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Jjingo CJ, Bala S, Waack U, Needles M, Bensman TJ, McMaster O, Smith T, Blakely B, Chan IZ, Puthawala K, Dixon C, Kim Y, Lim R, Colangelo P, St Clair C, Nambiar S, Moss RB, Botgros R, Bazaz R, Denning DW, Marr KA, Husain S, Berman L, Christensen DJ, Keywood C, Clayton RG, Walsh TJ, Song HSE, Shukla SJ, Farley J. Food and Drug Administration Public Workshop Summary-Addressing Challenges in Inhaled Antifungal Drug Development. Clin Infect Dis 2024; 78:1564-1570. [PMID: 37802928 DOI: 10.1093/cid/ciad607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/21/2023] [Accepted: 10/04/2023] [Indexed: 10/08/2023] Open
Abstract
Allergic bronchopulmonary aspergillosis and invasive fungal diseases represent distinct infectious entities that cause significant morbidity and mortality. Currently, administered inhaled antifungal therapies are unapproved, have suboptimal efficacy, and are associated with considerable adverse reactions. The emergence of resistant pathogens is also a growing concern. Inhaled antifungal development programs are challenged by inadequate nonclinical infection models, highly heterogenous patient populations, low prevalence rates of fungal diseases, difficulties defining clinical trial enrollment criteria, and lack of robust clinical trial endpoints. On 25 September 2020, the US Food and Drug Administration (FDA) convened a workshop with experts in pulmonary medicine and infectious diseases from academia, industry, and other governmental agencies. Key discussion topics included regulatory incentives to facilitate development of inhaled antifungal drugs and combination inhalational devices, limitations of existing nonclinical models and clinical trial designs, patient perspectives, and industry insights.
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Affiliation(s)
- Caroline J Jjingo
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shukal Bala
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ursula Waack
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mark Needles
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Timothy J Bensman
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Owen McMaster
- Division of Pharmacology/Toxicology for Infectious Diseases, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Thomas Smith
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Brandon Blakely
- Division of ENT, Sleep, Respiratory, and Anesthesia, Office of Health Technology 1, Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Irene Z Chan
- Division of Medication Error Prevention and Analysis, Office of Medication Error Prevention and Risk Management, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Khalid Puthawala
- Division of Pulmonology, Allergy, and Critical Care, Office of Immunology and Inflammation, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Cheryl Dixon
- Division of Biometrics IV, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yongman Kim
- Division of Biometrics III, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Lim
- Division of Pulmonology, Allergy, and Critical Care, Office of Immunology and Inflammation, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Philip Colangelo
- Division of Infectious Disease Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christopher St Clair
- Division of Clinical Outcome Assessment, Office of Drug Evaluation Science, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sumathi Nambiar
- Division of Anti-Infectives, Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard B Moss
- Department of Pediatrics, Lucile Packard Children's Hospital and Stanford Children's Health, Stanford University Medical Center, Palo Alto, California, USA
| | - Radu Botgros
- Office of Biological Health Threats and Vaccines Strategy, European Medicines Agency, Amsterdam, The Netherlands
| | - Rohit Bazaz
- National Aspergillosis Centre, University of Manchester, Manchester, United Kingdom
| | - David W Denning
- Global Action Fund for Fungal Infections, The University of Manchester, Manchester, United Kingdom
| | - Kieren A Marr
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shahid Husain
- Transplant Infectious Diseases Clinic, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
- Save Our Sick Kids Foundation, NewYork, New York, USA
| | | | - Sunita J Shukla
- Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - John Farley
- Office of Infectious Diseases, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Pennington KM, Martin MJ, Murad MH, Sanborn D, Saddoughi SA, Gerberi D, Peters SG, Razonable RR, Kennedy CC. Risk Factors for Early Fungal Disease in Solid Organ Transplant Recipients: A Systematic Review and Meta-analysis. Transplantation 2024; 108:970-984. [PMID: 37953478 DOI: 10.1097/tp.0000000000004871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Invasive fungal infections are associated with high morbidity in solid organ transplant recipients. Risk factor modification may help with preventative efforts. The objective of this study was to identify risk factors for the development of fungal infections within the first year following solid organ transplant. METHODS We searched for eligible articles through February 3, 2023. Studies published after January 1, 2001, that pertained to risk factors for development of invasive fungal infections in solid organ transplant were reviewed for inclusion. Of 3087 articles screened, 58 were included. Meta-analysis was conducted using a random-effects model to evaluate individual risk factors for the primary outcome of any invasive fungal infections and invasive candidiasis or invasive aspergillosis (when possible) within 1 y posttransplant. RESULTS We found 3 variables with a high certainty of evidence and strong associations (relative effect estimate ≥ 2) to any early invasive fungal infections across all solid organ transplant groups: reoperation (odds ratio [OR], 2.92; confidence interval [CI], 1.79-4.75), posttransplant renal replacement therapy (OR, 2.91; CI, 1.87-4.51), and cytomegalovirus disease (OR, 2.97; CI, 1.78-4.94). Both posttransplant renal replacement therapy (OR, 3.36; CI, 1.78-6.34) and posttransplant cytomegalovirus disease (OR, 2.81; CI, 1.47-5.36) increased the odds of early posttransplant invasive aspergillosis. No individual variables could be pooled across groups for invasive candidiasis. CONCLUSIONS Several common risk factors exist for the development of any invasive fungal infections in solid organ transplant recipients. Additional risk factors for invasive candidiasis and aspergillosis may be unique to the pathogen, transplanted organ, or both.
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Affiliation(s)
- Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Max J Martin
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David Sanborn
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Steve G Peters
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Raymund R Razonable
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN
| | - Cassie C Kennedy
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Magda G. Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial. Infect Dis Clin North Am 2024; 38:121-147. [PMID: 38280760 DOI: 10.1016/j.idc.2023.12.001] [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] [Indexed: 01/29/2024]
Abstract
Opportunistic infections are a leading cause of lung transplant recipient morbidity and mortality. Risk factors for infection include continuous exposure of the lung allograft to the external environment, high levels of immunosuppression, impaired mucociliary clearance and decreased cough reflex, and impact of the native lung microbiome in single lung transplant recipients. Infection risk is mitigated through careful pretransplant screening of recipients and donors, implementation of antimicrobial prophylaxis strategies, and routine surveillance posttransplant. This review describes common viral, fungal, and mycobacterial infectious after lung transplant and provides recommendations on prevention and treatment.
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Affiliation(s)
- Gabriela Magda
- Columbia University Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street PH-14, New York, NY 10032, USA.
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4
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Huang QY, Li PC, Yue JR. Diagnostic performance of serum galactomannan and β-D-glucan for invasive aspergillosis in suspected patients: A meta-analysis. Medicine (Baltimore) 2024; 103:e37067. [PMID: 38306560 PMCID: PMC10843323 DOI: 10.1097/md.0000000000037067] [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: 09/11/2023] [Accepted: 01/04/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Serum galactomannan (GM) and β-D-glucan (BG) are known markers of invasive aspergillosis (IA). The aim of this meta-analysis was to evaluate the efficiency of serum GM and BG as diagnostic markers of symptomatic IA infection and compare the performance of the combined tests with that of either test individually. METHODS A literature search was carried out using PubMed, Web of Science, and EMBASE databases to include relevant studies published in English up to May 2023. The quality assessment was performed using Review Manager 5.3 software. A bivariate model was applied to pool diagnostic parameters using Stata 14.0 software. We used Cochrane I2 index to assess heterogeneity and identify the potential source of heterogeneity by meta-regression. Paired t tests were used to compare the value of GM and BG for IA diagnosis when used in combination or alone. RESULTS Sixteen studies were eligible for inclusion in the meta-analysis. For proven or probable IA, serum GM and BG yielded a pooled sensitivity of 0.53 (95% CI 0.40-0.66) vs 0.72 (95% CI 0.61-0.81) and a pooled specificity of 0.94 (95% CI 0.91-0.97) vs 0.82 (95% CI 0.73-0.88). The area under the curve (AUC) of ROC was 0.90 (95% CI 0.87-0.92) vs 0.83 (95% CI 0.80-0.86) for all studies. The pooled sensitivity and specificity for IA diagnosis by combined GM and BG assays (GM/BG) were 0.84 (95% CI 0.69-0.86) and 0.76 (95% CI 0.69-0.81), respectively. The sensitivity of the combined GM/BG test to diagnose IA was higher than of the GM or BG test alone. CONCLUSION Serum GM and BG tests had a relatively high accuracy for IA diagnosis in suspected patients. The diagnostic accuracy of both assays is comparable, and the diagnostic sensitivity is further improved by the combined detection of the 2 markers.
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Affiliation(s)
- Qian-Yi Huang
- Department of Transfusion, Nanchong Central Hospital Second Clinical School of North Sichuan Medical College: Nanchong Central Hospital Affiliated to North Sichuan Medical College, Nanchong City, Sichuan Province, China
| | - Peng-Cheng Li
- Department of Neurosurgery, Nanchong Central Hospital Second Clinical School of North Sichuan Medical College: Nanchong Central Hospital Affiliated to North Sichuan Medical College, Nanchong City, Sichuan Province, China
| | - Jin-Rui Yue
- Department of Transfusion, Nanchong Central Hospital Second Clinical School of North Sichuan Medical College: Nanchong Central Hospital Affiliated to North Sichuan Medical College, Nanchong City, Sichuan Province, China
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5
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Huggins JP, Arthur D, Chow SC, Pease R, Stanly K, Workman A, Reynolds J, Alexander BD. Risk Factors for Invasive Fungal Infection in Lung Transplant Recipients on Universal Antifungal Prophylaxis. Open Forum Infect Dis 2024; 11:ofad640. [PMID: 38318603 PMCID: PMC10839422 DOI: 10.1093/ofid/ofad640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/18/2023] [Indexed: 02/07/2024] Open
Abstract
Background Many centers use universal antifungal prophylaxis after lung transplant, but risk factors for invasive fungal infection (IFI) in this setting are poorly described. Methods This retrospective, single-center cohort study including 603 lung transplant recipients assessed risk factors for early (within 90 days of transplant) invasive candidiasis (IC) and invasive mold infection (IMI) and late (90-365 days after transplant) IMI using Cox proportional hazard regression. Results In this cohort, 159 (26.4%) patients had 182 IFIs. Growth of yeast on donor culture (hazard ratio [HR], 3.30; 95% CI, 1.89-5.75) and prolonged length of stay (HR, 1.02; 95% CI, 1.01-1.03) were associated with early IC risk, whereas transplantation in 2016 or 2017 (HR, 0.21; 95% CI, 0.06-0.70; HR, 0.25; 95% CI, 0.08-0.80, respectively) and female recipient sex (HR, 0.53; 95% CI, 0.30-0.93) were associated with reduced risk. Antimold therapy (HR, 0.21; 95% CI, 0.06-0.78) was associated with lower early IMI risk, and female donor sex (HR, 0.40; 95% CI, 0.22-0.72) was associated with lower late IMI risk. Recent rejection was a risk factor for late IMI (HR, 1.73; 95% CI, 1.02-2.95), and renal replacement therapy predisposed to early IC, early IMI, and late IMI (HR, 5.67; 95% CI, 3.01-10.67; HR, 7.54; 95% CI, 1.93-29.45; HR, 5.33; 95% CI, 1.46-19.49, respectively). Conclusions In lung transplant recipients receiving universal antifungal prophylaxis, risk factors for early IC, early IMI, and late IMI differ.
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Affiliation(s)
- Jonathan P Huggins
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - David Arthur
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Shein-Chung Chow
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Robert Pease
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Kelly Stanly
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- School of Medicine, Duke University, Durham, North Carolina, USA
| | | | - John Reynolds
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Barbara D Alexander
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- School of Medicine, Duke University, Durham, North Carolina, USA
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Monforte A, Martin-Gomez MT, Los-Arcos I, Márquez-Algaba E, Berastegui C, Rosado J, Sacanell J, Gavaldà J, Len O. Effect of SARS-CoV-2 preventive measures on early lung transplant fungal acquisition: An observational study. Transpl Infect Dis 2024; 26:e14246. [PMID: 38269450 DOI: 10.1111/tid.14246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Arnau Monforte
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Ibai Los-Arcos
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ester Márquez-Algaba
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Cristina Berastegui
- Department of Pneumology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Joel Rosado
- Department of Thoracic Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Judith Sacanell
- Intensive Care Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Joan Gavaldà
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Oscar Len
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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7
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Crone CG, Wulff SM, Ledergerber B, Helweg-Larsen J, Bredahl P, Arendrup MC, Perch M, Helleberg M. Invasive Aspergillosis among Lung Transplant Recipients during Time Periods with Universal and Targeted Antifungal Prophylaxis-A Nationwide Cohort Study. J Fungi (Basel) 2023; 9:1079. [PMID: 37998886 PMCID: PMC10672607 DOI: 10.3390/jof9111079] [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: 09/27/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Abstract
The optimal prevention strategy for invasive aspergillosis (IA) in lung transplant recipients (LTXr) is unknown. In 2016, the Danish guidelines were changed from universal to targeted IA prophylaxis. Previously, we found higher rates of adverse events in the universal prophylaxis period. In a Danish nationwide study including LTXr, for 2010-2019, we compared IA rates in time periods with universal vs. targeted prophylaxis and during person-time with vs. person-time without antifungal prophylaxis. IA hazard rates were analyzed in multivariable Cox models with adjustment for time after LTX. Among 295 LTXr, antifungal prophylaxis was initiated in 183/193 and 6/102 during the universal and targeted period, respectively. During the universal period, 62% discontinued prophylaxis prematurely. The median time on prophylaxis was 37 days (IQR 11-84). IA was diagnosed in 27/193 (14%) vs. 15/102 (15%) LTXr in the universal vs. targeted period, with an adjusted hazard ratio (aHR) of 0.94 (95% CI 0.49-1.82). The aHR of IA during person-time with vs. person-time without antifungal prophylaxis was 0.36 (95% CI 0.12-1.02). No difference in IA was found during periods with universal vs. targeted prophylaxis. Prophylaxis was protective of IA when taken. Targeted prophylaxis may be preferred over universal due to comparable IA rates and lower rates of adverse events.
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Affiliation(s)
- Cornelia Geisler Crone
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; (S.M.W.); (B.L.); (J.H.-L.); (M.H.)
| | - Signe Marie Wulff
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; (S.M.W.); (B.L.); (J.H.-L.); (M.H.)
| | - Bruno Ledergerber
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; (S.M.W.); (B.L.); (J.H.-L.); (M.H.)
| | - Jannik Helweg-Larsen
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; (S.M.W.); (B.L.); (J.H.-L.); (M.H.)
- Department of Infectious Diseases, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
| | - Pia Bredahl
- Department of Thoracic Anesthesia, Copenhagen University Hospital —Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark;
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen, Denmark;
- Department of Clinical Microbiology, Copenhagen University Hospital —Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark;
| | - Michael Perch
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark;
- Department of Cardiology, Section for Lung Transplantation, Copenhagen University Hospital —Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
| | - Marie Helleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark; (S.M.W.); (B.L.); (J.H.-L.); (M.H.)
- Department of Infectious Diseases, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark;
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Wulff SM, Perch M, Helweg-Larsen J, Bredahl P, Arendrup MC, Lundgren J, Helleberg M, Crone CG. Associations between invasive aspergillosis and cytomegalovirus in lung transplant recipients: a nationwide cohort study. APMIS 2023; 131:574-583. [PMID: 37022293 DOI: 10.1111/apm.13317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 04/02/2023] [Indexed: 04/07/2023]
Abstract
Cytomegalovirus (CMV) and invasive aspergillosis (IA) cause morbidity among lung transplant recipients (LTXr). Early diagnosis and treatment could improve outcomes. We examined rates of CMV after IA and vice versa to assess whether screening for one infection is warranted after detecting the other. All Danish LTXr, 2010-2019, were followed for IA and CMV for 2 years after transplantation. IA was defined using ISHLT criteria. Adjusted incidence rate ratios (aIRR) were estimated by Poisson regression adjusted for time after transplantation. We included 295 LTXr, among whom CMV and IA were diagnosed in 128 (43%) and 48 (16%). The risk of CMV was high the first 3 months after IA, IR 98/100 person-years of follow-up (95% CI 47-206). The risk of IA was significantly increased in the first 3 months after CMV, aIRR 2.91 (95% CI 1.32-6.44). Numbers needed to screen to diagnose one case of CMV after IA, and one case of IA after CMV was approximately seven and eight, respectively. Systematic screening for CMV following diagnosis of IA, and vice versa, may improve timeliness of diagnosis and outcomes for LTXr.
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Affiliation(s)
- Signe Marie Wulff
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Pia Bredahl
- Department of Thoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Maiken Cavling Arendrup
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marie Helleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Cornelia Geisler Crone
- Centre of Excellence for Health, Immunity and Infections (CHIP), Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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9
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Tio SY, Chen SCA, Hamilton K, Heath CH, Pradhan A, Morris AJ, Korman TM, Morrissey O, Halliday CL, Kidd S, Spelman T, Brell N, McMullan B, Clark JE, Mitsakos K, Hardiman RP, Williams P, Campbell AJ, Beardsley J, Van Hal S, Yong MK, Worth LJ, Slavin MA. Invasive aspergillosis in adult patients in Australia and New Zealand: 2017-2020. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 40:100888. [PMID: 37701716 PMCID: PMC10494171 DOI: 10.1016/j.lanwpc.2023.100888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/25/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
Background New and emerging risks for invasive aspergillosis (IA) bring the need for contemporary analyses of the epidemiology and outcomes of IA, in order to improve clinical practice. Methods The study was a retrospective, multicenter, cohort design of proven and probable IA in adults from 10 Australasian tertiary centres (January 2017-December 2020). Descriptive analyses were used to report patients' demographics, predisposing factors, mycological characteristics, diagnosis and management. Accelerated failure-time model was employed to determine factor(s) associated with 90-day all-cause mortality (ACM). Findings Of 382 IA episodes, 221 (in 221 patients) fulfilled inclusion criteria - 53 proven and 168 probable IA. Median patient age was 61 years (IQR 51-69). Patients with haematologic malignancies (HM) comprised 49.8% of cases. Fifteen patients (6.8%) had no pre-specified immunosuppression and eleven patients (5.0%) had no documented comorbidity. Only 30% of patients had neutropenia. Of 170 isolates identified, 40 (23.5%) were identified as non-Aspergillus fumigatus species complex. Azole-resistance was present in 3/46 (6.5%) of A. fumigatus sensu stricto isolates. Ninety-day ACM was 30.3%. HM (HR 1.90; 95% CI 1.04-3.46, p = 0.036) and ICU admission (HR 4.89; 95% CI 2.93-8.17, p < 0.001) but not neutropenia (HR 1.45; 95% CI 0.88-2.39, p = 0.135) were associated with mortality. Chronic kidney disease was also a significant predictor of death in the HM subgroup (HR 3.94; 95% CI 1.15-13.44, p = 0.028). Interpretation IA is identified in high number of patients with mild/no immunosuppression in our study. The relatively high proportion of non-A. fumigatus species complex isolates and 6.5% azole-resistance rate amongst A. fumigatus sensu stricto necessitates accurate species identification and susceptibility testing for optimal patient outcomes. Funding This work is unfunded. All authors' financial disclosures are listed in detail at the end of the manuscript.
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Affiliation(s)
- Shio Yen Tio
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- National Centre for Infections in Cancer, Melbourne, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
| | - Sharon C.-A. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, Australia
- School of Medicine, University of Sydney, Australia
| | - Kate Hamilton
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, Australia
| | - Christopher H. Heath
- Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Department of Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Alyssa Pradhan
- Prince of Wales Hospital, Southeast Sydney LHD, NSW Health Pathology, Australia
- School of Medicine, University of Sydney, Australia
| | - Arthur J. Morris
- Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand
| | - Tony M. Korman
- Monash University and Monash Health, Clayton, Victoria, Australia
| | - Orla Morrissey
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Catriona L. Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, Australia
- School of Medicine, University of Sydney, Australia
| | - Sarah Kidd
- National Mycology Reference Centre, Microbiology & Infectious Diseases, SA Pathology, Adelaide, South Australia, Australia
| | - Timothy Spelman
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Nadiya Brell
- Prince of Wales Hospital, Southeast Sydney LHD, NSW Health Pathology, Australia
- University of New South Wales, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW, Australia
| | - Julia E. Clark
- Infection Management Service, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane 4101, Australia
- School of Clinical Medicine, CHQCU, University of Queensland, Australia
| | - Katerina Mitsakos
- Department of Infectious Disease and Microbiology, Royal North Shore Hospital, Sydney, Australia
| | - Robyn P. Hardiman
- Department of Infectious Disease and Microbiology, Royal North Shore Hospital, Sydney, Australia
| | - Phoebe Williams
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Australia
- School of Public Health, Faculty of Medicine, The University of Sydney, Australia
| | - Anita J. Campbell
- Department of Infectious Diseases, Perth Children’s Hospital, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Western Australia, Australia
| | - Justin Beardsley
- University of Sydney Infectious Disease Institute, Australia
- Westmead Hospital, Western Sydney LHD, NSW Health, Australia
- Westmead Institute for Medical Research, Australia
| | - Sebastiaan Van Hal
- School of Medicine, University of Sydney, Australia
- Department of Infectious Diseases and Microbiology Royal Prince Alfred Hospital, Australia
| | - Michelle K. Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- National Centre for Infections in Cancer, Melbourne, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
| | - Leon J. Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- National Centre for Infections in Cancer, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
| | - Monica A. Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- National Centre for Infections in Cancer, Melbourne, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
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Casutt A, Lamoth F, Lortholary O, Prior JO, Tonglet A, Manuel O, Bergeron A, Beigelman-Aubry C. Atypical imaging patterns during lung invasive mould diseases: lessons for clinicians. Eur Respir Rev 2023; 32:230086. [PMID: 37758271 PMCID: PMC10523149 DOI: 10.1183/16000617.0086-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/13/2023] [Indexed: 09/30/2023] Open
Abstract
Imaging of pulmonary invasive mould diseases (IMDs), which represents a cornerstone in their work-up, is mainly based on computed tomography (CT). The purpose of this review is to discuss their CT features, mainly those related to aspergillosis and mucormycosis. We will especially focus on atypical radiological presentations that are increasingly observed among non-neutropenic emerging populations of patients at risk, such as those receiving novel anticancer therapies or those in the intensive care unit. We will also discuss the interest of other available imaging techniques, mainly positron emission tomography/CT, that may play a role in the diagnosis as well as evaluation of disease extent and follow-up. We will show that any new airway-centred abnormality or caveated lesion should evoke IMDs in mildly immunocompromised hosts. Limitations in their recognition may be due to potential underlying abnormalities that increase the complexity of interpretation of lung imaging, as well as the non-specificity of imaging features. In this way, the differentials of all morphological/metabolic aspects must be kept in mind for the optimal management of patients, as well as the benefit of evaluation of the vascular status.
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Affiliation(s)
- Alessio Casutt
- Division of Pulmonology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- Division of Pulmonology, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- Institute of Microbiology, Department of Laboratories, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Olivier Lortholary
- University Paris Cité, Necker Enfants Malades University Hospital, AP-HP, IHU Imagine, Paris, France
- Institut Pasteur, National Reference Center for Invasive Mycoses and Antifungals, Paris, France
| | - John O Prior
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Andrea Tonglet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Oriol Manuel
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Anne Bergeron
- Department of Pulmonology, Geneva University Hospital, University of Geneva, Geneva, Switzerland
- A. Bergeron and C. Beigelman-Aubry contributed equally to this work
| | - Catherine Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- A. Bergeron and C. Beigelman-Aubry contributed equally to this work
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11
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Dvořáčková E, Šíma M, Zajacová A, Vyskočilová K, Kotowski T, Dunovská K, Klapková E, Havlín J, Lischke R, Slanař O. Dosing Optimization of Posaconazole in Lung-Transplant Recipients Based on Population Pharmacokinetic Model. Antibiotics (Basel) 2023; 12:1399. [PMID: 37760696 PMCID: PMC10525625 DOI: 10.3390/antibiotics12091399] [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: 08/04/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Although posaconazole tablets show relatively low variability in pharmacokinetics (PK), the proportion of patients achieving the PK/PD target at the approved uniform dose for both prophylaxis and therapy is not satisfactory. The aim of this study was to develop a posaconazole population PK model in lung-transplant recipients and to propose a covariate-based dosing optimization for both prophylaxis and therapy. In this prospective study, 80 posaconazole concentrations obtained from 32 lung-transplant patients during therapeutic drug monitoring were analyzed using nonlinear mixed-effects modelling, and a Monte Carlo simulation was used to describe the theoretical distribution of posaconazole PK profiles at various dosing regimens. A one-compartment model with both linear absorption and elimination best fit the concentration-time data. The population apparent volume of distribution was 386.4 L, while an apparent clearance of 8.8 L/h decreased by 0.009 L/h with each year of the patient's age. Based on the covariate model, a dosing regimen of 200 mg/day for prophylaxis in patients ˃60 years, 300 mg/day for prophylaxis in patients ˂60 years and for therapy in patients ˃60 years, and 400 mg/day for therapy in patients ˂60 years has been proposed. At this dosing regimen, the PK/PD target for prophylaxis and therapy is reached in 95% and 90% of population, respectively, representing significantly improved outcomes in comparison with the uniform dose.
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Affiliation(s)
- Eliška Dvořáčková
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, 128 00 Prague, Czech Republic; (E.D.); (O.S.)
| | - Martin Šíma
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, 128 00 Prague, Czech Republic; (E.D.); (O.S.)
| | - Andrea Zajacová
- Prague Lung Transplant Program, Department of Pneumology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, 150 06 Prague, Czech Republic; (A.Z.); (K.V.); (T.K.)
| | - Kristýna Vyskočilová
- Prague Lung Transplant Program, Department of Pneumology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, 150 06 Prague, Czech Republic; (A.Z.); (K.V.); (T.K.)
| | - Tereza Kotowski
- Prague Lung Transplant Program, Department of Pneumology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, 150 06 Prague, Czech Republic; (A.Z.); (K.V.); (T.K.)
| | - Kateřina Dunovská
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, 150 06 Prague, Czech Republic; (K.D.); (E.K.)
| | - Eva Klapková
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, 150 06 Prague, Czech Republic; (K.D.); (E.K.)
| | - Jan Havlín
- Prague Lung Transplant Program, 3rd Department of Surgery, First Faculty of Medicine, Charles University in Prague and Motol University Hospital, 150 06 Prague, Czech Republic; (J.H.); (R.L.)
| | - Robert Lischke
- Prague Lung Transplant Program, 3rd Department of Surgery, First Faculty of Medicine, Charles University in Prague and Motol University Hospital, 150 06 Prague, Czech Republic; (J.H.); (R.L.)
| | - Ondřej Slanař
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, 128 00 Prague, Czech Republic; (E.D.); (O.S.)
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12
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Sprute R, Nacov JA, Neofytos D, Oliverio M, Prattes J, Reinhold I, Cornely OA, Stemler J. Antifungal prophylaxis and pre-emptive therapy: When and how? Mol Aspects Med 2023; 92:101190. [PMID: 37207579 DOI: 10.1016/j.mam.2023.101190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 04/22/2023] [Accepted: 05/05/2023] [Indexed: 05/21/2023]
Abstract
The growing pool of critically ill or immunocompromised patients leads to a constant increase of life-threatening invasive infections by fungi such as Aspergillus spp., Candida spp. and Pneumocystis jirovecii. In response to this, prophylactic and pre-emptive antifungal treatment strategies have been developed and implemented for high-risk patient populations. The benefit by risk reduction needs to be carefully weighed against potential harm caused by prolonged exposure against antifungal agents. This includes adverse effects and development of resistance as well as costs for the healthcare system. In this review, we summarise evidence and discuss advantages and downsides of antifungal prophylaxis and pre-emptive treatment in the setting of malignancies such as acute leukaemia, haematopoietic stem cell transplantation, CAR-T cell therapy, and solid organ transplant. We also address preventive strategies in patients after abdominal surgery and with viral pneumonia as well as individuals with inherited immunodeficiencies. Notable progress has been made in haematology research, where strong recommendations regarding antifungal prophylaxis and pre-emptive treatment are backed by data from randomized controlled trials, whereas other critical areas still lack high-quality evidence. In these areas, paucity of definitive data translates into centre-specific strategies that are based on interpretation of available data, local expertise, and epidemiology. The development of novel immunomodulating anticancer drugs, high-end intensive care treatment and the development of new antifungals with new modes of action, adverse effects and routes of administration will have implications on future prophylactic and pre-emptive approaches.
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Affiliation(s)
- Rosanne Sprute
- 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; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Julia A Nacov
- 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; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Dionysios Neofytos
- Division of Infectious Diseases, Transplant Infectious Disease Service, University Hospital of Geneva, Geneva, Switzerland
| | - Matteo Oliverio
- 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
| | - Juergen Prattes
- 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; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Medical University of Graz, Department of Internal Medicine, Division of Infectious Disease, Excellence Center for Medical Mycology (ECMM), Graz, Austria
| | - Ilana Reinhold
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Zurich, Switzerland
| | - Oliver A Cornely
- 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; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and 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, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Jannik Stemler
- 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; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.
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13
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Escamilla JE, January SE, Vazquez Guillamet R. Diagnosis and Treatment of Fungal Infections in Lung Transplant Recipients. Pathogens 2023; 12:pathogens12050694. [PMID: 37242364 DOI: 10.3390/pathogens12050694] [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: 03/25/2023] [Revised: 04/27/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
Fungal infections are a significant source of morbidity in the lung transplant population via direct allograft damage and predisposing patients to the development of chronic lung allograft dysfunction. Prompt diagnosis and treatment are imperative to limit allograft damage. This review article discusses incidence, risk factors, and symptoms with a specific focus on diagnostic and treatment strategies in the lung transplant population for fungal infections caused by Aspergillus, Candida, Coccidioides, Histoplasma, Blastomyces, Scedosporium/Lomentospora, Fusarium, and Pneumocystis jirovecii. Evidence for the use of newer triazole and inhaled antifungals to treat isolated pulmonary fungal infections in lung transplant recipients is also discussed.
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Affiliation(s)
- Jesus E Escamilla
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63110, USA
- Rodrigo Vazquez Guillamet, 4921 Parkview Place, Saint Louis, MO 63110, USA
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14
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Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial. Clin Chest Med 2023; 44:159-177. [PMID: 36774162 DOI: 10.1016/j.ccm.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Opportunistic infections are a leading cause of lung transplant recipient morbidity and mortality. Risk factors for infection include continuous exposure of the lung allograft to the external environment, high levels of immunosuppression, impaired mucociliary clearance and decreased cough reflex, and impact of the native lung microbiome in single lung transplant recipients. Infection risk is mitigated through careful pretransplant screening of recipients and donors, implementation of antimicrobial prophylaxis strategies, and routine surveillance posttransplant. This review describes common viral, fungal, and mycobacterial infectious after lung transplant and provides recommendations on prevention and treatment.
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15
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Villalobos APC, Foroutan F, Davoudi S, Kothari S, Martinu T, Singer LG, Keshavjee S, Husain S. Statin Use May Be Associated With a Lower Risk of Invasive Aspergillosis in Lung Transplant Recipients. Clin Infect Dis 2023; 76:e1379-e1384. [PMID: 35900334 DOI: 10.1093/cid/ciac551] [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: 03/22/2022] [Revised: 06/23/2022] [Accepted: 06/30/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Statins are competitive inhibitors of 3-hydroxy-3methylglutaryl coenzyme A reductase (HMG-CoA reductase) that catalyses HMG-CoA conversion to mevalonate, a process involved in synthesizing cholesterol in humans and ergosterol in fungi. The effect of statin use on the risk of development of invasive aspergillosis (IA) in lung transplant recipients (LTRs) is not well documented. METHODS This retrospective study included LTRs from 2010 to 2017 who were followed for one-year post-transplant. Proven or probable IA was diagnosed as per ISHLT criteria. We performed a multivariable Cox proportional hazards model of the association between IA and statin use (minimum of 2 weeks duration prior to IA), adjusting for other known IA risk factors. RESULTS We identified 785 LTRs, 44% female, mean age 53 years old, the most common underlying disease being pulmonary fibrosis (23.8%). In total, 451 LTRs (57%) received statins post-transplant, atorvastatin was the most commonly used statin (68%). The mean duration of statins post-transplant was 347 days (interquartile range [IQR]: 305 to 346). And 55 (7%) LTRs developed IA in the first-year post-transplant. Out of these 55 LTRs, 9 (16.3%) had received statin before developing IA. In multivariable analysis, statin use was independently associated with a lower risk of IA (P = .002, SHR 0.30, 95% confidence interval [CI] 95% .14-.64). Statin use was also associated with a lower incidence of post-transplant Aspergillus colonization, 114 (34%) in the no statin group vs 123 (27%) in the statin group (P = .038). CONCLUSIONS The use of statin for a minimum of two weeks during the first-year post-transplant was associated with a 70% risk reduction of IA in LTRs.
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Affiliation(s)
- Armelle Pérez-Cortés Villalobos
- Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Farid Foroutan
- Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Setareh Davoudi
- Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Sagar Kothari
- Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Lung Transplant Program, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Lung Transplant Program, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Lung Transplant Program, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
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16
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Adverse Events Associated with Universal versus Targeted Antifungal Prophylaxis among Lung Transplant Recipients-A Nationwide Cohort Study 2010-2019. Microorganisms 2022; 10:microorganisms10122478. [PMID: 36557731 PMCID: PMC9787947 DOI: 10.3390/microorganisms10122478] [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: 11/08/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Invasive fungal infections in lung transplant (LTX) recipients cause substantial morbidity, but the best strategy for prevention has not yet been determined. We evaluated adherence to and rates of adverse events of universal versus targeted prophylaxis. Methods: All LTX recipients in the Danish National LTX Centre (2010−2019) were included. Before July 2016, universal voriconazole prophylaxis was used. After July 2016, only high-risk patients received targeted prophylaxis with posaconazole and inhaled amphotericin B. Proportions of triazole discontinuation, side-effects, off-target calcineurin-inhibitor (CNI) levels, and acute rejection were compared between the two periods. Results: Universal and targeted prophylaxis was initiated in 183/193 and 6/102 patients, respectively. Only 37% completed > 9 of the intended 12 weeks of voriconazole; 72% of discontinuations were due to hepatotoxicity. In the universal vs. targeted prophylaxis period, 89% vs. 72% (p < 0.001) patients had low CNI episodes, and 37% vs. 1% (p < 0.001) of these were associated with discontinuation of triazole; 40% vs. 14% (p < 0.001) had acute rejection; and 23% vs. 3% (p < 0.001) had acute rejection associated with low CNI episodes. Conclusions: Universal voriconazole prophylaxis was associated with high rates of discontinuation, mainly caused by hepatotoxicity. In comparison to the targeted posaconazole period, more patients had low CNI levels and acute rejection in the universal voriconazole period.
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17
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Boutin CA, Desjardins M, Luong ML. Fungal infection and chronic lung allograft dysfunction: A dangerous combination. Transpl Infect Dis 2022; 24:e13987. [PMID: 36380580 DOI: 10.1111/tid.13987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Catherine-Audrey Boutin
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Michaël Desjardins
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
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18
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Kriegl L, Boyer J, Egger M, Hoenigl M. Antifungal stewardship in solid organ transplantation. Transpl Infect Dis 2022; 24:e13855. [PMID: 35593394 PMCID: PMC9786549 DOI: 10.1111/tid.13855] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 05/10/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antifungal stewardship (AFS) has emerged as an important component of quality in managing invasive fungal infections (IFIs), and cost-benefit calculations suggest regular training in AFS is well worth the effort. METHODS This review will discuss the most common IFIs in solid organ transplantation (SOT)-recipients, how to diagnose them, and current recommendations for antifungal treatment and prophylaxis before demonstrating key takeaway points of AFS in this high-risk population. RESULTS Effective AFS starts before a patient is admitted for SOT, through education and regular interactions of the interdisciplinary clinical team involved in patient management, considering local factors such as epidemiological data and knowledge of diagnostic options including local turnaround times. Understanding the spectrum of antifungal agents, their efficacy and safety profiles, and pharmacokinetics, as well as duration of therapy is hereby essential. The most frequent IFIs in SOT recipients are caused by Candida species, followed by Aspergillus species, both with increasing resistance rates. Diagnosis of IFI can be challenging due to unspecific clinical presentation and difficult interpretation of microbiological findings and biomarkers. Prophylactic strategies, such as those for invasive aspergillosis in lung transplantation or invasive candidiasis (IC) in certain liver transplant settings, as well as the selection of the appropriate therapeutic agents require detailed knowledge on the pharmacokinetics and drug-drug interactions of antifungals. CONCLUSIONS Here in this review, we address what constitutes good AFS in this heterogeneous field of solid organ transplant recipients.
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Affiliation(s)
- Lisa Kriegl
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Johannes Boyer
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Matthias Egger
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria,BioTechMed‐GrazGrazAustria
| | - Martin Hoenigl
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria,BioTechMed‐GrazGrazAustria,Division of Infectious Diseases and Global Public HealthDepartment of MedicineUniversity of California San DiegoSan DiegoCaliforniaUSA
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Ju C, Lian Q, Chen A, Zhao B, Zhou S, Cai Y, Xie H, Wei L, Li S, He J. Antifungal prophylactic effectiveness and intrapulmonary concentrations of voriconazole versus posaconazole in lung transplant recipients. Med Mycol 2022; 60:6678431. [PMID: 36036471 PMCID: PMC9437723 DOI: 10.1093/mmy/myac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/22/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Invasive fungal diseases (IFDs) are one of the leading causes of death in lung transplant recipients. This study aimed to compare the antifungal prophylactic effectiveness, intrapulmonary and plasma levels of voriconazole with posaconazole in lung transplant recipients. This retrospective cohort study analyzed adult recipients who underwent lung transplantation between June 2017 and December 2020. Voriconazole oral tablets or posaconazole oral suspension were used for prophylaxis against posttransplant IFD. Drug concentrations in bronchoalveolar lavage fluid (BALF) and plasma were measured by using liquid chromatography-mass spectrometry. The 182 recipients included 142 in the voriconazole group and 40 in the posaconazole group. The trough plasma levels were comparable between voriconazole and posaconazole (1.65 ± 0.09 vs. 1.69 ± 0.03 μg/ml, p = 0.55). However, the BALF levels were significantly higher for posaconazole than voriconazole (17.47 ± 11.51 vs. 0.56 ± 0.49 μg/ml, p < 0.001). There was no significant difference in the total incidence of breakthrough IFDs between the voriconazole and posaconazole groups (10.6% vs. 7.5%, p = 0.77). The intrapulmonary concentrations of posaconazole were significantly higher than voriconazole. The two agents had comparable antifungal prophylactic effectiveness.
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Affiliation(s)
- Chunrong Ju
- Department of Respiratory and Critical Care Medicine, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiaoyan Lian
- Department of Organ Transplant, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ao Chen
- Department of Organ Transplant, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Boxin Zhao
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shouning Zhou
- Department of Pharmacy, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuhang Cai
- Department of Organ Transplant, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hui Xie
- Department of Pharmacy, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li Wei
- Department of Pharmacy, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shiyue Li
- Department of Respiratory and Critical Care Medicine, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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20
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Butler-Laporte G, Langevin MC, Lemieux C, Poirier C, Ferraro P, Théorêt Y, Luong ML. Voriconazole Therapeutic Drug Monitoring Among Lung Transplant Recipients Receiving Targeted Therapy for Invasive Aspergillosis. Clin Transplant 2022; 36:e14709. [PMID: 35575963 DOI: 10.1111/ctr.14709] [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: 03/01/2022] [Revised: 04/09/2022] [Accepted: 05/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Voriconazole is the first line treatment for invasive aspergillosis (IA) Current guidelines suggest performing regular voriconazole therapeutic drug monitoring (TDM) to optimize treatment efficacy. We aimed to determine if TDM was predictive of clinical outcome in LTRs. METHODS Retrospective chart review was performed for all LTRs with probable or proven IA, treated with voriconazole monotherapy and who underwent TDM during therapy. Clinical outcome and toxicity were measured at 12 weeks. Classification and regression tree (CART) analysis was used to determine the most predictive voriconazole level thresholds for successful outcome. RESULTS 118 TDM samples from 30 LTRs with IA were analyzed. Three LTRs were excluded due to early treatment discontinuation. The median TDM level was 1.2 μg/mL (range 0.06-7.3). At 12 weeks, 62% (17/27) of patients had a successful outcome, while 37% (10/27) of patients failed therapy. CART analysis determined that the best predictor for successful outcome was a median TDM level > 0.72 μg/mL. Seventy percent (14/20) of patients with median TDM above 0.72 μg/mL had a successful outcome, compared to 42.9% (3/7) of patients with a median TDM below 0.72 μg/mL (OR 3.11; 95% CI: 0.53-20.4; P = 0.21). CART analysis determined that a TDM level greater than 2.13 μg/mL was predictive of hepatotoxicity. CONCLUSIONS Our data suggests that a voriconazole TDM range between 0.72 μg/mL and 2.13 μg/mL may be associated with improved outcomes. Our study is in line with current recommendations on the use of voriconazole TDM in improving outcome and minimizing toxicity in LTR with IA. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Guillaume Butler-Laporte
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
| | - Marie-Claude Langevin
- Department of Pharmacy, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Claude Lemieux
- Department of Medical Microbiology, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Charles Poirier
- Division of Respirology, Department of Medicine, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Pasquale Ferraro
- Division of Thoracic Surgery, Department of Surgery, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Yves Théorêt
- Department of Pharmacology, Centre de Recherche Pédiatrique, Hôpital Ste-Justine, Montréal, Canada
| | - Me-Linh Luong
- Department of Medical Microbiology, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
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21
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Ahmed J, Singh G, Mohan A, Agarwal R, Sachdev J, Khullar S, Bhusan Xess A, Mathur P, Das B, Xess I. Invasive pulmonary aspergillosis infection in severely ill COPD patients in pulmonary ward and ICU. Indian J Med Microbiol 2022; 40:223-227. [DOI: 10.1016/j.ijmmb.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/03/2022] [Accepted: 02/23/2022] [Indexed: 11/05/2022]
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22
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Samanta P, Clancy CJ, Nguyen MH. Fungal infections in lung transplantation. J Thorac Dis 2022; 13:6695-6707. [PMID: 34992845 PMCID: PMC8662481 DOI: 10.21037/jtd-2021-26] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022]
Abstract
Lung transplant is a potential life-saving procedure for chronic lung diseases. Lung transplant recipients (LTRs) are at the greatest risk for invasive fungal infections (IFIs) among solid organ transplant (SOT) recipients because the allograft is directly exposed to fungi in the environment, airway and lung host defenses are impaired, and immunosuppressive regimens are particularly intense. IFIs occur within a year of transplant in 3-19% of LTRs, and they are associated with high mortality, prolonged hospital stays, and excess healthcare costs. The most common causes of post-LT IFIs are Aspergillus and Candida spp.; less common pathogens are Mucorales, other non-Aspergillus moulds, Cryptococcus neoformans, Pneumocystis jirovecii, and endemic mycoses. The majority of IFIs occur in the first year following transplant, although later onset is observed with prolonged antifungal prophylaxis. The most common manifestations of invasive mould infections (IMIs) include tracheobronchial (particularly at anastomotic sites), pulmonary and disseminated infections. The mortality rate of tracheobronchitis is typically low, but local complications such as bronchomalacia, stenosis and dehiscence may occur. Mortality rates associated with lung and disseminated infections can exceed 40% and 80%, respectively. IMI risk factors include mould colonization, single lung transplant and augmented immunosuppression. Candidiasis is less common than mould infections, and manifests as bloodstream or other non-pulmonary invasive candidiasis; tracheobronchial infections are encountered uncommonly. Risk factors for and outcomes of candidiasis are similar to those of non lung transplant recipients. There is evidence that IFIs and fungal colonization are risk factors for allograft failure due to chronic rejection. Mould-active azoles are frontline agents for treatment of IMIs, with local debridement as needed for tracheobronchial disease. Echinocandins and azoles are treatments for invasive candidiasis, in keeping with guidelines in other patient populations. Antifungal prophylaxis is commonly administered, but benefits and optimal regimens are not defined. Universal mould-active azole prophylaxis is used most often. Other approaches include targeted prophylaxis of high-risk LTRs or pre-emptive therapy based on culture or galactomannan (GM) (or other biomarker) results. Prophylaxis trials are needed, but difficult to perform due to heterogeneity in local epidemiology of IFIs and standard LT practices. The key to devising rational strategies for preventing IFIs is to understand local epidemiology in context of institutional clinical practices.
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Affiliation(s)
- Palash Samanta
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Hong Nguyen
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
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23
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Courtwright AM, Longworth S, Chojnowski D, Lee I, Hunt S. Treatment of a Pulmonary Aspergilloma in a Lung Transplant Recipient Using Catheter-directed Intracavitary Instillation of Liposomal Amphotericin B. Transplant Direct 2022; 8:e1270. [PMID: 34966841 PMCID: PMC8710325 DOI: 10.1097/txd.0000000000001270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/25/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Andrew M. Courtwright
- Advanced Lung Disease and Lung Transplantation, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sarah Longworth
- Division of Infectious Disease, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Donna Chojnowski
- Advanced Lung Disease and Lung Transplantation, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ingi Lee
- Division of Infectious Disease, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Stephen Hunt
- Department of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia PA
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24
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Ju C, Lian Q, Xu X, Cao Q, Lan C, Chen R, He J. Epidemiology and Prognosis of Invasive Fungal Disease in Chinese Lung Transplant Recipients. Front Med (Lausanne) 2021; 8:718747. [PMID: 34778284 PMCID: PMC8578561 DOI: 10.3389/fmed.2021.718747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
This study explored the epidemiology, risk factors, and prognosis of invasive fungal disease (IFD) in Chinese lung transplant recipients (LTRs). This retrospective cohort study included patients who received lung transplants at four hospitals in South China between January 2015 and June 2019. The participants were divided into IFD and non-IFD (NIFD) groups. The final analysis included 226 LTRs (83.2% males) aged 55.0 ± 14.2 years old. Eighty-two LTRs (36.3%) developed IFD (proven or probable diagnosis). The most common pathogens were Aspergillus (57.3%), Candida (19.5%), and Pneumocystis jiroveci (13.4%). Multivariate logistic regression revealed that anastomotic disease [odds ratio (OR): 11.86; 95% confidence interval (95%CI): 4.76–29.54; P < 0.001], cytomegalovirus (CMV) pneumonia (OR: 3.85; 95%CI: 1.88–7.91; P = 0.018), and pre-transplantation IFD (OR: 7.65; 95%CI: 2.55–22.96; P < 0.001) were associated with higher odds of IFD, while double-lung transplantation (OR: 0.40; 95%CI: 0.19–0.79; P = 0.009) was associated with lower odds of IFD. Logistic regression analysis showed that anastomotic disease was associated with higher odds of death (OR: 5.01; 95%CI: 1.24–20.20; P = 0.02) and that PJP prophylaxis was associated with lower odds of death (OR: 0.01; 95%CI: 0.001–0.11; P < 0.001). Invasive fungal disease is prevalent among LTRs in southern China, with Aspergillus the most common pathogen. Prophylaxis should be optimized based on likely pathogens.
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Affiliation(s)
- Chunrong Ju
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiaoyan Lian
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xin Xu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qingdong Cao
- Department of Thoracic Surgery and Lung Transplantation, The Fifth Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Zhuhai, China
| | - Cong Lan
- Department of Thoracic Surgery, Gaozhou People's Hospital, Gaozhou, China
| | - Rongchang Chen
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Southern University of Science and Technology, Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen Institute of Respiratory Diseases, Shenzhen, China
| | - Jianxing He
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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25
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Joean O, Welte T, Gottlieb J. Chest Infections after Lung Transplantation. Chest 2021; 161:937-948. [PMID: 34673023 DOI: 10.1016/j.chest.2021.10.014] [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: 08/02/2021] [Revised: 09/21/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Despite substantial progress in the long-term follow-up strategies for lung transplant recipients, morbidity and mortality remain high mostly due to the elevated infectious risk and to the development of chronic lung allograft dysfunction. The high immunosuppressive levels necessary to prevent acute rejection and the graft's constant exposure to the environment come at the high price of frequent infectious complications. Moreover, some infectious agents have been shown to trigger acute rejection or chronic allograft dysfunction. A rapid diagnostic approach followed by an early treatment and follow-up strategy are of paramount importance. They are, however, challenging endeavors due to the vast spectrum of possible pathogens and to the discrete clinical features as a consequence of transplant recipients' impaired immune response. This review proposes a stratified diagnostic strategy, discusses the most relevant pathogens and the corresponding therapeutic approaches while also offering an insight in the infection prevention strategies: vaccination, prophylaxis, preemptive therapy, antibiotic stewardship.
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Affiliation(s)
- Oana Joean
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany.
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease, Member of the German Center for Lung Research, Hannover, Germany
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26
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Phoompoung P, Villalobos APC, Jain S, Foroutan F, Orchanian-Cheff A, Husain S. Risk factors of invasive fungal infections in lung transplant recipients: A systematic review and meta-analysis. J Heart Lung Transplant 2021; 41:255-262. [PMID: 34872817 DOI: 10.1016/j.healun.2021.09.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/02/2021] [Accepted: 09/27/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Invasive fungal infection (IFI) remains a common complication after lung transplantation, causing significant morbidity and mortality. We have attempted to quantify systematically risk factors of IFI in lung transplant recipients. METHODS Studies were retrieved from Ovid MEDLINE, Ovid Embase, Cochrane database of systematic reviews and Cochrane central register of controlled trials. All case-control and cohort studies evaluating the risk factors of IFI in adult lung transplant recipients were screened. Two researchers reviewed and assessed all studies independently. We pooled the estimated effect of each factor associated with IFI by using a random effect model. RESULTS Eight studies were included in the systematic review and 5 studies were eligible for the meta-analysis. Rates of IFI range from 8% to 33% in lung transplant recipients. Independent risk factors for invasive aspergillosis (IA) in lung transplantation include previous fungal colonization (odds ratio [OR] 2.44; 95% confidence interval [CI] 0.08-0.47), cytomegalovirus infection (OR 1.96; 95% CI 1.08-3.56), and single lung transplantation (OR 1.77; 95% CI 1.08-2.91). Pre-emptive antifungal therapy is a protective factor for IA in lung transplant (OR 0.2; 95% CI 0.08-0.47). CONCLUSION Cytomegalovirus infection, previous fungal colonization and single lung transplantation independently increase the risk of IA in lung transplant recipients. Pre-emptive antifungal therapy is a protective factor for IA in the lung transplant population.
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Affiliation(s)
- Pakpoom Phoompoung
- Ajmera Transplant Center, University Health Network, Toronto, Canada; Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Farid Foroutan
- Ajmera Transplant Center, University Health Network, Toronto, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Canada
| | - Shahid Husain
- Ajmera Transplant Center, University Health Network, Toronto, Canada.
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27
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Laghi FA, Saad M, Lowery EM. A Case Report of Cystic Fibrosis Plus Tuberous Sclerosis: A Cautionary Tale Regarding Lung Transplantation. Transplant Proc 2021; 53:2609-2612. [PMID: 34548180 DOI: 10.1016/j.transproceed.2021.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) and tuberous sclerosis complex (TSC) are 2 rare genetic diseases that often affect the lungs. Pulmonary compromise in TSC or CF can be severe enough to require lung transplantation. In rare instances patients with CF undergo pneumonectomy to control recurrent lung infections and lung necrosis affecting one lung more than the other. Lung transplantation in these patients is exceedingly rare because preexistent pneumonectomy increases the risk of lung transplant-associated morbidity and mortality. CASE PRESENTATION We present the case of a young woman with co-occurrence of TSC and CF, who underwent left-sided pneumonectomy and, approximately 2 years later, right-sided single lung transplant. The posttransplant clinical course was complicated by phrenic nerve injury, ventilator dependency, Aspergillus endocarditis with embolic shower, and death. Pretransplant pneumonectomy, Aspergillus colonization, and posttransplant phrenic nerve injury contributed to the complex postoperative course, ventilatory dependence, and poor outcome. CONCLUSION This cautionary case should alert physicians on the challenges associated with single lung transplant in patients with preexistent pneumonectomy.
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Affiliation(s)
- Franco A Laghi
- Department of Thoracic Medicine and Surgery, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Marina Saad
- Department of Biomedical and Clinical Sciences (DIBIC), Division of Pulmonary Diseases, University of Milan, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco, Milan, Italy; Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Erin M Lowery
- Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois; Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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28
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Hirama T, Tomiyama F, Notsuda H, Watanabe T, Watanabe Y, Oishi H, Okada Y. Outcome and prognostic factors after lung transplantation for bronchiectasis other than cystic fibrosis. BMC Pulm Med 2021; 21:261. [PMID: 34384425 PMCID: PMC8361737 DOI: 10.1186/s12890-021-01634-z] [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: 05/06/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While lung transplant (LTX) can be an effective therapy to provide the survival benefit in selected populations, post-transplant outcome in LTX recipients with bronchiectasis other than cystic fibrosis (CF) has been less studied. Pseudomonas aeruginosa, often associated with exacerbations in bronchiectasis, is the most common micro-organism isolated from LTX recipients. We aimed to see the outcomes of patients with bronchiectasis other than CF after LTX and seek the risk factors associated with pre- and post-transplant Pseudomonas status. METHODS Patients who underwent LTX at Tohoku University Hospital between January 2000 and December 2020 were consecutively included into the retrospective cohort study. Pre- and post-transplant prevalence of Pseudomonas colonization between bronchiectasis and other diseases was reviewed. Post-transplant outcomes (mortality and the development of chronic lung allograft dysfunction (CLAD)) were assessed using a Cox proportional hazards and time-to-event outcomes were estimated using the Kaplan-Meier method. RESULTS LTX recipients with bronchiectasis experienced a high rate of pre- and post-transplant Pseudomonas colonization compared to other diseases with statistical significance (p < 0.001 and p < 0.001, respectively). Nevertheless, long-term survival in bronchiectasis was as great as non-bronchiectasis (Log-rank p = 0.522), and the bronchiectasis was not a trigger for death (HR 1.62, 95% CI 0.63-4.19). On the other hand, the chance of CLAD onset in bronchiectasis was comparable to non-bronchiectasis (Log-rank p = 0.221), and bronchiectasis was not a predictor of the development of CLAD (HR 1.88, 95% CI 0.65-5.40). CONCLUSIONS Despite high prevalence of pre- and post-transplant Pseudomonas colonization, the outcome in LTX recipients with bronchiectasis other than CF was comparable to those without bronchiectasis.
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Affiliation(s)
- Takashi Hirama
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Sendai, Miyagi, Japan. .,Division of Organ Transplantation, Tohoku University Hospital, 1-1 Seiryo-machi, Sendai, Miyagi, Japan.
| | - Fumiko Tomiyama
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Sendai, Miyagi, Japan
| | - Hirotsugu Notsuda
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Sendai, Miyagi, Japan
| | - Tatsuaki Watanabe
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Sendai, Miyagi, Japan
| | - Yui Watanabe
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Sendai, Miyagi, Japan
| | - Hisashi Oishi
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Sendai, Miyagi, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Sendai, Miyagi, Japan.,Division of Organ Transplantation, Tohoku University Hospital, 1-1 Seiryo-machi, Sendai, Miyagi, Japan
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29
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The Prediction and Prognosis of Fungal Infection in Lung Transplant Recipients-A Retrospective Cohort Study in South Korea. J Fungi (Basel) 2021; 7:jof7080639. [PMID: 34436178 PMCID: PMC8400395 DOI: 10.3390/jof7080639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 01/04/2023] Open
Abstract
(1) Background: Lung transplant recipients (LTRs) are at substantial risk of invasive fungal disease (IFD), although no consensus has been reached on the use of antifungal agents (AFAs) after lung transplantation (LTx). This study aimed to assess the risk factors and prognosis of fungal infection after LTx in a single tertiary center in South Korea. (2) Methods: The study population included all patients who underwent LTx between January 2012 and July 2019 at a tertiary hospital. It was a retrospective cohort study. Culture, bronchoscopy, and laboratory findings were reviewed during episodes of infection. (3) Results: Fungus-positive respiratory samples were predominant in the first 90 days and the overall cumulative incidence of Candida spp. was approximately three times higher than that of Aspergillus spp. In the setting of itraconazole administration for 6 months post-LTx, C. glabrata accounted for 36.5% of all Candida-positive respiratory samples. Underlying connective tissue disease-associated interstitial lung disease, use of AFAs before LTx, a longer length of hospital stay after LTx, and old age were associated with developing a fungal infection after LTx. IFD and fungal infection treatment failure significantly increased overall mortality. Host factors, antifungal drug resistance, and misdiagnosis of non-Aspergillus molds could attribute to the breakthrough fungal infections. (4) Conclusions: Careful bronchoscopy, prompt fungus culture, and appropriate use of antifungal therapies are recommended during the first year after LTx.
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Gioia F, Filigheddu E, Corbella L, Fernández-Ruiz M, López-Medrano F, Pérez-Ayala A, Aguado JM, Fariñas MC, Arnaiz F, Calvo J, Cifrian JM, Gonzalez-Rico C, Vidal E, Torre-Cisneros J, Ras MM, Pérez S, Sabe N, López-Soria LM, Rodríguez-Alvarez RJ, Montejo JM, Valerio M, Machado M, Muñoz P, Linares L, Bodro M, Moreno A, Fernández-Cruz A, Cantón R, Moreno S, Martin-Davila P, Fortún J. Invasive aspergillosis in solid organ transplantation: Diagnostic challenges and differences in outcome in a Spanish national cohort (Diaspersot study). Mycoses 2021; 64:1334-1345. [PMID: 33934405 DOI: 10.1111/myc.13298] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/18/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The diagnosis of invasive aspergillosis (IA) can be problematic in solid organ transplantation (SOT). The prognosis greatly varies according to the type of transplant, and the impact of prophylaxis is not well defined. PATIENTS AND METHODS The Diaspersot cohort analyses the impact of IA in SOT in Spain during the last 10 years. Proven and probable/putative IA was included. RESULTS We analysed 126 cases of IA. The incidences of IA were as follows: 6.5%, 2.9%, 1.8% and 0.6% for lung, heart, liver and kidney transplantation, respectively. EORTC/MSG criteria confirmed only 49.7% of episodes. Tree-in-bud sign or ground-glass infiltrates were present in 56.3% of patients, while serum galactomannan (optical density index >0.5) was positive in 50.6%. A total of 41.3% received combined antifungal therapy. Overall mortality at 3 months was significantly lower (p < 0.001) in lung transplant recipients (14.8%) than in all other transplants [globally: 48.6%; kidney 52.0%, liver 58.3%, heart 31.2%, and combined 42.9%]. Fifty-four percent of episodes occurred despite the receipt of antifungal prophylaxis, and in 10%, IA occurred during prophylaxis (breakthrough infection), with both nebulised amphotericin (in lung transplant recipients) and candins (in the rest). CONCLUSIONS Invasive aspergillosis diagnostic criteria, applied to SOT patients, may differ from those established for haematological patients. IA in lung transplants has a higher incidence, but is associated with a better prognosis than other transplants. Combination therapy is frequently used for IA in SOT. Prophylactic measures require optimisation of its use within this population.
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Affiliation(s)
- Francesca Gioia
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria), Universidad de Alcalá, Madrid, Spain
| | - Eta Filigheddu
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria), Universidad de Alcalá, Madrid, Spain
| | - Laura Corbella
- Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Mario Fernández-Ruiz
- Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco López-Medrano
- Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Ana Pérez-Ayala
- Microbiology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - Jose María Aguado
- Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Maria Carmen Fariñas
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Cantabria, Spain
| | - Francisco Arnaiz
- Infectious Diseases Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Cantabria, Spain
| | - Jorge Calvo
- Microbiology Department, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Jose Maria Cifrian
- Pneumology Department, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Claudia Gonzalez-Rico
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Cantabria, Spain
| | - Elisa Vidal
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Unit, Maimonides Institute for Biomedical Research (IMIBIC), Hospital Universitario Reina Sofía-IMIBIC-Universidad de Cordoba, Cordoba, Spain
| | - Julian Torre-Cisneros
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Unit, Maimonides Institute for Biomedical Research (IMIBIC), Hospital Universitario Reina Sofía-IMIBIC-Universidad de Cordoba, Cordoba, Spain
| | - Maria Mar Ras
- Infectious Disease Department, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Sandra Pérez
- Infectious Disease Department, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Nuria Sabe
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Disease Department, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | | | | | - José Miguel Montejo
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Disease Unit, Hospital Universitario Cruces, Barakaldo, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Marina Machado
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Laura Linares
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Spain
| | - Marta Bodro
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Spain
| | - Asuncion Moreno
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Spain
| | - Ana Fernández-Cruz
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Rafael Cantón
- Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.,Microbiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Santiago Moreno
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria), Universidad de Alcalá, Madrid, Spain
| | - Pilar Martin-Davila
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria), Universidad de Alcalá, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Fortún
- Infectious Diseases Department, Hospital Ramón y Cajal, IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria), Universidad de Alcalá, Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
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Neofytos D, Garcia-Vidal C, Lamoth F, Lichtenstern C, Perrella A, Vehreschild JJ. Invasive aspergillosis in solid organ transplant patients: diagnosis, prophylaxis, treatment, and assessment of response. BMC Infect Dis 2021; 21:296. [PMID: 33761875 PMCID: PMC7989085 DOI: 10.1186/s12879-021-05958-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients. Although IA has significant implications on graft and patient survival, data on diagnosis and management of this infection in SOT recipients are still limited. METHODS Discussion of current practices and limitations in the diagnosis, prophylaxis, and treatment of IA and proposal of means of assessing treatment response in SOT recipients. RESULTS Liver, lung, heart or kidney transplant recipients have common as well as different risk factors to the development of IA, thus each category needs a separate evaluation. Diagnosis of IA in SOT recipients requires a high degree of awareness, because established diagnostic tools may not provide the same sensitivity and specificity observed in the neutropenic population. IA treatment relies primarily on mold-active triazoles, but potential interactions with immunosuppressants and other concomitant therapies need special attention. CONCLUSIONS Criteria to assess response have not been sufficiently evaluated in the SOT population and CT lesion dynamics, and serologic markers may be influenced by the underlying disease and type and severity of immunosuppression. There is a need for well-orchestrated efforts to study IA diagnosis and management in SOT recipients and to develop comprehensive guidelines for this population.
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Affiliation(s)
- Dionysios Neofytos
- Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, Geneva, Switzerland.
| | - Carolina Garcia-Vidal
- Servicio de Enfermedades Infecciosas, Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, FungiCLINIC Research group (AGAUR), Barcelona, Spain
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, 1011, Lausanne, Switzerland
- Department of Laboratories, Institute of Microbiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Christoph Lichtenstern
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg, Germany
| | - Alessandro Perrella
- VII Department of Infectious Disease and Immunology, Hospital D. Cotugno, Naples, Italy
- CLSE-Liver Transplant Unit, Hospital A. Cardarelli, Naples, Italy
| | - Jörg Janne Vehreschild
- Medical Department II, Hematology and Oncology, University Hospital of Frankfurt, Frankfurt, Germany
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany
- German Centre for Infection Research, partner site Bonn-Cologne, University of Cologne, Cologne, Germany
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Le Pavec J, Pradère P, Gigandon A, Dauriat G, Dureault A, Aguilar C, Henry B, Lanternier F, Savale L, Dolidon S, Gazengel P, Mussot S, Mercier O, Husain S, Lortholary O, Fadel E. Risk of Lung Allograft Dysfunction Associated With Aspergillus Infection. Transplant Direct 2021; 7:e675. [PMID: 34113715 PMCID: PMC8184025 DOI: 10.1097/txd.0000000000001128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/26/2020] [Indexed: 11/25/2022] Open
Abstract
We sought to determine whether invasive aspergillosis (IA) during the first year after lung transplantation increased the risk of chronic lung allograft dysfunction (CLAD). Methods We retrospectively reviewed the records of 191 patients who underwent lung transplantation at our institution between January 2013 and December 2017. Screening for Aspergillus was with bronchial aspirates, bronchoalveolar lavage if indicated or during surveillance bronchoscopy, radiography, and computed tomography. We used Fine and Gray multivariable regression to identify potential risk factors for CLAD. Results During the first posttransplant year, 72 patients had at least 1 deep-airway sample positive for Aspergillus; 63 were classified as having IA and were included in the study. Median number of endoscopies per patient during the first year was 9 (range, 1-44). Median time from transplantation to first Aspergillus-positive sample was 121 d. Bronchial aspirate samples and bronchoalveolar lavage fluid were positive in 71 and 44 patients, respectively. Aspergillus fumigatus (n = 36, 50%) predominated; bacterial samples were also positive in 22 (31%) patients. IA within 4 mo after transplantation was independently associated with CLAD development (subdistribution hazard ratio, 3.75; 95% confidence interval [CI], 1.61-8.73; P < 0.01) by regression analysis. Survival at 3 and 5 y conditional on 1-y CLAD-free survival was 37% (95% CI, 24%-58%), and 24% (95% CI, 11%-52%) in the IA <4 mo group compared to 65% (95% CI, 57%-73%) and 54% (95% CI, 43%-66%) in the non-IA group and to 69% (95% CI, 58%-83%) and 54% (95% CI, 35%-82%) in the IA ≥4 mo group, respectively (P < 0.01, logrank test). Conclusions Our evaluation of de novo IA showed that this infection was most strongly associated with CLAD when found within 4 mo after transplantation.
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Affiliation(s)
- Jérôme Le Pavec
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Pauline Pradère
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Anne Gigandon
- Service de microbiologie, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Gaëlle Dauriat
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Amélie Dureault
- Molecular Mycology Unit, UMR2000, CNRS, Institut Pasteur, Paris, France.,Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants malades, AP-HP, IHU Imagine, Paris Descartes University, Université de Paris, Paris, France
| | - Claire Aguilar
- Molecular Mycology Unit, UMR2000, CNRS, Institut Pasteur, Paris, France.,Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants malades, AP-HP, IHU Imagine, Paris Descartes University, Université de Paris, Paris, France
| | - Benoît Henry
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Service de microbiologie, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Molecular Mycology Unit, UMR2000, CNRS, Institut Pasteur, Paris, France
| | - Fanny Lanternier
- Molecular Mycology Unit, UMR2000, CNRS, Institut Pasteur, Paris, France.,Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants malades, AP-HP, IHU Imagine, Paris Descartes University, Université de Paris, Paris, France
| | - Laurent Savale
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Samuel Dolidon
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Pierre Gazengel
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Sacha Mussot
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olaf Mercier
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Shahid Husain
- University of Toronto, University Health Network, Toronto, ON, Canada
| | - Olivier Lortholary
- Molecular Mycology Unit, UMR2000, CNRS, Institut Pasteur, Paris, France.,Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants malades, AP-HP, IHU Imagine, Paris Descartes University, Université de Paris, Paris, France
| | - Elie Fadel
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,UMR_S 999, Université Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Late Onset Invasive Pulmonary Aspergillosis in Lung Transplant Recipients in the Setting of a Targeted Prophylaxis/Preemptive Antifungal Therapy Strategy. Transplantation 2021; 104:2575-2581. [PMID: 32080158 DOI: 10.1097/tp.0000000000003187] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Invasive pulmonary aspergillosis (IPA) is a significant cause of morbidity and mortality in lung transplant recipients (LTRs). It is unclear how a targeted prophylaxis/ preemptive antifungal therapy strategy impacts the incidence of IPA beyond the first-year posttransplant. METHODS This is a retrospective cohort of LTRs from January 2010 to December 2014. We included all LTRs who survived beyond the first year and followed them until death or 4 years postoperatively. Incidence of probable/proven IPA and Aspergillus colonization were assessed as per International Society for Heart and Lung Transplantation (ISHLT) criteria. Patients with risk factors, positive Aspergillus cultures, or galactomannan (GM) received targeted prophylaxis/preemptive therapy within the first-year posttransplant. RESULTS During the study period, 350 consecutive LTRs underwent 1078 bronchoscopies. Positive bronchoalveolar lavage for GM or Aspergillus cultures was reported for 15% (52/350) of LTRs between 2 and 4 years after transplantation. Among them, the median time to positive Aspergillus culture or GM positivity was 703 days (interquartile range, 529-754 d). The incidence rate of IPA and Aspergillus colonization was 30 of 1000 patient-y, and 63 of 1000 patient-y, respectively. The mortality rate was significantly higher in patients with IPA than without IPA (107/1000 patient-years versus 18/1000 patient-years; P < 0.0001). Rate of first-year colonization and IPA was 33% and 9%, respectively. Among the 201 patients who had a negative bronchoscopy during the first year posttransplant, only 6 (3%) developed IPA during the follow-up. CONCLUSIONS A targeted prophylaxis/preemptive therapy strategy within the first-year posttransplant resulted in 4% incidence of IPA at 4-years after transplantation. However, IPA was associated with higher mortality.
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Strategies for the Prevention of Invasive Fungal Infections after Lung Transplant. J Fungi (Basel) 2021; 7:jof7020122. [PMID: 33562370 PMCID: PMC7914704 DOI: 10.3390/jof7020122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/31/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022] Open
Abstract
Long-term survival after lung transplantation is lower than that associated with other transplanted organs. Infectious complications, most importantly invasive fungal infections, have detrimental effects and are a major cause of morbidity and mortality in this population. Candida infections predominate in the early post-transplant period, whereas invasive mold infections, usually those related to Aspergillus, are most common later on. This review summarizes the epidemiology and risk factors for invasive fungal diseases in lung transplant recipients, as well as the current evidence on preventive measures. These measures include universal prophylaxis, targeted prophylaxis, and preemptive treatment. Although there is consensus that a preventive strategy should be implemented, current data show no superiority of one preventive measure over another. Data are also lacking regarding the optimal antifungal regimen and the duration of treatment. As all current recommendations are based on observational, single-center, single-arm studies, it is necessary that this longstanding debate is settled with a multicenter randomized controlled trial.
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Renner S, Nachbaur E, Jaksch P, Dehlink E. Update on Respiratory Fungal Infections in Cystic Fibrosis Lung Disease and after Lung Transplantation. J Fungi (Basel) 2020; 6:jof6040381. [PMID: 33371198 PMCID: PMC7766476 DOI: 10.3390/jof6040381] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/08/2020] [Accepted: 12/16/2020] [Indexed: 12/19/2022] Open
Abstract
Cystic fibrosis is the most common autosomal-recessive metabolic disease in the Western world. Impaired trans-membrane chloride transport via the cystic fibrosis transmembrane conductance regulator (CFTR) protein causes thickened body fluids. In the respiratory system, this leads to chronic suppurative cough and recurrent pulmonary infective exacerbations, resulting in progressive lung damage and respiratory failure. Whilst the impact of bacterial infections on CF lung disease has long been recognized, our understanding of pulmonary mycosis is less clear. The range and detection rates of fungal taxa isolated from CF airway samples are expanding, however, in the absence of consensus criteria and univocal treatment protocols for most respiratory fungal conditions, interpretation of laboratory reports and the decision to treat remain challenging. In this review, we give an overview on fungal airway infections in CF and CF-lung transplant recipients and focus on the most common fungal taxa detected in CF, Aspergillus fumigatus, Candida spp., Scedosporium apiospermum complex, Lomentospora species, and Exophiala dermatitidis, their clinical presentations, common treatments and prophylactic strategies, and clinical challenges from a physician’s point of view.
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Affiliation(s)
- Sabine Renner
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Associated National Center in the European Reference Network on Rare Respiratory Diseases ERN-LUNG and the European Reference Network on Transplantation in Children, ERN TRANSPLANT-CHILD, Medical University of Vienna, 1090 Vienna, Austria; (S.R.); (E.N.)
| | - Edith Nachbaur
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Associated National Center in the European Reference Network on Rare Respiratory Diseases ERN-LUNG and the European Reference Network on Transplantation in Children, ERN TRANSPLANT-CHILD, Medical University of Vienna, 1090 Vienna, Austria; (S.R.); (E.N.)
| | - Peter Jaksch
- Division of Thoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Eleonora Dehlink
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Associated National Center in the European Reference Network on Rare Respiratory Diseases ERN-LUNG and the European Reference Network on Transplantation in Children, ERN TRANSPLANT-CHILD, Medical University of Vienna, 1090 Vienna, Austria; (S.R.); (E.N.)
- Correspondence:
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36
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Abstract
Lung transplantation is a lifesaving intervention for patients with advanced lung disease. Due to a combination of immunosuppression, continuous exposure of the lungs to the environment, and complications at the anastomotic sites, lung transplant recipients are at high risk for infectious complications. The aim of this review is to summarize recent developments in the field of infectious diseases as it pertains to lung transplant recipients.
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Linder KA, Kauffman CA, Patel TS, Fitzgerald LJ, Richards BJ, Miceli MH. Evaluation of targeted versus universal prophylaxis for the prevention of invasive fungal infections following lung transplantation. Transpl Infect Dis 2020; 23:e13448. [PMID: 33448560 DOI: 10.1111/tid.13448] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/11/2020] [Accepted: 08/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Antifungal prophylaxis to prevent invasive fungal infections (IFI) is widely used following lung transplantation, but the optimal strategy remains unclear. We compared universal with targeted antifungal prophylaxis for effectiveness in preventing IFI. METHODS Adult patients who underwent lung transplantation at the University of Michigan from /1 July 2014-31 December 2017 were studied for 18 months post-transplant. Universal prophylaxis consisted of itraconazole with or without inhaled liposomal amphotericin B. Using specific criteria, targeted prophylaxis was given with voriconazole for patients at risk for invasive pulmonary aspergillosis (IPA) and with fluconazole or micafungin for patients at risk for invasive candidiasis. Risk factors, occurrence of proven/probable IFI, and mortality were analyzed for the two prophylaxis cohorts. RESULTS Of 105 lung transplant recipients, 84 (80%) received a double lung transplant, and 38 (36%) of patients underwent transplant for pulmonary fibrosis. Fifty-nine (56%) patients received universal antifungal prophylaxis, and 46 (44%), targeted antifungal prophylaxis. Among 20 proven/probable IFI, there were 14 IPA, 4 invasive candidiasis, 1 cryptococcosis, and 1 deep sternal mold infection. Six (10%) IFI occurred in the universal prophylaxis cohort and 14 (30%) in the targeted prophylaxis cohort. Five of 6 (83%) IFI in the universal prophylaxis cohort, compared with 9/14 (64%) in the targeted prophylaxis cohort, were IPA Candida infections occurred only in the targeted prophylaxis cohort. The development of IFI was more likely in the targeted prophylaxis cohort than the universal prophylaxis cohort, HR = 4.32 (1.51-12.38), P = .0064. CONCLUSIONS Universal antifungal prophylaxis appears to be more effective than targeted antifungal prophylaxis for prevention of IFI after lung transplant.
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Affiliation(s)
- Kathleen A Linder
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Carol A Kauffman
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Twisha S Patel
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Linda J Fitzgerald
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Blair J Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Marisa H Miceli
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, USA
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Pennington KM, Baqir M, Erwin PJ, Razonable RR, Murad MH, Kennedy CC. Antifungal prophylaxis in lung transplant recipients: A systematic review and meta-analysis. Transpl Infect Dis 2020; 22:e13333. [PMID: 32449237 PMCID: PMC7415601 DOI: 10.1111/tid.13333] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/13/2020] [Accepted: 05/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND No consensus exists regarding optimal strategy for antifungal prophylaxis following lung transplant. OBJECTIVE To review data regarding antifungal prophylaxis on the development of fungal infections. STUDY SELECTION/APPRAISAL We searched MEDLINE, Embase, and Scopus for eligible articles through December 10, 2019. Observational or controlled trials published after January 1, 2001, that pertained to the prevention of fungal infections in adult lung recipients were reviewed independently by two reviewers for inclusion. METHODS Of 1702 articles screened, 24 were included. Data were pooled using random effects model to evaluate for the primary outcome of fungal infection. Studies were stratified by prophylactic strategy, medication, and duration (short term < 6 months and long term ≥ 6 months). RESULTS We found no difference in the odds of fungal infection with universal prophylaxis (49/101) compared to no prophylaxis (36/93) (OR 0.76, CI: 0.03-17.98; I2 = 93%) and preemptive therapy (25/195) compared to universal prophylaxis (35/222) (OR 0.91, CI: 0.06-13.80; I2 = 93%). The cumulative incidence of fungal infections within 12 months was not different with nebulized amphotericin (0.08, CI: 0.04-0.13; I2 = 87%) compared to systemic triazoles (0.07, CI: 0.03-0.11; I2 = 21%) (P = .65). Likewise, duration of prophylaxis did not impact the incidence of fungal infections (short term: 0.11, CI: 0.05-0.17; I2 = 89%; long term: 0.06, CI: 0.03-0.08; I2 = 51%; P = .39). CONCLUSIONS We have insufficient evidence to support or exclude a benefit of antifungal prophylaxis.
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Affiliation(s)
- Kelly M. Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Raymund R. Razonable
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
- Division of Infectious Disease, Mayo Clinic, Rochester, MN
| | - M. Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Cassie C. Kennedy
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
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Gohir W, Klement W, Singer LG, Palmer SM, Mazzulli T, Keshavjee S, Husain S. Identifying host microRNAs in bronchoalveolar lavage samples from lung transplant recipients infected with Aspergillus. J Heart Lung Transplant 2020; 39:1228-1237. [PMID: 32771440 DOI: 10.1016/j.healun.2020.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/06/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND MicroRNAs (miRNAs) are small non-coding RNAs of ∼22 nucleotides that play a crucial role in post-transcriptional regulation of gene expression. Dysregulation of miRNA expression has been shown during microbial infections. We sought to identify miRNAs that distinguish invasive aspergillosis (IA) from non-IA in lung transplant recipients (LTRs). METHODS We used NanoString nCounter Human miRNA, version 3, panel to measure miRNAs in bronchoalveolar lavage (BAL) samples from LTRs with Aspergillus colonization (ASP group) (n = 10), those with Aspergillus colonization and chronic lung allograft dysfunction (CLAD) (ASPCLAD group) (n = 7), those with IA without CLAD (IA group) (n = 10), those who developed IA with CLAD (IACLAD group) (n = 9), and control patients (controls) (n = 9). The miRNA profile was compared using the permutation test of 100,000 trials for each of the comparisons. We used mirDIP to obtain their gene targets and pathDIP to determine the pathway enrichment. RESULTS We performed pairwise comparisons between patient groups to identify differentially expressed miRNAs. A total of 5 miRNAs were found to be specific to IA, including 4 (miR-145-5p, miR-424-5p, miR-99b-5p, and miR-4488) that were upregulated and the pair (miR-4454 + miR-7975) that was downregulated in IA group vs controls. The expression change for these miRNAs was specific to patients with IA; they were not significantly differentiated between IACLAD and IA groups. Signaling pathways associated with an immunologic response to IA were found to be significantly enriched. CONCLUSIONS We report a set of 5 differentially expressed miRNAs in the BAL of LTRs with IA that might help in the development of diagnostic and prognostic tools for IA in LTRs. However, further investigation is needed in a larger cohort to validate the findings.
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Affiliation(s)
- Wajiha Gohir
- Transplant Infectious Diseases, Ajmera Family Transplant Centre
| | - William Klement
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Tony Mazzulli
- Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shahid Husain
- Transplant Infectious Diseases, Ajmera Family Transplant Centre.
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Villalobos APC, Husain S. Infection prophylaxis and management of fungal infections in lung transplant. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:414. [PMID: 32355858 PMCID: PMC7186682 DOI: 10.21037/atm.2020.03.102] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Lung transplantation has emerged as a lifesaving treatment for a wide range of advanced lung diseases. While the survival of lung transplant recipients continues to improve, infectious complications contribute substantially to morbidity and mortality following lung transplantation. The incidence of invasive fungal infections is variable, with a mean occurrence of 8.6%. The majority of fungal infections in lung transplant recipients are caused Aspergillus and Candida species. This review provides an update in the current approaches for the diagnosis, management and prevention of fungal infections and the late complications that are associated.
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Affiliation(s)
| | - Shahid Husain
- Multi-Organ Transplant Unit, Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
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Prophylaxis and Treatment of Invasive Aspergillosis: Who and How of Prophylaxis, Treatment, and New Therapies. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00213-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
BACKGROUND Invasive aspergillosis, mucormycosis, and cryptococcosis are severe opportunistic infections in patients with long phases of neutropenia and also after allogeneic stem cell and organ transplantation. Due to the late appearance of clinical signs and the often poor outcome, these diseases require special attention and proactive interventions. MATERIAL AND METHODS Published guidelines and selected current literature were reviewed for this article. RESULTS Invasive aspergillosis and mucormycosis are typically observed in the upper and lower airways of severely immunocompromized patients. When invasive fungal diseases are suspected, sectional imaging and, if possible, serological testing should be performed as soon as possible. If imaging or serological tests confirm the suspected diagnosis, pre-emptive antimycotic treatment should be started and further confirmation of the diagnosis sought via microbiological and/or histological investigations. Treatment depends on comedication, comorbidity and risk factors, primarily with voriconazole, isavuconazole and liposomal amphotericin B. With the advent of antiretroviral treatment, a decrease of cryptococcosis cases in people with human immunodeficiency virus was observed; however, increasing cases have been reported in patients with new forms of immunosuppression. Cryptococcus spp. predominantly cause central nervous system infections but also pneumonia and bloodstream infections. Diagnostics include blood and cerebrospinal fluid cultures and antigen tests. First line treatment consists of a combination therapy with amphotericin B and flucytosine. CONCLUSION An interdisciplinary approach with microbiologists, infectious diseases specialists and radiologists is needed for diagnostics and treatment of invasive fungal diseases.
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Welte T, Len O, Muñoz P, Romani L, Lewis R, Perrella A. Invasive mould infections in solid organ transplant patients: modifiers and indicators of disease and treatment response. Infection 2019; 47:919-927. [PMID: 31576498 DOI: 10.1007/s15010-019-01360-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/18/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Invasive mould infections, in particular invasive aspergillosis (IA), are comparatively frequent complications of immunosuppression in patients undergoing solid organ transplantation (SOT). Guidelines provide recommendations as to the procedures to be carried out to diagnose and treat IA, but only limited advice for SOT recipients. METHODS Literature review and expert consensus summarising the existing evidence related to prophylaxis, diagnosis, treatment and assessment of response to IA and infections by Mucorales in SOT patients RESULTS: Response to therapy should be assessed early and at regular intervals. No indications of improvement should lead to a prompt change of the antifungal treatment, to account for possible infections by Mucorales or other moulds such as Scedosporium. Imaging techniques, especially CT scan and possibly angiography carried out at regular intervals during early and long-term follow-up and coupled with a careful clinical diagnostic workout, should be evaluated as diagnostic tools and outcome predictors, and standardised to improve therapy monitoring. The role of biomarkers such as the galactomannan test and PCR, as well as selected inflammation parameters, has not yet been definitively assessed in the SOT population and needs to be studied further. The therapeutic workup should consider a reduction of immunosuppressive therapy. CONCLUSIONS The role of immunosuppression and immune tolerance mechanisms in the response to invasive fungal infection treatment is an important factor in the SOT population and should not be underestimated. The choice of the antifungal should consider not only their toxicity but also their effects on the immune system, two features that are intertwined.
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Affiliation(s)
- Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl Neuberg Str 1, 30625, Hannover, Germany.
| | - Oscar Len
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, Universidad Complutense de Madrid, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Luigina Romani
- Department of Experimental Medicine, School of Medicine, University of Perugia, 06132, Perugia, Italy
| | - Russell Lewis
- Infectious Diseases Hospital, S. Orsola-Malpighi, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Perrella
- VII, Department of Infectious Disease and Immunology, Hospital D. Cotugno, Naples, Italy
- CLSE-Liver Transplant Unit, Hospital A. Cardarelli, Naples, Italy
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Herrera S, Gohir W, Foroutan F, Aguilar C, Juvet S, Martinu T, Kumar D, Humar A, Rotstein C, Keshavjee S, Singer LG, Husain S. Cytokine profile in lung transplant recipients with Aspergillus spp colonization. Transpl Infect Dis 2019; 21:e13060. [PMID: 30753747 DOI: 10.1111/tid.13060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 01/31/2019] [Accepted: 02/07/2019] [Indexed: 01/05/2023]
Abstract
We studied cytokine profiles in BAL of LTRs with Aspergillus spp colonization who did not progress to IPA in the absence of antifungal prophylaxis. This was a retrospective, single center case-control study. BAL samples were analyzed for cytokines. Patients with Aspergillus spp in BAL who did not receive prophylaxis and did not develop IPA were compared to LTRs with Aspergillus spp that received prophylaxis, LTRs with IPA and controls. Twenty-one patients with Aspergillus colonization who did not develop IPA, seven patients with suspected IPA who received prophylaxis, 4 IPA and 19 controls were included. IPA group had significantly higher levels (median [IQR]) of MIP-1 beta compared to the Suspected IPA group (5 vs 5 P: 0.03). The Suspected IPA group had significantly higher levels of IL-12 (11.38 vs 1 P: 0.0001), IL-1 RA (86.11 vs 23.98 P: 0.0118), IP-10 (22.47 vs 0.86 P: 0.0151), HGF (40.92 vs 16.82 P: 0.0055), and MIG (169.62 vs 5 P: 0.0005) than Colonization group. We have identified a unique cytokine signature in patients with Aspergillus colonization that do not develop IPA. Our study forms basis for a larger study to use these cytokines profile to identify patients at a lower risk of developing IPA.
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Affiliation(s)
- Sabina Herrera
- Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Wajiha Gohir
- Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Farid Foroutan
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Claire Aguilar
- Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Juvet
- Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tereza Martinu
- Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Deepali Kumar
- Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Atul Humar
- Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Coleman Rotstein
- Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shahid Husain
- Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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