Invasive Aspergillosis in solid-organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

Survey of current national and international guidance to reduce risk of aspergillosis in hospitals

Aspergillus spp. are most commonly associated with disease in the severely immunocompromised host and those with chronic chest disease. The scope of patients at risk is expanding, including intensive care (inclusive of severe viral pneumonia), trauma, burns and major surgery. As exposure or colonization is a prerequisite to Aspergillus-related disease, this has prompted a global review of preventative measures recommended in healthcare establishments. This global review includes 75 documents from 24 countries, categorized into clinical, infection prevention and control, and building-related guidance for prevention of invasive aspergillosis (IA). We overview the IA incubation period and different acceptable levels of airborne Aspergilli in protected environments (PEs), including critical care and operating rooms. Few documents cover all aspects of prevention, prophylaxis, avoidance, preventative measures and monitoring (environmental and clinical). A multi-disciplinary approach is required to identify and minimize the multiple risks and ensure adequate preventative measures. Most building-related guidance addresses construction and internal hospital alterations, but we also review the importance of good management of the healthcare environment (including ventilation systems) and uncertainties of environmental monitoring. We highlight the differences in standards recommended for protective patient environments including the critical care environment. The large capital investment required for PEs is often limited to patient groups most at risk. Single document comprehensive guidance is lacking, and many countries provide no guidance. Reduction in healthcare-associated acquisition of invasive aspergillosis during vulnerable inpatient episodes requires heightened awareness of patients at risk, careful risk assessment and attentive maintenance of the general hospital environment.

A Real-world Pharmacovigilance Study Of FDA Adverse Event Reporting System (FAERS) Events For Gender Of Voriconazole Drugs

To detect the gender variations in adverse events (AEs) of voriconazole, promote personalised medicine.A normalized dataset from Q1 2004 to Q4 2022 from the US Food and Drug Administration's Adverse Event Reporting System (FAERS) was analyses. The reporting odds ratio (ROR), proportional reporting ratio (PRR), and P value were used to examine data from the FAERS database to detect risk signals and quantify the presence and extent of gender variations in voriconazole adverse events.A total of 7670 cases (female/male (2785/4885)) of adverse reactions to voriconazole were analysed, and drug interaction (ROR 1.30 (1.10,1.54)), death and sudden death (ROR 1.31 (1.06,1.61)), actinic keratosis (ROR 1.98 (1.10,3.57)) were found to be significantly more frequent in male patients than in female patients.We found that gender was a determinant in voriconazole-related AEs using FAERS. Our results require future validation due to the inherent limits of this open data source, but they also identify potential contributing elements for a customised side effect profiling.

Epidemiology and Inpatient Outcomes of Invasive Aspergillosis in Patients with Liver Failure and Cirrhosis

OBJECTIVE

The aim of this study was to estimate the incidence and inpatient outcomes of liver failure and cirrhosis (LFC) admissions with invasive aspergillosis (IA) in the United States.

METHODS

This retrospective cohort study utilized the 2016-2020 National Inpatient Sample (NIS) database to analyze outcomes of IA in LFC admissions. Baseline variables, including demographics, comorbidities, and complications, were identified using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, and liver transplant admissions were excluded. Outcomes were compared between LFC admissions with and without IA.

RESULTS

During the study period, 9515 (0.36%) LFC admissions were associated with IA. This cohort experienced significantly higher rates of complications, including acute kidney injury (AKI) (73.36% vs. 42.96%; p < 0.001) and acute respiratory failure (ARF) (65.74% vs. 24.85%; p < 0.001). IA admissions required invasive mechanical ventilation (IMV) more frequently (58.17% vs. 18.78%; p < 0.001). All-cause inpatient mortality was significantly higher in the aspergillosis group (43.40% vs. 15.75%; p < 0.001). IA admissions had longer lengths of stay (LOS), with 38.89% exceeding 21 days compared to 6.20% (p < 0.001), and a mean LOS more than three times longer (22.9 vs. 7.5 days; p < 0.001). The IA group incurred over four times higher hospital charges (USD 459,414.9 vs. USD 104,389.4; p < 0.001) and hospitalization costs (USD 108,030.6 vs. USD 24,272.1; p < 0.001) compared to the LFC without aspergillosis group.

INTERPRETATION

LFC admissions with IA experienced poorer outcomes, longer hospital stays, and significantly higher healthcare costs, underscoring the need for targeted interventions in this high-risk, nonclassical population.

Longitudinal assessment of the effect of invasive fungal infections on transplant success in kidney transplant recipients

Invasive fungal infections (IFIs) significantly impact morbidity and mortality in kidney transplant recipients (KTRs), but their effect on allograft function remains poorly defined. This retrospective study examined adult KTRs transplanted at Johns Hopkins from 2012 to 2018, with follow-up through 2023. The association of IFIs with a composite outcome of graft failure and mortality was assessed using negative binomial regression. The association of IFI exposure on composite outcome was quantified by matching using a stochastic extension stratification method, followed by Cox regression. Among 1453 KTRs, 79 were diagnosed with proven/probable IFIs, predominantly invasive candidiasis (46.8%). KTRs with IFIs had worse outcome-free survival with higher composite outcome rates (53/79 [67.1%] vs 411/1338 [30.7%]; P < .001). The composite outcome incidence rate was 4.61-fold higher when IFIs occurred in the first 6 months posttransplant and decreased to 2.13-fold higher after 36 months (P < .001). IFI exposure was associated with 3.45-fold increased hazard of composite outcome (95% CI, 1.54-7.70; P < .01) and a 3.23-fold increased hazard of all-cause mortality (95% CI, 1.53-6.83; P < .01). The association of IFIs with increased risk of poor kidney transplant outcomes, particularly in the early posttransplant period, highlights the need for improved strategies for early IFI detection and management in KTRs.

Assessing the appropriateness of antifungal prescribing: key results from the implementation of a novel audit tool in Australian hospitals

OBJECTIVES

To utilize the Antifungal National Antimicrobial Prescribing Survey (Antifungal NAPS), a novel tool utilizing international consensus metrics for antifungal stewardship, to assess the quality of systemic antifungal prescribing in Australian hospitals, in order to identify quality improvement targets.

METHODS

Participating hospitals were directed to audit all systemic antifungals or focus on a specific antifungal drug or class. Data entry into the Antifungal NAPS online portal occurred between October 2022 and June 2023. The data collection tool comprised patient details, reasons precluding use of antifungals, prescription details (guideline compliance, appropriateness, and reasons for inappropriate prescribing) and patient outcomes. Descriptive statistics were used to analyse the data.

RESULTS

Eleven hospitals contributed data for 516 prescriptions for 438 patients. Of these, 77.1% of prescriptions were appropriate, with the highest appropriateness for prophylactic (189/222; 85.1%), followed by directed (105/130; 80.8%) and empirical therapy (104/164; 63.4%). Fluconazole was the most commonly prescribed agent, which had the lowest rate of appropriateness (132/209; 63.2%). The most common reasons for inappropriate prescribing were no antifungal required (35/105; 33.3%), incorrect dose or frequency (30/105; 28.6%) and incorrect duration (19/105; 18.1%). Compliance with guidelines was 73.6%.

CONCLUSIONS

This study outlines the successful implementation of the Antifungal NAPS, a standardized electronic audit tool for the assessment of antifungal prescribing quality. Key areas for quality improvement identified were the overuse of empirical fluconazole for urinary tract and intra-abdominal infections, the importance of invasive fungal infection risk assessment to guide prophylaxis prescribing and greater infectious diseases and antifungal stewardship oversight of antifungal prescribing to guide optimal prescribing.

Respiratory infections in lung transplant recipients

PURPOSE OF REVIEW

Morbidity and mortality rates after lung transplantation still remain higher than after other forms of solid organ transplantation, primarily due to a higher risk of infections and the development of chronic lung allograft dysfunction. Thus, a tiered approach highlighting the most significant respiratory pathogens including common opportunistic infections along with diagnostic, treatment and prevention strategies, including vaccination and prophylaxis is needed.

RECENT FINDINGS

The need for intense immunosuppressive therapy to prevent rejection, coupled with the transplanted lung's constant exposure to environment and impaired local defence mechanisms leads to frequent infections. Viral and bacterial infections are most frequent while fungal infections mainly involve the tracheobronchial tract but may be fatal in case of disseminated disease. Some infectious agents are known to trigger acute rejection or contribute to chronic allograft dysfunction. Invasive testing in the form of bronchoscopy with bronchoalveolar lavage is standard and increasing experience in point of care testing is gained to allow early preemptive therapy.

SUMMARY

Timely diagnosis, treatment, and ongoing monitoring are essential, but this can be difficult due to the wide variety of potential pathogens.

Appraisal of guidelines and variations in recommendations on drug therapy for invasive aspergillosis prevention and treatment

Background

In recent years, many guidelines related to aspergillosis have been published worldwide. However, no studies have applied assessment tools to systematically evaluate the quality of these guidelines.

Objectives

This study aimed to assess the quality of clinical practice guidelines and compared their recommendations related to drug therapy for the prevention and treatment of invasive aspergillosis.

Methods

Electronic databases, guideline development organizations, and professional society websites were searched to identify clinical practice guidelines for invasive aspergillosis published between 1 January 2013, and 12 September 2023. The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. Recommendations for the drug prevention and treatment of invasive aspergillosis were extracted and descriptively analyzed.

Results

Among the 18 included clinical practice guidelines, the median scores and interquartile range for each AGREE II domain were: scope and purpose, 76.39% (69.1%, 80.21%); stakeholder involvement, 59.72% (50.35%, 67.02%); rigor of development, 64.58% (44.4%, 72.27%); clarity and presentation, 81.25% (68.06%, 91.32%); applicability, 41.67% (36.46%, 47.92%); and editorial independence, 76.05% (50%, 87.5%). Voriconazole and isavuconazole are recommended as first-line therapy for invasive aspergillosis currently. Posaconazole remains the first choice for invasive aspergillosis prophylaxis in patients with hematological malignancies.

Conclusion

The development processes and reporting of invasive aspergillosis -related clinical practice guidelines varied and their quality requires improvement. The guideline recommendations have changed since the approval of isavuconazole.

Impact of current clinical guidelines on the management of invasive fungal disease

Isavuconazole is a new broad-spectrum antifungal triazole with a better safety profile in terms of drug-drug interactions, adverse effects, and tolerance compared to other azoles. Increasing evidence supports the usefulness of isavuconazole in the treatment of invasive fungal diseases. In this review, we aim to analyze the influence of this new evidence on the main clinical guidelines. We reviewed the most recent consensus guidelines issued by the major infectious diseases societies worldwide, focusing on the novelties regarding the recommendations for the use of isavuconazole in different invasive fungal infections and management strategies. Isavuconazole has been included as first-line therapy for invasive aspergillosis, with slight differences in preference for voriconazole or isavuconazole depending on the clinical scenario. In mucormycosis, isavuconazole is considered an alternative first-line therapy to liposomal amphotericin B, especially in those patients with underlying renal impairment. Additionally, the use of isavuconazole is suggested in salvage scenario for both conditions, and the combination with other mold-active drugs is considered. The guidelines report the promising results obtained with the use of this drug for treating mycoses caused by other molds and rare yeasts, as well as endemic mycoses, but since solid evidence is still lacking, the recommendations in this area are generally weak. Isavuconazole is a suitable therapeutic option for invasive fungal infections, offering efficacy against a range of pathogens, including Aspergillus and fungi within the order Mucorales. Its safety profile and its favorable drug interaction profile make it a valuable alternative to traditional agents like voriconazole or liposomal amphotericin B in certain scenarios. However, continued research is essential to better understand its role in combination therapies and to assess its effectiveness against other fungal species.

Fungal Pericarditis-A Systematic Review of 101 Cases

Fungal pericarditis is a rare disease but its incidence has risen in parallel with the global increase in invasive fungal infections. This systematic review analyzes data from previously reported cases of fungal pericarditis to provide an improved understanding of the etiology, clinical presentation, management, and outcomes of this rare disease. We reviewed Medline and Scopus databases from 1 January 1990 to 29 January 2024 for case reports that documented the isolation of a fungal pathogen from pericardial fluid or tissue. Of the 2330 articles screened, 101 cases met the inclusion criteria. Patients with fungal pericarditis and the involvement of at least one other organ-usually the lungs, brain, or kidney-had worse outcomes than patients with isolated pericardial disease. Immunosuppression was reported in 50% of cases and was associated with worse outcomes in adults. Patients who presented with chest pain, received adequate empiric antifungal therapy, and underwent pericardiocentesis and pericardiectomy had improved survival. The most common isolated pathogens were Candida spp., followed by Aspergillus spp. and Mucor spp., with the latter two linked to worse outcomes. Only 35% of patients received empiric antifungal medications before the causative pathogen was identified, and mortality was associated with a delay in appropriate therapy. Immunosuppression, disseminated disease, and presence of shock/multiorgan failure were additional risk factors associated with death. Fungal pericarditis carries a mortality rate of up to 50%, with nearly half of patients being immunocompromised. Clinicians frequently do not consider fungal pericarditis in the differential diagnoses, which leads to delays in treatment and poorer outcomes. Further prospective multicenter studies are urgently needed to better understand the epidemiology, improve diagnostic testing and management, and decrease unacceptably high mortality in patients with fungal pericarditis.

Invasive Aspergillosis in the Current Era

Despite significant advances, aspergillosis remains a critical health concern, with an evolving epidemiology and expanding populations of at-risk patients. Historically, fewer than 10 Aspergillus species were considered clinically significant. However, advancements in diagnostic technologies, such as DNA sequencing and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, have identified previously unrecognized "cryptic" Aspergillus species. This clinical review highlights the current epidemiology, risk factors, pathogenesis, clinical presentation, diagnosis, and invasive aspergillosis (IA) treatment. Diagnosing IA necessitates a multifaceted approach, integrating clinical evaluation, imaging studies, microbiological culture, serologic tests, and advanced molecular techniques.

Evaluation of a Perioperative Fungal Prophylaxis Protocol Change in Orthotopic Liver Transplant

BACKGROUND

Orthotopic liver transplant (OLT) carries a risk for invasive fungal infections (IFI). A targeted antifungal prophylaxis protocol can identify OLT patients who warrant antifungal prophylaxis. The optimal protocol and appropriate risk factors have yet to be confirmed.

OBJECTIVE

This study aimed to describe the impact of a targeted antifungal prophylaxis protocol post OLT on rates of IFI and protocol adherence.

METHODS

This was a retrospective observational cohort study of patients ≥18 years old with an OLT at Cleveland Clinic. Pre-protocol was defined as June 1, 2019 to May 31, 2020 and post-protocol was June 1, 2021 to May 31, 2022. The primary objective was to determine adherence to the prophylaxis protocol on postoperative day (POD) 0. Secondary objectives included comparing the 90-day incidence of proven or probable IFI post-OLT between groups.

RESULTS

The pre-protocol group included 134 patients, whereas the post-protocol group included 166. Prior to protocol implementation, 73% received clotrimazole, 13% fluconazole, 13% micafungin, and 1% nystatin. After protocol implementation, 63% received clotrimazole, 16% fluconazole, and 21% micafungin. Adherence to the protocol was 66% on POD0 and increased to 84% over the duration of prophylaxis. Rates of IFI development decreased to 3.6% after implementation from 6.7% prior to the protocol (P = 0.22). Median time to IFI was 8 days (interquartile range [IQR] = 2-19) pre-protocol and 15 days (IQR = 6-17) post-protocol.

CONCLUSIONS AND RELEVANCE

The implementation of a post-OLT-targeted antifungal prophylaxis protocol can promote consistency in antifungal prophylaxis. This study showed an 84% adherence rate to the implemented protocol, with numerically lower rates of IFIs post-protocol compared with pre-protocol.

Invasive fungal rhinosinusitis: current evidence and research opportunities

PURPOSE OF REVIEW

To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs.

RECENT FINDINGS

New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed.

SUMMARY

Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.

Population Pharmacokinetic and Pharmacodynamic of Atorvastatin in Chinese Lung Transplant Recipients

Atorvastatin is a widely prescribed cholesterol-lowering drug that inhibits 3-hydroxy-3-methylglutaryl coenzyme A reductase to reduce lipid levels. This study aimed to establish a population pharmacokinetic and pharmacodynamic model for atorvastatin in Chinese lung transplant recipients (LTRs), particularly those using voriconazole (VOR) and with different genotypes. It evaluated precise dosing regimens and analyzed the correlation between atorvastatin exposure and clinical outcomes. A nonlinear mixed-effects model was used for the population pharmacokinetic/pharmacodynamic (PK/PD) analysis. A one-compartment population PK model was developed, incorporating VOR, SLCO2A1 rs76906503, and SLC22A8 rs2187383 to assess apparent clearance and volume of distribution. LDL-C was modeled as a biomarker to evaluate atorvastatin efficacy. A Monte Carlo simulation was conducted to assess various dosing schemes and the effects of different covariates on achieving the target LDL concentration. The correlation between atorvastatin exposure and clinical outcomes was also evaluated. Results indicated that the average probability of target attainment for optimal dosing regimens across various covariate results exceeded 45.8%. Dosages of 10, 20, and 40 mg were deemed suitable for LTRs. A lower dose was recommended for LTRs taking VOR or with mutant-type genotypes to avoid overexposure and adverse reactions. The population PK/PD model offers valuable guidance for evaluating atorvastatin dosing regimens in clinical settings, particularly for LTRs using VOR and those with different genotypes.

Invasive aspergillosis caused by cryptic species in transplant recipients: A review

The clinical and microbiological characteristics of invasive aspergillosis (IA) caused by cryptic Aspergillus species have not been well-defined in transplant settings. However, IA is among the most common mould infections in solid organ and hematopoietic stem cell transplant recipients. Among 55 causative isolates in the 53 reported cases, Aspergillus calidoustus, A. lentulus, A. tubingensis, and A. udagawae were the four most common causative cryptic Aspergillus species. Newer diagnostic modalities, such as matrix-assisted laser desorption ionization-time of flight mass spectrometry, may help diagnose these cryptic species. Of the 24 cases with detailed clinical information, 13 had antifungal breakthrough infections. The 12-week mortality rates of all 24 cases, 7 cases of A. calidoustus, and 7 cases of A. lentulus were 46%, 43%, and 43%, respectively. Based on antifungal susceptibility profiles obtained from previous studies, an empiric antifungal regimen such as liposomal amphotericin B with or without echinocandin is recommended for A. calidoustus. A combination of an anti-mould azole and liposomal amphotericin B with or without an echinocandin is suggested for A. lentulus and A. udagawae. Additionally, any one of voriconazole, isavuconazole, or posaconazole with or without liposomal amphotericin B with or without an echinocandin is indicated for A. tubingensis. Newer antifungal agents may have more significant activity against Aspergillus cryptic species.

Fungal Infections in Kidney Transplant Recipients: A Comprehensive Narrative Review

BACKGROUND

Despite kidney transplantation being a life-saving procedure, patients experience a high risk of developing fungal infections (FIs), with an increased risk of both morbidity and mortality, especially during the first year after transplant.

METHODS

We herein conducted a narrative review of the most common FIs in kidney transplant recipients (KTRs), with a focus on prevalence, risk factors, mortality, and prevention strategies.

RESULTS

The most common fungal pathogens in KTRs include Candida species (up to 70% of the overall FIs), Aspergillus species, Pneumocystis jiroveci, and Cryptococcus species. Fungal colonization, diabetes mellitus, chronic liver disease, malnutrition, and pre-existing lung conditions should all be acknowledged as possible predisposing risk factors. The mortality rate can vary from 25 to 50% and according to different settings and the types of FIs. Preventive strategies are critical for reducing the incidence of FIs in this population. These include antifungal prophylaxis, environmental precautions, and infection control measures. The use of novel tools (such as PCR-based molecular assays and NGS) for rapid and accurate diagnosis may play an important role.

CONCLUSIONS

Early recognition, the appropriate use of antifungal therapy, and preventive strategies are essential for improving graft loss and fatal outcomes in this vulnerable population. Future research is needed to optimize diagnostic tools, identify novel antifungal agents, and develop better prophylactic strategies for high-risk transplant recipients.

The efficacy and safety of first-line monotherapies in primary therapy of invasive aspergillosis: a systematic review

Objective

Several antifungals are available for the treatment of patients with invasive aspergillosis (IA). This study aims to evaluate the relative efficacy and safety of the first-line monotherapies in primary therapy of IA through network meta-analysis (NMA).

Methods

We systematically searched PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, VIP database, Wanfang database, and China Biology Medicine for randomized controlled trials (RCTs) up to July 2023 that evaluated the efficacy and safety of monotherapies. We performed NMA with a frequentist random effects model and assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Primary outcomes were the all-cause mortality at week 12, and secondary outcomes included overall response rate, and incidence of adverse events (AEs) and severe adverse events (SAEs).

Results

A total of three RCTs involving 1,368 participants (four antifungals) were included. The NMA showed that compared to amphotericin B deoxycholate (D-AmB), the triazoles (posaconazole (POS), isavuconazole (ISA) and voriconazole (VCZ)) can improve the overall response rate in primary therapy of IA, but only VCZ and ISA can reduce the all-cause mortality at week 12 for patients with proven and probable IA (VCZ vs D-AmB: RR = 0.66, 95%CI = 0.47-0.93, moderate certainty; ISA vs D-AmB: RR = 0.52, 95%CI = 0 .31-0.86, low certainty). ISA (SUCRA = 93.50%; mean rank, 1.20) seemed to be the most effective therapy in the above population. As to proven, probable, and possible IA patients, the triazoles were superior to D-AmB in terms of reducing all-cause mortality. Furthermore, the risk of AEs and SAEs was comparable for the three triazoles, but the risk of SAEs was significantly higher for D-AmB than others.

Conclusion

The efficacy and safety of triazoles are more favorable than D-AmB in the primary therapy of IA, with ISA being the optimal choice.

Systematic Review Registration

PROSPERO CRD42023407632.

A 2-year Review of the Diagnostic Performance of Serum and Bronchoalveolar Lavage Galactomannan Testing in Lung Transplant Recipients in a National Heart and Lung Transplant Centre

BACKGROUND

The 2015 International Society for Heart and Lung Transplant (ISHLT) fungal guidelines recommend the use of bronchoalveolar lavage (BAL) galactomannan over serum galactomannan for the diagnosis of invasive aspergillosis (IA) in lung transplant (LTx) recipients, based on limited evidence. Galactomannan testing is costly.

METHODS

A single-center, retrospective cohort study reviewing all 814 serum and BAL galactomannan samples received from 184 LTx recipients in our center between 2021 and 2022 and assessing their diagnostic performance in the diagnosis of IA.

RESULTS

Over the study period, 394 serum galactomannan samples were received from 144 patients and 420 BAL galactomannan samples from 143 patients. Using a cut-off of ≥ 1.0 for BAL galactomannan, the sensitivity and specificity were 65.9% and 98.4%, respectively. In total, 30 patients had positive BAL galactomannan. Antifungal therapy was commenced or continued in 29 of these patients either as targeted or pre-emptive treatment. Using a cut-off of ≥ 0.5 for serum galactomannan, the sensitivity and specificity were 9.7% and 99.7%, respectively. In total, four patients had a positive serum galactomannan. All four patients were either already on antifungal treatment for IA or were started before the serum galactomannan result was available, supported by laboratory, clinical, and radiological findings. A positive serum galactomannan was used to monitor treatment response in one patient.

CONCLUSION

Serum galactomannan is not a valuable test in the diagnosis of IA in our LTx recipients, is costly, and does not remove the need for bronchoscopy and BAL galactomannan. This supports the ISHLT recommendation.

Evaluation of Crushed Posaconazole Delayed Release Tablets in Lung Transplant Recipients

BACKGROUND

Invasive fungal infections can cause serious complications after lung transplant; therefore, prophylaxis with posaconazole is common. The posaconazole delayed-release (DR) tablet is preferred. Although the package insert states DR tablets cannot be crushed, recent data suggest it is reasonable. We hypothesized that crushed posaconazole DR tablets could reach therapeutic levels in lung transplant recipients.

METHODS

A retrospective study of lung transplant recipients between January 2018 and July 2023, who received crushed posaconazole DR for at least 5 days was completed. Posaconazole troughs were evaluated, and differences were compared between subjects who were therapeutic to those who were subtherapeutic. A cost analysis was also performed.

RESULTS

Thirty subjects received crushed posaconazole DR and 50% were therapeutic. The median trough was 1 mg/L for those who were therapeutic and 0.4 mg/L for those who were not (p < 0.001). The median cumulative dose was 2000 mg, and there were no significant differences in the incidence of diarrhea or tube feeds. More subjects in the therapeutic group were loaded (33% vs. 13%), although this was not statistically significant (p = 0.39). No subjects had breakthrough aspergillus one month after starting crushed therapy.

CONCLUSION

Crushed posaconazole DR tablets are a viable and cost savings option, but loading doses and higher maintenance doses may be required to reach therapeutic levels. Those who received loading doses (intravenously or crushed) followed by a daily crushed dose of 400 mg were more likely to be therapeutic. Limitations of our study include that it is single-center, small in sample size, and retrospective.

Antifungal prophylaxis against invasive Candida and Aspergillus infection in adult heart transplant recipients: protocol for a systematic review and meta-analysis

INTRODUCTION

Invasive fungal infections (IFI) can contribute to increased mortality and morbidity rates after heart transplant in adults. The most common causes are Aspergillus and Candida species. There is uncertainty on how effective antifungal prophylaxis is against Candida spp infections and limited guidance on the prevention of Aspergillus spp infections. This systematic review and meta-analysis will assess the literature to see if antifungal prophylaxis reduces the incidence of IFI after heart transplant in adults.

METHODS AND ANALYSIS

This systematic review protocol follows the Preferred Reporting Items for Systematic reviews and Meta Analysis guidelines. A systematic search of the Cochrane Library, Web of Science, Scopus, Embase, MEDLINE, and Proquest databases will be undertaken. Reference lists of retrieved publications and conference abstracts will also be searched. Title, abstract and full-text screening will be undertaken by two reviewers. Discrepancies will be resolved by a third reviewer. Studies with paediatric patients, multi-organ transplants, or patients with a second heart transplant will be excluded, along with those who do not have clear definitions and diagnostic criteria for IFI. Risk of bias will be assessed using the Cochrane Risk of Bias 2 tool and the Risk of Bias in Non-randomised Studies of Interventions tool. A meta-analysis will be carried out, but if studies are not deemed to be sufficiently similar, only a narrative synthesis will be undertaken.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review as primary data will not be collected. The results of the review will be disseminated through publication in an academic journal and scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42024516588.

Epidemiology and Antifungal Susceptibilities of Clinically Isolated Aspergillus Species in Tertiary Hospital of Southeast China

Background and Aim

Infection caused by Aspergillus species poses a growing global concern, yet their prevalence in Southeast China lacks comprehensive documentation. This retrospective analysis aims to elucidate the epidemiological role and antifungal susceptibilities of Aspergillus species at Huashan Hospital of Fudan University, Shanghai, China.

Methods

Data spanning from 2018 to 2022, encompassing demographic, clinical, and laboratory information on Aspergillus species isolates were analyzed. The isolates were subjected to susceptibility testing using YeastOneTM broth microdilution system.

Results

A total of 253 Aspergillus isolates were identified, with A. fumigatus (57.71%) being the predominant species, followed by A. niger (26.88%), A. flavus (10.67%), and A. terreus (3.95%). Notably, the highest number of isolates originated from the Department of Infectious Disease (28.06%), with sputum (54.94%) being the primary source of isolation, where A. fumigatus was the dominant species. Gastrointestinal disorder (23.90%), hepatic disorder (9.09%), and diabetes (8.30%) were identified as the most prevalent underlying conditions, with A. fumigatus being the most abundant species in each case, accounting for 65.08%, 82.60%, and 73.91%, respectively, followed by A. flavus. Non-wild-type (NWT) Aspergillus isolates exhibited higher resistance against amphotericin B (AMB) compared to triazoles. Specifically, A. fumigatus showed greater resistance to AMB, with only 23.28% of isolates being susceptible, while the majority of isolates were susceptible to triazoles like itraconazole (ITR) and posaconazole (POS). POS demonstrated the highest efficacy against all species. Sequencing revealed mutations in the promoter region of the cyp51A gene and at positions Y121F and E247K in A, fumigatus which confer resistance to ITR, voriconazole (VRC), and POS.

Conclusion

These findings contribute to a better understanding of the epidemiology and antifungal resistance pattern of Aspergillus species in the region, providing valuable insights for the management of Aspergillus-related infections.

Case report: Unveiling the silent threat in the ICU - a case of disseminated invasive aspergillosis in a patient with fulminant myocarditis

Invasive aspergillosis (IA) significantly increases mortality in critically ill patients in the ICU and its occurrence is closely related to immunocompromise. Dissemination of IA is easily misdiagnosed and mistreated due to its ability to invade multiple systems throughout the body and lack of typical clinical manifestations. In this case, a 25-year-old previously healthy woman was hospitalized with fulminant myocarditis and treated with veno-arterial extracorporeal membrane pulmonary oxygenation (VA-ECMO) support and intravenous acyclovir, high-dose methylprednisolone, and immunoglobulin. 6 days later, she was successfully weaned from VA-ECMO and underwent cardiac rehabilitation. On day 10, she developed a fever (Tmax 38.3°C) and an irritating cough and began to experience reduced vision over the right eye with eye pain, redness, photophobia, and tearing 2 days later. Administration of levofloxacin eye drops and tobramycin/dexamethasone eye ointment was ineffective. The patient was positive for serum Aspergillus galactomannan antigen. Positron emission tomography/computed tomography (PET/CT) scan showed multiple hypermetabolic cavitary nodules in both lungs (SUVmax3.6) and thickening of the ocular ring wall with hypermetabolism in the right eye (SUVmax3.2). Ophthalmologic examination revealed that her best-corrected visual acuity in the right eye was reduced to light perception with an intraocular pressure of 21 mmHg, and B-scan ultrasonography showed vitreous opacity and retinal edema with mild detachment in the right eye. Metagenomic next-generation sequencing (mNGS) identified a large number of Aspergillus fumigatus sequences in bronchoalveolar lavage fluid, blood, and aqueous humor from the right eye, supporting the diagnosis of pulmonary and ocular involvement due to disseminated IA. Vitrectomy, anterior chamber irrigation, combined with intravenous and intravitreal injections of voriconazole and liposomal amphotericin B eventually cured the patient. This case highlights the importance of early identification and intervention regarding disseminated IA in immunocompromised critically ill patients, especially in the presence of multiple organ involvement.

Isavuconazole Versus Voriconazole as the First-line Therapy for Solid Organ Transplant Recipients With Invasive Aspergillosis: Comparative Analysis of 2 Multicenter Cohort Studies

BACKGROUND

Isavuconazole (ISA) and voriconazole (VORI) are recommended as the first-line treatment for invasive aspergillosis (IA). Despite theoretical advantages of ISA, both triazole agents have not been compared in solid organ transplant recipients.

METHODS

We performed a post hoc analysis of 2 retrospective multicenter cohorts of solid organ transplant recipients with invasive fungal disease (the SOTIS [Solid Organ Transplantation and ISavuconazole] and DiasperSOT [DIagnosis of ASPERgillosis in Solid Organ Transplantation] studies). We selected adult patients with proven/probable IA that were treated for ≥48 h with ISA (n = 57) or VORI (n = 77) as first-line therapy, either in monotherapy or combination regimen. The primary outcome was the rate of clinical response at 12 wk from the initiation of therapy. Secondary outcomes comprised 12-wk all-cause and IA-attributable mortality and the rates of treatment-emergent adverse events and premature treatment discontinuation.

RESULTS

Both groups were comparable in their demographics and major clinical and treatment-related variables. There were no differences in the rate of 12-wk clinical response between the ISA and VORI groups (59.6% versus 59.7%, respectively; odds ratio [OR], 0.99; 95% confidence interval [CI], 0.49-2.00). This result was confirmed after propensity score adjustment (OR, 0.81; 95% CI, 0.32-2.05) and matching (OR, 0.79; 95% CI, 0.31-2.04). All-cause and IA-attributable mortality were also similar. Patients in the ISA group were less likely to experience treatment-emergent adverse events (17.5% versus 37.7%; P = 0.011) and premature treatment discontinuation (8.8% versus 23.4%; P = 0.027).

CONCLUSIONS

Front-line treatment with ISA for posttransplant IA led to similar clinical outcomes than VORI, with better tolerability and higher treatment completion.

Perspectives on donor-derived infections from Germany

AIM

Often, organ transplantation is the only option to improve the life expectancy and quality of life of patients with terminal organ failure. Despite improved donor and organ assessment, a residual risk remains for transmitting infection, tumor, or other disease from the donor to recipients. Analysis, reporting, and managing of donor-derived diseases through a vigilance and surveillance system (V&S) is mandatory in many countries. We report on suspected and proven/probable donor-derived infections (DDI) in Germany over a period of 8 years (2016-2023).

METHODS

All incoming serious-adverse-event and serious-adverse-reaction (SAE/SAR) reports from 01.01.2016 to 31.12.2023 were evaluated for suspected DDI. Analysis of imputability followed the definition of the US Disease Transmission Advisory Committee (DTAC). Only probable and proven cases according to DTAC classification were defined as DDI.

RESULTS

During the study period, 9771 donors in Germany donated post-mortem organs to 27 919 recipients. In that period 612 SAE/SAR cases were reported, 377 (62%) involved infections. 41 cases were proven/probable DDI affecting 58 recipients (seven recipients died, 12%). Suspected infections were bacterial (182/377, 48%), fungal (135/377, 36%), viral (55/377, 15%), and parasitic (5/377, 1%). In case of bacterial DDI, no recipient died, but organ loss occurred in six recipients. In case of fungal or viral DDI, 19% (3/16) and 21% (3/14) of the recipients died, respectively.

CONCLUSIONS

DDI are rare in solid organ transplantation (58/27 919, 0.21%), but when they occur, they are associated with high morbidity and mortality in affected recipients. Careful and detailed donor evaluation and a reliable V&S help improve recipient safety.

Donor-derived mold infections in lung transplant recipients: The importance of active surveillance

Unexpected donor-derived fungal infections represent a rare but potentially fatal complication in lung transplant (Tx) recipients. Timely communication of the results of donor cultures and prompt treatment of recipients are crucial to mitigate the consequences of donor-derived transmissions. In this prospective cohort study, all consecutive patients who underwent lung transplantation from 2015 to 2022 were included. In December 2015, a Local Active Surveillance System has been implemented to provide biovigilance of donor culture results and optimize recipients' management. The aim of this study is to investigate the incidence of unexpected, mold-positive cultures among lung donors and the rate of transmission to recipients. Furthermore, management strategies and outcome of recipients with mold transmission are described. In case of isolation of the same mold in donor and recipient cultures, when possible, transmission was confirmed by dendrogram analysis. During the study period, 82 lung Tx were performed from 80 donors. The prevalence of donors with "unexpected" mold isolation from the respiratory tract was 3.75% (3/80). Isolated molds were Aspergillus niger, Rhizopus oryzae, and Aspergillus flavus. Transmissions occurred in all the three cases (100%) with a mean time of 5 days from lung Tx but none of the recipients developed invasive mold disease. Our Local Active Surveillance System allowed prompt recognition of lung donors unexpected mold colonization. Even though transmission occurred, introduction of early targeted antifungal therapy prevented potential catastrophic consequence of mold donor-derived infection in the immediate post-Tx period.

Invasive aspergillosis in liver transplant recipients in the current era

Invasive aspergillosis (IA) is a rare but fatal disease among liver transplant recipients (LiTRs). We performed a multicenter 1:2 case-control study comparing LiTRs diagnosed with proven/probable IA and controls with no invasive fungal infection. We included 62 IA cases and 124 matched controls. Disseminated infection occurred only in 8 cases (13%). Twelve-week all-cause mortality of IA was 37%. In multivariate analyses, systemic antibiotic usage (adjusted odds ratio [aOR], 4.74; P = .03) and history of pneumonia (aOR, 48.7; P = .01) were identified as independent risk factors associated with the occurrence of IA. Moreover, reoperation (aOR, 5.99; P = .01), systemic antibiotic usage (aOR, 5.03; P = .04), and antimold prophylaxis (aOR, 11.9; P = .02) were identified as independent risk factors associated with the occurrence of early IA. Among IA cases, Aspergillus colonization (adjusted hazard ratio [aHR], 86.9; P < .001), intensive care unit stay (aHR, 3.67; P = .02), disseminated IA (aHR, 8.98; P < .001), and dialysis (aHR, 2.93; P = .001) were identified as independent risk factors associated with 12-week all-cause mortality, while recent receipt of tacrolimus (aHR, 0.11; P = .001) was protective. Mortality among LiTRs with IA remains high in the current era. The identified risk factors and protective factors may be useful for establishing robust targeted antimold prophylactic and appropriate treatment strategies against IA.

Assessing the Impact of Posaconazole Cessation on Tacrolimus Serum Concentrations and Incident Cardiac Allograft Rejection: Take Caution

Invasive aspergillosis (IA) is a rare and often fatal complication of immunosuppression following orthotopic heart transplant. Prophylaxis plays a crucial role in preventing the emergence of this opportunistic infection. The azole class of medications are the bellwether agents utilized in this patient population. Unfortunately, given their impact on the Cytochrome P450 enzyme system, significant fluctuations in serum tacrolimus concentrations occur when initiating and stopping azole therapy, increasing the risk for prolonged periods of sub-optimal immunosuppression. While there are recommended dosing adjustments for these transition periods based on small data sets primarily with fluconazole, there is no published literature on recommended dosing adjustments for posaconazole. Given our institution utilizes posaconazole as the primary therapeutic for aspergillosis prophylaxis, we aimed to explore and report our local data to better guide dosing decisions during these transition periods.

Predictive performance of Metagenomic Next Generation Sequencing in early detection of post-liver transplantation infections

Objective

To evaluate the predictive performance of metagenomic next-generation sequencing (mNGS) in identifying and predicting pulmonary infections following liver transplantation and to investigate its association with patient outcomes within the initial four-week post-transplantation period.

Methods

We retrospectively analyzed 41 liver transplant patients with suspected pulmonary infections from August 2022 to May 2023. Bronchoalveolar lavage fluid (BALF) samples were collected on the first postoperative day for metagenomic next generation sequencing (mNGS) and culture. The predictive capability of mNGS for subsequent infections was assessed by monitoring inflammatory biomarkers and comparing the detection rates with culture methods. Real-time Polymerase Chain Reaction (Rt-PCR) was used to monitor Human betaherpesvirus 5 (CMV) and Human parvovirus B19 (B19) weekly during a four-week postoperative period. Inflammatory biomarkers and blood coagulation function were evaluated on specific days throughout the first, third, fifth, and during four weeks following surgery. The study was conducted until August 2023 to evaluate the patients' prognostic survival outcome, classifying them into groups based on the mortality and survival.

Results

The analysis included a total of 41 patients, comprising 32 males and 9 females, with an average age of 52 (47, 63) years. Within one week after liver transplantation, there were 7 cases of bacterial infections, 5 cases of fungal infections, 19 cases of mixed infections, 8 cases without any infection, and 2 cases with unidentified pathogen-associated infections. mNGS successfully predicted 39 (72 %) strains of pathogens, while culture-based methods only detected 28 (52 %) strains. Among the 8 patients diagnosed as non-infected, culture methods identified positive results in 4 cases (50 %), whereas mNGS yielded positive results in 7 cases (87.5 %). The detection rates of CMV and B19 by Rt-PCR within 4 weeks after liver transplantation were 61 % and 17 %, respectively (25/41, 7/41) among the patients. During the study period, a total of 9 patients succumbed while 32 patients survived. The death group and the survival group exhibited significant differences in CRP, HGB, and INR levels at specific monitoring time points. The proportion of CMV detection in blood was significantly higher in the death group compared to the surviving group. Elevated CRP level was identified as a prognostic risk factor.

Conclusions

Despite the presence of false positives, mNGS still presents a potential advantage in predicting pulmonary infection pathogens following liver transplantation. Furthermore, the levels of CRP and CMV carrier status within four weeks post-surgery exhibit significant associations with patient survival and prognosis.

Infectious Disease Prophylaxis During and After Immunosuppressive Therapy

Immune-mediated renal diseases are a diverse group of disorders caused by antibody, complement, or cell-mediated autosensitization. Although these diseases predispose to infection on their own, a growing array of traditional and newer, more targeted immunosuppressant medications are used to treat these diseases. By understanding their mechanisms of action and the infections associated with suppression of each arm of the immune system, nephrologists can better anticipate these risks and effectively prevent and recognize opportunistic infections. Focusing specifically on nonkidney transplant recipients, this review discusses the infections that can be associated with each of the commonly used immunosuppressants by nephrologists and suggest interventions to prevent infectious complications in patients with immune-mediated renal disease.

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

[Chest computed tomography manifestations in neonates with chronic granulomatous disease]

OBJECTIVES

To study chest computed tomography (CT) manifestations in neonates with chronic granulomatous disease (CGD) to provide clues for early diagnosis of this disease.

METHODS

A retrospective analysis was conducted on the clinical data and chest CT scan results of neonates diagnosed with CGD from January 2015 to December 2022 at Anhui Provincial Children's Hospital.

RESULTS

Nine neonates with CGD were included, with eight presenting respiratory symptoms as the initial sign. Chest CT findings included: consolidation in all 9 cases; nodules in all 9 cases, characterized by multiple, variably sized scattered nodules in both lungs; masses in 4 cases; cavities in 3 cases; abscesses in 6 cases; bronchial stenosis in 2 cases; pleural effusion, interstitial changes, and mediastinal lymphadenopathy each in 1 case. CT enhancement scans showed nodules and masses with uneven or ring-shaped enhancement; no signs of pulmonary emphysema, lung calcification, halo signs, crescent signs, bronchiectasis, or scar lesions were observed. There was no evidence of rib or vertebral bone destruction. Fungal infections were present in 8 of the 9 cases, including 6 with Aspergillus infections; three of these involved mixed infections with Aspergillus, with masses most commonly associated with mixed Aspergillus infections (3/4).

CONCLUSIONS

The primary manifestations of neonatal CGD on chest CT are consolidation, nodules, and/or masses, with Aspergillus as a common pathogen. These features can serve as early diagnostic clues for neonatal CGD.

A Novel Inhalable Dry Powder to Trigger Delivery of Voriconazole for Effective Management of Pulmonary Aspergillosis

Invasive pulmonary aspergillosis (IPA) is a fatal fungal infection with a high mortality rate. Voriconazole (VCZ) is considered a first-line therapy for IPA and shows efficacy in patients for whom other antifungal treatments have been unsuccessful. The objective of this study was to develop a high-potency VCZ-loaded liposomal system in the form of a dry-powder inhaler (DPI) using the spray-drying technique to convert liposomes into a nanocomposite microparticle (NCMP) DPI, formulated using a thin-film hydration technique. The physicochemical properties, including size, morphology, entrapment efficiency, and loading efficiency, of the formulated liposomes were evaluated. The NCMPs were then examined to determine their drug content, production yield, and aerodynamic size. The L3NCMP was formulated using a 1:1 lipid/L-leucine ratio and was selected for in vitro studies of cell viability, antifungal activity, and stability. These formulated inhalable particles offer a promising approach to the effective management of IPA.

Novel antifungals and treatment approaches to tackle resistance and improve outcomes of invasive fungal disease

SUMMARYFungal infections are on the rise, driven by a growing population at risk and climate change. Currently available antifungals include only five classes, and their utility and efficacy in antifungal treatment are limited by one or more of innate or acquired resistance in some fungi, poor penetration into "sequestered" sites, and agent-specific side effect which require frequent patient reassessment and monitoring. Agents with novel mechanisms, favorable pharmacokinetic (PK) profiles including good oral bioavailability, and fungicidal mechanism(s) are urgently needed. Here, we provide a comprehensive review of novel antifungal agents, with both improved known mechanisms of actions and new antifungal classes, currently in clinical development for treating invasive yeast, mold (filamentous fungi), Pneumocystis jirovecii infections, and dimorphic fungi (endemic mycoses). We further focus on inhaled antifungals and the role of immunotherapy in tackling fungal infections, and the specific PK/pharmacodynamic profiles, tissue distributions as well as drug-drug interactions of novel antifungals. Finally, we review antifungal resistance mechanisms, the role of use of antifungal pesticides in agriculture as drivers of drug resistance, and detail detection methods for antifungal resistance.

Compare the efficacy of antifungal agents as primary therapy for invasive aspergillosis: a network meta-analysis

BACKGROUND

Several antifungal agents are available for primary therapy in patients with invasive aspergillosis (IA). Although a few studies have compared the effectiveness of different antifungal agents in treating IA, there has yet to be a definitive agreement on the best choice. Herein, we perform a network meta-analysis comparing the efficacy of different antifungal agents in IA.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Clinical Trials databases to find studies (both randomized controlled trials [RCTs] and observational) that reported on treatment outcomes with antifungal agents for patients with IA. The study quality was assessed using the revised tool for risk of bias and the Newcastle Ottawa scale, respectively. We performed a network meta-analysis (NMA) to summarize the evidence on antifungal agents' efficacy (favourable response and mortality).

RESULTS

We found 12 studies (2428 patients) investigating 11 antifungal agents in the primary therapy of IA. There were 5 RCTs and 7 observational studies. When treated with monotherapy, isavuconazole was associated with the best probability of favourable response (SUCRA, 77.9%; mean rank, 3.2) and the best reduction mortality against IA (SUCRA, 69.1%; mean rank, 4.1), followed by voriconazole and posaconazole. When treated with combination therapy, Liposomal amphotericin B plus caspofungin was the therapy associated with the best probability of favourable response (SUCRA, 84.1%; mean rank, 2.6) and the best reduction mortality (SUCRA, 88.2%; mean rank, 2.2) against IA.

CONCLUSION

These findings suggest that isavuconazole, voriconazole, and posaconazole may be the best antifungal agents as the primary therapy for IA. Liposomal amphotericin B plus caspofungin could be an alternative option.

Triazole antifungal drug interactions-practical considerations for excellent prescribing

Systemic antifungal therapy is critical for reducing the mortality from many invasive and chronic fungal infections. Triazole antifungals are the most frequently prescribed antifungals but require attention to dosing and drug interactions. Nearly 600 severe drug-drug interactions and over 1100 moderate interactions requiring dose modifications are described or anticipated with systemic antifungal agents (see https://www.aspergillus.org.uk/antifungal-drug-interactions/). In this article, we address the common and less common, but serious, drug interactions observed in clinical practice with triazole antifungals, including a group of drugs that cannot be prescribed with all or most triazole antifungals (ivabradine, ranolazine, eplerenone, fentanyl, apomorphine, quetiapine, bedaquiline, rifampicin, rifabutin, sirolimus, phenytoin and carbamazepine). We highlight interactions with drugs used in children and new agents introduced for the treatment of haematological malignancies or graft versus host disease (midostaurin, ibrutinib, ruxolitinib and venetoclax). We also summarize the multiple interactions between oral and inhaled corticosteroids and triazole antifungals, and the strategies needed to optimize the therapeutic benefits of triazole antifungal therapy while minimizing potential harm to patients.

The epidemiology of invasive fungal infections in transplant recipients

Transplant patients, including solid-organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients, are exposed to various types of complications, particularly rejection. To prevent these outcomes, transplant recipients commonly receive long-term immunosuppressive regimens that in turn make them more susceptible to a wide array of infectious diseases, notably those caused by opportunistic pathogens. Among these, invasive fungal infections (IFIs) remain a major cause of mortality and morbidity in both SOT and HSCT recipients. Despite the continuing improvement in early diagnostics and treatments of IFIs, the management of these infections in transplant patients is still complicated. Here, we provide an overview concerning the most recent trends in the epidemiology of IFIs in SOT and HSCT recipients by describing the prominent yeast and mold species involved, the timing of post-transplant IFIs and the risk factors associated with their occurrence in these particularly weak populations. We also give special emphasis into basic research advances in the field that recently suggested a role of the global and long-term prophylactic regimen in orchestrating various biological disturbances in the organism and conditioning the emergence of the most adapted fungal strains to the particular physiological profiles of transplant patients.

CYP3A5 Genotype-Dependent Drug-Drug Interaction Between Tacrolimus and Voriconazole in Chinese Kidney Transplant Patients

BACKGROUND

The effect of drug-drug interaction (DDI) between tacrolimus and voriconazole on the pharmacokinetics of tacrolimus in different CYP3A5 genotypes has not been reported in previous studies.

OBJECTIVE

The objective of this study was to investigate whether CYP3A5 genotype could influence tacrolimus-voriconazole DDI in Chinese kidney transplant patients.

METHODS

All kidney transplant patients were divided into combination and non-combination groups based on whether tacrolimus was combined with or without voriconazole. Each group was subdivided into CYP3A5 expresser (CYP3A5*1/*1 or CYP3A5*1/*3) and CYP3A5 nonexpresser (CYP3A5*3/*3). A retrospective analysis compared tacrolimus dose (D)-corrected trough concentrations (C0) (C0/D) between combination and non-combination groups, respectively. Tacrolimus C0/D was also compared between CYP3A5 expresser and nonexpresser in both groups.

RESULTS

The C0/D values of tacrolimus were significantly different between CYP3A5 expresser and nonexpresser in combination group (378.20 [219.38, 633.48] ng/mL/[mg/kg/d] vs 720.00 [595.35, 1681.50] ng/mL/[mg/kg/d], P = 0.0010). Either in CYP3A5 expresser or nonexpresser, we found a statistically significant difference in tacrolimus C0/D between combination and non-combination group (P < 0.0001). The increase in CYP3A5 nonexpresser was 1.38 times higher than that in CYP3A5 expresser (320.93% vs 232.19%).

CONCLUSION AND RELEVANCE

The median C0/D values were 90.38% higher in kidney transplant recipients with CYP3A5*3/*3 genotype than in those with CYP3A5*1/*1 or CYP3A5*1/*3 genotype when treated with both tacrolimus and voriconazole. A CYP3A5 genotype-dependent DDI was found between tacrolimus and voriconazole. Therefore, personalized therapy accounting for CYP3A5 genotype detection and therapeutic drug monitoring is necessary for kidney transplant patients when treating with tacrolimus and voriconazole.

Management of infectious disease syndromes in thoracic organ transplants and mechanical circulatory device recipients: a Delphi panel

PURPOSE

Antimicrobial misuse contributes to antimicrobial resistance in thoracic transplant (TTx) and mechanical circulatory support (MCS) recipients. This study uses a modified Delphi method to define the expected appropriate antimicrobial prescribing for the common clinical scenarios encountered in TTx and MCS recipients.

METHODS

An online questionnaire on managing 10 common infectious disease syndromes was submitted to a multidisciplinary Delphi panel of 25 experts from various disciplines. Consensus was predefined as 80% agreement for each question. Questions where consensus was not achieved were discussed during live virtual live sessions adapted by an independent process expert.

RESULTS

An online survey of 62 questions related to 10 infectious disease syndromes was submitted to the Delphi panel. In the first round of the online questionnaire, consensus on antimicrobial management was reached by 6.5% (4/62). In Round 2 online live discussion, the remaining 58 questions were discussed among the Delphi Panel members using a virtual meeting platform. Consensus was reached among 62% (36/58) of questions. Agreement was not reached regarding the antimicrobial management of the following six clinical syndromes: (1) Burkholderia cepacia pneumonia (duration of therapy); (2) Mycobacterium abscessus (intra-operative antimicrobials); (3) invasive aspergillosis (treatment of culture-negative but positive BAL galactomannan) (duration of therapy); (4) respiratory syncytial virus (duration of antiviral therapy); (5) left ventricular assist device deep infection (initial empirical antimicrobial coverage) and (6) CMV (duration of secondary prophylaxis).

CONCLUSION

This Delphi panel developed consensus-based recommendations for 10 infectious clinical syndromes seen in TTx and MCS recipients.

Infections in lung transplanted patients: A review

Lung transplantation can improve the survival of patients with severe chronic pulmonary disorders. However, the short- and long-term risk of infections can increase morbidity and mortality rates. A non-systematic review was performed to provide the most updated information on pathogen, host, and environment-related factors associated with the occurrence of bacterial, fungal, and viral infections as well as the most appropriate therapeutic options. Bacterial infections account for about 50% of all infectious diseases in lung transplanted patients, while viruses represent the second cause of infection accounting for one third of all infections. Almost 10% of patients develop invasive fungal infections during the first year after lung transplant. Pre-transplantation comorbidities, disruption of physical barriers during the surgery, and exposure to nosocomial pathogens during the hospital stay are directly associated with the occurrence of life-threatening infections. Empiric antimicrobial treatment after the assessment of individual risk factors, local epidemiology of drug-resistant pathogens and possible drug-drug interactions can improve the clinical outcomes.

Therapeutic drug monitoring of antifungal therapies: do we really need it and what are the best practices?

INTRODUCTION

Despite advancements, invasive fungal infections (IFI) still carry high mortality rates, often exceeding 30%. The challenges in diagnosis, coupled with limited effective antifungal options, make managing IFIs complex. Antifungal drugs are essential for IFI management, but their efficacy can be diminished by drug-drug interactions and pharmacokinetic variability. Therapeutic Drug Monitoring (TDM), especially in the context of triazole use, has emerged as a valuable strategy to optimize antifungal therapy.

AREAS COVERED

This review provides current evidence regarding the potential benefits of TDM in IFI management. It discusses how TDM can enhance treatment response, safety, and address altered pharmacokinetics in specific patient populations.

EXPERT OPINION

TDM plays a crucial role in achieving optimal therapeutic outcomes in IFI management, particularly for certain antifungal agents. Preclinical studies consistently show a link between therapeutic drug levels and antifungal efficacy. However, clinical research in mycology faces challenges due to patient heterogeneity and the diversity of fungal infections. TDM's potential advantages in guiding Echinocandin therapy for critically ill patients warrant further investigation. Additionally, for drugs like Posaconazole, assessing whether serum levels or alternative markers like saliva offer the best measure of efficacy is an intriguing question.

The effects of nirmatrelvir/ritonavir on tacrolimus levels in lung transplant recipients: A single-center study

BACKGROUND

Lung transplant recipients (LTRs) have a higher risk of hospitalization and mortality due to COVID-19 compared with the immunocompetent population. The use of nirmatrelvir/ritonavir (NR), an effective oral treatment for COVID-19, is quite challenging due to its potent drug-drug interactions with immunosuppressants and azole antifungals. As there are few clinical reports of the use of NR in LTRs, we measured tacrolimus levels in patients receiving NR in our hospital to improve safety when prescribing NR.

METHODS

In total, 48 adult LTRs who received NR between November 19, 2022, and January 19, 2023, at China-Japan Friendship Hospital were retrospectively included and followed for 20 days after initiating NR. Tacrolimus was held at least 12 h before initiating NR and re-administered based on the trough levels after completing NR treatment. All concomitant medications, drug concentrations, laboratory results, and genotypes were recorded and analyzed.

RESULTS

Most patients showed stable tacrolimus trough levels despite high individual variability. Four patients exhibited supratherapeutic trough levels of tacrolimus (more than 15 ng/mL). Two patients who received 0.5 mg of tacrolimus during NR treatment had trough levels below 3.0 ng/mL. In addition, we found that in 13 patients, the trough levels were 130% of baseline after cessation of tacrolimus, and logistic regression revealed that increased trough level was significantly associated with age more than 60 years.

CONCLUSIONS

NR can be safely used in LTRs with close monitoring of tacrolimus levels and appropriate dose adjustments. However, more attention should be paid to elderly patients, as NR may more severely affect their drug metabolism. Due to the limited sample size, further studies are needed to guide the optimal use of tacrolimus following treatment with NR and explore the risk factors significantly affecting the interactions between NR and tacrolimus.

Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial

Opportunistic infections are a leading cause of lung transplant recipient morbidity and mortality. Risk factors for infection include continuous exposure of the lung allograft to the external environment, high levels of immunosuppression, impaired mucociliary clearance and decreased cough reflex, and impact of the native lung microbiome in single lung transplant recipients. Infection risk is mitigated through careful pretransplant screening of recipients and donors, implementation of antimicrobial prophylaxis strategies, and routine surveillance posttransplant. This review describes common viral, fungal, and mycobacterial infectious after lung transplant and provides recommendations on prevention and treatment.

Pipeline of Novel Antifungals for Invasive Fungal Disease in Transplant Recipients: A Pediatric Perspective

Invasive fungal disease (IFD) remains a significant cause of morbidity and mortality in children undergoing transplantation. There is a growing armamentarium of novel antifungal agents recently approved for use or in late stages of clinical development. The overarching goal of this review is to discuss the mechanisms of action, spectrum of activity, stage of development, and pediatric-specific data for the following agents: encochleated amphotericin B deoxycholate, fosmanogepix, ibrexafungerp, isavuconazole, olorofim, opelconazole, oteseconazole, and rezafungin. Additionally, key drug attributes of these novel agents and their potential future therapeutic roles in pediatric transplant recipients are discussed.

Beyond the First Year: Epidemiology and Management of Late-Onset Opportunistic Infections After Kidney Transplantation

Late opportunistic infections (OI) occurring beyond the first year after kidney transplantation (KT) are poorly described and not targeted by prophylactic strategies. We performed a ten-year retrospective monocentric cohort study describing epidemiology, risk factors and impact of late OI occurring 1 year after KT. We included clinically symptomatic OI requiring treatment besides BK virus nephropathy. Control groups included early OI occurring in the first year after KT, and KT recipients without OI since KT and alive with a functional allograft at 1 year. Among 1066 KT recipients, 185 (19.4%) presented a first episode of OI 21.0 (8.0-45.0) months after KT: 120 late OI (64.9%) and 65 early OI (35.1%). Late OI were mainly viral (N = 83, 69.2%), mostly herpes zoster (HZ) (N = 36, 43.4%). Pneumocystis represented most late fungal infections (N = 12/25, 48%). Compared to early OI, we reported more pneumocystis (p = 0.002) and less invasive aspergillosis (p = 0.01) among late OI. Patients with late OI were significatively younger at KT (54.0 ± 13.3 vs. 60.2 ± 14.3 years, p = 0.05). Patient and allograft survival rates between late OI and control groups were similar. Only age was independently associated with mortality. While late OI were not associated with higher mortality or graft loss, implementing prophylactic strategies might prevent such infections.

Prevalence and clinical significance of potential drug-drug interactions among lung transplant patients

Background: Drug-drug interactions (DDIs) are a major but preventable cause of adverse drug reactions. There is insufficient information regarding DDIs in lung transplant recipients. Objective: This study aimed to determine the prevalence of potential DDIs (pDDIs) in intensive care unit (ICU) lung transplant recipients, identify the real DDIs and the most frequently implicated medications in this vulnerable population, and determine the risk factors associated with pDDIs. Methods: This retrospective cross-sectional study included lung transplant recipients from January 2018 to December 2021. Pertinent information was retrieved from medical records. All prescribed medications were screened for pDDIs using the Lexicomp® drug interaction software. According to this interaction software, pDDIs were classified as C, D, or X (C = monitor therapy, D = consider therapy modification, X = avoid combination). The Drug Interaction Probability Scale was used to determine the causation of DDIs. All statistical analysis was performed in SPSS version 26.0. Results: 114 patients were qualified for pDDI analysis, and total pDDIs were 4051. The most common type of pDDIs was category C (3323; 82.0%), followed by D (653; 16.1%) and X (75; 1.9%). Voriconazole and posaconazole were the antifungal medicine with the most genuine DDIs. Mean tacrolimus concentration/dose (Tac C/D) before or after co-therapy was considerably lower than the Tac C/D during voriconazole or posaconazole co-therapy (p < 0.001, p = 0.027). Real DDIs caused adverse drug events (ADEs) in 20 patients. Multivariable logistic regression analyses found the number of drugs per patient (OR, 1.095; 95% CI, 1.048-1.145; p < 0.001) and the Acute Physiology and Chronic Health Evaluation II (APACHE Ⅱ) score (OR, 1.097; 95% CI, 1.021-1.179; p = 0.012) as independent risk factors predicting category X pDDIs. Conclusion: This study revealed a high incidence of both potential and real DDIs in ICU lung transplant recipients. Immunosuppressive drugs administered with azole had a high risk of causing clinically significant interactions. The number of co-administered drugs and APACHE Ⅱ score were associated with an increased risk of category × drug interactions. Close monitoring of clinical and laboratory parameters is essential for ensuring successful lung transplantation and preventing adverse drug events associated with DDIs.

Risk Factors for Invasive Fungal Infection in Lung Transplant Recipients on Universal Antifungal Prophylaxis

Background

Many centers use universal antifungal prophylaxis after lung transplant, but risk factors for invasive fungal infection (IFI) in this setting are poorly described.

Methods

This retrospective, single-center cohort study including 603 lung transplant recipients assessed risk factors for early (within 90 days of transplant) invasive candidiasis (IC) and invasive mold infection (IMI) and late (90-365 days after transplant) IMI using Cox proportional hazard regression.

Results

In this cohort, 159 (26.4%) patients had 182 IFIs. Growth of yeast on donor culture (hazard ratio [HR], 3.30; 95% CI, 1.89-5.75) and prolonged length of stay (HR, 1.02; 95% CI, 1.01-1.03) were associated with early IC risk, whereas transplantation in 2016 or 2017 (HR, 0.21; 95% CI, 0.06-0.70; HR, 0.25; 95% CI, 0.08-0.80, respectively) and female recipient sex (HR, 0.53; 95% CI, 0.30-0.93) were associated with reduced risk. Antimold therapy (HR, 0.21; 95% CI, 0.06-0.78) was associated with lower early IMI risk, and female donor sex (HR, 0.40; 95% CI, 0.22-0.72) was associated with lower late IMI risk. Recent rejection was a risk factor for late IMI (HR, 1.73; 95% CI, 1.02-2.95), and renal replacement therapy predisposed to early IC, early IMI, and late IMI (HR, 5.67; 95% CI, 3.01-10.67; HR, 7.54; 95% CI, 1.93-29.45; HR, 5.33; 95% CI, 1.46-19.49, respectively).

Conclusions

In lung transplant recipients receiving universal antifungal prophylaxis, risk factors for early IC, early IMI, and late IMI differ.

Controlling infections in hospitalized pretransplant candidates

PURPOSE OF REVIEW

Infections in hospitalized patients awaiting solid organ transplantation can pose complicated diagnostic and therapeutic challenges. Goals of management include stabilizing the patient, treating or controlling infections, and decreasing the risk of reactivation of infection after transplant.

RECENT FINDINGS

Groups such as The Organ Procurement and Transplantation Network, American Society of Transplantation Infectious Diseases Community of Practice and the European Society of Clinical Microbiology and Infectious Diseases have updated their guidelines on screening and treatment of infection in transplant candidates. There are also recent developments in therapeutic options for tuberculosis, COVID-19, Clostridioides difficile colitis, bloodstream infections, and other common infections.

SUMMARY

Ideally, antimicrobial therapy should be complete prior to transplantation. In situations in which completion of therapy prior to transplant is not feasible, therapy may need to be prolonged or modified. In most situations, infections can be managed similarly to the general population, although some infections, particularly fungal and mycobacterial, require a different management approach. We review disease- and organ-specific management.

Pharmacological management of invasive mold infections in solid organ transplant recipients

INTRODUCTION

Solid organ transplant (SOT) recipients face an increased susceptibility to invasive fungal infection (IFI) due to filamentous fungi. Post-transplant invasive aspergillosis (IA) and mucormycosis are related to exceedingly high mortality rates and graft loss risk, and its management involve a unique range of clinical challenges.

AREAS COVERED

First, the current treatment recommendations for IA and mucormycosis among SOT recipients are critically reviewed, including the supporting evidence. Next, we discussed particular concerns in this patient population, such as drug-drug interactions (DDIs) between triazoles and post-transplant immunosuppression or treatment-related toxicity. The role for immunomodulatory and host-targeted therapies is also considered, as well as the theoretical impact of the intrinsic antifungal activity of calcineurin inhibitors. Finally, a personal opinion is made on future directions in the pharmacological approach to post-transplant IFI.

EXPERT OPINION

Despite relevant advances in the treatment of mold IFIs in the SOT setting, such as the incorporation of isavuconazole (with lower incidence of DDIs and better tolerability than voriconazole), there remains a large room for improvement in areas such as the position of combination therapy or the optimal strategy for the reduction of baseline immunosuppression. Importantly, future studies should define the specific contribution of newer antifungal agents and classes.

The impact of extracorporeal membrane oxygenation on antifungal pharmacokinetics: A systematic review

BACKGROUND AND OBJECTIVE

The use of extracorporeal membrane oxygenation (ECMO) as a cardiocirculatory or respiratory support has tremendously increased in critically ill patients. In the setting of ECMO support, invasive fungal infections are a severe cause of morbidity and mortality. This vulnerable population is at risk of suboptimal antifungal exposure due to an increased volume of distribution (Vd), drug sequestration and decreased clearance. Here, we aimed to summarize ex-vivo and clinical studies on the potential impact of ECMO on the pharmacokinetics (PK) of antifungal agents and dosing requirements.

METHODS

A systematic search of the literature within electronic databases PubMed and EMBASE was conducted from database inception to 30 April 2023. Inclusion criteria were as follows: critically ill patients receiving ECMO regardless of age and reporting at least one PK parameter.

RESULTS

Thirty-six studies met inclusion criteria, including seven ex-vivo experiments and 29 clinical studies evaluating three classes of antifungals: polyenes, triazoles and echinocandins. Based on the available ex-vivo PK data, we found a significant sequestration of highly lipophilic and protein-bound antifungals within the ECMO circuit such as voriconazole, posaconazole and micafungin but the PK of several antifungals remains to be addressed such as amphotericin B, isavuconazole and anidulafungin. Most clinical studies have shown increased Vd of some antifungals like fluconazole and micafungin, particularly in the pediatric population. Conflicting data exist about caspofungin exposure.

CONCLUSIONS

The available literature on the antifungal PK changes in ECMO setting is scarce. Whenever possible, therapeutic drug monitoring is highly advised to personalize antifungal therapy.