.
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Affiliation(s)
- Gerd Klinkmann
- Department of Anaesthesiology and Intensive Care Medicine, University of Rostock, Schillingallee 35, 18055, Rostock, Germany. .,Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Schillingallee 35, 18057, Rostock, Germany.
| | - Thomas Wild
- ARTCLINE GmbH, Schillingallee 68, 18057, Rostock, Germany
| | | | - Fanny Doss
- ARTCLINE GmbH, Schillingallee 68, 18057, Rostock, Germany
| | - Sandra Doss
- ARTCLINE GmbH, Schillingallee 68, 18057, Rostock, Germany.,Department of Extracorporeal Therapy Systems, Fraunhofer Institute for Cell Therapy and Immunology, Schillingallee 68, 18057, Rostock, Germany
| | - Lubomir Arseniev
- Cellular Therapy Centre (CTC), Medizinische Hochschule Hannover, Feodor-Lynen-Str. 21, 30625, Hannover, Germany
| | - Krasimira Aleksandrova
- Cellular Therapy Centre (CTC), Medizinische Hochschule Hannover, Feodor-Lynen-Str. 21, 30625, Hannover, Germany
| | - Martin Sauer
- Center for Anesthesiology and Intensive Care Medicine, Hospital of Magdeburg, Birkenallee 34, 39130, Magdeburg, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology and Intensive Care Medicine, University of Rostock, Schillingallee 35, 18055, Rostock, Germany
| | - Steffen Mitzner
- Division of Nephrology, Department of Medicine, Medical Faculty, University of Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany.,Department of Extracorporeal Therapy Systems, Fraunhofer Institute for Cell Therapy and Immunology, Schillingallee 68, 18057, Rostock, Germany
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Wang Y, Xu H, Chen N, Yang J, Zhou H. LncRNA: A Potential Target for Host-Directed Therapy of Candida Infection. Pharmaceutics 2022; 14:pharmaceutics14030621. [PMID: 35335994 PMCID: PMC8954347 DOI: 10.3390/pharmaceutics14030621] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/25/2022] [Accepted: 03/09/2022] [Indexed: 02/01/2023] Open
Abstract
Despite various drugs work against Candida, candidiasis represents clinical management challenges worldwide due to the rising incidence and recurrence rate, as well as epidemics, of new drug-resistant pathogens. Recent insights into interactions between Candida and hosts contribute to exploring novel therapeutic strategies, termed host-directed therapies (HDTs). HDTs are viable adjuncts with good efficacy for the existing standard antifungal regimens. However, HDTs induce other response unintendedly, thus requiring molecular targets with highly specificity. Long noncoding RNAs (lncRNAs) with highly specific expression patterns could affect biological processes, including the immune response. Herein, this review will summarize recent advances of HDTs based on the Candida–host interaction. Especially, the findings and application strategies of lncRNAs related to the host response are emphasized. We propose it is feasible to target lncRNAs to modulate the host defense during Candida infection, which provides a new perspective in identifying options of HDTs for candidiasis.
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Doblinger N, Gruber M, Ahrens N. Granulozytentransfusion: Update 2020. TRANSFUSIONSMEDIZIN 2020. [DOI: 10.1055/a-1090-0369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungDie therapeutische Anwendung von Granulozytenkonzentraten erfolgt im klinischen Alltag im Gegensatz zu der anderer Blutprodukte nur selten und unregelmäßig. Der zurückhaltende Einsatz beruht unter anderem auf dem Fehlen einer breiten Evidenz, logistischen und wirtschaftlichen Problemen und dem Vorhandensein anderer potenter Therapieoptionen neutropener Infektionen. Dennoch gab es in den letzten Jahren neue wissenschaftliche Erkenntnisse nicht nur zu Physiologie und Pathophysiologie der Granulozyten, wie neu charakterisierten zellulären Verteidigungsstrategien oder deren Mitwirkung bei thrombotischen oder malignen Ereignissen, sondern auch zu deren therapeutischem Effekt. Dieser wird von einer Vielzahl an Parametern, wie der Art der Infektion, dem Transfusionszeitpunkt und der Dosis, beeinflusst. Das macht die Indikationsstellung zu einer komplexen Einzelfallentscheidung und es gilt, die heterogene Datenlage systematisch zusammenzufassen. Außerdem wurden die etablierten
Indikationen neutropener bzw. neutropathischer Infektionen um experimentelle, mögliche neue Anwendungsgebiete wie die Mukositis oder Leukämiebehandlung erweitert. Die erfolgreiche Anwendung setzt eine geeignete, moderne Herstellungsweise voraus. Neben der Apherese, bei der eine relativ hohe Spenderbelastung unter anderem durch Nebenwirkungen von Mobilisationsregime und Sedimentationsbeschleunigern berücksichtigt werden muss, existieren weitere Verfahren wie die Gewinnung von Granulozyten aus Buffy Coats von Vollblutspenden. Diese versprechen eine Reduktion logistischer Probleme und unerwünschter Wirkungen auf den Spender. Unerwünschte Wirkungen bei Empfängern von Granulozytentransfusionen sollten nach wie vor berücksichtigt und gegen einen erhofften therapeutischen Effekt abgewogen werden.
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Affiliation(s)
- Nina Doblinger
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg
| | - Michael Gruber
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg
| | - Norbert Ahrens
- Institut für Klinische Chemie und Laboratoriumsmedizin, Universitätsklinikum Regensburg
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6
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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7
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West KA, Conry-Cantilena C. Granulocyte transfusions: Current science and perspectives. Semin Hematol 2019; 56:241-247. [DOI: 10.1053/j.seminhematol.2019.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 11/01/2019] [Indexed: 01/28/2023]
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8
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Nitroglycerin-Citrate-Ethanol Catheter Lock Solution Is Highly Effective for In Vitro Eradication of Candida auris Biofilm. Antimicrob Agents Chemother 2019; 63:AAC.00299-19. [PMID: 31036689 DOI: 10.1128/aac.00299-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/20/2019] [Indexed: 12/23/2022] Open
Abstract
Candida auris poses emerging risks for causing severe central line-associated bloodstream infections. We tested in vitro the ability of antifungal lock solutions to rapidly eradicate C. auris biofilms. Liposomal amphotericin B, amphotericin B deoxycholate, fluconazole, voriconazole, micafungin, caspofungin, and anidulafungin failed to completely eradicate all 10 tested C. auris biofilms. Conversely, nitroglycerin-citrate-ethanol (NiCE) catheter lock solution completely eradicated all replicates for all of C. auris biofilms tested.
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9
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Garg A, Gupta A, Mishra A, Singh M, Yadav S, Nityanand S. Role of granulocyte transfusions in combating life-threatening infections in patients with severe neutropenia: Experience from a tertiary care centre in North India. PLoS One 2018; 13:e0209832. [PMID: 30589898 PMCID: PMC6307785 DOI: 10.1371/journal.pone.0209832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 12/12/2018] [Indexed: 11/19/2022] Open
Abstract
Bacterial and fungal infections still remain an important cause of mortality in patients with hematological malignancies and in recipients of hematopoietic stem cell transplants (HSCT) especially in developing countries like India. Granulocyte transfusions (GTX) from healthy donors may lead to early clearance of index infection and thus prevent mortality. The aim of the present study was to evaluate the efficacy of GTX in combating life-threatening infections and preventing mortality in patients of hematological disorders/recipients of HSCT with severe neutropenia. This study was a prospective, observational analysis of patients with different hematological disorders/recipients of HSCT, who received GTX from January 2014 to December 2017. All patients had an Absolute neutrophil Count (ANC) < 0.5 x 109/L and a life threatening sepsis defined by presence of hemodynamic instability/ impending septic shock/ continuous high fever despite the use of the highest line of antimicrobials. A total of 143 granulocyte collections were done for 66 infectious episodes (IEs) in 60 patients. Multidrug resistant organisms (MDROs) were observed in 47/66 IEs (71.2%) and fungal infections were seen in 9/66 IEs (13.6%). Resolution of index infection after GTX was seen in 45/66 IEs (68.2%), and the 30 day overall survival (OS) was 67.7%. OS was significantly higher in patients who received GTX within 7 days of neutropenic sepsis (p = 0.01). Patients with MDROs who received early GTX therapy had a better OS as compared to those who received late GTX (p = 0.02). GTX were well tolerated and only 6 patients' developed mild features of transfusion related acute lung injury (TRALI) which was managed conservatively, and 1 patient demonstrated hypocalcemic tetany. GTX may be of particular relevance in countries like India, where the incidence of infections is very high in neutropenic patients and there is an increasing emergence of MDROs.
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Affiliation(s)
- Akanksha Garg
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
| | - Anshul Gupta
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
| | - Ashish Mishra
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
| | - Manoj Singh
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
| | - Sanjeev Yadav
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
| | - Soniya Nityanand
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, India
- * E-mail: ,
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10
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Timme S, Lehnert T, Prauße MTE, Hünniger K, Leonhardt I, Kurzai O, Figge MT. Quantitative Simulations Predict Treatment Strategies Against Fungal Infections in Virtual Neutropenic Patients. Front Immunol 2018; 9:667. [PMID: 29670632 PMCID: PMC5893870 DOI: 10.3389/fimmu.2018.00667] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/19/2018] [Indexed: 11/26/2022] Open
Abstract
The condition of neutropenia, i.e., a reduced absolute neutrophil count in blood, constitutes a major risk factor for severe infections in the affected patients. Candida albicans and Candida glabrata are opportunistic pathogens and the most prevalent fungal species in the human microbiota. In immunocompromised patients, they can become pathogenic and cause infections with high mortality rates. In this study, we use a previously established approach that combines experiments and computational models to investigate the innate immune response during blood stream infections with the two fungal pathogens C. albicans and C. glabrata. First, we determine immune-reaction rates and migration parameters under healthy conditions. Based on these findings, we simulate virtual patients and investigate the impact of neutropenic conditions on the infection outcome with the respective pathogen. Furthermore, we perform in silico treatments of these virtual patients by simulating a medical treatment that enhances neutrophil activity in terms of phagocytosis and migration. We quantify the infection outcome by comparing the response to the two fungal pathogens relative to non-neutropenic individuals. The analysis reveals that these fungal infections in neutropenic patients can be successfully cleared by cytokine treatment of the remaining neutrophils; and that this treatment is more effective for C. glabrata than for C. albicans.
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Affiliation(s)
- Sandra Timme
- Research Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Faculty of Biological Sciences, Friedrich Schiller University Jena, Jena, Germany
| | - Teresa Lehnert
- Research Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Maria T. E. Prauße
- Research Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Faculty of Biological Sciences, Friedrich Schiller University Jena, Jena, Germany
| | - Kerstin Hünniger
- Fungal Septomics, Septomics Research Center, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Friedrich Schiller University, Jena, Germany
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Ines Leonhardt
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
- Fungal Septomics, Septomics Research Center, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Friedrich Schiller University, Jena, Germany
| | - Oliver Kurzai
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
- Fungal Septomics, Septomics Research Center, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Friedrich Schiller University, Jena, Germany
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Marc Thilo Figge
- Research Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Faculty of Biological Sciences, Friedrich Schiller University Jena, Jena, Germany
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
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11
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Abstract
Cellular immunotherapy holds great promise for the treatment of human disease. Clinical evidence suggests that T cell immunotherapies have the potential to combat cancers that evade traditional immunotherapy. Despite promising results, adverse effects leading to fatalities have left scientists seeking tighter control over these therapies, which is reflected in the growing body of synthetic biology literature focused on developing tightly controlled, context-independent parts. In addition, researchers are adapting these tools for other uses, such as for the treatment of autoimmune disease, HIV infection, and fungal interactions. We review this body of work and devote special attention to approaches that may lend themselves to the development of an "ideal" therapy: one that is safe, efficient, and easy to manufacture. We conclude with a look toward the future of immunotherapy: how synthetic biology can shift the paradigm from the treatment of disease to a focus on wellness and human health as a whole.
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Affiliation(s)
- Matthew J Brenner
- Department of Biomedical Engineering and Biological Design Center, Boston University, Boston, Massachusetts 02215, USA;
| | - Jang Hwan Cho
- Department of Biomedical Engineering and Biological Design Center, Boston University, Boston, Massachusetts 02215, USA;
| | - Nicole M L Wong
- Department of Biomedical Engineering and Biological Design Center, Boston University, Boston, Massachusetts 02215, USA;
| | - Wilson W Wong
- Department of Biomedical Engineering and Biological Design Center, Boston University, Boston, Massachusetts 02215, USA;
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12
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Busca A, Cesaro S, Teofili L, Delia M, Cattaneo C, Criscuolo M, Marchesi F, Fracchiolla NS, Valentini CG, Farina F, Di Blasi R, Prezioso L, Spolzino A, Candoni A, del Principe MI, Verga L, Nosari A, Aversa F, Pagano L. SEIFEM 2017: from real life to an agreement on the use of granulocyte transfusions and colony-stimulating factors for prophylaxis and treatment of infectious complications in patients with hematologic malignant disorders. Expert Rev Hematol 2018; 11:155-168. [DOI: 10.1080/17474086.2018.1420472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Alessandro Busca
- SSD Trapianto Cellule Staminali, A.O.U. Citta’ della Salute, Torino, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata Verona, Italy
| | - Luciana Teofili
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Delia
- Dipartimento dell’Emergenza e dei Trapianti Di Organo, U.O Ematologia con Trapianto - Azienda Ospedaliero-Universitaria - Policlinico di Bari, Italy
| | | | - Marianna Criscuolo
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Marchesi
- Hematology and Stem Cell Transplant Unit Regina Elena National Cancer Institute, Rome, Italy
| | | | - Caterina Giovanna Valentini
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Farina
- Unità di ematologia e trapianti di midollo osseo, IRCCS San Raffaele, Milano, Italy
| | - Roberta Di Blasi
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Anna Candoni
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari, Azienda Sanitaria Universitaria Integrata di Udine, Italy
| | | | - Luisa Verga
- Ematologia adulti e CTA ASST Monza, Universita’ Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | - Annamaria Nosari
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Milano.Italy
| | | | - Livio Pagano
- Department of Onco-Hematology, Fondazione Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Rome, Italy
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13
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Strauss RG. Principles of Neutrophil (Granulocyte) Transfusions. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00114-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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14
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Scriven JE, Tenforde MW, Levitz SM, Jarvis JN. Modulating host immune responses to fight invasive fungal infections. Curr Opin Microbiol 2017; 40:95-103. [PMID: 29154044 PMCID: PMC5816974 DOI: 10.1016/j.mib.2017.10.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/24/2017] [Indexed: 11/28/2022]
Abstract
Modulation of host immunity in invasive fungal infection is an appealing but as yet mostly elusive treatment strategy. Animal studies in invasive candidiasis and aspergillosis have demonstrated beneficial effects of colony stimulating factors, interferon-gamma and monoclonal antibodies. More recent studies transfusing leukocytes pre-loaded with lipophilic anti-fungal drugs, or modulated T-cells, along with novel vaccination strategies show great promise. The translation of immune therapies into clinical studies has been limited to date but this is changing and the results of new Candida vaccine trials are eagerly awaited. Immune modulation in HIV-associated mycoses remains complicated by the risk of immune reconstitution inflammatory syndrome and although exogenous interferon-gamma therapy may be beneficial in cryptococcal meningitis, early initiation of anti-retroviral therapy leads to increased mortality. Further study is required to better target protective immune responses.
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Affiliation(s)
- James E Scriven
- Liverpool School of Tropical Medicine, Liverpool, UK; Birmingham Heartlands Hospital, Birmingham, UK.
| | - Mark W Tenforde
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | - Stuart M Levitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK; Botswana UPenn Partnership, Gaborone, Botswana; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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15
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Granulocyte Transfusions: A Critical Reappraisal. Biol Blood Marrow Transplant 2017; 23:2034-2041. [DOI: 10.1016/j.bbmt.2017.07.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 07/31/2017] [Indexed: 11/23/2022]
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16
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Jandú JJB, Moraes Neto RN, Zagmignan A, de Sousa EM, Brelaz-de-Castro MCA, Dos Santos Correia MT, da Silva LCN. Targeting the Immune System with Plant Lectins to Combat Microbial Infections. Front Pharmacol 2017; 8:671. [PMID: 29046636 PMCID: PMC5632806 DOI: 10.3389/fphar.2017.00671] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 09/07/2017] [Indexed: 12/21/2022] Open
Abstract
The arsenal of drugs available to treat infections caused by eukaryotic and prokaryotic microbes has been declining exponentially due to antimicrobial resistance phenomenon, leading to an urgent need to develop new therapeutic strategies. Host-directed immunotherapy has been reported as an attractive option to treat microbial infections. It consists in the improvement of host defenses by increasing the expression of inflammatory mediators and/or controlling of inflammation-induced tissue injury. Although the in vitro antimicrobial and immunomodulatory activities of lectins have been extensively demonstrated, few studies have evaluated their in vivo effects on experimental models of infections. This review aims to highlight the experimental use of immunomodulatory plant lectins to improve the host immune response against microbial infections. Lectins have been used in vivo both prophylactically and therapeutically resulting in the increased survival of mice under microbial challenge. Other studies successfully demonstrated that lectins could be used in combination with parasite antigens in order to induce a more efficient immunization. Therefore, these plant lectins represent new candidates for management of microbial infections. Furthermore, immunotherapeutic studies have improved our knowledge about the mechanisms involved in host–pathogen interactions, and may also help in the discovery of new drug targets.
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Affiliation(s)
- Jannyson J B Jandú
- Departamento de Bioquímica, Centro de Biociências, Universidade Federal de Pernambuco, Recife, Brazil
| | | | - Adrielle Zagmignan
- Pós-Graduação em Biologia Parasitária, Universidade Ceuma, São Luís, Brazil
| | - Eduardo M de Sousa
- Pós-Graduação em Biologia Parasitária, Universidade Ceuma, São Luís, Brazil
| | | | | | - Luís C N da Silva
- Pós-Graduação em Biologia Parasitária, Universidade Ceuma, São Luís, Brazil
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17
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Granulocyte transfusions: A concise review for practitioners. Cytotherapy 2017; 19:1256-1269. [PMID: 28916227 DOI: 10.1016/j.jcyt.2017.08.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/09/2017] [Accepted: 08/15/2017] [Indexed: 01/05/2023]
Abstract
Granulocyte transfusions (GTXs) have been used to treat and prevent infections in neutropenic patients for more than 40 years, despite persistent controversy regarding their efficacy. This narrative review attempts to complement recent systematic reviews by the Cochrane Collaboration and provide both historical context and critical assessment of the most significant clinical studies published over the years. The data suggest that properly collected and promptly infused granulocytes are active against infections, both bacterial and fungal. The most important question that remains unanswered is in which patients the administration of granulocytes will be beneficial. The preponderance of evidence suggests that granulocyte transfusions may be efficacious in few select cases as a temporizing measure to control an infection that is expected (or proven) to be refractory to optimal antimicrobial treatment, and that could otherwise be controlled by marrow recovery, which is expected to happen. In this regard, they are best considered a "bridge" that grants enough time for the recipient to develop their own response to the infection. The challenges to use GTXs successfully are both clinical, in terms of timely identifying the patients who may benefit, and logistical, in terms of optimal selection of donors and collection technique.
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18
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Okinaka K. Candidemia in Cancer Patients: Focus Mainly on Hematological Malignancyand Hematopoietic Stem Cell Transplantation. Med Mycol J 2017; 57:J117-23. [PMID: 27581780 DOI: 10.3314/mmj.16.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although many new antifungals have become commercially available since 2000, candidemia remains an important public health issue because of its poor prognosis. Some studies have suggested that early antifungal therapy is associated with decreased mortality; however, it is difficult to promptly diagnose candidemia because of the poor sensitivity of blood cultures. Thus, prophylaxis against Candida infection is recommended in patient groups in whom the risk of infection is high, such as allogeneic hematopoietic stem cell transplant recipients or those undergoing intensive remission-induction chemotherapy for acute leukemia. Non-Candida albicans candidemia is dominant among hematology patients, and the use of an echinocandin is recommended as the initial therapy. However, echinocandin-resistant Candida have been reported with increasing frequency, mainly in Candida glabrata. Several studies have reported that echinocandin resistance is associated with prior exposure to an echinocandin. Therefore, susceptibility testing is vital in treating severe or refractory candidemia, and the introduction of an antifungal stewardship program is recommended.
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Affiliation(s)
- Keiji Okinaka
- Division of General Internal Medicine, National Cancer Center Hospital East / Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital
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19
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West KA, Gea-Banacloche J, Stroncek D, Kadri SS. Granulocyte transfusions in the management of invasive fungal infections. Br J Haematol 2017; 177:357-374. [PMID: 28295178 DOI: 10.1111/bjh.14597] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/14/2016] [Indexed: 01/01/2023]
Abstract
Granulocyte transfusions have a long history of being used in patients with neutropenia or neutrophil dysfunction to prevent and treat invasive fungal infections. However, there are limited and conflicting data concerning its clinical effectiveness, considerable variations in current granulocyte transfusion practices, and uncertainties about its benefit as an adjunct to modern antifungal therapy. In this review, we provide an overview on granulocyte transfusions and summarize the evidence on their role in the prevention and treatment of invasive fungal infections.
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Affiliation(s)
- Kamille A West
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Juan Gea-Banacloche
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bethesda, MD, USA
| | - David Stroncek
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
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20
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Mortaz E, Adcock IM, Tabarsi P, Darazam IA, Movassaghi M, Garssen J, Jamaati H, Velayati A. Pattern recognitions receptors in immunodeficiency disorders. Eur J Pharmacol 2017; 808:49-56. [PMID: 28095323 DOI: 10.1016/j.ejphar.2017.01.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 01/04/2017] [Accepted: 01/13/2017] [Indexed: 01/13/2023]
Abstract
Pattern recognition receptors (PRRs) recognize common microbial or host-derived macromolecules and have important roles in early activation and response of the immune system. Initiation of the innate immune response starts with the recognition of microbial structures called pathogen associated molecular patterns (PAMPs). Recognition of PAMPs is performed by germline-encoded receptors expressed mainly on immune cells termed pattern recognition receptors (PRRs). Several classes of pattern recognition receptors (PRRs) are involved in the pathogenesis of diseases, including Toll-like receptors (TLRs), C-type lectin receptors (CLRs), and Nod-like receptors (NLRs). Patients with primary immune deficiencies (PIDs) affecting TLR signaling can elucidate the importance of these proteins in the human immune system. Defects in interleukin-1 receptor-associated kinase-4 and myeloid differentiation factor 88 (MyD88) lead to susceptibility to infections with bacteria, while mutations in nuclear factor-κB essential modulator (NEMO) and other downstream mediators generally induce broader susceptibility to bacteria, viruses, and fungi. In contrast, TLR3 signaling defects are associated with susceptibility to herpes simplex virus type 1 encephalitis. Other PIDs induce functional alterations of TLR signaling pathways, such as common variable immunodeficiency in which plasmacytoid dendritic cell defects enhance defective responses of B cells to shared TLR agonists. Altered TLR responses to TLR2 and 4 agonists are seen in chronic granulomatous disease (CGD) and X-linked agammaglobulinemia (XLA). Enhanced TLR responses, meanwhile, are seen for TLRs 5 and 9 in CGD, TLRs 4, 7/8, and 9 in XLA, TLRs 2 and 4 in hyper IgE syndrome (HIES), and for most TLRs in adenosine deaminase deficiency. In this review we provide the reader with an update on the role of TLRs and downstream signaling pathways in PID disorders.
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Affiliation(s)
- Esameil Mortaz
- Department of Immunology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ian M Adcock
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Payam Tabarsi
- Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ilad Alavi Darazam
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti, University of Medical Sciences,Tehran, Iran
| | - Masoud Movassaghi
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA), USA
| | - Johan Garssen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Sciences, Utrecht University, Utrecht, The Netherlands; Department of Immunology, Nutricia Research, Utrecht, the Netherlands
| | - Hamidreza Jamaati
- Chronic Respiratory Diseases Research Center and National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Aliakbar Velayati
- Mycobacteriology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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21
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Bioartificial Therapy of Sepsis: Changes of Norepinephrine-Dosage in Patients and Influence on Dynamic and Cell Based Liver Tests during Extracorporeal Treatments. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7056492. [PMID: 27433475 PMCID: PMC4940519 DOI: 10.1155/2016/7056492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/02/2016] [Indexed: 01/28/2023]
Abstract
Purpose. Granulocyte transfusions have been used to treat immune cell dysfunction in sepsis. A granulocyte bioreactor for the extracorporeal treatment of sepsis was tested in a prospective clinical study focusing on the dosage of norepinephrine in patients and influence on dynamic and cell based liver tests during extracorporeal therapies. Methods and Patients. Ten patients with severe sepsis were treated twice within 72 h with the system containing granulocytes from healthy donors. Survival, physiologic parameters, extended hemodynamic measurement, and the indocyanine green plasma disappearance rate (PDR) were monitored. Plasma of patients before and after extracorporeal treatments were tested with a cell based biosensor for analysis of hepatotoxicity. Results. The observed mortality rate was 50% during stay in hospital. During the treatments, the norepinephrine-dosage could be significantly reduced while mean arterial pressure was stable. In the cell based analysis of hepatotoxicity, the viability and function of sensor-cells increased significantly during extracorporeal treatment in all patients and the PDR-values increased significantly between day 1 and day 7 only in survivors. Conclusion. The extracorporeal treatment with donor granulocytes showed promising effects on dosage of norepinephrine in patients, liver cell function, and viability in a cell based biosensor. Further studies with this approach are encouraged.
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22
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Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1-50. [PMID: 26679628 PMCID: PMC4725385 DOI: 10.1093/cid/civ933] [Citation(s) in RCA: 1812] [Impact Index Per Article: 226.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor
| | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Thomas J Walsh
- Weill Cornell Medical Center and Cornell University, New York, New York
| | | | - Jack D Sobel
- Harper University Hospital and Wayne State University, Detroit, Michigan
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23
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Efficacy of transfusion with granulocytes from G-CSF/dexamethasone-treated donors in neutropenic patients with infection. Blood 2015; 126:2153-61. [PMID: 26333778 DOI: 10.1182/blood-2015-05-645986] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/06/2015] [Indexed: 11/20/2022] Open
Abstract
High-dose granulocyte transfusion therapy has been available for 20 years, yet its clinical efficacy has never been conclusively demonstrated. We report here the results of RING (Resolving Infection in Neutropenia with Granulocytes), a multicenter randomized controlled trial designed to address this question. Eligible subjects were those with neutropenia (absolute neutrophil count <500/μL) and proven/probable/presumed infection. Subjects were randomized to receive either (1) standard antimicrobial therapy or (2) standard antimicrobial therapy plus daily granulocyte transfusions from donors stimulated with granulocyte colony-stimulating factor (G-CSF) and dexamethasone. The primary end point was a composite of survival plus microbial response, at 42 days after randomization. Microbial response was determined by a blinded adjudication panel. Fifty-six subjects were randomized to the granulocyte arm and 58 to the control arm. Transfused subjects received a median of 5 transfusions. Mean transfusion dose was 54.9 × 10(9) granulocytes. Overall success rates were 42% and 43% for the granulocyte and control groups, respectively (P > .99), and 49% and 41%, respectively, for subjects who received their assigned treatments (P = .64). Success rates for granulocyte and control arms did not differ within any infection type. In a post hoc analysis, subjects who received an average dose per transfusion of ≥0.6 × 10(9) granulocytes per kilogram tended to have better outcomes than those receiving a lower dose. In conclusion, there was no overall effect of granulocyte transfusion on the primary outcome, but because enrollment was half that planned, power to detect a true beneficial effect was low. RING was registered at www.clinicaltrials.gov as #NCT00627393.
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Abstract
PURPOSE OF REVIEW Pneumonia is the leading cause of death among neutropenic cancer patients, particularly those with acute leukaemia. Even with empiric therapy, case fatality rates of neutropenic pneumonias remain unacceptably high. However, recent advances in the management of neutropenic pneumonia offer hope for improved outcomes in the cancer setting. This review summarizes recent literature regarding the clinical presentation, microbiologic trends, diagnostic advances and therapeutic recommendations for cancer-related neutropenic pneumonia. RECENT FINDINGS Although neutropenic patients acquire pathogens both in community and nosocomial settings, patients' obligate healthcare exposures result in the frequent identification of multidrug-resistant bacterial organisms on conventional culture-based assessment of respiratory secretions. Modern molecular techniques, including expanded use of galactomannan testing, have further facilitated identification of fungal pathogens, allowing for aggressive interventions that appear to improve patient outcomes. Multiple interested societies have issued updated guidelines for antibiotic therapy of suspected neutropenic pneumonia. The benefit of antibiotic medications may be further enhanced by agents that promote host responses to infection. SUMMARY Neutropenic cancer patients have numerous potential causes for pulmonary infiltrates and clinical deterioration, with lower respiratory tract infections among the most deadly. Early clinical suspicion, diagnosis and intervention for neutropenic pneumonia provide cancer patients' best hope for survival.
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25
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Cannas G, Thomas X. Supportive care in patients with acute leukaemia: historical perspectives. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:205-20. [PMID: 25369611 PMCID: PMC4385068 DOI: 10.2450/2014.0080-14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 06/24/2014] [Indexed: 01/09/2023]
Affiliation(s)
- Giovanna Cannas
- Haemovigilance Unit, Edouard Herriot Hospital and Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Xavier Thomas
- Leukaemia Unit, Haematology Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
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26
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Ochi Y, Hiramoto N, Takegawa H, Yonetani N, Doi A, Ichikawa C, Imai Y, Ishikawa T. Infective endocarditis caused by Scedosporium prolificans infection in a patient with acute myeloid leukemia undergoing induction chemotherapy. Int J Hematol 2015; 101:620-5. [DOI: 10.1007/s12185-015-1752-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/19/2015] [Accepted: 01/21/2015] [Indexed: 10/24/2022]
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Schmidt S, Tramsen L, Schneider A, Balan A, Lehrnbecher T. Immunotherapeutic strategies against mucormycosis in haematopoietic stem cell transplantation. Mycoses 2014; 57 Suppl 3:8-12. [PMID: 25231156 DOI: 10.1111/myc.12241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 12/22/2013] [Accepted: 01/31/2014] [Indexed: 11/26/2022]
Abstract
Mucormycoses remain a serious complication in patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT). In these patients, mortality rates of mucormycosis reach up to 90%, which is due, at least in part, to the severe and prolonged immunosuppression after transplantation. Although prolonged neutropaenia is one of the most important risk factors for mucormycosis, other cell populations, such as CD4(+) T cells may also provide critical defence mechanisms against this infection. The management of mucormycosis includes antifungal therapy, surgery and, most importantly, the control of the underlying predisposing conditions, such as the correction of an impaired immune system. Here, we review the current data of granulocytes, antifungal T cells and natural killer cells regarding their activity against mucormycetes and regarding a potential immunotherapeutic approach. It is hoped that further animal studies and clinical trials assessing immunotherapeutic strategies will ultimately improve the poor prognosis of allogeneic HSCT recipients suffering from mucormycosis.
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Affiliation(s)
- Stanislaw Schmidt
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
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28
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Al-Anazi KA, Al-Jasser AM. Infections Caused by Acinetobacter baumannii in Recipients of Hematopoietic Stem Cell Transplantation. Front Oncol 2014; 4:186. [PMID: 25072028 PMCID: PMC4095644 DOI: 10.3389/fonc.2014.00186] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 07/02/2014] [Indexed: 01/21/2023] Open
Abstract
Acinetobacter baumannii (A. baumannii) is a Gram-negative, strictly aerobic, non-fermentative coccobacillus, which is widely distributed in nature. Recently, it has emerged as a major cause of health care-associated infections (HCAIs) in addition to its capacity to cause community-acquired infections. Risk factors for A. baumannii infections and bacteremia in recipients of hematopoietic stem cell transplantation include: severe underlying illness such as hematological malignancy, prolonged use of broad-spectrum antibiotics, invasive instrumentation such as central venous catheters or endotracheal intubation, colonization of respiratory, gastrointestinal, or urinary tracts in addition to severe immunosuppression caused by using corticosteroids for treating graft versus host disease. The organism causes a wide spectrum of clinical manifestations, but serious complications such as bacteremia, septic shock, ventilator-associated pneumonia, extensive soft tissue necrosis, and rapidly progressive systemic infections that ultimately lead to multi-organ failure and death are prone to occur in severely immunocompromised hosts. The organism is usually resistant to many antimicrobials including penicillins, cephalosporins, trimethoprim-sulfamethoxazole, almost all fluoroquinolones, and most of the aminoglycosides. The recently increasing resistance to carbapenems, colistin, and polymyxins is alarming. Additionally, there are geographic variations in the resistance patterns and several globally and regionally resistant strains have already been described. Successful management of A. baumannii infections depends upon appropriate utilization of antibiotics and strict application of preventive and infection control measures. In uncomplicated infections, the use of a single active beta-lactam may be justified, while definitive treatment of complicated infections in critically ill individuals may require drug combinations such as colistin and rifampicin or colistin and carbapenem. Mortality rates in patients having bacteremia or septic shock may reach 70%. Good prognosis is associated with presence of local infection, absence of multidrug resistant strain, and presence of uncomplicated infection while poor outcome is associated with severe underlying medical illness, bacteremia, septic shock, multi-organ failure, HCAIs, admission to intensive care facilities for higher levels of care, and culture of certain aggressive genotypes of A. baumannii.
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Affiliation(s)
- Khalid Ahmed Al-Anazi
- Section of Adult Hematology and Oncology, Department of Medicine, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Asma M. Al-Jasser
- Central Regional Laboratory, Ministry of Health, Riyadh, Saudi Arabia
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29
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Wang H, Wu Y, Fu R, Qu W, Ruan E, Wang G, Liu H, Song J, Xing L, Guan J, Li L, Liu C, Shao Z. Granulocyte transfusion combined with granulocyte colony stimulating factor in severe infection patients with severe aplastic anemia: a single center experience from China. PLoS One 2014; 9:e88148. [PMID: 24505406 PMCID: PMC3914902 DOI: 10.1371/journal.pone.0088148] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 01/06/2014] [Indexed: 12/14/2022] Open
Abstract
Objective To investigate the efficacy and safety of granulocyte transfusion combined with granulocyte colony stimulating factor (G-CSF) in severe infection patients with severe aplastic anemia (SAA). Methods Fifty-six patients in severe infections with SAA who had received granulocyte transfusions combined with G-CSF from 2006 to 2012 in our department were analyzed. A retrospective analysis was undertaken to investigate the survival rates (at 30 days, 90 days and 180 days), the responses to treatment (at 7 days and 30 days, including microbiological, radiographic and clinical responses), the neutrophil count and adverse events after transfusion. Results All SAA patients with severe infections were treated with granulocyte transfusions combined with G-CSF. Forty-seven patients had received antithymocyte globulin/antilymphocyte globulin and cyclosporine A as immunosuppressive therapy. The median number of granulocyte components transfused was 18 (range, 3–75). The survival at 30 days, 90 days and 180 days were 50(89%), 39(70%) and 37(66%) respectively. Among 31 patients who had invasive fungal infections, the survival at 30 days, 90 days and 180 days were 27(87%), 18(58%) and 16(52%) respectively. Among the 25 patients who had refractory severe bacterial infections, the survival at 30 days, 90 days and 180 days were 23(92%), 21(84%) and 21(84%) respectively. Survival rate was correlated with hematopoietic recovery. Responses of patients at 7 and 30 days were correlated with survival rate. Common adverse effects of granulocyte transfusion included mild to moderate fever, chills, allergy and dyspnea. Conclusion Granulocyte transfusions combined with G-CSF could be an adjunctive therapy for treating severe infections of patients with SAA.
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Affiliation(s)
- Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Yuhong Wu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Rong Fu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Wen Qu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Erbao Ruan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Guojin Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Hong Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Jia Song
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Limin Xing
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Jing Guan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Lijuan Li
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Chunyan Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
- * E-mail:
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Abstract
Invasive yeast infections are a significant cause of morbidity and mortality in patients with defective immune response, such as those with cancer-related immunosuppression, organ transplantation or other immunodeficiencies, and neonates. Hospitalization in the intensive care unit may increase the risk for such infections. Despite the advent of new antifungal agents, the problem is escalating as the number of susceptible hosts increase and virulent, more resistant fungal strains emerge. Over the past few years, advances in immunology and molecular biology have greatly contributed to a better understanding of the pathogenesis of yeast infections. There is evidence that reconstitution of the host immune function is a major contributor to the resolution of yeast infections. Strategies aiming to increase the phagocyte number (e.g., granulocyte transfusions), to stimulate immune response (e.g., administration of hematopoietic growth factors and other proinflammatory cytokines) and to stimulate antigen-specific immunity (e.g., antibody therapy or vaccination) benefit patients at risk of, or suffering from, yeast infections. Further preclinical and clinical studies, as well as improving our understanding of immune system functions and dysfunctions, remain a future challenge.
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Affiliation(s)
- Jorge Garbino
- University Hospitals of Geneva, Infectious Diseases Division (Clinical Research), 24 Rue Micheli du Crest, 1211 Geneva 14, Switzerland.
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Radia R, Pamphilon D. Transfusion strategies in patients undergoing stem-cell transplantation. Expert Rev Hematol 2014; 4:213-20. [DOI: 10.1586/ehm.11.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Safdar A, Rodriguez G, Zuniga J, Al Akhrass F, Pande A. High-dose caspofungin as a component of combination antifungal therapy in 91 patients with neoplastic diseases and hematopoietic stem cell transplantation: a critical review of short-term and long-term adverse events. J Pharm Pract 2013; 28:175-82. [PMID: 24366977 DOI: 10.1177/0897190013515927] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The antifungal activity of echinocandins is concentration dependent. Previously, we demonstrated that high-dose caspofungin (HD-CSP; 100 mg daily) was well tolerated in 34 immunosuppressed patients with cancer and may have favorably influenced outcomes. We retrospectively assessed all 91 patients in whom HD-CSP was given for the treatment of invasive fungal disease (IFD). The median number of doses was 18.5 ± 21.5, and in 8 (9%) patients more than 40 doses were given. Most (62%) of the patients had leukemia. A total of 45 (49%) patients had undergone stem cell transplantation; 80% received allogeneic grafts and 47% had graft-versus-host disease. High-dose corticosteroids were given during antifungal therapy in 26 (29%) patients. In all, 8 (9%) patients had new elevation in serum bilirubin during HD-CSP therapy; normalization occurred after voriconazole and HD-CSP were discontinued in 4 patients each. No other short-term or delayed adverse events were observed. In all, 40 (44%) patients died of IFD. High-dose corticosteroids during HD-CSP (odds ratio [OR] 8, 95% confidence interval [CI] 2.1-30.4; P < .002) and starting HD-CSP in the critical care unit (OR 67.5, 95% CI 5.25-868.9; P < .001) were associated with death from fungal disease. Prolonged HD-CSP therapy was well tolerated. Drug-induced hyperbilirubinemia may pose a potential limitation for continued HD-CSP use in highly susceptible patients with hematologic neoplasms and stem cell transplantation.
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Affiliation(s)
- Amar Safdar
- Department of Medicine, NYU Langone Medical Center, New York, NY, USA
| | - Gilhen Rodriguez
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Jorge Zuniga
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Fadi Al Akhrass
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Anupam Pande
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Safdar A, Rodriguez G, Zuniga J, Al Akhrass F, Pande A. Use of healthy-donor granulocyte transfusions to treat infections in neutropenic patients with myeloid or lymphoid neoplasms: experience in 74 patients treated with 373 granulocyte transfusions. Acta Haematol 2013; 131:50-8. [PMID: 24051981 DOI: 10.1159/000351174] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 04/06/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS Despite limited evidence for efficacy, granulocyte transfusions (GTX) are used to prevent and treat opportunistic infections in patients with neutropenia. METHODS Three hundred and seventy-three GTX given to 74 patients were assessed retrospectively. RESULTS GTX were discontinued because of clinical improvement more often in patients with severe infections than in patients without severe infections (27 vs. 12%; p ≤ 0.002), whereas deaths resulted in discontinuation of GTX therapy less often in patients with severe infections than without (8 vs. 39%; p ≤ 0.002). Patients who died by 12 weeks after GTX initiation were more likely to have leukemia (p = 0.03), not to have recovery of neutrophil counts (p < 0.0001), and to have started GTX during a critical care unit stay (p < 0.001). Uses of granulocyte colony-stimulating factor (p ≤ 0.02) and interferon-γ (p ≤ 0.04) were more common in patients who survived. In patients with comorbidities (31%; odds ratio, OR, 12.6; 95% confidence interval, CI, 2.4-65.7; p ≤ 0.003), GTX was started in the critical care unit (OR 8.8; 95% CI 2.5-30.9; p < 0.001), and a high total bilirubin level at the end of GTX (OR 2.1; 95% CI 1.1-4.2; p = 0.03) had a higher probability of death 12 weeks after GTX therapy commenced. CONCLUSIONS The possibility that a niche population may benefit from GTX requires further assessment.
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Affiliation(s)
- Amar Safdar
- The University of Texas MD Anderson Cancer Center, Houston, Tex., USA
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Mousset S, Buchheidt D, Heinz W, Ruhnke M, Cornely OA, Egerer G, Krüger W, Link H, Neumann S, Ostermann H, Panse J, Penack O, Rieger C, Schmidt-Hieber M, Silling G, Südhoff T, Ullmann AJ, Wolf HH, Maschmeyer G, Böhme A. Treatment of invasive fungal infections in cancer patients-updated recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 2013; 93:13-32. [PMID: 24026426 PMCID: PMC3889633 DOI: 10.1007/s00277-013-1867-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 07/29/2013] [Indexed: 11/28/2022]
Abstract
The Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) here presents its updated recommendations for the treatment of documented fungal infections. Invasive fungal infections are a main cause of morbidity and mortality in cancer patients undergoing intensive chemotherapy regimens. In recent years, new antifungal agents have been licensed, and agents already approved have been studied in new indications. The choice of the most appropriate antifungal treatment depends on the fungal species suspected or identified, the patient's risk factors (e.g., length and depth of neutropenia), and the expected side effects. This guideline reviews the clinical studies that served as a basis for the following recommendations. All recommendations including the levels of evidence are summarized in tables to give the reader rapid access to the information.
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Affiliation(s)
- Sabine Mousset
- Interdisziplinäres Zentrum für Palliativmedizin, Agaplesion Markus Krankenhaus, Wilhelm Epstein-Straße 4, 60431, Frankfurt, Germany,
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Abstract
Bacterial and fungal infections continue to be a major cause of morbidity and mortality in severely neutropenic patients undergoing aggressive chemotherapy regimens or hematopoietic stem cell transplantation. Traditional granulocyte transfusion therapy, a logical approach in treating these infections, has been available for many years, and several controlled studies have shown this therapy to be useful. However, granulocyte transfusion therapy fell out of favor because the results were not clinically impressive, and adverse results were reported. These disappointing results were felt to be, in part, because of the low doses of granulocytes provided. More recent studies have attempted to increase the numbers of transfused cells by stimulating normal granulocyte donors with G-CSF (+/-corticosteroids). With these techniques, the number of granulocytes transfused can be increased 3-4 fold. The cells have been shown to circulate in recipients, and daily transfusions are capable of maintaining normal or near-normal blood neutrophil counts in previously severely neutropenic patients. The cells appear to function normally by a variety of in vitro and in vivo tests. Clinical benefit, as defined by survival or clearance of infection, has not been definitively determined. Results of an ongoing randomized controlled clinical trial should be available in the near future.
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Affiliation(s)
- Anthony A. Marfin
- Puget Sound Blood Center, Seattle, WA, USA
- Current Address: HIV Prevention Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Thomas H. Price
- Puget Sound Blood Center, Seattle, WA, USA
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
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Pikman R, Ben-Ami R. Immune modulators as adjuncts for the prevention and treatment of invasive fungal infections. Immunotherapy 2013; 4:1869-82. [PMID: 23240754 DOI: 10.2217/imt.12.127] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Invasive fungal diseases are increasingly important opportunistic infections that are intimately linked to immune-suppression in the context of cytotoxic treatment of neoplastic diseases, stem cell and solid-organ transplantation, and primary immune deficiencies. Mortality rates remain high despite the availability of novel antifungals that are both safe and highly active in vitro, suggesting that clinical outcomes may be improved through modulation of host immunity. Ongoing advances in our knowledge of fungal-host interactions facilitate rational design of novel immunotherapeutics. Thus, antifungal immunotherapy now includes age-old interventions such as granulocyte and immunoglobulin transfusions, as well as promising experimental techniques such as antifungal vaccines and adoptive immunotherapy. To realize the potential of these rapidly evolving technologies, transition from the bench to clinical-phase studies must occur at a more rapid pace.
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Affiliation(s)
- Regina Pikman
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center & Sackler School of Medicine, 6 Weizman, Tel Aviv 64239, Israel
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Experimental evidence that granulocyte transfusions are efficacious in treatment of neutropenic hosts with pulmonary aspergillosis. Antimicrob Agents Chemother 2013; 57:1882-7. [PMID: 23380731 DOI: 10.1128/aac.02533-12] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although polymorphonuclear leukocytes (PMNs) are powerfully anti-Aspergillus, transfusion therapy remains controversial, with conflicting results, and experimental support has been lacking. We devised a pulmonary infection model in neutropenic BALB/c mice, used an antibacterial regimen to prevent confounding sepsis, and optimized PMN induction, purifications, and dose. Mice were given 150 mg/kg cyclophosphamide every 4 days and a gentamicin-vancomycin-clindamycin-imipenem regimen daily beginning 4 days before intranasal challenge with 5 × 10(5) Aspergillus conidia. This regimen produced leukopenia (~10% of normal white blood cell [WBC] count; ≤ 10% PMNs) for 10 days, without bacterial superinfection. PMN donors given 100 μg/kg recombinant murine granulocyte colony-stimulating factor (G-CSF) for 10 days yielded 11 × 10(7) to 13.6 × 10(7) WBC/ml (81 to 87% PMNs). Infected mice were given PMN transfusions intravenously. In 2 experiments with up to 70% mortality of neutropenic controls, transfusion of 10(7) PMNs 1 and 4 days after challenge had negligible effects on peripheral WBC counts but improved survival (P = 0.007, 0.02), decreased lung CFU (P = 0.03, 0.005), and cleared infection in 28 to 50% of survivors. Transfusion of 5 × 10(6) PMNs showed partial protection. Transfusions given every other day did not improve protection. Our present results provide an experimental basis for enthusiasm for PMN transfusions in the therapy of aspergillosis in humans.
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Invasive fungal infection and impaired neutrophil killing in human CARD9 deficiency. Blood 2013; 121:2385-92. [PMID: 23335372 DOI: 10.1182/blood-2012-08-450551] [Citation(s) in RCA: 227] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Caspase recruitment domain-containing protein 9 (CARD9) is an adaptor molecule in the cytosol of myeloid cells, required for induction of T-helper cells producing interleukin-17 (Th17 cells) and important in antifungal immunity. In a patient suffering from Candida dubliniensis meningoencephalitis, mutations in the CARD9 gene were found to result in the loss of protein expression. Apart from the reduced numbers of CD4(+) Th17 lymphocytes, we identified a lack of monocyte-derived cytokines in response to Candida strains. Importantly, CARD9-deficient neutrophils showed a selective Candida albicans killing defect with abnormal ultrastructural phagolysosomes and outgrowth of hyphae. The neutrophil killing defect was independent of the generation of reactive oxygen species by the reduced NAD phosphate oxidase system. Taken together, this demonstrates that human CARD9 deficiency results in selective defect in the host defense against invasive fungal infection, caused by an impaired phagocyte killing.
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Safdar A, Rodriguez G, Zuniga J, Al Akhrass F, Georgescu G, Pande A. Granulocyte macrophage colony-stimulating factor in 66 patients with myeloid or lymphoid neoplasms and recipients of hematopoietic stem cell transplantation with invasive fungal disease. Acta Haematol 2012; 129:26-34. [PMID: 23038157 DOI: 10.1159/000342121] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/11/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Adding granulocyte macrophage colony-stimulating factor (GM-CSF) may improve the response to antifungal therapy in immunosuppressed patients with invasive fungal disease (IFD). METHODS We retrospectively assessed 66 patients in whom GM-CSF was given during antifungal therapy. RESULTS Severe neutropenia (77%) and refractory/relapsed cancer (65%) were common in the group. Prior to GM-CSF therapy, 15% of patients received high-dose corticosteroids for a median of 30 ± 16 days [median cumulative dose (c.d.) 1,184 ± 1,019 mg], and 9 received steroids during GM-CSF therapy for a median of 16 ± 12 days (median c.d. 230 ± 1,314 mg). Mild toxic effects were noted in 9% of patients; there were no cases of cardiopulmonary toxicity. All-cause deaths were observed in 68% of patients and 48% died of progressive IFD. High-dose corticosteroids prior to GM-CSF (OR 24; 95% CI 2.21-264.9; p ≤ 0.009), GM-CSF started in the intensive care unit (OR 10; 95% CI 1.66-63.8; p ≤ 0.01), concurrent granulocyte transfusions (OR 5; 95% CI 1.27-16.8; p ≤ 0.02) and proven/probable IFD (OR 4; 95% CI 1-16.2; p ≤ 0.05) predicted antifungal treatment failure. CONCLUSIONS GM-CSF adjuvant therapy was tolerated without serous toxicity and antifungal treatment failure remained a challenge in patients treated with high-dose systemic corticosteroids.
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Affiliation(s)
- Amar Safdar
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Cherif H, Axdorph U, Kalin M, Björkholm M. Clinical experience of granulocyte transfusion in the management of neutropenic patients with haematological malignancies and severe infection. ACTA ACUST UNITED AC 2012; 45:112-6. [DOI: 10.3109/00365548.2012.714906] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Armstrong-James D, Harrison TS. Immunotherapy for fungal infections. Curr Opin Microbiol 2012; 15:434-9. [PMID: 22884572 DOI: 10.1016/j.mib.2012.06.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/02/2012] [Accepted: 06/04/2012] [Indexed: 02/02/2023]
Abstract
Invasive fungal infections have become a major cause of mortality in immunocompromised individuals. Despite the current availability of number of highly active antifungal agents, overall mortality remains around 40%. Importantly, it is clear that a failure to restore host immunity leads to worse outcomes. These observations provide clear rationale for the development of novel immunotherapies to improve outcomes in immunocompromised individuals with invasive fungal infections. In this article we summarise the key advances that have been made in the field of immunotherapy for fungal infections in recent years, with a particular focus on clinical studies of interferon-γ therapy, adoptive T cell therapy, and gene therapy for chronic granulomatous disorder. In addition a number of pre-clinical approaches are reviewed.
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Affiliation(s)
- Darius Armstrong-James
- Section of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
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Strauss RG. Role of granulocyte/neutrophil transfusions for haematology/oncology patients in the modern era. Br J Haematol 2012; 158:299-306. [DOI: 10.1111/j.1365-2141.2012.09190.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 05/02/2012] [Indexed: 12/17/2022]
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Lin L, Ibrahim AS, Baquir B, Palosaari A, Spellberg B. Luminescent-activated transfected killer cells to monitor leukocyte trafficking during systemic bacterial and fungal infection. J Infect Dis 2011; 205:337-47. [PMID: 22124127 DOI: 10.1093/infdis/jir725] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Activated transfected killer (ATAK) cells are immortal phagocytes transfected with a luminescence reporter that effectively treat lethal infections in neutropenic mice. Their in vivo trafficking, lifespan, and immunogenicity are unknown. METHODS Mice were made neutropenic; infected or not with Staphylococcus aureus, Acinetobacter baumannii, Candida albicans, or Aspergillus fumigatus; and treated intraperitoneally with ATAK cells. Cell trafficking and lifespan were assessed by in vivo imaging and reverse transcription-polymerase chain reaction. RESULTS In uninfected neutropenic mice, ATAK cells spread from the mesentery into visceral organs on days 1-3. Splenic accumulation of ATAK cells increased at day 1 after infection with S. aureus and A. baumannii, and kidney accumulation increased in mice infected with C. albicans. Lung accumulation was seen at day 3 in mice infected by inhalation with A. fumigatus. By day 8, coincident with increasing anti-ATAK antibodies, luminescence signal was lost and there was no detectable mRNA transcription from ATAK cells. CONCLUSIONS ATAK cells accumulated in target organs with distinct profiles, depending on the microbial etiology of infection. Finally, generation of an anti-ATAK immune response may provide an important safety mechanism that helps clear the cells from the host as the marrow recovers.
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Affiliation(s)
- Lin Lin
- Department of Medicine, Division of General Internal Medicine, Los Angeles Biomedical Research Institute, Harbor-University of California at Los Angeles Medical Center, Torrance, CA, USA
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Ruhnke M, Rickerts V, Cornely OA, Buchheidt D, Glöckner A, Heinz W, Höhl R, Horré R, Karthaus M, Kujath P, Willinger B, Presterl E, Rath P, Ritter J, Glasmacher A, Lass-Flörl C, Groll AH. Diagnosis and therapy of Candida infections: joint recommendations of the German Speaking Mycological Society and the Paul-Ehrlich-Society for Chemotherapy. Mycoses 2011; 54:279-310. [PMID: 21672038 DOI: 10.1111/j.1439-0507.2011.02040.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Invasive Candida infections are important causes of morbidity and mortality in immunocompromised and hospitalised patients. This article provides the joint recommendations of the German-speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMyKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG) for diagnosis and treatment of invasive and superficial Candida infections. The recommendations are based on published results of clinical trials, case-series and expert opinion using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA). Key recommendations are summarised here: The cornerstone of diagnosis remains the detection of the organism by culture with identification of the isolate at the species level; in vitro susceptibility testing is mandatory for invasive isolates. Options for initial therapy of candidaemia and other invasive Candida infections in non-granulocytopenic patients include fluconazole or one of the three approved echinocandin compounds; liposomal amphotericin B and voriconazole are secondary alternatives because of their less favourable pharmacological properties. In granulocytopenic patients, an echinocandin or liposomal amphotericin B is recommended as initial therapy based on the fungicidal mode of action. Indwelling central venous catheters serve as a main source of infection independent of the pathogenesis of candidaemia in the individual patients and should be removed whenever feasible. Pre-existing immunosuppressive treatment, particularly by glucocorticosteroids, ought to be discontinued, if feasible, or reduced. The duration of treatment for uncomplicated candidaemia is 14 days following the first negative blood culture and resolution of all associated symptoms and findings. Ophthalmoscopy is recommended prior to the discontinuation of antifungal chemotherapy to rule out endophthalmitis or chorioretinitis. Beyond these key recommendations, this article provides detailed recommendations for specific disease entities, for antifungal treatment in paediatric patients as well as a comprehensive discussion of epidemiology, clinical presentation and emerging diagnostic options of invasive and superficial Candida infections.
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Affiliation(s)
- Markus Ruhnke
- Medizinische Klinik m S Onkologie u Hämatologie, Charité Universitätsmedizin, Charité, Campus Mitte, Berlin, Germany.
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Lehrnbecher T, Tramsen L, Koehl U, Schmidt S, Bochennek K, Klingebiel T. Immunotherapy against invasive fungal diseases in stem cell transplant recipients. Immunol Invest 2011; 40:839-52. [PMID: 21627412 DOI: 10.3109/08820139.2011.581732] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Despite the availability of new antifungal compounds, morbidity and mortality of invasive fungal disease in allogeneic hematopoietic stem cell recipients are still unacceptably high. Over the past decade, one could witness an exciting improvement of the understanding of the molecular pathogenesis and of the complexity of host antifungal immune responses. This, in turn, provides critical information to augment host immunity against fungal pathogens. Strategies for enhancing the immune system include the administration of effector and regulatory cells (e.g., granulocytes, antigen-specific T cells, dendritic cells) as well as the administration of recombinant cytokines, interferons and growth factors (e.g., interferon-γ, keratinocyte growth factor, granulocyte- and granulocyte-macrophage colony stimulating factor). One has to recognize at the same time, however, that data of in vitro assays and animal models cannot necessarily be transferred into the clinical setting. In addition, meaningful clinical trials in allogeneic stem cell recipients suffering from invasive fungal disease require sufficiently large and homogenous cohorts of patients and can only be performed in international collaboration, but may ultimately improve the outcome of allogeneic transplant recipients with invasive fungal disease.
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Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Children's Hospital III, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, Frankfurt, Germany.
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Saria M. Preventing and Managing Infections in Neutropenic Stem Cell Transplantation Recipients: Evidence-Based Review. Clin J Oncol Nurs 2011; 15:133-9. [DOI: 10.1188/11.cjon.133-139] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Altrichter J, Sauer M, Kaftan K, Birken T, Gloger D, Gloger M, Henschel J, Hickstein H, Klar E, Koball S, Pertschy A, Nöldge-Schomburg G, Vagts DA, Mitzner SR. Extracorporeal cell therapy of septic shock patients with donor granulocytes: a pilot study. Crit Care 2011; 15:R82. [PMID: 21371308 PMCID: PMC3219336 DOI: 10.1186/cc10076] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Revised: 01/14/2011] [Accepted: 03/03/2011] [Indexed: 11/24/2022] Open
Abstract
Introduction Neutrophil granulocytes are the first defense line in bacterial infections. However, granulocytes are also responsible for severe local tissue impairment. In order to use donor granulocytes, but at the same time to avoid local side effects, we developed an extracorporeal immune support system. This first-in-man study investigated whether an extracorporeal plasma treatment with a granulocyte bioreactor is tolerable in patients with septic shock. A further intention was to find suitable efficacy end-points for subsequent controlled trials. Methods The trial was conducted as a prospective uncontrolled clinical phase I/II study with 28-day follow-up at three university hospital intensive care units. Ten consecutive patients (five men, five women, mean age 60.3 ± 13.9 standard deviation (SD) years) with septic shock with mean ICU entrance scores of Acute Physiology and Chronic Health Evaluation (APACHE) II of 29.9 ± 7.2 and of Simplified Acute Physiology Score (SAPS) II of 66.2 ± 19.5 were treated twice within 72 hours for a mean of 342 ± 64 minutes/treatment with an extracorporeal bioreactor containing 1.41 ± 0.43 × 10E10 granulocytes from healthy donors. On average, 9.8 ± 2.3 liters separated plasma were treated by the therapeutic donor cells. Patients were followed up for 28 days. Results Tolerance and technical safety during treatment, single organ functions pre/post treatment, and hospital survival were monitored. The extracorporeal treatments were well tolerated. During the treatments, the bacterial endotoxin concentration showed significant reduction. Furthermore, noradrenaline dosage could be significantly reduced while mean arterial pressure was stable. Also, C-reactive protein, procalcitonin, and human leukocyte antigen DR (HLA-DR) showed significant improvement. Four patients died in the hospital on days 6, 9, 18 and 40. Six patients could be discharged. Conclusions The extracorporeal treatment with donor granulocytes appeared to be well tolerated and showed promising efficacy results, encouraging further studies. Trial registration ClinicalTrials.gov Identifier: NCT00818597
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Affiliation(s)
- Jens Altrichter
- Department of Medicine, Division of Nephrology, Medical Faculty of University of Rostock, Ernst-Heydemann-Str. 6, Rostock, D-18057, Germany
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Ang AL, Linn YC. Treatment of severe neutropenic sepsis with granulocyte transfusion in the current era--experience from an adult haematology unit in Singapore. Transfus Med 2010; 21:13-24. [PMID: 20735762 DOI: 10.1111/j.1365-3148.2010.01035.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Granulocyte transfusion's (GT) efficacy among adult severe neutropenic sepsis (SNS) patients remains uncertain. We assessed GT's efficacy and its determinants among SNS patients in an adult haematology unit. The feasibility and safety of granulocyte donation (GD) and determinants of granulocyte yield were also evaluated. METHODS Retrospective analysis of granulocyte donors and recipients from March 2008 to October 2009. RESULTS Donors: Sixty GDs with a median WBC yield (WBCY) of 65·49 (31·30-131·72) × 10(9) were collected from 48 donors (9 repeat donors) using hydroxyethyl starch and intermittent flow centrifugation aphaeresis after receiving 8 mg dexamethasone and 300 mcg granulocyte colony-stimulating factor, with no serious adverse reactions (SAR). Six donations were urgently collected <3 h after pre-medication, the median WBCY of which was not significantly different from donations collected >12 h after pre-medication [59·18 (45·68-62·90) × 10(9) vs 67·45 (31·30-131·72) × 10(9) , P = 0·140]. Only pre-GD absolute neutrophil count (ANC) correlated with WBCY. PATIENTS Fifteen patients (12 acute leukaemias, 1 severe AA, 1 myelodysplastic syndrome and 1 lymphoma) received median 3 (2-9) ABO/RhD-matched GTs over 2-24 (median 7) days at 3-61 (median 28) days from severe neutropenia (SN) onset without SAR. They received intensive chemotherapies (N = 9), allogeneic transplant (N = 3), autologous stem cell rescue (N = 1) or immunosuppressants (N = 2). Fourteen had bacterial (N = 1) infections, fungal (N = 3) infections or both (N = 10) and one had severe viral pneumonitis; 63·6 and 30·8% of bacterial and fungal infections responded, respectively. Median ANC increase (ANC(increase) ) was 1·26 (0-9·25) × 10(9) at 5-20 (median 11) h post-GT. On multivariate analysis, each patient's median ANC(increase) only significantly correlated positively with median WBC dose/kg (P = 0·013). Five (33·3%) patients survived to discharge; the rest had infection-related mortality (IRM). IRM was significantly associated with inotropic requirement (P = 0·004), ventilatory requirement (P = 0·017) and persistent SN (P = 0·007). CONCLUSION GD is safe and feasible with good WBCY obtainable using our protocol. The effect of shortening pre-medication interval on WBCY which may prevent delay in initiating GT is worth evaluating. GT most likely benefits SNS patients with prospects of neutrophil recovery before haemodynamic deterioration. Large randomised trials investigating the role and timing of GT among such patients are required.
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Affiliation(s)
- A L Ang
- Department of Haematology, Singapore General Hospital, Singapore.
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Al-Tanbal H, Al Humaidan H, Al-Nounou R, Roberts G, Tesfamichael K, Owaidah T. The value and practicality of granulocyte transfusion: a single oncology centre experience. Transfus Med 2010; 20:160-8. [DOI: 10.1111/j.1365-3148.2009.00988.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lin L, Ibrahim AS, Baquir B, Fu Y, Applebaum D, Schwartz J, Wang A, Avanesian V, Spellberg B. Safety and efficacy of activated transfected killer cells for neutropenic fungal infections. J Infect Dis 2010; 201:1708-17. [PMID: 20397927 DOI: 10.1086/652496] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Invasive fungal infections cause considerable morbidity and mortality in neutropenic patients. White blood cell transfusions are a promising treatment for such infections, but technical barriers have prevented their widespread use. METHODS To recapitulate white blood cell transfusions, we are developing a cell-based immunotherapy using a phagocytic cell line, HL-60. We sought to stably transfect HL-60 cells with a suicide trap (herpes simplex virus thymidine kinase), to enable purging of the cells when desired, and a bioluminescence marker, to track the cells in vivo in mice. RESULTS Transfection was stable despite 20 months of continuous culture or storage in liquid nitrogen. Activation of these transfected cells with retinoic acid and dimethyl sulfamethoxazole enhanced their microbicidal effects. Activated transfected killer (ATAK) cells were completely eliminated after exposure to ganciclovir, confirming function of the suicide trap. ATAK cells improved the survival of neutropenic mice with lethal disseminated candidiasis and inhalational aspergillosis. Bioluminescence and histopathologic analysis confirmed that the cells were purged from surviving mice after ganciclovir treatment. Comprehensive necropsy, histopathology, and metabolomic analysis revealed no toxicity of the cells. CONCLUSIONS These results lay the groundwork for continued translational development of this promising, novel technology for the treatment of refractory infections in neutropenic hosts.
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Affiliation(s)
- Lin Lin
- Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-University of California at Los Angeles (UCLA) Medical Center, 1124 West Carson Street, Torrance, CA 90502, USA
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