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Fumarola B, Signorini L, Lorenzotti S, Lanza P, Saccani B, Van Hauwermeiren E, Mulè A, Piva S, Rota M, Zuccalà F, Rasulo FA, Filippini M, Bertazzoli A, Del Fabro G, Matteelli A. Use of nebulized liposomal amphotericin B and posaconazole as antifungal prophylaxis in patients with severe SARS-CoV2 infection in intensive care unit. Infection 2024:10.1007/s15010-024-02234-9. [PMID: 38530518 DOI: 10.1007/s15010-024-02234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/12/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE COVID-19 associated pulmonary aspergillosis (CAPA) is common and linked with high fatality rates. To assess the impact on the incidence and outcome of CAPA of an antifungal prophylaxis (AFP) we compared two cohorts of COVID-19 patients admitted to intensive care units (ICU) in Brescia, Italy, from January to August 2021. METHODS The study cohort included all mechanically ventilated patients observed between April 2021 and August 2021 with SARS-CoV-2-pneumonia, who received AFP with oral posaconazole (200 mg every 6 h) and nebulized liposomal amphotericin B (50 mg every 2 weeks) from ICU admission to 7 days after discharge or, if applicable, until tracheostomy removal. The control cohort included COVID-19 patients admitted to the same ICU between January and March 2021 who did not receive any AFP. Subjects with CAPA at ICU admission were excluded. RESULTS We included 270 patients, of whom 64 (23.7%) received AFP. In patients in the study group, CAPA-related mortality was significantly reduced (29% vs. 48% p = 0.04), as well as the incidence of CAPA (3.1% vs 12.1%, p = 0.03). Patients who developed CAPA were older (mean of 70-y-old vs 63-y-old, p < 0.001). One subject discontinued posaconazole due to an adverse reaction. Among the 46 patients who received it, only one patient reached an effective plasma concentration of posaconazole. CONCLUSION AFP was associated with reduced incidence and mortality from CAPA and was well tolerated in patients with severe COVID-19. Posaconazole concentrations below the efficacy threshold in almost all patients may be attributable to drug interactions and prompt further studies to define its clinical significance.
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Affiliation(s)
| | - Liana Signorini
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | | | - Paola Lanza
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | - Barbara Saccani
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
| | | | - Alice Mulè
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Medicine, University of Brescia, Brescia, Italy
| | - Simone Piva
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Matteo Rota
- Department of Molecular and Translational Medicine, Università degli Studi di Brescia, Brescia, Italy
| | - Francesco Zuccalà
- Department of Anesthesia and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Francesco Antonio Rasulo
- Intensive Care and Anesthesiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and Spedali Civili Hospital, Brescia, Italy
| | - Matteo Filippini
- Intensive Care and Anesthesiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and Spedali Civili Hospital, Brescia, Italy
| | - Alberto Bertazzoli
- Department of Anesthesia and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Giovanni Del Fabro
- Department of Infectious Diseases, ASFO "Santa Maria Degli Angeli" Hospital of Pordenone, Pordenone, Italy
| | - Alberto Matteelli
- Clinic of Infectious Diseases, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Medicine, University of Brescia, Brescia, Italy
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König C, Göpfert M, Kluge S, Wichmann D. Posaconazole exposure in critically ill ICU patients: a need for action. Infection 2023; 51:1767-1772. [PMID: 37498488 PMCID: PMC10665255 DOI: 10.1007/s15010-023-02078-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/16/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE Posaconazole is an antifungal drug currently being used for prophylaxis and treatment of invasive fungal infections such as aspergillosis. To date, therapeutic drug monitoring (TDM) of posaconazole is recommended with the use of oral suspension, but the potential need of TDM with the use of IV formulations is rising. Therefore, we aimed to investigate the pharmacokinetics of IV posaconazole in critically ill patients. METHODS In a prospective study, we analysed 168 consecutivelly collected posaconazole levels from 10 critically ill patients drawn during a 7 day curse. Posaconazole concentrations were measured using a chromatographic method. Demographic and laboratory data were collected, and the data was analysed using descriptive statistics. RESULTS We included 168 posaconazole levels, resulting in a median trough of 0.62 [0.29-1.05] mg/L with 58% not reaching the suggested target of 0.5 mg/L for fungal prophylaxis. Moreover, 74% of the trough levels were under the target of 1 mg/L which is proposed for the treatment of aspergillosis. CONCLUSION Posaconazole exposure is highly variable in critically ill patients resulting in potentially insufficient drug concentrations in many cases. TDM is highly recommended to identify and avoid underexposure. TRIAL REGISTRATION NUMBER NCT05275179, March 11, 2022.
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Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 42, 20251, Hamburg, Germany
| | - Melanie Göpfert
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 42, 20251, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 42, 20251, Hamburg, Germany
| | - Dominic Wichmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 42, 20251, Hamburg, Germany.
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Hawes AM, Permpalung N. Diagnosis and Antifungal Prophylaxis for COVID-19 Associated Pulmonary Aspergillosis. Antibiotics (Basel) 2022; 11:antibiotics11121704. [PMID: 36551361 PMCID: PMC9774425 DOI: 10.3390/antibiotics11121704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
The COVID-19 pandemic has redemonstrated the importance of the fungal-after-viral phenomenon, and the question of whether prophylaxis should be used to prevent COVID-19-associated pulmonary aspergillosis (CAPA). A distinct pathophysiology from invasive pulmonary aspergillosis (IPA), CAPA has an incidence that ranges from 5% to 30%, with significant mortality. The aim of this work was to describe the current diagnostic landscape of CAPA and review the existing literature on antifungal prophylaxis. A variety of definitions for CAPA have been described in the literature and the performance of the diagnostic tests for CAPA is limited, making diagnosis a challenge. There are only six studies that have investigated antifungal prophylaxis for CAPA. The two studied drugs have been posaconazole, either a liquid formulation via an oral gastric tube or an intravenous formulation, and inhaled amphotericin. While some studies have revealed promising results, they are limited by small sample sizes and bias inherent to retrospective studies. Additionally, as the COVID-19 pandemic changes and we see fewer intubated and critically ill patients, it will be more important to recognize these fungal-after-viral complications among non-critically ill, immunocompromised patients. Randomized controlled trials are needed to better understand the role of antifungal prophylaxis.
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Affiliation(s)
- Armani M. Hawes
- Correspondence: ; Tel.: +1-410-955-5000; Fax: +1-210-892-3847
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