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Couchepin J, Reinhold I, Kronig I, Guidi M, Buclin T, Schreiber PW, Neofytos D, Lamoth F. Isavuconazole for the Treatment of Fungal Infections: A Real-life Experience From the Fungal Infection Network of Switzerland (FUNGINOS). Open Forum Infect Dis 2024; 11:ofae223. [PMID: 38756765 PMCID: PMC11097116 DOI: 10.1093/ofid/ofae223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/24/2024] [Indexed: 05/18/2024] Open
Abstract
This analysis of 116 isavuconazole therapy courses shows that hepatic test disturbances (HTDs) were relatively frequent (29% of cases) but rarely led to treatment interruption (5%). Importantly, patients with baseline HTDs, including those attributed to a first-line triazole, did not exhibit a higher risk of subsequent HTD under isavuconazole therapy.
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Affiliation(s)
- Jade Couchepin
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ilana Reinhold
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Ilona Kronig
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Monia Guidi
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Buclin
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Peter W Schreiber
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Frederic Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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2
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Kunvarjee B, Siver M, Mathew S, Steiger S, Lee YJ, Spitzer B. Characterization of the Use and Efficacy of Isavuconazonium Sulfate in a Pediatric Oncology and Stem Cell Transplant Population: A Single Institution Retrospective Review. J Pediatr Hematol Oncol 2024; 46:e143-e146. [PMID: 38237014 DOI: 10.1097/mph.0000000000002812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/22/2023] [Indexed: 02/28/2024]
Abstract
Isavuconazonium sulfate (ISA) is a triazole antifungal approved for the treatment of invasive aspergillosis and mucormycosis in adults. This single-center, retrospective review of pediatric oncology and stem cell transplant patients receiving ISA for prophylaxis (n=20) or treatment (n=6) of invasive fungal disease (IFD) aims to characterize real-world clinical efficacy and toxicity of ISA in patients <18 years of age. Of 20 patients receiving ISA for prophylaxis, three patients had presumed breakthrough IFD (1 proven, 2 probable/possible). No adverse effects were attributed to ISA use or led to the discontinuation of therapy.
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Affiliation(s)
| | | | | | | | - Yeon Joo Lee
- Department of Medicine, Infectious Diseases Service
| | - Barbara Spitzer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, NY
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3
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Hsu AJ, Hanisch BR, Fisher BT, Huppler AR. Pipeline of Novel Antifungals for Invasive Fungal Disease in Transplant Recipients: A Pediatric Perspective. J Pediatric Infect Dis Soc 2024; 13:S68-S79. [PMID: 38417087 DOI: 10.1093/jpids/piad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 01/04/2024] [Indexed: 03/01/2024]
Abstract
Invasive fungal disease (IFD) remains a significant cause of morbidity and mortality in children undergoing transplantation. There is a growing armamentarium of novel antifungal agents recently approved for use or in late stages of clinical development. The overarching goal of this review is to discuss the mechanisms of action, spectrum of activity, stage of development, and pediatric-specific data for the following agents: encochleated amphotericin B deoxycholate, fosmanogepix, ibrexafungerp, isavuconazole, olorofim, opelconazole, oteseconazole, and rezafungin. Additionally, key drug attributes of these novel agents and their potential future therapeutic roles in pediatric transplant recipients are discussed.
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Affiliation(s)
- Alice Jenh Hsu
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Benjamin R Hanisch
- Department of Pediatric Infectious Diseases, Children's National, Washington, District of Columbia, USA
| | - Brian T Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna R Huppler
- Division of Pediatric Infectious Diseases, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Mori G, Diotallevi S, Farina F, Lolatto R, Galli L, Chiurlo M, Acerbis A, Xue E, Clerici D, Mastaglio S, Lupo Stanghellini MT, Ripa M, Corti C, Peccatori J, Puoti M, Bernardi M, Castagna A, Ciceri F, Greco R, Oltolini C. High-Risk Neutropenic Fever and Invasive Fungal Diseases in Patients with Hematological Malignancies. Microorganisms 2024; 12:117. [PMID: 38257945 PMCID: PMC10818361 DOI: 10.3390/microorganisms12010117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Invasive fungal diseases (IFDs) still represent a relevant cause of mortality in patients affected by hematological malignancies, especially acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) undergoing remission induction chemotherapy, and in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. Mold-active antifungal prophylaxis (MAP) has been established as a standard of care. However, breakthrough IFDs (b-IFDs) have emerged as a significant issue, particularly invasive aspergillosis and non-Aspergillus invasive mold diseases. Here, we perform a narrative review, discussing the major advances of the last decade on prophylaxis, the diagnosis of and the treatment of IFDs in patients with high-risk neutropenic fever undergoing remission induction chemotherapy for AML/MDS and allo-HSCT. Then, we present our single-center retrospective experience on b-IFDs in 184 AML/MDS patients undergoing high-dose chemotherapy while receiving posaconazole (n = 153 induction treatments, n = 126 consolidation treatments, n = 60 salvage treatments). Six cases of probable/proven b-IFDs were recorded in six patients, with an overall incidence rate of 1.7% (6/339), which is in line with the literature focused on MAP with azoles. The incidence rates (IRs) of b-IFDs (95% confidence interval (95% CI), per 100 person years follow-up (PYFU)) were 5.04 (0.47, 14.45) in induction (n = 2), 3.25 (0.0013, 12.76) in consolidation (n = 1) and 18.38 (3.46, 45.06) in salvage chemotherapy (n = 3). Finally, we highlight the current challenges in the field of b-IFDs; these include the improvement of diagnoses, the expanding treatment landscape of AML with molecular targeted drugs (and related drug-drug interactions with azoles), evolving transplantation techniques (and their related impacts on IFDs' risk stratification), and new antifungals and their features (rezafungin and olorofim).
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Affiliation(s)
- Giovanni Mori
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, Ospedale Santa Chiara, 38122 Trento, Italy
| | - Sara Diotallevi
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Francesca Farina
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Riccardo Lolatto
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Laura Galli
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Matteo Chiurlo
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Andrea Acerbis
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Elisabetta Xue
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Centre for Immuno-Oncology, National Cancer Institute, Eliminate NIH, Bethesda, MD 20850, USA
| | - Daniela Clerici
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sara Mastaglio
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | | | - Marco Ripa
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Consuelo Corti
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Jacopo Peccatori
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Massimo Puoti
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20161 Milan, Italy
- Faculty of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Massimo Bernardi
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Antonella Castagna
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Fabio Ciceri
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Raffaella Greco
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Chiara Oltolini
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20161 Milan, Italy
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5
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Walker J, Edwards WS, Hall NM, Pappas PG. Challenges in management of invasive fungal infections in stem cell transplant. Transpl Infect Dis 2023; 25 Suppl 1:e14175. [PMID: 37864814 DOI: 10.1111/tid.14175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/23/2023]
Abstract
Invasive fungal infections cause significant morbidity and mortality in hematopoietic stem cell transplant recipients. In order to minimize these infections, prophylaxis has become routine, although the agents used have changed over time. This presents new challenges as we consider an approach to breakthrough infections and recognize the epidemiologic shift toward isolates with higher rates of drug resistance. This review outlines the management of the most common pathogens (Candida, Aspergillus, Mucorales) as well as rarer pathogens that have higher rates of resistance (Trichosporon, Fusarium, Scedosporium, and Lomentospora). We discuss potential approaches to proven or possible breakthrough infections with yeast and pulmonary mold disease. Finally, we outline the role for combination therapy and newer antifungals, acknowledging current knowledge gaps and areas for future exploration.
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Affiliation(s)
- Jeremey Walker
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - W Seth Edwards
- Department of Pharmacy, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nicole M Hall
- Department of Pharmacy, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Khatri AM, Natori Y, Anderson A, Jabr R, Shah SA, Natori A, Chandhok NS, Komanduri K, Morris MI, Camargo JF, Raja M. Breakthrough invasive fungal infections on isavuconazole prophylaxis in hematologic malignancy & hematopoietic stem cell transplant patients. Transpl Infect Dis 2023; 25 Suppl 1:e14162. [PMID: 37794708 DOI: 10.1111/tid.14162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Isavuconazole (ISA) is a newer antifungal used in patients with history of hematologic malignancies and hematopoietic transplant and cellular therapies (HM/TCT). Although it has a more favorable side-effect profile, breakthrough invasive fungal infections (bIFIs) while on ISA have been reported. METHODS In this single-center retrospective study evaluating HM/TCT patients who received prophylactic ISA for ≥7 days, we evaluated the incidence and potential risk factors for bIFIs. RESULTS We evaluated 106 patients who received prophylactic ISA. The patients were predominantly male (60.4%) with median age of 65 (range: 21-91) years. Acute myeloid leukemia (48/106, 45.3%) was the most common HM, with majority having relapsed and/or refractory disease (43/106, 40.6%) or receiving ongoing therapy (38/106, 35.8%). Nineteen patients (17.9%) developed bIFIs-nine proven [Fusarium (3), Candida (2), Mucorales plus Aspergillus (2), Mucorales (1), Colletotrichum (1)], four probable invasive pulmonary Aspergillus, and six possible infections. Twelve patients were neutropenic for a median of 28 (8-253) days prior to bIFI diagnosis. ISA levels checked within 7 days of bIFI diagnosis (median: 3.65 μg/mL) were comparable to industry-sponsored clinical trials. All-cause mortality among the bIFI cases was 47.4% (9/19).We also noted clinically significant cytomegalovirus co-infection in 5.3% (1/19). On univariate analysis, there were no significant differences in baseline comorbidities and potential risk factors between the two groups. CONCLUSION ISA prophylaxis was associated with a significant cumulative incidence of bIFIs. Despite the appealing side-effect and drug-interaction profile of ISA, clinicians must be vigilant about the potential risk for bIFIs.
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Affiliation(s)
- Akshay M Khatri
- Division of Infectious Diseases, Department of Medicine, UnityPoint Health-Des Moines, Des Moines, USA
| | - Yoichiro Natori
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
- Miami Transplant Institute, Jackson Health System, Miami, USA
| | - Anthony Anderson
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, Miami, USA
| | - Ra'ed Jabr
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic Health System-Eau Claire, Miami, USA
| | - Shreya A Shah
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, Miami, USA
| | - Akina Natori
- Division of Medical Oncology, Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Namrata S Chandhok
- Division of Hematology, Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Krishna Komanduri
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Michele I Morris
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Jose F Camargo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Mohammed Raja
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
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Wu L, Li S, Gao W, Zhu X, Luo P, Xu D, Liu D, He Y. Real-World, Multicenter Case Series of Patients Treated with Isavuconazole for Invasive Fungal Disease in China. Microorganisms 2023; 11:2229. [PMID: 37764073 PMCID: PMC10535861 DOI: 10.3390/microorganisms11092229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The incidence of invasive fungal disease (IFD) has increased significantly, and IFD is a major cause of mortality among those with hematological malignancies. As a novel second-generation triazole antifungal drug offering both efficacy and safety, isavuconazole (ISA) is recommended by various guidelines internationally for the first-line treatment of invasive aspergillosis (IA) and invasive mucormycosis (IM) infecting adults. Given that it was only approved in China at the end of 2021, there is currently a lack of statistical data regarding its usage in the Chinese population. The primary objective of this report is to describe early experiences with ISA for the treatment of IFD. METHODS This was a real-world, multicenter, observational case series study conducted in China. It included patients from three centers who received ISA treatment from January 2022 to April 2023. A retrospective assessment on patient characteristics, variables related to ISA administration, the treatment response of IFD to ISA, and potential adverse events attributed to ISA was conducted. RESULTS A total of 40 patients met the inclusion criteria. Among them, 12 (30%) were diagnosed with aspergillosis, 2 (5%) were diagnosed with candidiasis, 12 (30%) were diagnosed with mucormycosis, and 14 cases did not present mycological evidence. The predominant site of infection was the lungs (36), followed by the blood stream (8), sinuses (4), and respiratory tract (2). The overall response rate was 75% (30 patients), with male patients having a higher clinical response than female patients (24/24 versus 6/16, p = 0.000) and autologous stem cell transplant patients having a higher clinical response than allogeneic stem cell transplant patients (6/6 versus 4/10, p = 0.027). During the observation period, four patients experienced adverse effects associated with ISA, but none of them discontinued the treatment. CONCLUSIONS Our findings suggest that ISA, a novel first-line treatment for IA and IM, is associated with a high clinical response rate, low incidence, and a low grade of adverse effects. Given the short time that ISA has been available in China, further research is needed to identify its efficacy and safety in the real world.
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Affiliation(s)
- Lisha Wu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.W.); (P.L.)
- Department of Pharmacy, Huangjiahu Hospital, Hubei University of Traditional Chinese Medicine, Wuhan 430065, China
| | - Shougang Li
- Department of Rehabilitation Medicine, General Hospital of Central Theater Command of Chinese People’s Liberation Army, Wuhan 430070, China;
| | - Weixi Gao
- Department of Pharmacy, Hubei General Hospital, Renmin Hospital of Wuhan University, Wuhan 430060, China;
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Pan Luo
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.W.); (P.L.)
| | - Dong Xu
- Department of Infection Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Dong Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.W.); (P.L.)
| | - Yan He
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.W.); (P.L.)
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Criscuolo M, Fracchiolla N, Farina F, Verga L, Pagano L, Busca A. A review of prophylactic regimens to prevent invasive fungal infections in hematology patients undergoing chemotherapy or stem cell transplantation. Expert Rev Hematol 2023; 16:963-980. [PMID: 38044878 DOI: 10.1080/17474086.2023.2290639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION The recent introduction of targeted therapies, including monoclonal antibodies, tyrosine-kinase inhibitors, and immunotherapies has improved the cure rate of hematologic patients. The implication of personalized treatment on primary antifungal prophylaxis will be discussed. AREAS COVERED We reviewed the literature for clinical trials reporting the rate of invasive fungal infections during targeted and cellular therapies and stem cell transplant, and the most recent international guidelines for primary antifungal prophylaxis. EXPERT OPINION As the use of personalized therapies is growing, the risk of invasive fungal infection has emerged in various clinical settings. Therefore, it is possible that the use of mold-active antifungal prophylaxis would spread in the next years and the risk of breakthrough infections would increase. The introduction of new antifungal agents in the clinical armamentarium is expected to reduce clinical unmet needs concerning the management of primary antifungal prophylaxis and improve outcome of patients.
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Affiliation(s)
- Marianna Criscuolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Nicola Fracchiolla
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | | | | | - Livio Pagano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessandro Busca
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Department of Oncology, SSCVD Trapianto di Cellule Staminali Torino, Torino, Italy
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9
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Stemler J, Mellinghoff SC, Khodamoradi Y, Sprute R, Classen AY, Zapke SE, Hoenigl M, Krause R, Schmidt-Hieber M, Heinz WJ, Klein M, Koehler P, Liss B, Koldehoff M, Buhl C, Penack O, Maschmeyer G, Schalk E, Lass-Flörl C, Karthaus M, Ruhnke M, Cornely OA, Teschner D. Primary prophylaxis of invasive fungal diseases in patients with haematological malignancies: 2022 update of the recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society for Haematology and Medical Oncology (DGHO). J Antimicrob Chemother 2023:dkad143. [PMID: 37311136 PMCID: PMC10393896 DOI: 10.1093/jac/dkad143] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
Patients with haematological malignancies (HM) are at high risk of developing invasive fungal disease (IFD) with high morbidity and attributable mortality. We reviewed data published until September 2021 to update the 2017 antifungal prophylaxis recommendations of the German Society of Haematology and Medical Oncology (DGHO). The strong recommendation to administer antifungal prophylaxis in patients with HM with long-lasting neutropenia, i.e. <500 cells/μL for >7 days remains unchanged. Posaconazole remains the drug of choice for mould-active prophylaxis in these patients. Novel treatment options in HM, such as CAR-T-cell treatment or novel targeted therapies for acute myeloid leukaemia (AML) were considered, however, data are insufficient to give general recommendations for routine antifungal prophylaxis in these patients. Major changes regarding specific recommendations compared to the 2017 edition are the now moderate instead of mild support for the recommendations of isavuconazole and voriconazole. Furthermore, published evidence on micafungin allows recommending it at moderate strength for its use in HM. For the first time we included recommendations for non-pharmaceutical measures regarding IFD, comprising the use of high-efficiency particulate air (HEPA) filters, smoking, measures during construction work and neutropenic diets. We reviewed the impact of antifungal prophylaxis with triazoles on drug-drug interactions with novel targeted therapies that are metabolized via cytochrome p450 where triazoles inhibit CYP3A4/5. The working group recommends reducing the dose of venetoclax when used concomitantly with strong CYP3A4 inhibiting antifungals. Furthermore, we reviewed data on the prophylactic use of novel antifungal agents. Currently there is no evidence to support their use in a prophylactic setting in clinical practice.
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Affiliation(s)
- Jannik Stemler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Sibylle C Mellinghoff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Yascha Khodamoradi
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Rosanne Sprute
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Annika Y Classen
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Sonja E Zapke
- Department Hematology, Oncology, Infectious disease and Palliatve Care, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical University of Graz, Graz, Austria and BioTechMed, Graz, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical University of Graz, Graz, Austria and BioTechMed, Graz, Austria
| | - Martin Schmidt-Hieber
- 2nd Medical Clinic (Hematology, Oncology, Pneumology, Nephrology), Carl-Thiem Clinic Cottbus, Cottbus, Germany
| | - Werner J Heinz
- Medical Clinic II, Caritas Hospital, Bad Mergentheim, Germany
| | - Michael Klein
- Department of Hematology and Medical Oncology, Klinikum Vest, Knappschaftskrankenhaus, Recklinghausen, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Blasius Liss
- Department Hematology, Oncology, Infectious disease and Palliatve Care, Helios University Hospital Wuppertal, Wuppertal, Germany
- School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Michael Koldehoff
- Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hygiene and Environmental Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Olaf Penack
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin, Germany
- Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Berlin, Germany
| | - Georg Maschmeyer
- Formerly Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Enrico Schalk
- Department of Haematology and Oncology, Medical Centre, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, ECMM Excellence Centre, Medical University of Innsbruck, Innsbruck, Austria
| | - Meinolf Karthaus
- Department of Hematology, Oncology and Palliative Care, Klinikum Neuperlach, Munich, Germany
| | - Markus Ruhnke
- Helios Klinikum Aue, Klinik für Hämatologie/Onkologie & Palliativmedizin, Aue, Germany
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, NRW, Germany
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Daniel Teschner
- Department of Hematology, and Medical Oncology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
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10
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Yang N, Zhang L, Feng S. Clinical Features and Treatment Progress of Invasive Mucormycosis in Patients with Hematological Malignancies. J Fungi (Basel) 2023; 9:jof9050592. [PMID: 37233303 DOI: 10.3390/jof9050592] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023] Open
Abstract
The incidence rate of invasive mucormycosis (IM) in patients with hematological malignancies (HMs) is increasing year by year, ranging from 0.07% to 4.29%, and the mortality rate is mostly higher than 50%. With the ongoing pandemic of COVID-19, COVID-19-associated mucormycosis (CAM) also became a global health threat. Patients with high risk factors such as active HMs, relapsed/refractory leukemia, prolonged neutropenia may still develop breakthrough mucormycosis (BT-MCR) even under the prophylaxis of Mucorales-active antifungals, and such patients often have higher mortality. Rhizopus spp. is the most common genus associated with IM, followed by Mucor spp. and Lichtheimia spp. Pulmonary mucormycosis (PM) is the most common form of IM in patients with HMs, followed by rhino-orbital-cerebral mucormycosis (ROCM) and disseminated mucormycosis. The prognosis of IM patients with neutrophil recovery, localized IM and receiving early combined medical-surgical therapy is usually better. As for management of the disease, risk factors should be eliminated firstly. Liposome amphotericin B (L-AmB) combined with surgery is the initial treatment scheme of IM. Those who are intolerant to L-AmB can choose intravenous formulations or tablets of isavuconazole or posaconazole. Patients who are refractory to monotherapy can turn to combined antifungals therapy.
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Affiliation(s)
- Nuobing Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
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11
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Villalobos APC, Bow EJ. Isavuconazole as an alternative for antifungal prophylaxis in patients with hematological malignancies: Is the signal sufficient to support clinical practice? Transpl Infect Dis 2023; 25:e14046. [PMID: 36864665 DOI: 10.1111/tid.14046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 03/04/2023]
Affiliation(s)
- Armelle Perez-Cortes Villalobos
- Department of Medical Microbiology and Infectious Diseases, Max Rady School of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Infectious Diseases, Department of Internal Medicine, Max Rady School of Medicine, The University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric J Bow
- Department of Medical Microbiology and Infectious Diseases, Max Rady School of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Infectious Diseases, Department of Internal Medicine, Max Rady School of Medicine, The University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Haematology/Oncology, Department of Internal Medicine, Max Rady School of Medicine, The University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada.,Infection Control Services, CancerCare Manitoba, Winnipeg, Manitoba, Canada
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12
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Scott SA, Perry C, Mahmoudjafari Z, Martin GA, Boyd S, Thompson J, Thomas B. Incidence of breakthrough fungal infections on isavuconazole prophylaxis compared to posaconazole and voriconazole. Transpl Infect Dis 2023; 25:e14045. [PMID: 36856447 DOI: 10.1111/tid.14045] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Invasive fungal infections (IFIs) are a common infectious complication during the treatment of acute myeloid leukemia (AML), high-risk myelodysplastic syndrome (MDS) or post hematopoietic cell transplantation (HCT). For these patients, the National Comprehensive Cancer Network recommends posaconazole or voriconazole for IFI prophylaxis. In clinical practice, however, there has been increased use of isavuconazole due to favorable pharmacokinetic and pharmacodynamic parameters despite limited data for this indication. The comparative prophylactic efficacy of antifungals in this patient population has not been reported, and an analysis is warranted. METHODS This retrospective, matched cohort, single-center study, included AML, MDS, or HCT patients who began treatment or underwent transplant between January 1, 2015 and July 31, 2021. Isavuconazole patients were matched 1:2 with patients receiving posaconazole or voriconazole prophylaxis. RESULTS A total of 126 patients were included, 42 received isavuconazole, 81 received posaconazole, and three received voriconazole. The majority of patients were male receiving secondary IFI prophylaxis while receiving steroids for treatment of GVHD. The incidence of possible, probable or proven IFI was 16.7% in the isavuconazole group compared to 10.7% in the posaconazole and voriconazole group (OR 1.28, 95% CI -0.9-1.4; p = .67). Hepatotoxicity occurred in 16 total patients, 14 receiving posaconazole and two receiving isavuconazole. CONCLUSION Patients who received isavuconazole prophylaxis during AML induction therapy or post-HCT experienced a similar incidence of breakthrough fungal infections compared to those who received posaconazole or voriconazole. These results suggest no difference in antifungal prophylactic efficacy; however larger prospective comparative studies are needed.
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Affiliation(s)
- Sara A Scott
- Department of Pharmacy, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Cory Perry
- Department of Pharmacy, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Zahra Mahmoudjafari
- Department of Pharmacy, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Grace A Martin
- Department of Pharmacy, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Samuel Boyd
- Department of Biostatistics and Data Science, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey Thompson
- Department of Biostatistics and Data Science, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Beth Thomas
- Department of Pharmacy, The University of Kansas Health System, Kansas City, Kansas, USA
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13
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Ping Y, Hongmei J, Bellmann C, Inês M, Macmillan T, Webb N, Aram JA, Penack O. Effectiveness and safety of isavuconazole prophylaxis for invasive fungal infections in the haematologic setting. Hematology 2022; 27:723-732. [PMID: 35688453 DOI: 10.1080/16078454.2022.2076046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Patients with haematologic malignancies are at high risk of developing invasive fungal infections (IFIs). Current guidelines recommend the use of azoles for IFI prophylaxis; however, in many clinical situations, antifungal prophylaxis is used off-label. We conducted a systematic literature review to provide haematologists with the available evidence on the effectiveness and safety of isavuconazole in IFI prophylaxis in interventional and real-world, observational studies. METHODS Embase, MEDLINE and Cochrane Library databases, and relevant conference proceedings and clinical trial registries, were searched for studies on the effectiveness and safety of isavuconazole prophylaxis in adults at high risk of IFIs. Studies were assessed for inclusion and risk of bias. RESULTS Nine studies were eligible for inclusion in the review, eight of which were in haematologic populations (patients undergoing haematopoietic stem cell transplantation or with acute myeloid leukaemia or myelodysplastic syndromes; n = 5) or included haematologic populations (n = 3). Evidence from these studies suggests isavuconazole is effective for IFI prophylaxis in the haematologic setting. However, the studies frequently lacked safety data, most were based on small patient populations from single centres and risk of bias could not be assessed for five studies. DISCUSSION These findings provide evidence for isavuconazole as an alternative azole for prophylaxis in high-risk populations. Limitations include lack of applicability of risk of bias assessment tools, level of filtering applied in the search strategy and focus on English-language publications. CONCLUSION Isavuconazole may be an effective azole for IFI prophylaxis in high-risk haematologic populations, although further studies are needed.
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Affiliation(s)
- Yang Ping
- Peking University Third Hospital, Beijing, People's Republic of China
| | - Jing Hongmei
- Peking University Third Hospital, Beijing, People's Republic of China
| | | | - Mónica Inês
- Patient Health Impact, Pfizer Inc, Porto Salvo, Portugal
| | | | | | | | - Olaf Penack
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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14
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Zhang T, Shen Y, Feng S. Clinical research advances of isavuconazole in the treatment of invasive fungal diseases. Front Cell Infect Microbiol 2022; 12:1049959. [PMID: 36530445 PMCID: PMC9751058 DOI: 10.3389/fcimb.2022.1049959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/16/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose Invasive fungal diseases (IFD) are a major global public health concern. The incidence of IFD has increased the demand for antifungal agents. Isavuconazole (ISA) is a new triazole antifungal agent that has shown promising efficacy in the prophylaxis and treatment of invasive fungal diseases. The aim of this review is to summarize the recent real-world experiences of using ISA for the treatment and prevention of IFD. Methods We performed a comprehensive literature search of the MEDLINE, PubMed, Embase, and Cochrane databases for clinical applications of ISA in the real world. Tables and reference lists are presented for this systematic review. Results IFD poses a major threat to public health and causes high mortality rates. ISA may provide a good treatment. For example, the efficacy of ISA in the treatment of invasive aspergillosis (IA) is comparable to that of voriconazole, and its efficacy in the treatment of invasive mucormycosis (IM) is similar to that of liposomal amphotericin B (L-AmB); therefore, ISA is recommended as the first-line treatment for IA and IM. ISA can also achieve good efficacy in the treatment of invasive candidiasis (IC) and can be used as an alternative to de-escalation therapy after first-line drug therapy. In addition, most studies have shown the efficacy and safety of ISA for the prophylaxis of IFD. Conclusion Taken together, ISA are expected to become a new choice for the treatment and prevention of IFD because of their good tolerability, high bioavailability, and few drug interactions.
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Affiliation(s)
- Tingting Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China,Hematopoietic Stem Cell Transplantation Center, Tianjin Institutes of Health Science, Tianjin, China
| | - Yuyan Shen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China,Hematopoietic Stem Cell Transplantation Center, Tianjin Institutes of Health Science, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China,Hematopoietic Stem Cell Transplantation Center, Tianjin Institutes of Health Science, Tianjin, China,*Correspondence: Sizhou Feng,
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15
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Abstract
Isavuconazole is the newest of the clinically available advanced generation triazole antifungals and is active against a variety of yeasts, molds, and dimorphic fungi. Its current FDA-approved indications include the management of invasive aspergillosis as well as mucormycosis, though the latter indication is supported by limited clinical data. Isavuconazole did not achieve noninferiority to caspofungin for the treatment of invasive candidiasis and therefore lacks an FDA-approved indication for this invasive disease. Significant advantages of isavuconazole, primarily over voriconazole but in some circumstances posaconazole as well, make it an appealing option for the management of complex patients with invasive fungal infections. These potential advantages include lack of QTc interval prolongation, more predictable pharmacokinetics, a less complicated drug interaction profile, and improved tolerability, particularly when compared to voriconazole. This review discusses these topics in addition to addressing the in vitro activity of the compound against a variety of fungi and provides insight into other distinguishing factors among isavuconazole, voriconazole, and posaconazole. The review concludes with an opinion section in which the authors provide the reader with a framework for the current role of isavuconazole in the antifungal armamentarium and where further data are required.
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16
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Isavuconazole for COVID-19-Associated Invasive Mold Infections. J Fungi (Basel) 2022; 8:jof8070674. [PMID: 35887431 PMCID: PMC9323932 DOI: 10.3390/jof8070674] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/31/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Isavuconazole is a broad-spectrum antifungal drug recently approved as a first-line treatment for invasive aspergillosis and as a first or alternative treatment for mucormycosis. The purpose of this review was to report and discuss the use of isavuconazole for the treatment of COVID-19-associated aspergillosis (CAPA), and COVID-19-associated mucormycosis (CAM). Among all studies which reported treatment of CAPA, approximately 10% of patients were reportedly treated with isavuconazole. Considering 14 identified studies that reported the use of isavuconazole for CAPA, isavuconazole was used in 40% of patients (95 of 235 treated patients), being first-line monotherapy in over half of them. We identified six studies that reported isavuconazole use in CAM, either alone or in combination therapy. Overall, isavuconazole was used as therapy in 13% of treated CAM patients, frequently as combination or sequential therapy. The use of isavuconazole in CAPA and CAM is complicated by the challenge of achieving adequate exposure in COVID-19 patients who are frequently obese and hospitalized in the ICU with concomitant renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO). The presence of data on high efficacy in the treatment of aspergillosis, lower potential for drug–drug interactions (DDIs) and for subtherapeutic levels, and no risk of QT prolongation compared to other mold-active azoles, better safety profile than voriconazole, and the possibility of using an intravenous formulation in the case of renal failure are the advantages of using isavuconazole in this setting.
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17
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Lindsay J, Krantz EM, Morris J, Sweet A, Tverdek F, Joshi A, Yeh R, Hill JA, Greenwood M, Chen SCA, Kong DCM, Slavin M, Pergam SA, Liu C. Voriconazole in hematopoietic stem cell transplantation and cellular therapies: Real-world usage and therapeutic level attainment at a major transplant center. Transplant Cell Ther 2022; 28:511.e1-511.e10. [PMID: 35623614 DOI: 10.1016/j.jtct.2022.05.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Voriconazole (VCZ) was one of the first mold-active triazoles available; however, its current use among high-risk hematology populations is unknown as the uptake of posaconazole (PCZ) and isavuconazole (ISZ) increases. OBJECTIVES We evaluated the usage and therapeutic level attainment of VCZ in hematopoietic cell transplant (HCT) and chimeric antigen receptor T cell (CAR-T) therapy patients at our cancer center. STUDY DESIGN Electronic medical records for all adult HCT or CAR-T patients with an order for VCZ, PCZ or ISV between January 1, 2018, and June 30, 2020 were extracted. Clinical characteristics, VCZ indication, trough VCZ levels, and frequency of VCZ initiation from 6 months pre- to 6 months post HCT/CAR-T infusion in consecutive HCT/CAR-T recipients within the study period (infusion between July 1, 2018, and January 1, 2020) were assessed. The association between relevant clinical characteristics and the attainment of sub- or supratherapeutic levels was also evaluated. RESULTS Of 468 patients prescribed mold-active triazoles, 256 (54.7%) were prescribed VCZ, 324 (69.2%) PCZ, and 60 (12.8%) ISZ; 152/468 (32.5%) treatment regimens were sequentially modified to alternate mold-active triazoles. Among consecutive HCT and CAR-T recipients at our center, evaluated 6 months pre- or post- HCT/ CAR-T, VCZ was commonly initiated pre- or post-allogeneic HCT (102/381, 26.8%), with most use in the first 30 days post stem cell infusion (40/381, 10.5%); VCZ use was less common in autologous HCT (13/276, 4.7%) and CAR-T (10/153, 6.5%). Of 223 VCZ orders that met inclusion for analysis, indications included empiric treatment in 108/223 (48.4%), directed therapy in 25/223 (11.2%), primary prophylaxis in 69/223 (30.9%) and secondary prophylaxis in 21/223 (9.4%). Of 223 eligible VCZ patients, 144 (64.6%) had at least one VCZ level measured during the study period; 75/144 (52.1%) had a therapeutic VCZ level (1.0-5.5mg/L) at the first measurement (median 2.8mg/L [range 0.1 - 13.5]) at a median of 6 days of therapy, with 26.4% subtherapeutic and 21.5% supratherapeutic; 46/88 (52.3%) were therapeutic at the second measurement (2.1mg/L [0.1 - 9.9]) at a median of 17 days of therapy; and 33/48 (68.8%) at the third (2.3mg/L [0.1 - 7.7]) at a median of 29 days. In multivariable analysis of factors associated with sub- or supratherapeutic levels (body mass index ≥30, concurrent omeprazole use, concurrent letermovir use, indication for VCZ, history/timeframe of HCT), the only significant association was lower odds of a supratherapeutic VCZ level among those undergoing HCT within the previous 30 days compared to those without a history of HCT. CONCLUSIONS VCZ continues to remain an important option in the treatment and prevention of invasive fungal infections in an era when alternative oral mold-active triazoles are available. In spite of long-standing experience with VCZ prescribing, therapeutic level attainment remains a challenge.
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Affiliation(s)
- Julian Lindsay
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America; National Centre for Infection in Cancer (NCIC), Peter MacCallum Cancer Centre, Melbourne, Australia.
| | - Elizabeth M Krantz
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Jessica Morris
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Ania Sweet
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Frank Tverdek
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America; Department of Pharmacy, University of Washington, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Avadhut Joshi
- Pharmacokinetics Laboratory, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Rosa Yeh
- Pharmacokinetics Laboratory, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Joshua A Hill
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America; Division of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Matthew Greenwood
- Haematology Department, Royal North Shore Hospital, Sydney, Australia; Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Sharon C-A Chen
- National Centre for Infection in Cancer (NCIC), Peter MacCallum Cancer Centre, Melbourne, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, The University of Sydney, and the Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, Australia
| | - David C M Kong
- NHMRC National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, Parkville, Victoria, Australia; Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Monica Slavin
- National Centre for Infection in Cancer (NCIC), Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
| | - Steven A Pergam
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America; Division of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Catherine Liu
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America; Division of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
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Kably B, Launay M, Derobertmasure A, Lefeuvre S, Dannaoui E, Billaud EM. Antifungal Drugs TDM: Trends and Update. Ther Drug Monit 2022; 44:166-197. [PMID: 34923544 DOI: 10.1097/ftd.0000000000000952] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The increasing burden of invasive fungal infections results in growing challenges to antifungal (AF) therapeutic drug monitoring (TDM). This review aims to provide an overview of recent advances in AF TDM. METHODS We conducted a PubMed search for articles during 2016-2020 using "TDM" or "pharmacokinetics" or "drug-drug-interaction" with "antifungal," consolidated for each AF. Selection was limited to English language articles with human data on drug exposure. RESULTS More than 1000 articles matched the search terms. We selected 566 publications. The latest findings tend to confirm previous observations in real-life clinical settings. The pharmacokinetic variability related to special populations is not specific but must be considered. AF benefit-to-risk ratio, drug-drug interaction (DDI) profiles, and minimal inhibitory concentrations for pathogens must be known to manage at-risk situations and patients. Itraconazole has replaced ketoconazole in healthy volunteers DDI studies. Physiologically based pharmacokinetic modeling is widely used to assess metabolic azole DDI. AF prophylactic use was studied more for Aspergillus spp. and Mucorales in oncohematology and solid organ transplantation than for Candida (already studied). Emergence of central nervous system infection and severe infections in immunocompetent individuals both merit special attention. TDM is more challenging for azoles than amphotericin B and echinocandins. Fewer TDM requirements exist for fluconazole and isavuconazole (ISZ); however, ISZ is frequently used in clinical situations in which TDM is recommended. Voriconazole remains the most challenging of the AF, with toxicity limiting high-dose treatments. Moreover, alternative treatments (posaconazole tablets, ISZ) are now available. CONCLUSIONS TDM seems to be crucial for curative and/or long-term maintenance treatment in highly variable patients. TDM poses fewer cost issues than the drugs themselves or subsequent treatment issues. The integration of clinical pharmacology into multidisciplinary management is now increasingly seen as a part of patient care.
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Affiliation(s)
- Benjamin Kably
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
| | - Manon Launay
- Laboratoire de Pharmacologie-Toxicologie-Gaz du sang, Hôpital Nord-CHU Saint Etienne, Saint-Etienne
| | - Audrey Derobertmasure
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
| | - Sandrine Lefeuvre
- Laboratoire de Toxicologie et Pharmacocinétique, CHU de Poitiers, Poitiers; and
| | - Eric Dannaoui
- Faculté de Médecine, Université de Paris, Paris, France
- Unité de Parasitologie-Mycologie, Laboratoire de Microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Eliane M Billaud
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
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Sivasubramanian G, Chandrasekar PH. Efficacy and safety of Isavuconazole for the treatment of invasive Aspergillus infection - an update of the literature. Expert Opin Pharmacother 2022; 23:543-549. [PMID: 35099351 DOI: 10.1080/14656566.2022.2032645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Invasive aspergillosis is associated with high morbidity and mortality in immunocompromised patients. It is now increasingly reported in critically ill patients, including those with respiratory viral infections, such as influenza and COVID-19. Antifungal management is challenging due to diagnostic delay, adverse drug reactions, drug-drug interactions, narrow therapeutic window, and the emergence of resistance. Isavuconazole is the most recent FDA approved azole for the treatment of invasive aspergillosis, with data continuing to accumulate. AREAS COVERED The authors review the safety and efficacy of isavuconazole in the management of invasive aspergillosis based on the currently available evidence. The authors also report on the structure, mechanism of action, pharmacokinetic properties, in vitro and in vivo studies as well as clinical safety and efficacy reports of isavuconazole since its FDA approval. EXPERT OPINION Isavuconazole is non-inferior to voriconazole and is a safe, effective, and better tolerated option for the treatment of invasive aspergillosis. It offers several advantages over other antifungal agents, including having a better adverse event profile with respect to hepatotoxicity, neuro-visual toxicity, QTc prolongation, as well as a stable pharmacokinetic profile obviating the need for therapeutic drug monitoring. Further studies are needed to evaluate its performance in prophylaxis against invasive aspergillosis as well as in the treatment of aspergillosis in critically ill patients without underlying cancer or transplant.
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Affiliation(s)
- Geetha Sivasubramanian
- Division of Infectious Diseases, University of California, San Francisco, Fresno, CA, USA
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Abstract
ABSTRACT Venetoclax has transformed the therapeutic landscape of acute myeloid leukemia (AML). Hypomethylating agents with venetoclax (HMA-VEN) have significantly improved outcomes and have become the standard therapy for older/unfit patients with newly diagnosed AML and are comparable to intensive chemotherapy in salvage setting. Venetoclax with intensive chemotherapy have shown high response rates in both frontline and salvage setting in younger patients, and triplet combinations with HMA-VEN and FLT3 inhibitors have shown encouraging results in FLT3mut AML. While patients with NPM1mut, IDH1/2mut experience favorable outcomes, those with TP53mut and secondary AML may experience minimal benefit from the addition of venetoclax. Despite improved outcomes, severe cytopenias and infectious complications are common with venetoclax-based regimens. Early response evaluation, dose reductions, venetoclax interruptions, use of growth factors, and prophylactic antimicrobials may minimize such myelosuppression and risk of infections. Outcomes after failure of frontline HMA-VEN are dismal, and novel approaches are needed to abrogate primary and acquired resistance.
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21
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Teh BW, Yeoh DK, Haeusler GM, Yannakou CK, Fleming S, Lindsay J, Slavin MA. Consensus guidelines for antifungal prophylaxis in haematological malignancy and haemopoietic stem cell transplantation, 2021. Intern Med J 2021; 51 Suppl 7:67-88. [PMID: 34937140 DOI: 10.1111/imj.15588] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Antifungal prophylaxis can reduce morbidity and mortality from invasive fungal disease (IFD). However, its use needs to be optimised and appropriately targeted to patients at highest risk to derive the most benefit. In addition to established risks for IFD, considerable recent progress in the treatment of malignancies has resulted in the development of new 'at-risk' groups. The changing epidemiology of IFD and emergence of drug resistance continue to impact choice of prophylaxis, highlighting the importance of active surveillance and knowledge of local epidemiology. These guidelines aim to highlight emerging risk groups and review the evidence and limitations around new formulations of established agents and new antifungal drugs. It provides recommendations around use and choice of antifungal prophylaxis, discusses the potential impact of the changing epidemiology of IFD and emergence of drug resistance, and future directions for risk stratification to assist optimal management of highly vulnerable patients.
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Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Daniel K Yeoh
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Costas K Yannakou
- Department of Molecular Oncology and Cancer Immunology, Epworth Freemasons Hospital, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Shaun Fleming
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health, Melbourne, Victoria, Australia
| | - Julian Lindsay
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Immunocompromised Host Infection Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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22
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Thompson GR, Garcia-Diaz J, Miceli MH, Nguyen MH, Ostrosky-Zeichner L, Young JAH, Fisher CE, Clark NM, Greenberg RN, Spec A, Kovanda L, Croos-Dabrera R, Kontoyiannis DP. Systemic antifungal therapy with isavuconazonium sulfate or other agents in adults with invasive mucormycosis or invasive aspergillosis (non-fumigatus): A multicentre, non-interventional registry study. Mycoses 2021; 65:186-198. [PMID: 34888961 DOI: 10.1111/myc.13412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/17/2021] [Accepted: 12/07/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Isavuconazole, administered as isavuconazonium sulfate (ISAVUSULF), is a broad-spectrum triazole agent for the treatment of invasive fungal disease. In phase 3 studies, ISAVUSULF showed comparable efficacy to voriconazole and amphotericin B for the treatment of invasive aspergillosis (IA) and invasive mucormycosis (IM), respectively. OBJECTIVES The objective of this study is to determine all-cause mortality and safety outcomes among adults with IM and/or IA non-fumigatus (nf) treated with ISAVUSULF or other antifungal therapies (AFT). PATIENTS AND METHODS This multicentre, non-interventional registry enrolled patients aged ≥18 years with IM or IA-nf who received systemic AFT from January 2016 to November 2018. Patients received primary ISAVUSULF, non-primary ISAVUSULF, or other AFT, as monotherapy or combination therapy. The primary end point was all-cause mortality at Days 42 and 84; safety outcomes were adverse drug reactions (ADRs) to ISAVUSULF. RESULTS Of 204 patients enrolled, 74 received primary ISAVUSULF, 30 non-primary ISAVUSULF, and 100 other AFT. All-cause mortality through Day 42 was numerically lower in the non-primary ISAVUSULF group than in the primary ISAVUSULF and other AFT groups, for patients with IM (20.0% vs. 33.3% and 41.3%, respectively) or IA-nf (0% vs. 14.8% and 17.8%, respectively). All-cause mortality tended to be lower with combination therapy than with monotherapy, except for patients with IM receiving primary ISAVUSULF. Of 111 patients receiving ISAVUSULF, 14 (12.6%) reported ADRs, of whom three (2.7%) developed serious ADRs. There were no drug-related deaths. CONCLUSIONS This study supports the effectiveness and tolerability of ISAVUSULF in clinical practice. Further research is required to confirm the value of ISAVUSULF combination therapy over monotherapy.
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Affiliation(s)
| | | | | | - M Hong Nguyen
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | | | | | - Nina M Clark
- Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | | | - Andrej Spec
- Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Laura Kovanda
- Astellas Pharma Global Development, Inc, Northbrook, Illinois, USA
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23
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Lindsay J, Othman J, Kong Y, Yip A, Van Hal S, Larsen S, Bryant C, Gibson J, Kerridge I, Fay K, Stevenson W, Arthur C, Chen SCA, Kong DCM, Greenwood M, Pergam SA, Liu C, Slavin MA. SUBA-Itraconazole for Primary Antifungal Prophylaxis After Allogeneic Hematopoietic Cell Transplantation. Open Forum Infect Dis 2021; 8:ofab502. [PMID: 35559121 PMCID: PMC9088511 DOI: 10.1093/ofid/ofab502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/29/2021] [Indexed: 11/08/2022] Open
Abstract
Background Itraconazole (ITZ) is an effective agent when used as primary invasive fungal disease (IFD) prophylaxis, but is limited by drug tolerability and variability in serum concentrations. A new formulation, SUBA-itraconazole (for "super bioavailability"; S-ITZ), addresses the limitations of conventional ITZ formulations. Methods We conducted a retrospective cohort study at 2 Australian centers to evaluate the safety, tolerability, and effectiveness of S-ITZ as primary antifungal prophylaxis in hematopoietic cell transplant (HCT) recipients without grade II-IV acute graft-vs-host disease, from day 1 until approximately day 100 (cohort A) or day 1 until neutrophil engraftment (cohort B). A total of 204 patients and 1410 trough plasma ITZ concentrations were assessed. Results The incidence of breakthrough proven/probable IFD at day 180 was 1.0% (95% confidence interval [CI], .2%-3.2%), with 1.6% in cohort A and 0% in cohort B, and overall fungal-free survival of proven/probable IFD was 82.9% (95% CI, 76.8%-87.4%). Preengraftment early permanent S-ITZ discontinuation was 3.4% overall, with no significant difference between cohorts. No patients required cessation due to gastrointestinal intolerance attributed to S-ITZ. The geometric mean trough plasma ITZ concentration was 1130ng/mL (interquartile range, 566-1801ng/mL; coefficient of variation, 56.57%) and the median time to achieve therapeutic levels was 10 days. Conclusions S-ITZ is a safe and well-tolerated oral formulation and is a novel alternative for primary IFD prophylaxis after HCT.
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Affiliation(s)
- Julian Lindsay
- National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia,Haematology Department, Royal North Shore Hospital, Sydney, Australia,Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Correspondence: Julian Lindsay, BPharm(Hons), MClinPharm, National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000 Australia ()
| | - Jad Othman
- Haematology Department, Royal North Shore Hospital, Sydney, Australia
| | - Yvonne Kong
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Annie Yip
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Sebastiaan Van Hal
- Infectious Diseases Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Stephen Larsen
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christian Bryant
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - John Gibson
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ian Kerridge
- Haematology Department, Royal North Shore Hospital, Sydney, Australia,Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Keith Fay
- Haematology Department, Royal North Shore Hospital, Sydney, Australia
| | - William Stevenson
- Haematology Department, Royal North Shore Hospital, Sydney, Australia,Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Chris Arthur
- Haematology Department, Royal North Shore Hospital, Sydney, Australia
| | - Sharon C A Chen
- National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia,Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, and Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - David C M Kong
- National Health and Medical Research Council National Centre for Antimicrobial Stewardship at the Peter Doherty Institute for Infections and Immunity, Parkville, Victoria, Australia,Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia,Pharmacy Department, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Matthew Greenwood
- Haematology Department, Royal North Shore Hospital, Sydney, Australia,Northern Blood Research Centre, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Steven A Pergam
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Catherine Liu
- Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Monica A Slavin
- National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
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24
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Bogler Y, Stern A, Su Y, Lee YJ, Seo SK, Shaffer B, Perales MA, Papanicolaou GA, Neofytos D. Efficacy and safety of isavuconazole compared with voriconazole as primary antifungal prophylaxis in allogeneic hematopoietic cell transplant recipients. Med Mycol 2021; 59:970-979. [PMID: 34036319 PMCID: PMC8487767 DOI: 10.1093/mmy/myab025] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/10/2021] [Accepted: 05/15/2021] [Indexed: 12/17/2022] Open
Abstract
Voriconazole is frequently discontinued prematurely as primary antifungal prophylaxis (AFP) in allogeneic hematopoietic cell transplant (HCT) recipients due to adverse events. Limited data exists for isavuconazole as AFP. We analyzed adult HCT recipients who received voriconazole or isavuconazole AFP to estimate rate of premature AFP discontinuation, identify risk factors for premature AFP discontinuation, and compare incidence of invasive fungal infection (IFI) and survival at day + 180 post-HCT between patients who received voriconazole/isavuconazole-AFP. This was a propensity score matched cohort analysis of 210 HCT-recipients who received voriconazole-AFP (9/1/2014-12/31/2016; voriconazole-cohort), and 95 HCT-recipients who received isavuconazole-AFP (5/1/2017-10/31/2018; isavuconazole-cohort). AFP discontinuation for any reason prior to completion was defined as "premature". Median (interquartile range, IQR) duration of AFP was longer in the isavuconazole-cohort (94 days, 87-100) vs. the voriconazole-cohort (76 days, 23-94; P-value < 0.0001). Premature AFP discontinuation was more frequent in the voriconazole-cohort (92/210, 43.8%) vs. the isavuconazole-cohort (14/95, 14.7%; P-value < 0.0001). The most common reason for premature discontinuation was biochemical hepatotoxicity (voriconazole-cohort: 48/210, 22.8% vs. isavuconazole-cohort: 5/95, 5.26%; P-value = 0.0002). Transaminase values between baseline and end-of-treatment (EOT) and up to 14 days post-EOT significantly increased in the voriconazole-cohort, but remained unchanged in the isavuconazole-cohort. The incidence of IFI at day + 180 was 2.9% (6/210) and 3.2% (3/95) in the voriconazole-cohort and isavuconazole-cohort, respectively (P-value = 0.881). All-cause mortality at day + 180 was 2.4% (5/210) and 6.3% (6/95) in the voriconazole-cohort and isavuconazole-cohort, respectively (P-value = 0.089). When compared to voriconazole, isavuconazole was a safer and as effective primary AFP during the first 3 months after HCT. LAY SUMMARY When compared to voriconazole, isavuconazole is a safer and as effective primary antifungal prophylaxis during the first 3 months after allogeneic hematopoietic cell transplant, with lower rates of hepatotoxicity, and similar rates of fungal infections and all-cause mortality.
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Affiliation(s)
- Yael Bogler
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anat Stern
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yiqi Su
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yeon Joo Lee
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Susan K Seo
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Brian Shaffer
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Dionysios Neofytos
- Infectious Disease Service, Geneva University Hospital, Geneva, Switzerland
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25
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Kronig I, Masouridi-Levrat S, Chalandon Y, Glampedakis E, Vernaz N, Van Delden C, Neofytos D. Clinical Considerations of Isavuconazole Administration in High-Risk Hematological Patients: A Single-Center 5-Year Experience. Mycopathologia 2021; 186:775-788. [PMID: 34432216 PMCID: PMC8602163 DOI: 10.1007/s11046-021-00583-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 08/03/2021] [Indexed: 11/25/2022]
Abstract
Background There are limited real-life data on isavuconazole prophylaxis and treatment of invasive mold infections (IMI) in hematological patients and allogeneic hematopoietic cell transplant (HCT) recipients. Objectives Primary objective was to describe the indications of real-life isavuconazole administration at a university hospital. Secondary objectives included the description of liver function tests and QTc interval between baseline and end of treatment (EOT), clinical outcomes and breakthrough IMI by the EOT. Patients/Methods This was a 5-year single-center retrospective study of all adult patients with acute myeloid leukemia and/or allogeneic HCT recipients who received isavuconazole as prophylaxis and/or treatment between June 1, 2016, and July 31, 2020. Results Among 30 identified patients, the indications for isavuconazole administration were adverse events associated with prior antifungal treatment (N: 18, 60%: hepatotoxicity, renal insufficiency, long QTc interval, neurotoxicity, and potential drug–drug interactions in 6, 4, 3, 1 and 4 patients, respectively), clinical efficacy (N: 5, 16.6%), and other reasons (N: 10, 33.3%; 5/10 patients treated with isavuconazole to facilitate hospital discharge with orally administered appropriate treatment). Alanine aminotransferase significantly decreased from baseline (mean: 129 IU/L, range: 73, 202) to a mean of 48 IU/L (range: 20, 80) by day 14 (P-value: 0.02), 23.5 IU/L (range: 20, 27) by day 28 (P-value: 0.03) and 16.5 IU/L (range: 16, 17) by day 42 (P-value: 0.009). The QTc interval decreased from baseline (mean: 456.8 ms, range: 390, 533) to EOT (mean: 433.8 ms, range: 400, 472; P-value: 0.03). The mean isavuconazole plasma concentration was 2.9 mg/L (range: 0.9, 6.7). There was no breakthrough IMI observed. Conclusion Isavuconazole is a safe and reliable antifungal agent in complex hematological patients, with relatively low hepatotoxicity and QTc interval shortening properties.
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Affiliation(s)
- Ilona Kronig
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Stavroula Masouridi-Levrat
- Bone Marrow Transplant Unit, Division of Hematology, Faculty of Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Bone Marrow Transplant Unit, Division of Hematology, Faculty of Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | - Emmanouil Glampedakis
- Division of Infectious Diseases, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nathalie Vernaz
- Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Christian Van Delden
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
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Cerchione C, Peleteiro Raíndo A, Mosquera Orgueira A, Mosquera Torre A, Bao Pérez L, Marconi G, Isidori A, Pérez Encinas MM, Martinelli G. Safety of FLT3 inhibitors in patients with acute myeloid leukemia. Expert Rev Hematol 2021; 14:851-865. [PMID: 34424108 DOI: 10.1080/17474086.2021.1969911] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Introduction: Acute myeloblastic leukemia (AML) is the most frequent type of acute leukemia in adults with an incidence of 4.2 cases per 100,000 inhabitants and poor 5-year survival. Patients with mutations in the FMS-like tyrosine kinase 3 (FLT3) gene have poor survival and higher relapse rates compared with wild-type cases.Areas covered: Several FLT3 inhibitors have been proved in FLT3mut AML patients, with differences in their pharmacokinetics, kinase inhibitory and adverse events profiles. First-generation multi-kinase inhibitors (midostaurin, sorafenib, lestaurtinib) target multiple proteins, whereassecond-generation inhibitors (crenolanib, quizartinib, gilteritinib) are more specific and potent inhibitors of FLT3, so they are associated with less off-target toxic effects. All of these drugs have primary and acquired mechanisms of resistance, and therefore their combinations with other drugs (checkpoint inhibitors, hypomethylating agents, standard chemotherapy) and its application in different clinical settings are under study.Expert opinion: The recent clinical development of various FLT3 inhibitors for the treatment of FLT3mut AML is an effective therapeutic strategy. However, there are unique toxicities and drug-drug interactions that need to be resolved. It is necessary to understand the mechanisms of toxicity in order to recognize and manage them adequately.
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Affiliation(s)
- Claudio Cerchione
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Andrés Peleteiro Raíndo
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Adrián Mosquera Orgueira
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Alicia Mosquera Torre
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Laura Bao Pérez
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain
| | - Giovanni Marconi
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, Aormn Hospital, Pesaro, Italy
| | - Manuel Mateo Pérez Encinas
- Health Research Institute of Santiago De Compostela (Idis), Santiago De Compostela, Spain.,Division of Hematology, Complejo Hospitalario Universitario De Santiago (Chus), Santiago De Compostela, Spain.,University of Santiago De Compostela, Santiago De Compostela, Spain
| | - Giovanni Martinelli
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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27
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Coussement J, Lindsay J, Teh BW, Slavin M. Choice and duration of antifungal prophylaxis and treatment in high-risk haematology patients. Curr Opin Infect Dis 2021; 34:297-306. [PMID: 34039878 DOI: 10.1097/qco.0000000000000737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize available guidelines as well as the emerging evidence for the prevention and treatment of invasive fungal diseases in high-risk haematology patients. RECENT FINDINGS Primary mould-active prophylaxis is the strategy used in many centres to manage the risk of invasive fungal disease in high-risk haematology patients, and posaconazole remains the antifungal of choice for most of these patients. Data on the use of other antifungals for primary prophylaxis, including isavuconazole, are limited. There is considerable interest in identifying a strategy that would limit the use of mould-active agents to the patients who are the most likely to benefit from them. In this regard, a recent trial demonstrated that the preemptive strategy is noninferior to the empiric strategy. For primary treatment of invasive aspergillosis, two randomized trials found isavuconazole and posaconazole to be noninferior to voriconazole. Isavuconazole does not appear to require therapeutic drug monitoring. SUMMARY Prophylaxis and treatment of invasive fungal diseases in high-risk haematology patients is a rapidly evolving field. Critical clinical questions remain unanswered, especially regarding the management of suspected invasive fungal diseases breaking through mould-active prophylaxis, and the duration of antifungal therapy for invasive mould infections.
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Affiliation(s)
- Julien Coussement
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne
| | - Julian Lindsay
- National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia.,Vaccine and Infectious Disease and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Benjamin W Teh
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
| | - Monica Slavin
- Department of Infectious Diseases.,National Centre for Infection in Cancer, Peter MacCallum Cancer Centre, Melbourne.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
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Gu TM, Lewis JS, Le H, Bubalo JS. Comparative effects of fluconazole, posaconazole, and isavuconazole upon tacrolimus and cyclosporine serum concentrations. J Oncol Pharm Pract 2021; 28:1357-1362. [PMID: 34192963 DOI: 10.1177/10781552211029046] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Calcineurin inhibitors are commonly used in hematopoietic stem cell transplant (HSCT) patients to prevent graft versus host disease, but as CYP3A4 substrates they are frequently involved in drug-drug interactions. The purpose of this study is to characterize the effects of isavuconazole, fluconazole, and posaconazole on tacrolimus and cyclosporine serum concentrations and dose adjustments in allogeneic HSCT patients. METHODS This retrospective study included patients admitted to Oregon Health and Science University between April 2008 and December 2018 who underwent hematopoietic stem cell transplantation and received concomitant tacrolimus or cyclosporine and fluconazole, isavuconazole or posaconazole therapy. Data on patient characteristics, drug dosing, and serum drug concentrations were collected through chart review, and descriptive statistics were used to summarize the results. RESULTS A total of 139 patients were included in this study. We found fluconazole initiation leads to a 25% reduction in both tacrolimus and cyclosporine doses in order to maintain goal serum concentrations. Posaconazole and isavuconazole initiation requires tacrolimus dose reductions by 53% and 21%, respectively. CONCLUSIONS Based on our experience, FLC, POS, and ISA initiation may require CNI dose reductions and close monitoring of CNI levels to ensure levels remain within goal serum concentrations. Larger studies are needed to fully quantify the percentage in CNI dose reductions and characterize differences among these antifungals.
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Affiliation(s)
- Tina M Gu
- Department of Pharmacy, University of California San Francisco, San Francisco, USA
| | - James S Lewis
- Department of Pharmacy, Oregon Health & Science University, Portland, USA
| | - Henry Le
- Department of Pharmacy, Yale New Haven Hospital, New Haven, USA
| | - Joseph S Bubalo
- Department of Pharmacy, Oregon Health & Science University, Portland, USA
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29
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Young JAH. Both "Small Ball" and "Big Inning" Teams Are Progressing the Value of Antifungal Prophylaxis Among Patients With Hematologic Malignancy. Clin Infect Dis 2021; 72:1764-1766. [PMID: 32424426 DOI: 10.1093/cid/ciaa569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/13/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jo-Anne H Young
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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30
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Herity LB, Cruz OADL, Aziz MT. Evaluation of a primary antifungal prophylaxis protocol for preventing invasive mold infections after allogeneic hematopoietic stem cell transplantation. J Oncol Pharm Pract 2021; 28:794-804. [PMID: 33906508 DOI: 10.1177/10781552211011221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Invasive mold infections contribute to morbidity and mortality in patients undergoing allogeneic hematopoietic stem cell transplantation. The optimal strategy for primary antifungal prophylaxis in this patient population remains uncertain. METHODS Medical records of patients who underwent allogeneic hematopoietic stem cell transplantation between 1 January 2013 and 31 December 2017 were retrospectively reviewed. Adult patients were included if they received micafungin followed by fluconazole, with the option to escalate to voriconazole, for antifungal prophylaxis. The primary outcome was the incidence rate of proven or probable invasive mold infection. Secondary outcomes were time to invasive mold infection diagnosis, invasive mold infection-related mortality, and risk factors associated with invasive mold infection. RESULTS Two hundred patients were included in the study, a majority of whom underwent matched unrelated (46%) or matched related (33%) donor transplants. The incidence rate of proven or probable invasive mold infection was 18.4 cases per 100 patient-years, with a one-year cumulative incidence of 14%. Median time to proven or probable invasive mold infection was 94 days post-transplant (IQR 26-178), with invasive mold infection-related mortality occurring in 18 (64%) of 28 patients diagnosed with invasive mold infection. Comparison of invasive mold infection-free survival by potential risk factors failed to show any significant differences. CONCLUSIONS In this real-life cohort of allogeneic hematopoietic stem cell transplantation recipients, the incidence of proven or probable invasive mold infection was higher than expected based on previous literature. In the absence of standard guidance on anti-mold prophylaxis in this patient population and given that unique risk factors for invasive mold infection may differ between institutions, it is essential that centers performing allogeneic hematopoietic stem cell transplantation routinely monitor their antifungal prophylaxis strategies for effectiveness.
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Affiliation(s)
- Leah B Herity
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA.,Department of Pharmacy Services, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Oveimar A De la Cruz
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - May T Aziz
- Department of Pharmacy Services, Virginia Commonwealth University Health System, Richmond, VA, USA
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Liberatore C, Farina F, Greco R, Giglio F, Clerici D, Oltolini C, Lupo Stanghellini MT, Barzaghi F, Vezzulli P, Orsenigo E, Corti C, Ciceri F, Peccatori J. Breakthrough Invasive Fungal Infections in Allogeneic Hematopoietic Stem Cell Transplantation. J Fungi (Basel) 2021; 7:jof7050347. [PMID: 33925188 PMCID: PMC8146885 DOI: 10.3390/jof7050347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 01/17/2023] Open
Abstract
Despite the recent introduction of mold-active antifungal prophylaxis (MAP), breakthrough invasive fungal infections (b-IFI) still represent a possible complication and a cause of morbidity and mortality in hematological patients and allogeneic hematopoietic stem-cell transplantation recipients (HSCT). Data on incidence and type of b-IFI are limited, although they are mainly caused by non-fumigatus Aspergillus and non-Aspergillus molds and seem to depend on specific antifungal prophylaxis and patients’ characteristics. Herein, we described the clinical presentation and management of two cases of rare b-IFI which recently occurred at our institution in patients undergoing HSCT and receiving MAP. The management of b-IFI is challenging due to the lack of data from prospective trials and high mortality rates. A thorough analysis of risk factors, ongoing antifungal prophylaxis, predisposing conditions and local epidemiology should drive the choice of antifungal treatments. Early broad-spectrum preemptive therapy with a lipid formulation of amphotericin-B, in combination with a different mold-active azole plus/minus terbinafine, is advisable. The therapy would cover against rare azole-susceptible and -resistant fungal strains, as well as atypical sites of infections. An aggressive diagnostic work-up is recommended for species identification and subsequent targeted therapy.
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Affiliation(s)
- Carmine Liberatore
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Francesca Farina
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
| | - Raffaella Greco
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
| | - Fabio Giglio
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
| | - Daniela Clerici
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
| | - Chiara Oltolini
- Clinic of Infectious Diseases, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Maria Teresa Lupo Stanghellini
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
| | - Federica Barzaghi
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Paolo Vezzulli
- Neuroradiology Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Elena Orsenigo
- Department of General and Emergency Surgery, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Consuelo Corti
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Correspondence: ; Tel.: +39-0226437703
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; (C.L.); (F.F.); (R.G.); (F.G.); (D.C.); (M.T.L.S.); (C.C.); (J.P.)
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Risum M, Vestergaard MB, Weinreich UM, Helleberg M, Vissing NH, Jørgensen R. Therapeutic Drug Monitoring of Isavuconazole: Serum Concentration Variability and Success Rates for Reaching Target in Comparison with Voriconazole. Antibiotics (Basel) 2021; 10:487. [PMID: 33922419 PMCID: PMC8145181 DOI: 10.3390/antibiotics10050487] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/13/2021] [Accepted: 04/21/2021] [Indexed: 12/13/2022] Open
Abstract
Isavuconazole (ISZ) is used in the treatment of aspergillosis and mucormycosis. The purpose of this study was to evaluate the therapeutic drug monitoring (TDM) of ISZ samples from a clinical setting performed at Statens Serum Institut. Materials/methods: Isavuconazole serum concentrations were determined by fluorescent detection on a UHPLC. Serum-ISZ (s-ISZ) results were included and compared to those of serum-voriconazole (s-VRZ) in a 33 month period from March 2017. Clinical data were obtained for patients receiving ISZ. The therapeutic range was initially 2-10 mg/L, but was adjusted to 2-5 mg/L during the study period except for selected patients with Mucorales infections who received off-label doses of ISZ. Results: A total of 273 s-ISZ and 1242 s-VRZ measurements from 35 and 283 patients, respectively, were included. Seventeen patients had received both ISZ and VRZ with TDM within the study period. The median s-ISZ was 4.3 mg/L (0.5-15.4 mg/L) with 83% of measurements within the therapeutic index. The median s-VRZ was 2.6 mg/L (0.2-21.9 mg/L) with 67% of measurements within the therapeutic index. The median intra-/interindividual coefficient of variation (CV) was 43.4%/54.8% for ISZ compared to 53.2%/83.3% for VRZ. For patients receiving ISZ, the adverse events were mostly gastroenteric and few drug-drug interactions were observed. Furthermore, immediate change from ISZ to VRZ treatment seemed to lead to prolonged metabolism of ISZ with detection up to 35 days after discontinuation. Conclusions: The majority of patients achieved s-ISZ levels well within the therapeutic range with less intra/interindividual CV than patients receiving VRZ.
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Affiliation(s)
- Malene Risum
- Unit of Mycology, Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen, Denmark;
- Department of Haematology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Mai-Britt Vestergaard
- Department of Respiratory Diseases, Aalborg University Hospital, 9000 Aalborg, Denmark; (M.-B.V.); (U.M.W.)
| | - Ulla Møller Weinreich
- Department of Respiratory Diseases, Aalborg University Hospital, 9000 Aalborg, Denmark; (M.-B.V.); (U.M.W.)
- The Clinical Institute, Aalborg University, 9000 Aalborg, Denmark
| | - Marie Helleberg
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Nadja Hawwa Vissing
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - René Jørgensen
- Unit of Mycology, Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen, Denmark;
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Chu S, McCormick TS, Lazarus HM, Leal LO, Ghannoum MA. Invasive fungal disease and the immunocompromised host including allogeneic hematopoietic cell transplant recipients: Improved understanding and new strategic approach with sargramostim. Clin Immunol 2021; 228:108731. [PMID: 33892201 DOI: 10.1016/j.clim.2021.108731] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/12/2021] [Accepted: 04/17/2021] [Indexed: 12/17/2022]
Abstract
In hosts with damaged or impaired immune systems such as those undergoing hematopoietic cell transplant (HCT) or intensive chemotherapy, breakthrough fungal infections can be fatal. Risk factors for breakthrough infections include severe neutropenia, use of corticosteroids, extended use of broad-spectrum antibiotics, and intensive care unit admission. An individual's cumulative state of immunosuppression directly contributes to the likelihood of experiencing increased infection risk. Incidence of invasive fungal infection (IFI) after HCT may be up to 5-8%. Early intervention may improve IFI outcomes, although many infections are resistant to standard therapies (voriconazole, caspofungin, micafungin, amphotericin B, posaconazole or itraconazole, as single agents or in combination). We review herein several contributing factors that may contribute to the net state of immunosuppression in recipients of HCT. We also review a new approach for IFI utilizing adjunctive therapy with sargramostim, a yeast-derived recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF).
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Affiliation(s)
- Sherman Chu
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA; College of Osteopathic Medicine of the Pacific, Northwest (COMP), Lebanon, OR, USA.
| | - Thomas S McCormick
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA.
| | - Hillard M Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, USA.
| | - Luis O Leal
- Partner Therapeutics, Inc., 19 Muzzey St, Lexington, MA, USA.
| | - Mahmoud A Ghannoum
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA; Center for Medical Mycology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Isavuconazole prophylaxis against invasive fungal infections in allogeneic stem cell transplantation: A single-center experience. Hematol Transfus Cell Ther 2021; 44:440-443. [PMID: 33583766 PMCID: PMC9477761 DOI: 10.1016/j.htct.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/23/2020] [Accepted: 01/07/2021] [Indexed: 12/05/2022] Open
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Isavuconazole-Animal Data and Clinical Data. J Fungi (Basel) 2020; 6:jof6040209. [PMID: 33036295 PMCID: PMC7712195 DOI: 10.3390/jof6040209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 12/14/2022] Open
Abstract
The treatment of invasive fungal infections has deeply evolved in the last years with the inclusion of new antifungals, mainly new azoles (i.e., posaconazole, isavuconazole), to the therapeutic armamentarium. This review focuses on the role of isavuconazole for treating the most important invasive fungal infections both in animals and humans (hematological and non-hematological patients).
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36
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37
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Jenks JD, Cornely OA, Chen SCA, Thompson GR, Hoenigl M. Breakthrough invasive fungal infections: Who is at risk? Mycoses 2020; 63:1021-1032. [PMID: 32744334 DOI: 10.1111/myc.13148] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 12/18/2022]
Abstract
The epidemiology of invasive fungal infections (IFIs) in immunocompromised individuals has changed over the last few decades, partially due to the increased use of antifungal agents to prevent IFIs. Although this strategy has resulted in an overall reduction in IFIs, a subset of patients develop breakthrough IFIs with substantial morbidity and mortality in this population. Here, we review the most significant risk factors for breakthrough IFIs in haematology patients, solid organ transplant recipients, and patients in the intensive care unit, focusing particularly on host factors, and highlight areas that require future investigation.
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Affiliation(s)
- Jeffrey D Jenks
- Division of General Internal Medicine, Department of Medicine, University of California San Diego, La Jolla, California, USA.,Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA.,Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, California, USA
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Department I of Internal Medicine, ECMM Center of Excellence for Medical Mycology, German Centre for Infection Research, Partner Site Bonn-Cologne (DZIF), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - George R Thompson
- Department of Internal Medicine Division of Infectious Diseases and Department of Medical Microbiology and Immunology, UC-Davis Medical Center, Sacramento, California, USA
| | - Martin Hoenigl
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA.,Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, California, USA.,Division of Pulmonology and Section of Infectious Diseases, Medical University of Graz, Graz, Austria
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38
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Martino R, Garrido A, Santaliestra M, García-Cadenas I, Novelli S, Saavedra SD, Esquirol A, Granell M, Briones J, Moreno C, Brunet S, Giménez A, Hidalgo A, Sánchez F, Sierra J. Low Rate of Invasive Fungal Infections During Induction and Consolidation Chemotherapy for Adults with De Novo Acute Myeloid Leukemia Without Anti-mold Prophylaxis: Single-Center 2002-2018 Empirical/Pre-emptive Approach. Mycopathologia 2020; 185:639-652. [PMID: 32564177 DOI: 10.1007/s11046-020-00461-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/25/2020] [Indexed: 11/30/2022]
Abstract
Broad-spectrum antifungal prophylaxis is currently considered the standard of care for adults with de novo AML for the prevention of invasive fungal infections (IFIs), especially invasive pulmonary aspergillosis (IPA). Because fluconazole has been used in our center as anti-yeast prophylaxis, we sought to analyze in detail the incidence of IFIs over a 17-year period, as well as their impact on outcome. A standardized protocol of patient management, including serum galactomannan screening and thoracic CT-guided diagnostic-driven antifungal therapy, was used in all patients. A total of 214 consecutive adults with de novo AML who were treated in 3 CETLAM (Grupo Cooperativo para el Estudio y Tratamiento de las Leucemias Agudas y Mielodisplasias) protocols from 2002 to 2018 were included. The 90-day incidence of any IFI (including possible cases) was 11% (95% CI 4-15%), most cases occurred during induction chemotherapy (8%, 95% CI 4-12%), and most cases were probable/proven IPA (8%, 95% CI 3-13%). Developing an IFI during induction and consolidation had no impact on 1-year survival. A case-control study with 23 cases of IPA and 69 controls identified induction/re-induction chemotherapy, chronic pulmonary disease and age > 60 years/poor baseline performance status as potential pretreatment risk factors. The current study proves that inpatient induction and consolidation chemotherapy for de novo AML can be given in areas with "a priori" high-burden of airborne molds with fluconazole prophylaxis, while the selective use of anti-mold prophylaxis in patients at very high risk may further reduce the incidence of IFI in this specific clinical scenario.
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Affiliation(s)
- Rodrigo Martino
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain.
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain.
| | - Ana Garrido
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Marta Santaliestra
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Irene García-Cadenas
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Silvana Novelli
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Silvanna Daniella Saavedra
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Albert Esquirol
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Miquel Granell
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Javier Briones
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Carolina Moreno
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Salut Brunet
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Ana Giménez
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Alberto Hidalgo
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Fernando Sánchez
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Jorge Sierra
- Division of Clinical Hematology, Department of Radiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Av. Mas Casanovas, 90, 08041, Barcelona, Spain
- Department of Microbiology, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
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