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Namale PE, Boloko L, Vermeulen M, Haigh KA, Bagula F, Maseko A, Sossen B, Lee-Jones S, Msomi Y, McIlleron H, Mnguni AT, Crede T, Szymanski P, Naude J, Ebrahim S, Vallie Y, Moosa MS, Bandeker I, Hoosain S, Nicol MP, Samodien N, Centner C, Dowling W, Denti P, Gumedze F, Little F, Parker A, Price B, Schietekat D, Simmons B, Hill A, Wilkinson RJ, Oliphant I, Hlungulu S, Apolisi I, Toleni M, Asare Z, Mpalali MK, Boshoff E, Prinsloo D, Lakay F, Bekiswa A, Jackson A, Barnes A, Johnson R, Wasserman S, Maartens G, Barr D, Schutz C, Meintjes G. Testing novel strategies for patients hospitalised with HIV-associated disseminated tuberculosis (NewStrat-TB): protocol for a randomised controlled trial. Trials 2024; 25:311. [PMID: 38720383 PMCID: PMC11077808 DOI: 10.1186/s13063-024-08119-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/16/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND HIV-associated tuberculosis (TB) contributes disproportionately to global tuberculosis mortality. Patients hospitalised at the time of the diagnosis of HIV-associated disseminated TB are typically severely ill and have a high mortality risk despite initiation of tuberculosis treatment. The objective of the study is to assess the safety and efficacy of both intensified TB treatment (high dose rifampicin plus levofloxacin) and immunomodulation with corticosteroids as interventions to reduce early mortality in hospitalised patients with HIV-associated disseminated TB. METHODS This is a phase III randomised controlled superiority trial, evaluating two interventions in a 2 × 2 factorial design: (1) high dose rifampicin (35 mg/kg/day) plus levofloxacin added to standard TB treatment for the first 14 days versus standard tuberculosis treatment and (2) adjunctive corticosteroids (prednisone 1.5 mg/kg/day) versus identical placebo for the first 14 days of TB treatment. The study population is HIV-positive patients diagnosed with disseminated TB (defined as being positive by at least one of the following assays: urine Alere LAM, urine Xpert MTB/RIF Ultra or blood Xpert MTB/RIF Ultra) during a hospital admission. The primary endpoint is all-cause mortality at 12 weeks comparing, first, patients receiving intensified TB treatment to standard of care and, second, patients receiving corticosteroids to those receiving placebo. Analysis of the primary endpoint will be by intention to treat. Secondary endpoints include all-cause mortality at 2 and 24 weeks. Safety and tolerability endpoints include hepatoxicity evaluations and corticosteroid-related adverse events. DISCUSSION Disseminated TB is characterised by a high mycobacterial load and patients are often critically ill at presentation, with features of sepsis, which carries a high mortality risk. Interventions that reduce this high mycobacterial load or modulate associated immune activation could potentially reduce mortality. If found to be safe and effective, the interventions being evaluated in this trial could be easily implemented in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT04951986. Registered on 7 July 2021 https://clinicaltrials.gov/study/NCT04951986.
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Affiliation(s)
- Phiona E Namale
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
- Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Linda Boloko
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marcia Vermeulen
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kate A Haigh
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Fortuna Bagula
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Alexis Maseko
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bianca Sossen
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Scott Lee-Jones
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yoliswa Msomi
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ayanda Trevor Mnguni
- Department of Medicine, Khayelitsha Hospital, Cape Town, South Africa
- Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Thomas Crede
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Mitchells Plain Hospital, Cape Town, South Africa
| | - Patryk Szymanski
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Mitchells Plain Hospital, Cape Town, South Africa
| | - Jonathan Naude
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Mitchells Plain Hospital, Cape Town, South Africa
| | - Sakeena Ebrahim
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Mitchells Plain Hospital, Cape Town, South Africa
| | - Yakoob Vallie
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | | | - Ismail Bandeker
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | - Shakeel Hoosain
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | - Mark P Nicol
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- Division of Infection and Immunity School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Nazlee Samodien
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Chad Centner
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Wentzel Dowling
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Arifa Parker
- Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Brendon Price
- Division of Anatomical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Denzil Schietekat
- Department of Medicine, Khayelitsha Hospital, Cape Town, South Africa
- Department of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Bryony Simmons
- LSE Health, London School of Economics and Political Science, London, UK
| | - Andrew Hill
- LSE Health, London School of Economics and Political Science, London, UK
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Francis Crick Institute, London, UK
- Department of Medicine, Imperial College London, London, UK
| | - Ida Oliphant
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Siphokazi Hlungulu
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ivy Apolisi
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Monica Toleni
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zimkhitha Asare
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Mkanyiseli Kenneth Mpalali
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Erica Boshoff
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Denise Prinsloo
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Francisco Lakay
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Abulele Bekiswa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Amanda Jackson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ashleigh Barnes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ryan Johnson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Barr
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Sweeney DA, Lobo SM, Póvoa P, Kalil AC. Choosing immunomodulating therapies for the treatment of COVID-19: recommendations based on placebo-controlled trial evidence. Clin Microbiol Infect 2024; 30:611-618. [PMID: 38182048 DOI: 10.1016/j.cmi.2023.12.028] [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: 11/01/2023] [Revised: 12/24/2023] [Accepted: 12/31/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Immunomodulatory therapy has been extensively studied in randomized clinical trials for the treatment of patients hospitalized for COVID-19 with inconsistent findings. Guideline committees, reviewing the same clinical trial data, have generated different recommendations for immunomodulatory therapy. OBJECTIVES We hypothesize that trial design differences, specifically whether the study utilized an open-label or placebo-controlled design, accounted for the inconsistent mortality effects reported in clinical trials of immunomodulator therapies for COVID-19. SOURCES We reviewed COVID-19 treatment guidelines (World Health Organization [WHO], Infectious Diseases Society of America [IDSA] and The National Institutes of Health [NIH]) and identified the meta-analyses associated with glucocorticoids, IL-6 inhibitors, JAK kinase inhibitors, and complement C5a inhibitors that were available to the guideline authors at the time recommendations were either made or updated. CONTENT We identified a meta-analysis for each of the immunomodulator classes that are included in current COVID-19 treatment guidelines: glucocorticoids [WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group; Shankar-Hari M, Vale CL, Godolphin PJ, Fisher D, Higgins JPT, et al. Association between administration of IL-6 antagonists and mortality among patients hospitalized for COVID-19: A meta-analysis. JAMA. 2021;326:499-518] (cited 419), IL-6 antagonists [WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group; Shankar-Hari M, Vale CL, Godolphin PJ, Fisher D, Higgins JPT, et al. Association between administration of IL-6 antagonists and mortality among patients hospitalized for COVID-19: A meta-analysis. JAMA. 2021;326:499-518] (cited 419), JAK inhibitors [Kramer A, Prinz C, Fichtner F, Fischer AL, Thieme V, Grundeis F, et al. Janus kinase inhibitors for the treatment of COVID-19. Cochrane Database Syst Rev. 2022;6:CD015209] (cited 34), and complement C5a inhibitors [Tsai CL, Lai CC, Chen CY, Lee HS. The efficacy and safety of complement C5a inhibitors for patients with severe COVID-19: A systematic review and meta-analysis. Expert Rev Anti Infect Ther. 2023;21:77-86] (cited 1). Using the same randomized clinical trials, we evaluated the four meta-analyses accounting for trial design: placebo-controlled or open-label. Glucocorticoids (Risk Ratio [RR] 0.91 [95% CI, 0.49-1.69]), IL-6 inhibitors sarilumab (RR 1.17 [95% CI, 0.96-01.43]), and tocilizumab (RR 0.95 [95% CI, 0.76-1.19]) did not reduce mortality in placebo-controlled trials, whereas baricitinib did confer a large survival benefit (RR 0.65 [95% CI, 0.52-0.81]). The complement C5a inhibitor, vilobelimab, also reduced mortality in a single placebo-controlled trial (RR 0.76 [95% CI, 0.57-1.0]). IMPLICATIONS Placebo-controlled trial evidence indicates that baricitinib should be the first choice immunomodulator for patients hospitalized for COVID-19 who require any form of oxygen support-low- or high-flow oxygen, non-invasive or invasive ventilation. Vilobelimab warrants study in a large placebo-controlled trial. Treatment guidelines for future pandemics should prioritize the results of placebo-controlled trials.
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Affiliation(s)
- Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, San Diego, La Jolla, CA, USA.
| | - Suzana M Lobo
- Faculdade de Medicina, Hospital de Base de São José do Rio Preto (FAMERP), São José do Rio Preto-SP, Brazil
| | - Pedro Póvoa
- NOVA Medical School, New University of Lisbon, Lisbon, Portugal; Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark; Department of Critical Care Medicine, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center Omaha, NE, USA
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Saadatzadeh T, Angarone M, Stosor V. Pneumocystis jirovecii in solid organ transplant recipients: updates in epidemiology, diagnosis, treatment, and prevention. Curr Opin Infect Dis 2024; 37:121-128. [PMID: 38230604 DOI: 10.1097/qco.0000000000001002] [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: 01/18/2024]
Abstract
PURPOSE OF REVIEW This review highlights the epidemiology of Pneumocystis jirovecii pneumonia in solid organ transplant recipients, advancements in the diagnostic landscape, and updates in treatment and prevention. RECENT FINDINGS The increasing use of immune-depleting agents in the context of solid organ transplantation has given rise to P. jirovecii pneumonia in this population. The use of prophylaxis has dramatically reduced risk of infection; however, late-onset infections occur after cessation of prophylaxis and in the setting of lymphopenia, advancing patient age, acute allograft rejection, and cytomegalovirus infection. Diagnosis requires respiratory specimens, with PCR detection of Pneumocystis replacing traditional staining methods. Quantitative PCR may be a useful adjunct to differentiate between infection and colonization. Metagenomic next-generation sequencing is gaining attention as a noninvasive diagnostic tool. Trimethoprim-sulfamethoxazole remains the drug of choice for treatment and prevention of Pneumocystis pneumonia. Novel antifungal agents are under investigation. SUMMARY P. jirovecii is a fungal opportunistic pathogen that remains a cause of significant morbidity and mortality in solid organ transplant recipients. Early detection and timely treatment remain the pillars of management.
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Affiliation(s)
| | | | - Valentina Stosor
- Divisions of Infectious Diseases
- Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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4
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Jayasimhan D, Matthay M. Corticosteroids in adults with acute respiratory distress syndrome and severe pneumonia. BJA Educ 2023; 23:456-463. [PMID: 38009137 PMCID: PMC10667747 DOI: 10.1016/j.bjae.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 11/28/2023] Open
Affiliation(s)
- D. Jayasimhan
- Wellington Regional Hospital, Wellington, New Zealand
| | - M.A. Matthay
- University of California–San Francisco, San Francisco, CA, USA
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5
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Dequin PF, Ramirez JA, Waterer G. What's new with glucocorticoids in severe community-acquired pneumonia? Intensive Care Med 2023; 49:1397-1399. [PMID: 37606740 DOI: 10.1007/s00134-023-07179-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/26/2023] [Indexed: 08/23/2023]
Affiliation(s)
- Pierre-François Dequin
- INSERM UMR 1100, Research Center for Respiratory Diseases, Tours University, Tours, France.
- Médecine Intensive Réanimation and INSERM Centre d'Investigation Clinique 1415, Bretonneau University Hospital, Tours, France.
- CRICS-TriGGERSep Network, Tours, France.
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
- Emeritus Professor of Medicine, Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Grant Waterer
- East Metropolitan Health Service, Perth, WA, Australia
- Royal Perth Hospital, Perth, WA, Australia
- University of Western Australia, Perth, WA, Australia
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Aboul-Fotouh S, Mahmoud AN, Elnahas EM, Habib MZ, Abdelraouf SM. What are the current anti-COVID-19 drugs? From traditional to smart molecular mechanisms. Virol J 2023; 20:241. [PMID: 37875904 PMCID: PMC10594888 DOI: 10.1186/s12985-023-02210-z] [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: 11/05/2022] [Accepted: 10/13/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Coronavirus disease 19 (COVID-19) is the disease caused by SARS-CoV-2, a highly infectious member of the coronavirus family, which emerged in December 2019 in "Wuhan, China". It induces respiratory illness ranging from mild symptoms to severe disease. It was declared a "pandemic" by the World Health Organization (WHO) in March 2020. Since then, a vast number of clinical and experimental studies have been conducted to identify effective approaches for its prevention and treatment. MAIN BODY The pathophysiology of COVID-19 represents an unprecedented challenge; it triggers a strong immune response, which may be exacerbated by "a cytokine storm syndrome". It also induces thrombogenesis and may trigger multi-organ injury. Therefore, different drug classes have been proposed for its treatment and prevention, such as antivirals, anti-SARS-CoV-2 antibody agents (monoclonal antibodies, convalescent plasma, and immunoglobulins), anti-inflammatory drugs, immunomodulators, and anticoagulant drugs. To the best of our knowledge, this review is the first to present, discuss, and summarize the current knowledge about the different drug classes used for the treatment of COVID-19, with special emphasis on their targets, mechanisms of action, and important adverse effects and drug interactions. Additionally, we spotlight the latest "October 2023" important guidelines (NIH, IDSA, and NICE) and FDA approval or authorization regarding the use of these agents in the management of COVID-19. CONCLUSION Despite the wide array of therapeutic strategies introduced for the treatment of COVID-19, one of the most prominent therapeutic challenges is SARS-CoV-2 mutations and emerging new variants and subvariants. Currently, the anti-COVID-19 drug pipeline is continuously affording novel treatments to face this growing challenge.
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Affiliation(s)
- Sawsan Aboul-Fotouh
- Department of Clinical Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Clinical Pharmacology Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Nageh Mahmoud
- Department of Clinical Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Esraa M Elnahas
- Department of Clinical Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Z Habib
- Department of Clinical Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Sahar M Abdelraouf
- Department of Biochemistry, Faculty of Pharmacy, Misr International University, Cairo, Egypt
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Bradley J, Khurana S, Cavallazzi R. Adjunctive immunomodulation in severe community-acquired pneumonia. J Bras Pneumol 2023; 49:e20230248. [PMID: 37729338 PMCID: PMC10578938 DOI: 10.36416/1806-3756/e20230248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Affiliation(s)
- James Bradley
- . Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville (KY) USA
| | - Shriya Khurana
- . Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville (KY) USA
| | - Rodrigo Cavallazzi
- . Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville (KY) USA
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Huang J, Zeng F, Li J, Xu W, Shen M, Shu Q, Liu D. Case report: A HIV-negative hemodialysis patient positive for pANCA with severe pneumocystis pneumonia: A case report and review of literature. Medicine (Baltimore) 2023; 102:e33351. [PMID: 36961149 PMCID: PMC10035997 DOI: 10.1097/md.0000000000033351] [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: 01/31/2023] [Accepted: 03/03/2023] [Indexed: 03/25/2023] Open
Abstract
RATIONALE Pneumocystis pneumonia (PCP) is an opportunistic fungal infection that occurs in people with impaired or suppressed immunity such as patients with human immunodeficiency virus or organ transplant. However, the incidence and characteristics of PCP in the population with long-term hemodialysis is poorly described in the literature. PATIENT CONCERNS We present a case of a 50-year-old female patient being transferred to our hospital in February 2022 with a 20-day history of cough and tight breath. She received amoxicillin and cephalosporin anti-infection treatment successively in local hospital but no significant improvement in symptoms. She had a 2-year history of hemodialysis and no relevant transplantation and human immunodeficiency virus infection. She was diagnosed as ANCA associated vasculitis (AAV) and given oral prednisone acetate (20 mg/day) and methotrexate (2.5 mg/week) half a year ago. DIAGNOSES Based on the patient's medical history, Lung computerized tomography image, the Next generation sequencing report, the patient was diagnosed with renal failure, anti-neutrophil cytoplasmic antibody associated vasculitis, and Pneumocystis pneumonia. INTERVENTIONS The dosage of immunosuppressant was reduced due to leucocyte dripping and fever, and antibiotic and antifungal treatment were also given. The patient's lung condition was getting worse and noninvasive ventilator was required to maintain blood oxygen. Blood filtration is used to remove toxins. Ganciclovir and trimethoprim-sulfamethoxazole was used based on the next generation sequencing report. OUTCOMES The patient died of respiratory failure. LESSONS The risk of PCP in hemodialysis patients may be higher than that in ordinary population, and the prognosis of patients with immunosuppression may be worse. Dynamic assessment of vasculitis activity is necessary for hemodialysis patients with AAV because infections may obscure lung symptoms of AAV. It is not recommended that hemodialysis patients with long-term immunosuppression should reduce or stop the dosage of immunosuppressive drugs during the treatment because it may aggravate the condition of PCP. There is still no clear conclusion on whether hemodialysis patients need preventive medicine, but the identification of risk factors and early diagnosis and treatment are important for the prognosis of PCP on hemodialysis population.
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Affiliation(s)
- Jingda Huang
- Department of Nephrology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Fang Zeng
- Department of Nephrology, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Jiajie Li
- Department of Hepatobiliary and Pancreatic, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Wang Xu
- Department of Cardiovascular, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Meirong Shen
- Department of Critical Care Medicine, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Qiao Shu
- Department of Nephrology, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
| | - Dehui Liu
- Department of Nephrology, Ganzhou People’s Hospital, Ganzhou, Jiangxi, China
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Abstract
Coronavirus disease 2019 (COVID-19) pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in significant mortality in pandemic proportions. Inflammation in response to the infection contributes to the pathogenesis of pneumonia. This review will discuss prior studies on the use of glucocorticoids to treat respiratory infections, the rationale for the use glucocorticoids in COVID-19, and review of existing data. We will also highlight outstanding research questions for future studies.
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Affiliation(s)
- Francesco Amati
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - John Huston
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, Connecticut
| | - Charles S. Dela Cruz
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, Connecticut
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10
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The Impact of Corticosteroids on the Outcome of Fungal Disease: a Systematic Review and Meta-analysis. CURRENT FUNGAL INFECTION REPORTS 2023; 17:54-70. [PMID: 36852004 PMCID: PMC9947451 DOI: 10.1007/s12281-023-00456-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/25/2023]
Abstract
Purpose of Review Corticosteroids have a complex relationship with fungal disease - risk for many, benefit for others. This systematic review aims to address the effect of corticosteroids on mortality and visual outcome in different fungal diseases. Recent Findings Corticosteroids are a risk factor of aspergillosis for patients who have COVID-19, and they also led to a worse outcome. Similarity, corticosteroids are a risk factor for candidemia and mucormycosis. Some researchers reported that using topical corticosteroid in keratitis was associated with worse visual outcome if fungal keratitis. Some studies showed that corticosteroids are linked to a negative outcome for non-HIV patients with Pneumocystis jirovecii pneumonia (PCP), in contrast to those with HIV and PCP. Summary In 59 references, we found that corticosteroid therapy showed a worse clinical outcome in invasive aspergillosis (IA) (HR: 2.50, 95%CI: 1.89-3.31, p < 0.001) and chronic pulmonary aspergillosis (CPA) (HR: 2.74, 95%CI: 1.48-5.06, p = 0.001), PCP without HIV infection (OR: 1.29, 95%CI: 1.09-1.53, p = 0.003), invasive candidiasis and candidaemia (OR: 2.13, 95%CI: 1.85-2.46, p < 0.001), mucormycosis (OR: 4.19, 95%CI: 1.74-10.05, p = 0.001) and early in the course of fungal keratitis (OR: 2.99, 95%CI: 1.14-7.84, p = 0.026). There was equivocal outcome in cryptococcal meningoencephalitis in AIDS and primary coccidioidomycosis, while corticosteroid therapy showed a better outcome in PCP in HIV-infected patients (RR: 0.62, 95%CI: 0.46-0.83, p=0.001) and fungal keratitis patients after keratoplasty surgery (OR: 0.01, 95%CI: 0.00-0.41, p = 0.041) and probably in cryptococcal meningoencephalitis in non-immunocompromised patients. A sub-analysis in invasive aspergillosis and CPA showed that use of more than 2 mg/kg/day of prednisolone equivalents per day is a significant factor in increasing mortality (HR: 2.94, 95%CI: 2.13-4.05, p < 0.001). Corticosteroid therapy during invasive fungal disease was usually associated with a slightly or greatly increased mortality or worse visual outcome (in fungal keratitis), with two disease exceptions. Avoiding the addition of corticosteroids, or minimising dose and duration in those who require them, is likely to improve the outcome of most life- and vision-threatening fungal diseases. This review provides a cornerstone for further research in exploring the accuracy of suitable dose and duration of corticosteroids treatment in fungal diseases. Supplementary Information The online version contains supplementary material available at 10.1007/s12281-023-00456-2.
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Zhang Z, Li Q, Shen X, Liao L, Wang X, Song M, Zheng X, Zhu Y, Yang Y. The medication for pneumocystis pneumonia with glucose-6-phosphate dehydrogenase deficiency patients. Front Pharmacol 2022; 13:957376. [PMID: 36160421 PMCID: PMC9490050 DOI: 10.3389/fphar.2022.957376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
Pneumocystis pneumonia (PCP) is an opportunity acquired infection, which is usually easy to occur in patients with AIDS, organ transplantation, and immunosuppressive drugs. The prevention and treatment must be necessary for PCP patients with immunocompromise. And the oxidants are currently a typical regimen, including sulfanilamide, dapsone, primaquine, etc. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked gene-disease that affects about 400 million people worldwide. The lack of G6PD in this population results in a decrease in intracellular glutathione synthesis and a weakening of the detoxification ability of the oxidants. As a result, oxidants can directly damage haemoglobin in red blood cells, inducing methemoglobin and hemolysis. When patients with G6PD deficiency have low immunity, they are prone to PCP infection, so choosing drugs that do not induce hemolysis is essential. There are no clear guidelines to recommend the drug choice of this kind of population at home and abroad. This paper aims to demonstrate the drug choice for PCP patients with G6PD deficiency through theoretical research combined with clinical cases.
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Affiliation(s)
- Ziyu Zhang
- Department of Pharmacy, The First People’s Hospital of Ziyang, Ziyang, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qinhui Li
- Department of Medical, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoyan Shen
- Department of Pharmacy, Chengdu Qingbaijiang District People’s Hospital, Chengdu, China
| | - Lankai Liao
- Intensive Care Unit, The Third Hospital of Mianyang, Mianyang, China
| | - Xia Wang
- Department of Pharmacy, The First People’s Hospital of Ziyang, Ziyang, China
| | - Min Song
- Department of Pharmacy, The First People’s Hospital of Ziyang, Ziyang, China
| | - Xi Zheng
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yulian Zhu
- Department of Pharmacy, Ziyang People’s Hospital, Ziyang, China
- *Correspondence: Yulian Zhu, ; Yong Yang,
| | - Yong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- *Correspondence: Yulian Zhu, ; Yong Yang,
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Huang YM, Lu CH, Cheng CF, Shen CY, Hsieh SC, Li KJ, Chien JY, Hsueh PR. Clinical features and prognostic predictors in patients with rheumatic diseases complicated by Pneumocystis pneumonia. Int J Infect Dis 2022; 122:1018-1025. [DOI: 10.1016/j.ijid.2022.07.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/19/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022] Open
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Asai N, Motojima S, Ohkuni Y, Matsunuma R, Nakashita T, Kaneko N, Mikamo H. Pathophysiological mechanism of non-HIV Pneumocystis jirovecii pneumonia. Respir Investig 2022; 60:522-530. [PMID: 35501264 DOI: 10.1016/j.resinv.2022.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/18/2022] [Accepted: 04/03/2022] [Indexed: 06/14/2023]
Abstract
While Pneumocystis jirovecii pneumonia (PCP) can occur in immunocompromised patients with HIV infection, the prognosis of non-HIV PCP is still poor, showing a high mortality rate of 30%-75%. The pathophysiological mechanism of non-HIV PCP is quite different from that of HIV-PCP. Aging, underlying disease, dysbiotic gut microbiome, and Th1 predominance, leads to macrophagic polarization shifting from M2 to M1. These cause dysregulation in the host immunity against P. jirovecii, resulting in severe lung injury and a high mortality rate among non-HIV PCP patients. This review describes poor prognostic factors, an issue of predictive values used for general pneumonia practice, and new aspects, including the dysbiosis of the gut microbiome and macrophagic polarization in the treatment of non-HIV PCP.
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Affiliation(s)
- Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan; Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Shinji Motojima
- Department of Rheumatology & Allergy, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Yoshihiro Ohkuni
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Ryo Matsunuma
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Tamao Nakashita
- Department of Rheumatology & Allergy, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Norihiro Kaneko
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan.
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Amratia DA, Viola H, Ioachimescu OC. Glucocorticoid therapy in respiratory illness: bench to bedside. J Investig Med 2022; 70:1662-1680. [DOI: 10.1136/jim-2021-002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/07/2022]
Abstract
Each year, hundreds of millions of individuals are affected by respiratory disease leading to approximately 4 million deaths. Most respiratory pathologies involve substantially dysregulated immune processes that either fail to resolve the underlying process or actively exacerbate the disease. Therefore, clinicians have long considered immune-modulating corticosteroids (CSs), particularly glucocorticoids (GCs), as a critical tool for management of a wide spectrum of respiratory conditions. However, the complex interplay between effectiveness, risks and side effects can lead to different results, depending on the disease in consideration. In this comprehensive review, we present a summary of the bench and the bedside evidence regarding GC treatment in a spectrum of respiratory illnesses. We first describe here the experimental evidence of GC effects in the distal airways and/or parenchyma, both in vitro and in disease-specific animal studies, then we evaluate the recent clinical evidence regarding GC treatment in over 20 respiratory pathologies. Overall, CS remain a critical tool in the management of respiratory illness, but their benefits are dependent on the underlying pathology and should be weighed against patient-specific risks.
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15
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Kottom TJ, Schaefbauer K, Carmona EM, Yi ES, Limper AH. Preclinical and Toxicology Studies of BRD5529, a Selective Inhibitor of CARD9. Drugs R D 2022; 22:165-173. [PMID: 35486318 PMCID: PMC9167333 DOI: 10.1007/s40268-022-00389-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The caspase recruitment domain-containing protein 9 (CARD9) inhibitor BRD5529 has been shown to be an effective in vitro inhibitor of Pneumocystis β-glucan-induced proinflammatory signaling, suggesting its viability as a candidate for preliminary anti-Pneumocystis drug testing in the rodent Pneumocystis pneumonia (PCP) model. METHODS Mice were injected intraperitoneally (IP) daily with either vehicle or BRD5529 at 0.1 or 1.0 mg/kg for 2 weeks. Mouse weights were taken daily. At day 14, mice were euthanized, weighed, and analyzed by flexiVent™ for lung stiffness. Lungs, liver, and kidney were then harvested for hematoxylin and eosin (H&E) staining and pathology scoring. Lung samples were further analyzed for proinflammatory cytokines via enzyme-linked immunosorbent assay (ELISA) and extracellular matrix generation via quantitative polymerase chain reaction (qPCR). Blood collection postmortem was performed for blood chemistry analysis. Furthermore, administration of BRD5529 prior to the intratracheal inoculation of fungal β-glucans, which are known proinflammatory mediators via the Dectin-1-CARD9 pathway, resulted in significant reductions in lung tissue interleukin-6 and tumor necrosis factor-α, suggesting the exciting possibility of the use of this CARD9 inhibitor as an additional therapeutic tool in fungal infections. RESULTS BRD5529 at both IP doses resulted in no significant changes in daily or final weight gain, and analysis of lung stiffness by flexiVent™ showed no significant differences between the groups. Furthermore, ELISA results of proinflammatory cytokines showed no major differences in the respective groups. qPCR analysis of extracellular matrix transcripts were statistically similar. Examination and pathology scoring of H&E slides from lung, liver, and kidney in all groups, as well as subsequent pathology scoring, showed no significant change. Blood chemistry analysis revealed similar, non-significant patterns. CONCLUSIONS In our initial general safety and toxicology assessments, BRD5529 displayed no inherent safety concerns in the analyzed parameters. These data support broader in vivo testing of the inhibitor as a timed adjunct therapy to the deleterious proinflammatory host immune response often associated with anti-Pneumocystis therapy.
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Affiliation(s)
- Theodore J Kottom
- Thoracic Diseases Research Unit, Departments of Medicine and Biochemistry, Mayo Clinic, 8-23 Stabile, Rochester, MN, 55905, USA.
| | - Kyle Schaefbauer
- Thoracic Diseases Research Unit, Departments of Medicine and Biochemistry, Mayo Clinic, 8-23 Stabile, Rochester, MN, 55905, USA
| | - Eva M Carmona
- Thoracic Diseases Research Unit, Departments of Medicine and Biochemistry, Mayo Clinic, 8-23 Stabile, Rochester, MN, 55905, USA
| | - Eunhee S Yi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Andrew H Limper
- Thoracic Diseases Research Unit, Departments of Medicine and Biochemistry, Mayo Clinic, 8-23 Stabile, Rochester, MN, 55905, USA
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Mohapatra S, Ayash Kumar P, Farooq U, Jain P, khan R, Hasan N, Shamim A, Javed Ansari M, Alalaiwe AS, Aldawsari MF, Aamir Mirza M, Iqbal Z. COVID 19 pandemic challenges and their management: A review of medicines, vaccines, patents and clinical trials with emphasis on psychological health issues. Saudi Pharm J 2022; 30:879-905. [PMID: 35645588 PMCID: PMC9128298 DOI: 10.1016/j.jsps.2022.05.004] [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: 01/11/2022] [Accepted: 05/20/2022] [Indexed: 12/15/2022] Open
Abstract
The SARS‐CoV‐2 (COVID 19) paroxysm is a dominant health exigency that caused significant distress, affecting physical and mental health. Increased mortality, a stressed healthcare system, financial crisis, isolation, and new living and working styles enhanced societal commiseration leading to poor health outcomes. Though people try to maintain good physical health but unfortunately the mental affliction is still ignored. Poor psychological health has emerged as a burgeoning social issue and demands attention. Henceforth, the fundamental objective of this review article is to collate information about COVID-linked physical and psychological agony in diverse population groups with related symptoms and accessible diagnosis techniques. Recent studies have unraveled the fragile mental states of people who have either contracted COVID 19 or had near and dear ones falling prey to it. The impact of the epidemic on the human mind both in short and long-term, with possible risk and preventive factors together with suggested solutions for maintaining good health have also been discussed here. It also enlists the available medications, vaccines and investigational research in the form of patents and clinical trials. This article can be taken as an updated information sheet for COVID 19, accompanied by its management techniques with special emphasis on coping strategies for mental health. Further, it may also assist the policymakers to devise approaches that could enable the public to overcome the pandemic-driven adversity not only in the given situation but also futuristically.
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Manickam M, Meenakshisundaram S, Pillaiyar T. Activating endogenous resolution pathways by soluble epoxide hydrolase inhibitors for the management of COVID-19. Arch Pharm (Weinheim) 2022; 355:e2100367. [PMID: 34802171 PMCID: PMC9011438 DOI: 10.1002/ardp.202100367] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022]
Abstract
Anti-inflammatory, specialized proresolving mediators such as resolvins, protectins, maresins, and lipoxins derived from polyunsaturated acids may play a potential role in lung diseases as they protect different organs in animal disease models. Polyunsaturated fatty acids are an important resource for epoxy fatty acids (EET, EEQ, and EDP) that mediate a broad array of anti-inflammatory and proresolving mechanisms, such as mitigation of the cytokine storm. However, epoxy fatty acids are rapidly metabolized by soluble epoxide hydrolase (sEH). In animal studies, administration of sEH inhibitors (sEHIs) increases epoxy fatty acid levels, reduces lung inflammation, and improves lung function, making it a viable COVID-19 treatment approach. Thus, using sEHIs to activate endogenous resolution pathways might be a novel method to minimize organ damage in severe cases and improve outcomes in COVID-19 patients. This review focuses on the use of sEH inhibitors to activate endogenous resolution mechanisms for the treatment of COVID-19.
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Affiliation(s)
- Manoj Manickam
- Department of ChemistryPSG Institute of Technology and Applied ResearchCoimbatoreTamil NaduIndia
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18
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Abstract
Invasive fungal diseases are rare in individuals with intact immunity. This, together with the fact that there are only a few species that account for most mycotic diseases, implies a remarkable natural resistance to pathogenic fungi. Mammalian immunity to fungi rests on two pillars, powerful immune mechanisms and elevated temperatures that create a thermal restriction zone for most fungal species. Conditions associated with increased susceptibility generally reflect major disturbances of immune function involving both the cellular and humoral innate and adaptive arms, which implies considerable redundancy in host defense mechanisms against fungi. In general, tissue fungal invasion is controlled through either neutrophil or granulomatous inflammation, depending on the fungal species. Neutrophils are critical against Candida spp. and Aspergillus spp. while macrophages are essential for controlling mycoses due to Cryptococcus spp., Histoplasma spp., and other fungi. The increasing number of immunocompromised patients together with climate change could significantly increase the prevalence of fungal diseases. Expected final online publication date for the Annual Review of Immunology, Volume 40 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Arturo Casadevall
- Department of Molecular Microbiology and Immunology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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19
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Kanjee Z, Metlay JP, Moskowitz A, Reynolds EE. How Would You Treat This Patient Hospitalized With Community-Acquired Pneumonia? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2021; 174:1719-1726. [PMID: 34904883 DOI: 10.7326/m21-3650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Community-acquired pneumonia is a major cause of morbidity and mortality in the United States, leading to 1.5 million hospitalizations and at least 200 000 deaths annually. The 2019 American Thoracic Society/Infectious Diseases Society of America clinical practice guideline on diagnosis and treatment of adults with community-acquired pneumonia provides an evidence-based overview of this common illness. Here, 2 experts, a general internist who served as the co-primary author of the guidelines and a pulmonary and critical care physician, debate the management of a patient hospitalized with community-acquired pneumonia. They discuss disease severity stratification methods, whether to use adjunctive corticosteroids, and when to prescribe empirical treatment for multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., E.E.R.)
| | - Joshua P Metlay
- Massachusetts General Hospital, Boston, Massachusetts (J.P.M.)
| | | | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., E.E.R.)
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Chapman MM, Muse VV, Mojica JE, Anahtar MN. Case 35-2021: A 50-Year-Old Woman with Pain in the Left Upper Quadrant and Hypoxemia. N Engl J Med 2021; 385:1995-2001. [PMID: 34788511 DOI: 10.1056/nejmcpc2107356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Margaret M Chapman
- From the Departments of Medicine (M.M.C., J.E.M.), Radiology (V.V.M.), and Pathology (M.N.A.), Massachusetts General Hospital, and the Departments of Medicine (M.M.C., J.E.M.), Radiology (V.V.M.), and Pathology (M.N.A.), Harvard Medical School - both in Boston
| | - Victorine V Muse
- From the Departments of Medicine (M.M.C., J.E.M.), Radiology (V.V.M.), and Pathology (M.N.A.), Massachusetts General Hospital, and the Departments of Medicine (M.M.C., J.E.M.), Radiology (V.V.M.), and Pathology (M.N.A.), Harvard Medical School - both in Boston
| | - James E Mojica
- From the Departments of Medicine (M.M.C., J.E.M.), Radiology (V.V.M.), and Pathology (M.N.A.), Massachusetts General Hospital, and the Departments of Medicine (M.M.C., J.E.M.), Radiology (V.V.M.), and Pathology (M.N.A.), Harvard Medical School - both in Boston
| | - Melis N Anahtar
- From the Departments of Medicine (M.M.C., J.E.M.), Radiology (V.V.M.), and Pathology (M.N.A.), Massachusetts General Hospital, and the Departments of Medicine (M.M.C., J.E.M.), Radiology (V.V.M.), and Pathology (M.N.A.), Harvard Medical School - both in Boston
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Patel VK, Shirbhate E, Patel P, Veerasamy R, Sharma PC, Rajak H. Corticosteroids for treatment of COVID-19: effect, evidence, expectation and extent. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2021; 10:78. [PMID: 34751250 PMCID: PMC8567120 DOI: 10.1186/s43088-021-00165-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 10/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) announced the COVID-19 occurrence as a global pandemic in March 2020. The treatment of SARS-CoV-2 patients is based on the experience gained from SARS-CoV and MERS-CoV infection during 2003. There is no clinically accepted therapeutic drug(s) accessible yet for the treatment of COVID-19. MAIN BODY Corticosteroids, i.e., dexamethasone, methylprednisolone, hydrocortisone and prednisone are used alone or in combination for the treatment of moderate, severe and critically infected COVID-19 patients who are hospitalized and require supplemental oxygen as per current management strategies and guidelines for COVID-19 published by the National Institutes of Health. Corticosteroids are recorded in the WHO model list of essential medicines and are easily accessible worldwide at a cheaper cost in multiple formulations and various dosage forms. Corticosteroid can be used in all age group of patients, i.e., children, adult, elderly and during pregnancy or breastfeeding women. Corticosteroids have potent anti-inflammatory and immunosuppressive effects in both primary and secondary immune cells, thereby reducing the generation of proinflammatory cytokines and chemokines and lowering the activation of T cells, monocytes and macrophages. The corticosteroids should not be used in the treatment of non-severe COVID-19 patients because corticosteroids suppress the immune response and reduce the symptoms and associated side effects such as slow recovery, bacterial infections, hypokalemia, mucormycosis and finally increase the chances of death. CONCLUSION Intensive research on corticosteroid therapy in COVID-19 treatment is urgently needed to elucidate their mechanisms and importance in contributing toward successful prevention and treatment approaches. Hence, this review emphasizes on recent advancement on corticosteroid therapy for defining their importance in overcoming SARS-CoV-2 pandemic, their mechanism, efficacy and extent of corticosteroids in the treatment of COVID-19 patients.
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Affiliation(s)
- Vijay K. Patel
- Institute of Pharmaceutical Sciences, Guru Ghasidas University, Bilaspur, C.G. 495 009 India
| | - Ekta Shirbhate
- Institute of Pharmaceutical Sciences, Guru Ghasidas University, Bilaspur, C.G. 495 009 India
| | - Preeti Patel
- Institute of Pharmaceutical Sciences, Guru Ghasidas University, Bilaspur, C.G. 495 009 India
| | - Ravichandran Veerasamy
- Faculty of Pharmacy, AIMST University, 08100 Semeling, Bedong, Kedah Darul Aman Malaysia
| | - Prabodh C. Sharma
- Department of Pharmaceutical Chemistry, Delhi Pharmaceutical Sciences and Research University, MB Road, Pushp Vihar, New Delhi, 110 017 India
| | - Harish Rajak
- Institute of Pharmaceutical Sciences, Guru Ghasidas University, Bilaspur, C.G. 495 009 India
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Gharamti AA, Mundo W, Chastain DB, Franco-Paredes C, Henao-Martínez AF, Shapiro L. Pneumocystis jirovecii pneumonia: a proposed novel model of corticosteroid benefit. Ther Adv Infect Dis 2021; 8:20499361211032034. [PMID: 34349985 PMCID: PMC8295936 DOI: 10.1177/20499361211032034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Amal A Gharamti
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - William Mundo
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Carlos Franco-Paredes
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA
| | - Andrés F Henao-Martínez
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, 12700 E. 19th Avenue, Mail Stop B168. Aurora, CO 80045, USA
| | - Leland Shapiro
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA
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Khiali S, Entezari-Maleki T. Therapeutic Application of Corticosteroids in COVID-19: A Focus on Optimum Dose and Duration of Therapy. J Clin Pharmacol 2021; 61:1145-1148. [PMID: 34157144 PMCID: PMC8426861 DOI: 10.1002/jcph.1929] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/21/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Sajad Khiali
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taher Entezari-Maleki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran.,Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Giri A, Srinivasan A, Sundar IK. COVID-19: Sleep, Circadian Rhythms and Immunity - Repurposing Drugs and Chronotherapeutics for SARS-CoV-2. Front Neurosci 2021; 15:674204. [PMID: 34220430 PMCID: PMC8249936 DOI: 10.3389/fnins.2021.674204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/05/2021] [Indexed: 01/08/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has affected nearly 28 million people in the United States and has caused more than five hundred thousand deaths as of February 21, 2021. As the novel coronavirus continues to take its toll in the United States and all across the globe, particularly among the elderly (>65 years), clinicians and translational researchers are taking a closer look at the nexus of sleep, circadian rhythms and immunity that may contribute toward a more severe coronavirus disease-19 (COVID-19). SARS-CoV-2-induced multi-organ failure affects both central and peripheral organs, causing increased mortality in the elderly. However, whether differences in sleep, circadian rhythms, and immunity between older and younger individuals contribute to the age-related differences in systemic dysregulation of target organs observed in SARS-CoV-2 infection remain largely unknown. Current literature demonstrates the emerging role of sleep, circadian rhythms, and immunity in the development of chronic pulmonary diseases and respiratory infections in human and mouse models. The exact mechanism underlying acute respiratory distress syndrome (ARDS) and other cardiopulmonary complications in elderly patients in combination with associated comorbidities remain unclear. Nevertheless, understanding the critical role of sleep, circadian clock dysfunction in target organs, and immune status of patients with SARS-CoV-2 may provide novel insights into possible therapies. Chronotherapy is an emerging concept that is gaining attention in sleep medicine. Accumulating evidence suggests that nearly half of all physiological functions follow a strict daily rhythm. However, healthcare professionals rarely take implementing timed-administration of drugs into consideration. In this review, we summarize recent findings directly relating to the contributing roles of sleep, circadian rhythms and immune response in modulating infectious disease processes, and integrate chronotherapy in the discussion of the potential drugs that can be repurposed to improve the treatment and management of COVID-19.
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Affiliation(s)
| | | | - Isaac Kirubakaran Sundar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
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Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Fungal pneumonia in kidney transplant recipients. Respir Med 2021; 185:106492. [PMID: 34139578 DOI: 10.1016/j.rmed.2021.106492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.
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Affiliation(s)
- D Wilmes
- Division of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - E Coche
- Division of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - H Rodriguez-Villalobos
- Division of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - N Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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Tinti F, Lai S, Noce A, Rotondi S, Marrone G, Mazzaferro S, Di Daniele N, Mitterhofer AP. Chronic Kidney Disease as a Systemic Inflammatory Syndrome: Update on Mechanisms Involved and Potential Treatment. Life (Basel) 2021; 11:419. [PMID: 34063052 PMCID: PMC8147921 DOI: 10.3390/life11050419] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/26/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease (CKD) is characterized by manifestations and symptoms involving systemic organs and apparatus, associated with elevated cardiovascular morbidity and mortality, bone disease, and other tissue involvement. Arterial hypertension (AH), diabetes mellitus (DM), and dyslipidemia, with glomerular or congenital diseases, are the traditional risk factors recognized as the main causes of progressive kidney dysfunction evolving into uremia. Acute kidney injury (AKI) has recently been considered an additional risk factor for the worsening of CKD or the development of CKD de novo. Evidence underlies the role of systemic inflammation as a linking factor between AKI and CKD, recognizing the role of inflammation in AKI evolution to CKD. Moreover, abnormal increases in oxidative stress (OS) and inflammatory status in CKD seem to exert an important pathogenetic role, with significant involvement in the clinical management of this condition. With our revision, we want to focus on and update the inflammatory mechanisms responsible for the pathologic conditions associated with CKD, with particular attention on the development of AKI and AKI-CKD de novo, the alteration of calcium-phosphorus metabolism with bone disease and CKD-MBD syndrome, the status of malnutrition and malnutrition-inflammation complex syndrome (MICS) and protein-energy wasting (PEW), uremic sarcopenia, the status of OS, and the different inflammatory pathways, highlighting a new approach to CKD. The depth comprehension of the mechanisms underlying the development of inflammation in CKD may present new possible therapeutic approaches in CKD and hopefully improve the management of correlated morbidities and provide a reduction in associated mortality.
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Affiliation(s)
- Francesca Tinti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Silvia Lai
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Annalisa Noce
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
| | - Silverio Rotondi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Giulia Marrone
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
- PhD School of Applied Medical, Surgical Sciences, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy
| | - Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Nicola Di Daniele
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
| | - Anna Paola Mitterhofer
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
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Assal M, Lambert J, Chow-Chine L, Bisbal M, Servan L, Gonzalez F, de Guibert JM, Faucher M, Vey N, Sannini A, Mokart D. Prognostic impact of early adjunctive corticosteroid therapy in non-HIV oncology or haematology patients with Pneumocystis jirovecii pneumonia: A propensity score analysis. PLoS One 2021; 16:e0250611. [PMID: 33886692 PMCID: PMC8061944 DOI: 10.1371/journal.pone.0250611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 04/10/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose While early adjunctive corticosteroid therapy (EACST) has been proven effective in HIV patients with Pneumocystis Jirovecii Pneumonia (PJP), data remains controversial concerning non-HIV oncology or haematology patients. Methods This retrospective study included cancer patients without HIV and with diagnosis of PJP admitted in a cancer referral centre, from January-1-2010 to March-31-2017. We compared 30-day and 1-year mortality rate, change in the respiratory item of the Sequential Organ Failure Assessment score(SOFA-resp worsening), use of tracheal intubation between day-1 and day-5 of anti-pneumocystis therapy and occurrence of coinfections between patients with EACST and those with no or late corticosteroid therapy, using an inverse probability weighting propensity score-based (IPW) analysis. Results 133 non-HIV oncology or haematology PJP patients were included (EACST n = 58, others n = 75). The main underlying conditions were haematological malignancies (n = 107, 80,5%), solid tumour (n = 27, 20,3%) and allogeneic stem cell transplantation (n = 17, 12,8%). Overall 30-day and 1-year mortality rate was 24,1% and 56,4%, respectively. IPW analysis found no difference on 30-day (HR = 1.45, 95% CI [0.7–3.04], p = 0.321) and 1-year (HR = 1.25, CI 95% [0.75–2.09], p = 0.39) mortality rate between groups. Conclusion No difference in SOFA-resp worsening, tracheal intubation and coinfections was found between groups. Combination of EACST with anti-pneumocystis therapy in non-HIV onco-haematology PJP-patients was not associated with clinical improvement.
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Affiliation(s)
- Mehdi Assal
- Intensive Care Unit, Hôpital La Timone, Marseille, France
| | - Jérôme Lambert
- Biostatistics Department, Saint Louis Teaching Hospital, Paris, France
| | | | - Magali Bisbal
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Luca Servan
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | | | | | - Marion Faucher
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Norbert Vey
- Department of Haematology, Institut Paoli-Calmettes, Marseille, France
| | - Antoine Sannini
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Djamel Mokart
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
- * E-mail:
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Weyant RB, Kabbani D, Doucette K, Lau C, Cervera C. Pneumocystis jirovecii: a review with a focus on prevention and treatment. Expert Opin Pharmacother 2021; 22:1579-1592. [PMID: 33870843 DOI: 10.1080/14656566.2021.1915989] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Pneumocystis jirovecii (PJ) is an opportunistic fungal pathogen that can cause severe pneumonia in immunocompromised hosts. Risk factors for Pneumocystis jirovecii pneumonia (PJP) include HIV, organ transplant, malignancy, certain inflammatory or rheumatologic conditions, and associated therapies and conditions that result in cell-mediated immune deficiency. Clinical signs of PJP are nonspecific and definitive diagnosis requires direct detection of the organism in lower respiratory secretions or tissue. First-line therapy for prophylaxis and treatment remains trimethoprim-sulfamethoxazole (TMP-SMX), though intolerance or allergy, and rarely treatment failure, may necessitate alternate therapeutics, such as dapsone, pentamidine, atovaquone, clindamycin, primaquine and most recently, echinocandins as adjunctive therapy. In people living with HIV (PLWH), adjunctive corticosteroid use in treatment has shown a mortality benefit.Areas covered: This review article covers the epidemiology, pathophysiology, diagnosis, microbiology, prophylaxis indications, prophylactic therapies, and treatments.Expert opinion: TMP-SMX has been first-line therapy for treating and preventing pneumocystis for decades. However, its adverse effects are not uncommon, particularly during treatment. Second-line therapies may be better tolerated, but often sacrifice efficacy. Echinocandins show some promise for new combination therapies; however, further studies are needed to define optimal antimicrobial therapy for PJP as well as the role of corticosteroids in those without HIV.
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Affiliation(s)
- R Benson Weyant
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Doucette
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cecilia Lau
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Gingerich AD, Norris KA, Mousa JJ. Pneumocystis Pneumonia: Immunity, Vaccines, and Treatments. Pathogens 2021; 10:pathogens10020236. [PMID: 33669726 PMCID: PMC7921922 DOI: 10.3390/pathogens10020236] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/11/2021] [Accepted: 02/16/2021] [Indexed: 12/18/2022] Open
Abstract
For individuals who are immunocompromised, the opportunistic fungal pathogen Pneumocystis jirovecii is capable of causing life-threatening pneumonia as the causative agent of Pneumocystis pneumonia (PCP). PCP remains an acquired immunodeficiency disease (AIDS)-defining illness in the era of antiretroviral therapy. In addition, a rise in non-human immunodeficiency virus (HIV)-associated PCP has been observed due to increased usage of immunosuppressive and immunomodulating therapies. With the persistence of HIV-related PCP cases and associated morbidity and mortality, as well as difficult to diagnose non-HIV-related PCP cases, an improvement over current treatment and prevention standards is warranted. Current therapeutic strategies have primarily focused on the administration of trimethoprim-sulfamethoxazole, which is effective at disease prevention. However, current treatments are inadequate for treatment of PCP and prevention of PCP-related death, as evidenced by consistently high mortality rates for those hospitalized with PCP. There are no vaccines in clinical trials for the prevention of PCP, and significant obstacles exist that have slowed development, including host range specificity, and the inability to culture Pneumocystis spp. in vitro. In this review, we overview the immune response to Pneumocystis spp., and discuss current progress on novel vaccines and therapies currently in the preclinical and clinical pipeline.
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Affiliation(s)
- Aaron D. Gingerich
- Center for Vaccines and Immunology, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA; (A.D.G.); (K.A.N.)
- Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
| | - Karen A. Norris
- Center for Vaccines and Immunology, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA; (A.D.G.); (K.A.N.)
- Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
| | - Jarrod J. Mousa
- Center for Vaccines and Immunology, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA; (A.D.G.); (K.A.N.)
- Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
- Correspondence:
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Yuan C, Li R, Liu G, Pan Y. Potential of Immune-Related Therapy in COVID-19. Front Pharmacol 2021; 11:609212. [PMID: 33574756 PMCID: PMC7870867 DOI: 10.3389/fphar.2020.609212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022] Open
Abstract
At the beginning of 2020, a sudden outbreak of new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), infections led to anxiety, panic, and crisis among people worldwide. The outbreak first occurred in Wuhan, China, in late December 2019 and then spread rapidly across the globe, thus becoming a major public health emergency. Although the current epidemic situation in China tends to be stable, coronavirus disease 2019 (COVID-19) continues to spread globally. At present, no specific therapeutic drugs and vaccines are available against COVID-19. Also, the pathogenesis of the SARS-CoV-2 is not fully clear. Human immunity is important in SARS-CoV-2 infection. Studies have shown that excessive inflammation caused by SARS-CoV-2 infection and subsequent induced uncontrolled cytokine storm are the main causes of disease deterioration and death of severe patients. Therefore, immune-related research is of great significance for the prevention, control, and prognosis of COVID-19. This study aimed to review the latest research on immune-related treatment of COVID-19.
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Affiliation(s)
- Chunjue Yuan
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Ruoyun Li
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Guohong Liu
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Yunbao Pan
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
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Rombauts A, Abelenda-Alonso G, Cuervo G, Gudiol C, Carratalà J. Role of the inflammatory response in community-acquired pneumonia: clinical implications. Expert Rev Anti Infect Ther 2021; 20:1261-1274. [PMID: 33034228 DOI: 10.1080/14787210.2021.1834848] [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: 12/15/2022]
Abstract
INTRODUCTION Despite adequate antibiotic coverage, community-acquired pneumonia (CAP) remains a leading cause of hospitalization and mortality worldwide. It induces both a local pulmonary and a systemic inflammatory response, particularly significant in severe cases. The intensity of the dysregulated host response varies from patient to patient and has a negative impact on survival and other outcomes. AREAS COVERED This comprehensive review summarizes the pathophysiological aspects of the inflammatory response in CAP, briefly discusses the usefulness of biomarkers, and assesses the clinical evidence for modulating the inflammatory pathways. We searched PubMed for the most relevant studies, reviews, and meta-analysis until August 2020. EXPERT OPINION Notable efforts have been made to identify biomarkers that can accurately differentiate between viral and bacterial etiology, and indeed, to enhance risk stratification in CAP. However, none has proven ideal and no recommended biomarker-guided algorithms exist. Biomarker signatures from proteomic and metabolomic studies could be more useful for such assessments. To date, most studies have produced contradictory results concerning the role of immunomodulatory agents (e.g. corticosteroids, macrolides, and statins) in CAP. Adequately identifying the population who may benefit most from effective modulation of the inflammatory response remains a challenge.
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Affiliation(s)
- Alexander Rombauts
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Guillermo Cuervo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain.,Institut Català d'Oncologia (ICO), Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain
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El-Goly AMM. Lines of Treatment of COVID-19 Infection. COVID-19 INFECTIONS AND PREGNANCY 2021. [PMCID: PMC8298380 DOI: 10.1016/b978-0-323-90595-4.00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Successful Treatment of Severe Parainfluenza Pneumonia in a Liver Transplant Recipient with Oral Ribavirin and Intravenous Immunoglobulin. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2020. [DOI: 10.5812/archcid.100462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
: The most common viruses affecting immunocompromised hosts include cytomegalovirus, herpes simplex virus, varicella-zoster virus, influenza virus, measles virus, and adenovirus. Parainfluenza virus infection is common among human populations. It causes non-specific symptoms in immune-competent hosts; therefore, it may go undiagnosed. However, it is particularly dangerous for immunocompromised patients by presenting a high risk of morbidity and sometimes mortality among them. Patients who have bone marrow or solid organ transplantation need to follow an intense immunosuppressing routine, which leaves them extremely vulnerable to opportunistic agents such as parainfluenza viruses. Several factors determine the severity of parainfluenza virus infections, such as the type of the virus, the level of immunosuppression, and co-infection with other agents. Co-infection is especially important because it makes a correct differential diagnosis difficult. While almost all bodies of influenza infection information in immunocompromised patients are from studies of bone marrow transplant recipients, there are very limited data available on influenza infections in liver transplant patients. We present a liver transplant patient with severe parainfluenza pneumonia that was improved significantly with oral ribavirin and intravenous immunoglobulin. A 23-year-old female patient with a history of liver transplantation from 18 months ago presented with a one-week cough and tachypnea. Chest computed tomography demonstrated ground-glass opacities and diffuse infiltrates throughout both lungs. A multiplex polymerase chain reaction for the detection of respiratory viruses in the nasopharynx was positive for parainfluenza virus type 3 and she was successfully treated with oral ribavirin and intravenous immunoglobulin. Respiratory infection with the parainfluenza virus in immunocompromised adults, including transplant patients, is associated with significant morbidity and mortality, and early treatment with ribavirin and intravenous immunoglobulin may markedly improve their outcomes. To the best of our knowledge, this is the first case report of the successful treatment of parainfluenza infection with ribavirin and intravenous immunoglobulin in a patient with liver transplantation.
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Verbeke K, Verbuyst R, Brands C, Slabbynck H. Dyspnea in homosexual male patients: throwback to an occasionally forgotten but severe clinical presentation of HIV/AIDS. Acta Clin Belg 2020; 75:411-415. [PMID: 31130106 DOI: 10.1080/17843286.2019.1622880] [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: 10/26/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) can be a severe indicator disease of acquired immunodeficiency syndrome (AIDS). We present two cases of homosexual male patients who came to the emergency unit of a Belgian hospital because of shortness of breath. Both men had been sent back home, initially diagnosed with a benign viral infection. Because of worsening symptoms and gradually evolving hypoxemia, both patients came back and were admitted to the hospital with a diagnosis of (microbiology proven) Pneumocystis jirovecii pneumonia. HIV serology in both men was tested and was clearly positive, indicating a new diagnosis of HIV infection. In this article, we provide an overview of this possibly severe AIDS defining condition. First, we give an introduction of the history of HIV/AIDS and its occurrence in homosexual males in Europe. Secondly, we provide an overview of the diagnosis and treatment of Pneumocystis jirovecii pneumonia. Finally, since the first case reports of Pneumocystis jirovecii pneumonia at the beginning of the AIDS epidemic also included homosexual men, we emphasize the potential importance of a sexual anamnesis in young male patients with an initial complaint of dyspnea.
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Affiliation(s)
- Koen Verbeke
- Department of Pulmonology, ZNA Middelheim, Antwerp, Belgium
| | - Roel Verbuyst
- Department of Pulmonology, ZNA Stuyvenberg, Antwerp, Belgium
| | | | - Hans Slabbynck
- Department of Pulmonology, ZNA Middelheim, Antwerp, Belgium
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Mundo W, Morales-Shnaider L, Tewahade S, Wagner E, Archuleta S, Bandali M, Chadalawada S, Johnson SC, Franco-Paredes C, Shapiro L, Henao-Martínez AF. Lower Mortality Associated With Adjuvant Corticosteroid Therapy in Non-HIV-Infected Patients With Pneumocystis jirovecii Pneumonia: A Single-Institution Retrospective US Cohort Study. Open Forum Infect Dis 2020; 7:ofaa354. [PMID: 33005696 PMCID: PMC7518367 DOI: 10.1093/ofid/ofaa354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/10/2020] [Indexed: 01/19/2023] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) remains a cause of mortality in HIV-negative patients. The clinical benefit of adjuvant corticosteroids in these patients is uncertain. This study aimed to determine if corticosteroids would reduce mortality in a cohort of HIV-negative PJP patients. Methods We examined a retrospective case series of patients diagnosed with PJP at the University of Colorado Hospital between 1995 and 2019. Data were collected in 71 PJP-infected patients. Twenty-eight patients were HIV-negative, and 43 were infected with HIV. We performed bivariate and forward, stepwise multivariable logistic regressions to identify mortality predictors. Results Common underlying conditions in HIV-negative patients were hematologic malignancies (28.6%), autoimmune disorders (25.9%), and solid organ transplantation (10.7%). HIV-negative patients had higher rates and durations of mechanical ventilation and intensive care unit stay. Survival was significantly increased in HIV-negative patients receiving adjuvant corticosteroids, with 100% mortality in patients not receiving corticosteroids vs 60% mortality in patients receiving corticosteroids (P = .034). In an adjusted multivariable model, no adjuvant corticosteroid use was associated with higher mortality (odds ratio, 13.5; 95% CI, 1.1–158.5; P = .039) regardless of HIV status. Conclusions We found substantial mortality among HIV-negative patients with PJP, and adjuvant corticosteroid use was associated with decreased mortality. Response to corticosteroids is best established in HIV-infected patients, but emerging reports suggest a similar beneficial response in PJP patients without HIV infection. Further prospective studies may establish a more definitive role of the addition of corticosteroids among HIV-negative patients with PJP.
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Affiliation(s)
- William Mundo
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Selam Tewahade
- School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eric Wagner
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Solana Archuleta
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mohamed Bandali
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sindhu Chadalawada
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Steven C Johnson
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Carlos Franco-Paredes
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,NRI Medical College, NRI General Hospital, Guntur, Andhra Pradesh, India.,Hospital Infantil de México, Federico Gómez, México City, México
| | - Leland Shapiro
- NRI Medical College, NRI General Hospital, Guntur, Andhra Pradesh, India.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,The Emily Foundation for Medical Research, Boston, Massachusetts, USA
| | - Andrés F Henao-Martínez
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,NRI Medical College, NRI General Hospital, Guntur, Andhra Pradesh, India
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Bani-Sadr F, Hentzien M, Pascard M, N'Guyen Y, Servettaz A, Andreoletti L, Kanagaratnam L, Jolly D. Corticosteroid therapy for patients with COVID-19 pneumonia: a before-after study. Int J Antimicrob Agents 2020; 56:106077. [PMID: 32634602 PMCID: PMC7342082 DOI: 10.1016/j.ijantimicag.2020.106077] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/16/2020] [Accepted: 06/28/2020] [Indexed: 12/14/2022]
Abstract
Severe COVID-19 patients present overwhelming inflammatory reactions leading to lung injury. Corticosteroids may beneficially modulate the host immune response to COVID-19 pneumonia. Before–after study evaluating the effect of corticosteroid addition to COVID-19 pneumonia treatment on hospital mortality. In multivariate analysis, the ‘after’ period was associated with an adjusted lower risk of death (aHR = 0.47; P = 0.04). ‘After’ period was also associated with lower risk of ICU admission or death before ICU admission (aHR = 0.37; P < 0.001).
Anti-inflammatory drugs such as corticosteroids may beneficially modulate the host inflammatory response to coronavirus disease 2019 (COVID-19) pneumonia. The aim of this study was to evaluate the impact of addition of corticosteroids to the hospital protocol for treatment of suspected or confirmed COVID-19 pneumonia on rates of death or intensive care unit (ICU) admission. A before–after study was performed to evaluate the effect of addition of corticosteroids to our institution's COVID-19 treatment protocol on hospital mortality. A total of 257 patients with a COVID-19 diagnosis were included in this study between 3 March 2020 and 14 April 2020. As corticosteroids were widely used after 27 March 2020, two periods were considered for the purposes of this study: the ‘before’ period from 3–20 March 2020 (n = 85); and the ‘after’ period from 26 March–14 April 2020 (n = 172). The ‘after’ period was associated with a lower risk of death [adjusted hazard ratio (aHR) = 0.47, 95% confidence interval (CI) 0.23–0.97; P = 0.04] and a lower risk of ICU admission or of death before ICU admission (aHR = 0.37, 95% CI 0.21–0.64; P = 0.0005) by multivariate analysis adjusted for age, National Early Warning score and institutionalisation status. In conclusion, addition of corticosteroids to our institution's COVID-19 treatment protocol was associated with a significant reduction in hospital mortality in the ‘after’ period.
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Affiliation(s)
- Firouzé Bani-Sadr
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Reims University Hospital, Reims, France.
| | - Maxime Hentzien
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Reims University Hospital, Reims, France
| | - Madeline Pascard
- Department of Research and Public Health, Reims University Hospital, Reims, France
| | - Yohan N'Guyen
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Reims University Hospital, Reims, France
| | - Amélie Servettaz
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Reims University Hospital, Reims, France
| | | | - Lukshe Kanagaratnam
- Department of Research and Public Health, Reims University Hospital, Reims, France
| | - Damien Jolly
- Department of Research and Public Health, Reims University Hospital, Reims, France
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Baburao A, Singh A, Narayanswamy H, Shivalingaiah B. A double whammy in an immunocompromised patient. Indian J Sex Transm Dis AIDS 2020; 41:201-204. [PMID: 33817596 PMCID: PMC8000680 DOI: 10.4103/ijstd.ijstd_70_18] [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: 09/05/2018] [Revised: 01/29/2019] [Accepted: 03/24/2019] [Indexed: 12/02/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) is a common opportunistic infection in immunocompromised patients, especially those with human immunodeficiency virus (HIV) infection. Cytomegalovirus (CMV) pneumonia most often occurs as a coinfection with another opportunistic pathogen especially in patients with severe immunosuppression. We present a case of PCP-CMV coinfection in a newly diagnosed HIV patient who was treated with the recommended therapy for both diseases and had a favorable outcome. The presence of CMV in the context of another opportunistic respiratory tract infection is often to be not treated, due to conflicting evidence of its therapeutic benefit. Our report highlights the importance of CMV treatment to achieve clinical stability and recovery in newly diagnosed patients with HIV and severely immuno-compromised status.
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Affiliation(s)
- Archana Baburao
- Department of Pulmonary Medicine, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
| | - Amandeep Singh
- Department of Pulmonary Medicine, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
| | - Huliraj Narayanswamy
- Department of Pulmonary Medicine, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
| | - Bhavya Shivalingaiah
- Department of Pulmonary Medicine, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
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Ding L, Huang H, Wang H, He H. Adjunctive corticosteroids may be associated with better outcome for non-HIV Pneumocystis pneumonia with respiratory failure: a systemic review and meta-analysis of observational studies. Ann Intensive Care 2020; 10:34. [PMID: 32198645 PMCID: PMC7083987 DOI: 10.1186/s13613-020-00649-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/06/2020] [Indexed: 11/23/2022] Open
Abstract
Background Evidence supporting corticosteroids adjunctive treatment (CAT) for Pneumocystis jirovecii pneumonia (PCP) in non-HIV patients is highly controversial. We aimed to systematically review the literature and perform a meta-analysis of available data relating to the effect of CAT on mortality of PCP in non-HIV patients. Methods We searched Pubmed, Medline, Embase, and Cochrane database from 1989 through 2019. Data on clinical outcomes from non-HIV PCP were extracted with a standardized instrument. Heterogeneity was assessed with the I2 index. Pooled odds ratios and 95% confidence interval were calculated using a fixed effects model. We analyzed the impact of CAT on mortality of non-HIV PCP in the whole PCP population, those who had hypoxemia (PaO2 < 70 mmHg) and who had respiratory failure (PaO2 < 60 mmHg). Results In total, 259 articles were identified, and 2518 cases from 16 retrospective observational studies were included. In all non-HIV PCP cases included, there was an association between CAT and increased mortality (odds ratio, 1.37; 95% confidence interval 1.07–1.75; P = 0.01). CAT showed a probable benefit of decreasing mortality in hypoxemic non-HIV PCP patients (odds ratio, 0.69; 95% confidence interval 0.47–1.01; P = 0.05). Furthermore, in a subgroup analysis, CAT showed a significantly lower mortality in non-HIV PCP patients with respiratory failure compared to no CAT (odds ratio, 0.63; 95% confidence interval 0.41–0.95; P = 0.03). Conclusions Our meta-analysis suggests that among non-HIV PCP patients with respiratory failure, CAT use may be associated with better clinical outcomes, and it may be associated with increased mortality in unselected non-HIV PCP population. Clinical trials are needed to compare CAT vs no-CAT in non-HIV PCP patients with respiratory failure. Furthermore, CAT use should be withheld in non-HIV PCP patients without hypoxemia.
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Affiliation(s)
- Lin Ding
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Beijing, China
| | - Huixue Huang
- Department of Medicine, Beijing University of Technology Hospital, Beijing, China
| | - Heyan Wang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang, Guizhou, China
| | - Hangyong He
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China. .,Beijing Engineering Research Center for Diagnosis and Treatment of Pulmonary and Critical Care, Beijing, China. .,Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
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Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
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Antimicrobial Therapy in the Context of the Damage-Response Framework: the Prospect of Optimizing Therapy by Reducing Host Damage. Antimicrob Agents Chemother 2020; 64:AAC.01800-19. [PMID: 31740558 DOI: 10.1128/aac.01800-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
By design, antimicrobial agents act directly on microbial targets. These drugs aim to eliminate microbes and are remarkably effective against susceptible organisms. Nonetheless, some patients succumb to infectious diseases despite appropriate antimicrobial therapy. Today, with very few exceptions, physicians select antimicrobial therapy based on its activity against the targeted organism without consideration of how the regimen affects patients' immune responses. An important concept to emerge in the past few decades is that immune responses to microbes can be detrimental by enhancing host damage, which can translate into clinical disease. A central tenet of the damage-response framework (DRF) of microbial pathogenesis is that the relevant outcome of host-microbe interaction is the damage that occurs in the host, which can be due to microbial factors, host factors, or both. Given that host damage can make patients sick, reducing it should be a goal of treating infectious diseases. Inflammation and damage that stem from the host response to an infectious disease can increase during therapy with some antimicrobial agents and decrease during therapy with others. When a patient cannot eliminate a microbe with their own immune response, antimicrobial therapy is essential for microbial elimination, and yet it can affect the inflammatory response. In this essay, we discuss antimicrobial therapy in the context of the DRF and propose that consideration of the DRF may help tailor therapy to a patient's need to augment or reduce inflammation.
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A Pilot Study of Echinocandin Combination with Trimethoprim/Sulfamethoxazole and Clindamycin for the Treatment of AIDS Patients with Pneumocystis Pneumonia. J Immunol Res 2019; 2019:8105075. [PMID: 31886310 PMCID: PMC6914895 DOI: 10.1155/2019/8105075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/15/2019] [Indexed: 01/23/2023] Open
Abstract
Background and Objectives Pneumocystis pneumonia (PCP) is a common opportunistic infection in acquired immune deficiency syndrome (AIDS) patients that continues to result in a high mortality rate. To develop a better treatment strategy and improve PCP prognosis, a cohort study was conducted to evaluate the therapeutic potential of echinocandin treatment for AIDS patients with PCP (AIDS-PCP). Methods The AIDS-PCP patients were analyzed in our retrospective cohort study that were hospitalized in The First Affiliated Hospital of Zhejiang University during 2013–2018. The antifungal effects of echinocandins were evaluated in two subgroups that were classified by oxygenation as a proxy for the disease state: PaO2/FiO2 > 200 mmHg and PaO2/FiO2 ≤ 200 mmHg. Intergroup comparisons and survival curves were used to evaluate the effectiveness of the two AIDS-PCP treatment regimens. Results During the follow-up, 182 AIDS-PCP patients were diagnosed and analyzed in the study. After excluding 55 patients with other superinfections and five patients that were treated with HAART, the remaining 122 patients were enrolled in the study. The group treated with echinocandins combined with trimethoprim-sulfamethoxazole (TMP-SMZ) and clindamycin exhibited a lower mortality rate (9.62%, 5/52) than did the group with TMP-SMZ and clindamycin treatment (20%, 14/70). For AIDS-PCP patients in the PaO2/FiO2 > 200 mmHg subgroup, treatment with echinocandins combined with TMP-SMZ and clindamycin significantly reduced their mortality rate (4.44% (2/45) vs. 18.18% (10/55), P = 0.035). Conclusion The results of this study indicate that treatment with echinocandins in combination with the standard TMP-SMZ and clindamycin regimen can improve the prognosis and reduce the mortality rate in patients with mild to moderate AIDS-PCP disease.
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Gaborit BJ, Tessoulin B, Lavergne RA, Morio F, Sagan C, Canet E, Lecomte R, Leturnier P, Deschanvres C, Khatchatourian L, Asseray N, Garret C, Vourch M, Marest D, Raffi F, Boutoille D, Reignier J. Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study. Ann Intensive Care 2019; 9:131. [PMID: 31776705 PMCID: PMC6881486 DOI: 10.1186/s13613-019-0604-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/13/2019] [Indexed: 01/11/2023] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lavage fluid cytology profiles at diagnosis. Methods We prospectively enrolled all patients meeting pre-defined diagnostic criteria for PJP admitted at Nantes university hospital, France, from January 2012 to January 2017. Diagnostic criteria for PJP were typical clinical features with microbiological confirmation of P. jirovecii cysts by direct examination or a positive specific quantitative real-time polymerase chain reaction (PCR) assay. Severe PJP was defined as hypoxemic acute respiratory failure requiring high-flow nasal oxygen with at least 50% FiO2, non-invasive ventilation, or MV. Results Of 2446 respiratory samples investigated during the study period, 514 from 430 patients were positive for P. jirovecii. Of these 430 patients, 107 met criteria for PJP and were included in the study, 53 (49.5%) patients had severe PJP, including 30 who required MV. All patients were immunocompromised with haematological malignancy ranking first (n = 37, 35%), followed by solid organ transplantation (n = 27, 25%), HIV-infection (n = 21, 20%), systemic diseases (n = 13, 12%), solid tumors (n = 12, 11%) and primary immunodeficiency (n = 6, 8%). By multivariate analysis, factors independently associated with severity were older age (OR, 3.36; 95% CI 1.4–8.5; p < 0.05), a P. jirovecii microscopy-positive result from bronchoalveolar lavage (BAL) (OR, 1.3; 95% CI 1.54–9.3; p < 0.05); and absence of a BAL fluid alveolitis profile (OR, 3.2; 95% CI 1.27–8.8; p < 0.04). The 90-day mortality rate was 27%, increasing to 50% in the severe PJP group. Factors independently associated with 90-day mortality were worse SOFA score on day 1 (OR, 1.05; 95% CI 1.02–1.09; p < 0.001) whereas alveolitis at BAL was protective (OR, 0.79; 95% CI 0.65–0.96; p < 0.05). In the subgroup of HIV-negative patients, similar findings were obtained, then viral co-infection were independently associated with higher 90-day mortality (OR, 1.25; 95% CI 1.02–1.55; p < 0.05). Conclusions Older age and P. jirovecii oocysts at microscopic examination of BAL were independently associated with severe PJP. Both initial PJP severity as evaluated by the SOFA score and viral co-infection predicted 90-day mortality. Alveolitis at BAL examination was associated with less severe PJP. The pathophysiological mechanism underlying this observation deserves further investigation.
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Affiliation(s)
- Benjamin Jean Gaborit
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France. .,EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, Nantes, France.
| | - Benoit Tessoulin
- Service d'Hématologie, University Hospital, INSERM, U1232, Université de Nantes, Nantes, France
| | - Rose-Anne Lavergne
- Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Florent Morio
- Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | | | - Emmanuel Canet
- Medical Intensive Care, University Hospital, Nantes, France
| | - Raphael Lecomte
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Paul Leturnier
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Colin Deschanvres
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Lydie Khatchatourian
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Nathalie Asseray
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | | | - Michael Vourch
- Medical Intensive Care, University Hospital, Nantes, France
| | | | - François Raffi
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - David Boutoille
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France.,EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, Nantes, France
| | - Jean Reignier
- Medical Intensive Care, University Hospital, Nantes, France
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Saag M, Mendoza DP, Sherman MS, Cote GM, Shih AR. Case 36-2019: A 34-Year-Old Man with Dyspnea, Odynophagia, and Abdominal Pain. N Engl J Med 2019; 381:2052-2061. [PMID: 31747731 DOI: 10.1056/nejmcpc1909625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Michael Saag
- From the Department of Medicine, University of Alabama Birmingham School of Medicine, Birmingham (M.S.); and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
| | - Dexter P Mendoza
- From the Department of Medicine, University of Alabama Birmingham School of Medicine, Birmingham (M.S.); and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
| | - Marc S Sherman
- From the Department of Medicine, University of Alabama Birmingham School of Medicine, Birmingham (M.S.); and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
| | - Gregory M Cote
- From the Department of Medicine, University of Alabama Birmingham School of Medicine, Birmingham (M.S.); and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
| | - Angela R Shih
- From the Department of Medicine, University of Alabama Birmingham School of Medicine, Birmingham (M.S.); and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Radiology (D.P.M.), Medicine (M.S.S., G.M.C.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
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Azoulay É, de Castro N, Barbier F. Critically Ill Patients With HIV: 40 Years Later. Chest 2019; 157:293-309. [PMID: 31421114 DOI: 10.1016/j.chest.2019.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/25/2019] [Accepted: 08/04/2019] [Indexed: 01/27/2023] Open
Abstract
The development of combination antiretroviral therapies (cARTs) in the mid-1990s has dramatically modified the clinical presentation of critically ill, HIV-infected patients. Most cART-treated patients aging with controlled HIV replication are currently admitted to the ICU for non-AIDS-related events, mostly bacterial pneumonia and exacerbation of comorbidities, variably affected by chronic HIV infection (COPD, cardiovascular diseases, or solid neoplasms). Today, Pneumocystis jirovecii pneumonia, cerebral toxoplasmosis, TB, and other severe opportunistic infections only occur in patients with unknown viral status, limited access to cART, viral resistance, or compliance issues. Acute respiratory failure, neurological disorders, and sepsis remain the main conditions that lead HIV-infected patients to the ICU, although admissions for liver diseases or acute kidney injury are increasing. Case fatality dropped substantially over the past decades, reaching figures of HIV-uninfected critically ill patients with similar demographic characteristics, comorbidities, and level of organ dysfunctions. Several other facets of critical care management have evolved in this population, including diagnostic procedures, cART management at the acute phase of critical illness, and ethical considerations. The goal of this narrative review was to depict the current evidence and emerging challenges for the management of critically ill, HIV-infected patients, almost 40 years following the onset of the AIDS epidemic.
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Affiliation(s)
- Élie Azoulay
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France; ECSTRA, SBIM, and the Saint-Louis Hospital, APHP, Paris, France.
| | - Nathalie de Castro
- Department of Infectious Diseases, Saint-Louis Hospital, APHP, Paris, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
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Ando T, Abe Y, Endo Y, Tada K, Yamaji K, Tamura N. Rapid glucocorticoid tapering therapy to reduce mortality from pneumocystis pneumonia in patients with rheumatic disease. Mod Rheumatol 2019; 29:656-661. [PMID: 29972334 DOI: 10.1080/14397595.2018.1496873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Pneumocystis pneumonia (PCP) is a serious complication in patients with rheumatic diseases who are receiving immunosuppressive therapy. These patients have a higher mortality from PCP than those with human immunodeficiency virus. We examined factors associated with poor prognosis in patients with rheumatic diseases and evaluated PCP treatment in this population. Methods: This retrospective, single-center, observational cohort study included 31 patients with rheumatic diseases who were admitted to Juntendo University Hospital for PCP treatment from June 2006 to December 2017. The primary outcome was non-disease-specific mortality at discharge. Results: The median age at PCP diagnosis was 64 years. The survival rate was 61.3% (19/31). Twelve patients died, in all cases due to respiratory failure due to PCP. Among variables at PCP diagnosis and those related to PCP treatment, the presence of coexisting pulmonary diseases and greater glucocorticoid dose at PCP diagnosis were associated with higher mortality. The mortality related to biological agents for PCP was low. Rapid tapering of glucocorticoids improved survivability. Conclusion: In the treatment of PCP in patients with rheumatic diseases, rapid tapering of glucocorticoids was associated with a higher survival rate than the use of conventional therapy.
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Affiliation(s)
- Taiki Ando
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Yoshiyuki Abe
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Yukari Endo
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Kurisu Tada
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Ken Yamaji
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
| | - Naoto Tamura
- a Department of Internal Medicine and Rheumatology , Juntendo University School of Medicine , Tokyo , Japan
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Abstract
Great progress has been made in caring for persons with human immunodeficiency virus. However, a significant proportion of individuals still present to care with advanced disease and a low CD4 count. Careful considerations for selection of antiretroviral therapy as well as close monitoring for opportunistic infections and immune reconstitution inflammatory syndrome are vitally important in providing care for such individuals.
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Affiliation(s)
- Nathan A Summers
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 341 Ponce de Leon Avenue, Atlanta, GA 30308, USA
| | - Wendy S Armstrong
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 341 Ponce de Leon Avenue, Atlanta, GA 30308, USA.
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Liu CJ, Lee TF, Ruan SY, Yu CJ, Chien JY, Hsueh PR. Clinical characteristics, treatment outcomes, and prognostic factors of Pneumocystis pneumonia in non-HIV-infected patients. Infect Drug Resist 2019; 12:1457-1467. [PMID: 31239724 PMCID: PMC6554003 DOI: 10.2147/idr.s199761] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/21/2019] [Indexed: 01/01/2023] Open
Abstract
Objectives: The incidence of Pneumocystis pneumonia (PCP) has been increasing among non-HIV-infected patients. Here, we investigated the clinical characteristics, treatment outcomes, and prognostic factors of PCP in non-HIV-infected patients. Patients and methods: Information on clinical characteristics, treatment outcomes, and prognostic factors of PCP patients who were treated at a medical center in northern Taiwan from October 2015 to October 2016 were retrieved from medical records and evaluated. Results: Among the patients with PCP included in the study, 84 were non-HIV-infected and 25 were HIV-infected. Non-HIV-infected patients with PCP had a longer duration between radiographic findings and treatment (P<0.001), and a higher rate of hospital-associated PCP (P<0.001), hypoxia (P=0.015), respiratory failure (P<0.001), and mortality (P=0.006) than HIV-infected patients with PCP. Among non-HIV-infected patients, non-survivors had a higher fungal burden (46.2% vs 22.2%, P=0.039), higher requirement for adjunctive steroid treatment (94.9% vs 71.1%, P=0.011), and higher rate of pneumothorax (17.9% vs 2.2%, P=0.038) than survivors. Multiple logistic regression revealed that lymphopenia (odds ratio [OR] =3.24, 95% confidence interval [CI] =1.07–9.79; P=0.037), adjunctive steroid use (OR =6.23, 95% CI =1.17–33.14; P=0.032), and pneumothorax (OR =10.68, 95% CI =1.00–113.93; P=0.050) were significantly associated with increased 60-day mortality among non-HIV-infected PCP patients. Conclusion: Lymphopenia, adjunctive steroid therapy, and pneumothorax were significantly associated with higher mortality in non-HIV-infected patients with PCP.
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Affiliation(s)
- Chia-Jung Liu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tai-Fen Lee
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sheng-Yuan Ruan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Shibata S, Kikuchi T. Pneumocystis pneumonia in HIV-1-infected patients. Respir Investig 2019; 57:213-219. [PMID: 30824356 DOI: 10.1016/j.resinv.2019.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/12/2019] [Accepted: 01/30/2019] [Indexed: 06/09/2023]
Abstract
Pneumocystis pneumonia (PCP) is an opportunistic disease that mainly affects patients with a deficiency of cell-mediated immunity, especially acquired immunodeficiency syndrome (AIDS). The incidence of PCP in these patients has declined substantially owing to the widespread use of antiretroviral therapy and PCP prophylaxis. However, PCP is still a major AIDS-related opportunistic infection, particularly in patients with advanced immunosuppression in whom human immunodeficiency virus type 1 (HIV-1) infection remains undiagnosed or untreated. The clinical manifestations, diagnosis, treatment, and prevention of PCP in patients with HIV-1 infection are addressed in this review.
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Affiliation(s)
- Satoshi Shibata
- Department of Respiratory Medicine, Niigata City General Hospital, Niigata 950-1197, Japan
| | - Toshiaki Kikuchi
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachidori, Chuoku, Niigata 951-8510, Japan.
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Lee EH, Kim EY, Lee SH, Roh YH, Leem AY, Song JH, Kim SY, Chung KS, Jung JY, Kang YA, Kim YS, Chang J, Park MS. Risk factors and clinical characteristics of Pneumocystis jirovecii pneumonia in lung cancer. Sci Rep 2019; 9:2094. [PMID: 30765832 PMCID: PMC6375945 DOI: 10.1038/s41598-019-38618-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
Solid malignancies are associated with the development of Pneumocystis jirovecii pneumonia (PJP). This study aimed to evaluate the risk factors for PJP among patients with lung cancer. This retrospective case-control study compared patients who had lung cancer with PJP (n = 112) or without PJP (n = 336) matched according to age, sex, histopathology, and stage. PJP definition was based on (i) positive PCR or direct immunofluorescence results for pneumocystis, (ii) clinical symptoms and radiological abnormalities that were consistent with a pneumonic process, and (iii) received targeted PJP treatment. The development of PJP was associated with radiotherapy (RTx), concurrent chemoradiotherapy (CCRTx), lymphopenia, and prolonged high-dose steroid therapy (20 mg of prednisolone equivalent per day for ≥3 weeks). Multivariate analysis revealed independent associations with prolonged high-dose steroid therapy (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.06-3.63; p = 0.032) and CCRTx (OR: 2.09, 95% CI: 1.27-3.43; p = 0.004). Steroid use was frequently related to RTx pneumonitis or esophagitis (29 patients, 43.3%). Prolonged high-dose steroid therapy and CCRTx were risk factors for PJP development among patients with lung cancer. As these patients had a poor prognosis, clinicians should consider PJP prophylaxis for high-risk patients with lung cancer.
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Affiliation(s)
- Eun Hye Lee
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Young Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Lee
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Han Song
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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