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Michallet M, Cheikh JE, Herbrecht R, Yakoub-Agha I, Caillot D, Gangneux JP. Systemic antifungal strategies in allogeneic hematopoietic stem cell recipients hospitalized in french hematology units: a post-hoc analysis of the cross-sectional observational AFHEM study. BMC Infect Dis 2022; 22:352. [PMID: 35397492 PMCID: PMC8994341 DOI: 10.1186/s12879-022-07216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Invasive fungal diseases (IFD) remain a major complication of allogeneic hematopoietic stem cell transplantation (alloHSCT) and are associated with high mortality rates in patients receiving alloHSCT. Antifungal prophylaxis is increasingly being used in the management of IFDs in patients receiving alloHSCT.
Methods
A post-hoc analysis of the cross-sectional observational AFHEM study was carried out to describe the use of antifungal drugs in real-life clinical practice in alloHSCT recipients hospitalized in French hematological units.
Results
A total of 147 alloHSCT recipients were enrolled; most were adults (n = 135; 92%) and had received alloHSCT < 6 months prior to enrollment (n = 123; 84%). Overall, 119 (81%) patients received a systemic antifungal therapy; of these, 95 (80%) patients received antifungal prophylaxis. Rates of patients receiving systemic antifungal treatment were similar irrespective of transplant time, neutropenic, and graft-versus-host disease status. Among patients on systemic antifungal treatment, 83 (70%) received an azole, 22 (18%) received an echinocandin, and 16 (13%) received a polyene.
Conclusions
This work provides evidence of the antifungal strategies used in alloHSCT recipients hospitalized in French hematological units. Unlike earlier studies, the AFHEM study showed that prophylaxis appears to be the leading antifungal strategy used in alloHSCT recipients in France.
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Population Pharmacokinetic Analysis and Dosing Optimization of Prophylactic Fluconazole in Japanese Patients with Hematological Malignancy. J Fungi (Basel) 2021; 7:jof7110975. [PMID: 34829262 PMCID: PMC8618010 DOI: 10.3390/jof7110975] [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: 09/30/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 11/24/2022] Open
Abstract
We conducted population pharmacokinetic (PPK) analysis and Monte Carlo simulations to determine the appropriate prophylactic dose of fluconazole to prevent invasive candidiasis in patients with hematological malignancies. Patients receiving chemotherapy or hematopoietic stem cell transplantation at Yokohama City University Hospital between November 2018 and March 2020 were included. Additionally, patients receiving oral fluconazole for prophylaxis were recruited. We set the free area under the curve/minimum inhibitory concentration (MIC) = 50 as the target and determined the largest MIC (breakpoint MIC) that could achieve more than 90% probability of target attainment. The blood fluconazole concentration of 54 patients (119 points) was used for PPK analysis. The optimal model was the one-compartment model with first-order administration and first-order elimination incorporating creatinine clearance (CLcr) as a covariate of clearance and body weight as a covariate of distribution volume. We conducted Monte Carlo simulation with fluconazole at 200 mg/day or 400 mg/day dosing schedules and patient body weight and CLcr ranging from 40 to 70 kg and 40–140 mL/min, respectively. The breakpoint MICs on the first dosing day and at steady state were 0.5–1.0 μg/mL and 1.0–2.0 μg/mL for 200 mg/day and 1.0–2.0 μg/mL and 2.0–4.0 μg/mL for 400 mg/day, respectively. The recommended dose was 400–700 mg/day for the loading dose and 200–400 mg/day for the maintenance dose. Our findings suggest that the optimal prophylactic dose of fluconazole in hematological malignancy patients depends on CLcr and body weight, and a sufficient loading and maintenance dose may be needed to completely prevent invasive candidiasis.
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Giordano A, Di Landro F, De Carolis E, Criscuolo M, Dragonetti G, Fianchi L, Pagano L. Disseminated Geosmithia argillacea Infection in a Patient with Ph-Positive Acute Lymphoblastic Leukemia. Case Report and Literature Review. J Fungi (Basel) 2021; 7:jof7090778. [PMID: 34575816 PMCID: PMC8466501 DOI: 10.3390/jof7090778] [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: 08/20/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 11/20/2022] Open
Abstract
Invasive fungal infection (IFI) remains the major complication in patients with either acute leukemia, allogeneic stem cell transplantation setting, or both, especially regarding pulmonary localization. We report an experience of a 74-year-old Caucasian male with a Philadelphia-positive (BCR-ABL p190) Common B-acute lymphoblastic leukemia (ALL) who developed a pulmonary infection due to Geosmithia argillacea. Furthermore, we describe the management of this complication and the results of microbiological tests useful to guide the treatment. All cases reported show failure of voriconazole treatment. In the majority of cases a good susceptibility to posaconazole has been reported, which seems to have a good clinical impact; however, only L-AmB shows a clinical effect to produce quick clinical improvement and so it should be a drug of choice. A literature revision shows that only a few papers have thus far described this infection, at present only one case was reported in a hematological setting like a gastrointestinal graft versus host disease in an allogeneic HSCT recipient. The severity of clinical conditions in hematological malignancy settings requires improving the management of this emerging invasive fungal infection. Indeed, a molecular diagnostic approach with a tight laboratory collaboration and targeted therapy should become the gold standard.
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Affiliation(s)
- Antonio Giordano
- Department of Hematology, Fondazione Policlinico Universitario Agostino Gemelli—IRCCS, 00168 Roma, Italy; (F.D.L.); (M.C.); (G.D.); (L.F.)
- Correspondence: (A.G.); (L.P.)
| | - Francesca Di Landro
- Department of Hematology, Fondazione Policlinico Universitario Agostino Gemelli—IRCCS, 00168 Roma, Italy; (F.D.L.); (M.C.); (G.D.); (L.F.)
| | - Elena De Carolis
- Department of Microbiology, Fondazione Policlinico Universitario Agostino Gemelli—IRCCS, 00168 Roma, Italy;
| | - Marianna Criscuolo
- Department of Hematology, Fondazione Policlinico Universitario Agostino Gemelli—IRCCS, 00168 Roma, Italy; (F.D.L.); (M.C.); (G.D.); (L.F.)
| | - Giulia Dragonetti
- Department of Hematology, Fondazione Policlinico Universitario Agostino Gemelli—IRCCS, 00168 Roma, Italy; (F.D.L.); (M.C.); (G.D.); (L.F.)
| | - Luana Fianchi
- Department of Hematology, Fondazione Policlinico Universitario Agostino Gemelli—IRCCS, 00168 Roma, Italy; (F.D.L.); (M.C.); (G.D.); (L.F.)
| | - Livio Pagano
- Department of Hematology, Fondazione Policlinico Universitario Agostino Gemelli—IRCCS, 00168 Roma, Italy; (F.D.L.); (M.C.); (G.D.); (L.F.)
- Institute of Hematology, Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Correspondence: (A.G.); (L.P.)
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Khoury MK, Heid CA, Cripps MW, Pickett ML, Nagaraj MB, Johns M, Lee F, Hennessy SA. Antifungal Therapy in Fungal Necrotizing Soft Tissue Infections. J Surg Res 2020; 256:187-192. [PMID: 32711174 DOI: 10.1016/j.jss.2020.06.013] [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] [Received: 03/20/2020] [Revised: 05/28/2020] [Accepted: 06/16/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are life-threatening surgical emergencies associated with high morbidity and mortality. Fungal NSTIs are considered rare and have been largely understudied. The purpose of this study was to study the impact of fungal NSTIs and antifungal therapy on mortality after NSTIs. METHODS A retrospective chart review was performed on patients with NSTIs from 2012 to 2018. Patient baseline characteristics, microbiologic data, antimicrobial therapy, and clinical outcomes were collected. Patients were excluded if they had comfort care before excision. The primary outcome measured was in-hospital mortality. RESULTS A total of 215 patients met study criteria with a fungal species identified in 29 patients (13.5%). The most prevalent fungal organism was Candida tropicalis (n = 11). Fungal NSTIs were more prevalent in patients taking immunosuppressive medications (17.2% versus 3.2%, P = 0.01). A fungal NSTI was significantly associated with in-hospital mortality (odds ratio, 3.13; 95% confidence interval, 1.16-8.40; P = 0.02). Furthermore, fungal NSTI patients had longer lengths of stay (32 d [interquartile range, 16-53] versus 19 d [interquartile range, 11-31], P < 0.01), more likely to require initiation of renal replacement therapy (24.1% versus 8.6%, P = 0.02), and more likely to require mechanical ventilation (64.5% versus 42.0%, P = 0.02). Initiation of antifungals was associated with a significantly lower rate of in-hospital mortality (6.7% versus 57.1%, P = 0.01). CONCLUSIONS Fungal NSTIs are more common in patients taking immunosuppressive medications and are significantly associated with in-hospital mortality. Antifungal therapy is associated with decreased in-hospital mortality in those with fungal NSTIs. Consideration should be given to adding antifungals in empiric treatment regimens, especially in those taking immunosuppressive medications.
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Affiliation(s)
- Mitri K Khoury
- Division of General and Acute Care Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas; Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Christopher A Heid
- Division of General and Acute Care Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Michael W Cripps
- Division of General and Acute Care Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Maryanne L Pickett
- Division of General and Acute Care Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Madhuri B Nagaraj
- Division of General and Acute Care Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Meagan Johns
- Division of Pharmacologic Sciences, Department of Biomedical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Francesca Lee
- Department of Internal Medicine and Pathology, UT Southwestern Medical Center, Dallas, Texas
| | - Sara A Hennessy
- Division of General and Acute Care Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas.
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Paige E, Haywood P, Xie M, Worth L, Thursky K, Urbancic K, Bajel A, Slavin M. Auditing fungal disease in leukemia patients in a tertiary care center: opportunities and challenges for an antifungal stewardship program. Leuk Lymphoma 2019; 60:2373-2383. [PMID: 31096813 DOI: 10.1080/10428194.2019.1590570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Invasive fungal disease (IFD) is responsible for significant morbidity and mortality in patients with acute leukemia. Antifungal stewardship (AFS) programs are utilized in this patient group but have been infrequently evaluated in clinical practice. Adults diagnosed with acute leukemia at an Australian tertiary center over two years were identified, with subsequent auditing of IFD prophylaxis and treatment, and identification of further opportunities for AFS activities. Proven or probable IFD occurred in 6% of cases, including 14% of acute lymphoblastic leukemia (ALL) patients and 6% of acute myeloid leukemia (AML) patients. Mold-active antifungal prophylaxis was used in 84% of cases overall, including in 94% of AML cases and 23% of ALL cases. Local auditing identified target areas for AFS in this complex patient cohort, including modification of clinical guidelines, enhanced patient screening, improved access to fungal diagnostics and therapeutic drug monitoring, and the establishment of a specialized, embedded AFS program.
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Affiliation(s)
- Emma Paige
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,Department of Infectious Diseases, Alfred Hospital , Melbourne , Australia
| | - Peter Haywood
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Mingdi Xie
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Leon Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia
| | - Karen Urbancic
- NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Antimicrobial Stewardship, Peter Doherty Institute , Melbourne , Australia.,Department of Medicine, University of Melbourne , Parkville , Australia
| | - Ashish Bajel
- Department of Haematology, Royal Melbourne Hospital , Parkville , Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre , Melbourne , Australia.,NHMRC National Centre for Infections in Cancer, Peter MacCallum Cancer Centre , Melbourne , Australia
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Efficacy of Posaconazole Prophylaxis in Patients with Acute Myeloid Leukemia Undergoing Induction Chemotherapy: An Observational Study in Resource Limited Settings. Indian J Hematol Blood Transfus 2018; 34:460-465. [DOI: 10.1007/s12288-018-0916-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 01/02/2018] [Indexed: 10/18/2022] Open
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Rosanova MT, Bes D, Serrano Aguilar P, Sberna N, Lede R. Efficacy and safety of voriconazole in immunocompromised patients: systematic review and meta-analysis. Infect Dis (Lond) 2017; 50:489-494. [PMID: 29262742 DOI: 10.1080/23744235.2017.1418531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Voriconazole is a second-generation triazole. It has excellent bioavailability and broad antifungal spectrum; thus, it is an attractive option for patients at high risk of invasive fungal infections (IFIs). Comparing efficacy and safety of voriconazole with other antifungals in prophylaxis or treatment of IFIs would be useful to draw conclusions regarding prevention and therapeutics of these infections. AIM To assess efficacy and safety of voriconazole compared with other options as prophylaxis or treatment of IFIs in haematology-oncology patients. MATERIALS AND METHODS A literature search was performed in MEDLINE database using the search term 'voriconazole' and completed with manual search. STUDY SELECTION Randomized controlled trials (RCTs) comparing voriconazole with other antifungal agents or placebo. DATA EXTRACTION Seven studies fulfilled the eligibility criteria. RESULTS Five studies compared voriconazole to another comparator as prophylaxis of IFIs and two as treatment. Pooled results showed that voriconazole was more effective than the comparator (RR = 1.17; 95%CI = 1.01-1.34), but heterogeneity was significant (Q test 32.7; p = .00001). Sub-analysis according to prophylaxis showed RR = 1.17; 95%CI = 1.00-1.37; while as treatment, RR = 1.23; 95%CI = 0.68-2.22. Risk of adverse events was not different from that observed for the comparator (RR = 1.06, 95%CI = 0.66-1.72) though significant heterogeneity was detected (p < .01). CONCLUSIONS Voriconazole was as effective and safe as comparators, probably better as prophylaxis than as treatment, but limitations due to variability in the sample size of studies, differences in the age of patients, and heterogeneity between studies' outcome measures indicate the need for further research.
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Affiliation(s)
| | - David Bes
- b Hospital J. P. Garrahan, CABA , Buenos Aires , Argentina
| | - Pedro Serrano Aguilar
- c Servicio de Evaluación del Servicio Canario de la Salud (SESCS) , Red de investigación de servicios de salud en enfermedades crónicas (REDISSEC) , Tenerife , Spain
| | - Norma Sberna
- d Hospital de Pediatría J. P. Garrahan, CABA , Buenos Aires , Argentina
| | - Roberto Lede
- e Universidad Abierta Interamericana (UAI), CABA , Buenos Aires , Argentina
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Predicting early post-chemotherapy adverse events in patients with hematological malignancies: a retrospective study. Support Care Cancer 2016; 24:2727-33. [PMID: 26803835 DOI: 10.1007/s00520-016-3085-6] [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: 07/21/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to develop a mathematical model that predicts the definite adverse events following chemotherapy in patients with hematological malignancies (HMs). METHODS This is a retrospective cohort study including 1157 cases with HMs. Firstly, we screened and verified the independent risk factors associated with post-chemotherapy adverse events by both univariate and multivariate logistic regression analysis using 70 % of randomly selected cases (training set). Secondly, we proposed a mathematical model based on those selected factors. The calibration and discrimination of the model were assessed by Hosmer-Lemeshow (H-L) test and area under the receiver operating characteristic (ROC) curve, respectively. Lastly, the predicative power of this model was further tested in the remaining 30 % of cases (validation set). RESULTS Our statistical analysis indicated that liver dysfunction (OR = 2.164), active infection (OR = 3.619), coagulation abnormalities (OR = 4.614), intensity of chemotherapy (OR = 10.001), acute leukemia (OR = 2.185), and obesity (OR = 1.604) were independent risk factors for post-chemotherapy adverse events in HM patients (all P < 0.05). Based on the verified risk factors, a predictive model was proposed. This model had good discrimination and calibration. When 0.648 was selected as the cutoff point, the sensitivity and specificity of this predictive model in validation sets was 72.7 and 87.4 %, respectively. Furthermore, this proposed model's positive predictive value, negative predictive value, and consistency rate were 87.3, 73.0 and 80.0 %, respectively. CONCLUSIONS Our study indicated that this six risk factor-based mathematical model is accurate and sufficient enough to predict definite post-chemotherapy adverse events in a HM patient and it may aid clinicians to optimize treatment for a HM patient.
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Zhao YJ, Khoo AL, Tan G, Teng M, Tee C, Tan BH, Ong B, Lim BP, Chai LYA. Network Meta-analysis and Pharmacoeconomic Evaluation of Fluconazole, Itraconazole, Posaconazole, and Voriconazole in Invasive Fungal Infection Prophylaxis. Antimicrob Agents Chemother 2016; 60:376-86. [PMID: 26525782 PMCID: PMC4704197 DOI: 10.1128/aac.01985-15] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 10/22/2015] [Indexed: 11/20/2022] Open
Abstract
Invasive fungal infections (IFIs) are associated with high mortality rates and large economic burdens. Triazole prophylaxis is used for at-risk patients with hematological malignancies or stem cell transplants. We evaluated both the efficacy and the cost-effectiveness of triazole prophylaxis. A network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating fluconazole, itraconazole capsule and solution, posaconazole, and voriconazole was conducted. The outcomes of interest included the incidences of IFIs and deaths. This was coupled with a cost-effectiveness analysis from patient perspective over a lifetime horizon. Probabilities of transitions between health states were derived from the NMA. Resource use and costs were obtained from the Singapore health care institution. Data on 5,505 participants in 21 RCTs were included. Other than itraconazole capsule, all triazole antifungals were effective in reducing IFIs. Posaconazole was better than fluconazole (odds ratio [OR], 0.35 [95% confidence interval [CI], 0.16 to 0.73]) and itraconazole capsule (OR, 0.25 [95% CI, 0.06 to 0.97]), but not voriconazole (OR, 1.31 [95% CI, 0.43 to 4.01]), in preventing IFIs. Posaconazole significantly reduced all-cause deaths, compared to placebo, fluconazole, and itraconazole solution (OR, 0.49 to 0.54 [95% CI, 0.28 to 0.88]). The incremental cost-effectiveness ratio for itraconazole solution was lower than that for posaconazole (Singapore dollars [SGD] 12,546 versus SGD 26,817 per IFI avoided and SGD 5,844 versus SGD 12,423 per LY saved) for transplant patients. For leukemia patients, itraconazole solution was the dominant strategy. Voriconazole was dominated by posaconazole. All triazole antifungals except itraconazole capsule were effective in preventing IFIs. Posaconazole was more efficacious in reducing IFIs and all-cause deaths than were fluconazole and itraconazole. Both itraconazole solution and posaconazole were cost-effective in the Singapore health care setting.
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Affiliation(s)
- Ying Jiao Zhao
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Ai Leng Khoo
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Gloria Tan
- Pharmacoeconomics and Drug Utilisation, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Monica Teng
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Caroline Tee
- Department of Pharmacy, National University Health System, Singapore
| | - Ban Hock Tan
- Department of General Internal Medicine and Infectious Diseases, Singapore General Hospital, Singapore
| | - Benjamin Ong
- Pharmacoeconomics and Drug Utilisation, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Boon Peng Lim
- Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore
| | - Louis Yi Ann Chai
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore
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Cowan AJ, Altemeier WA, Johnston C, Gernsheimer T, Becker PS. Management of Acute Myeloid Leukemia in the Intensive Care Setting. J Intensive Care Med 2014; 30:375-84. [DOI: 10.1177/0885066614530959] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/16/2013] [Indexed: 01/18/2023]
Abstract
Patients with acute myeloid leukemia (AML) who are newly diagnosed or relapsed and those who are receiving cytotoxic chemotherapy are predisposed to conditions such as sepsis due to bacterial and fungal infections, coagulopathies, hemorrhage, metabolic abnormalities, and respiratory and renal failure. These conditions are common reasons for patients with AML to be managed in the intensive care unit (ICU). For patients with AML in the ICU, providers need to be aware of common problems and how to manage them. Understanding the pathophysiology of complications and the recent advances in risk stratification as well as newer therapy for AML are relevant to the critical care provider.
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Affiliation(s)
- Andrew J. Cowan
- Division of Hematology, University of Washington, Seattle, WA, USA
- Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - William A. Altemeier
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Christine Johnston
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Terry Gernsheimer
- Division of Hematology, University of Washington, Seattle, WA, USA
- Puget Sound Blood Center, Seattle, WA, USA
| | - Pamela S. Becker
- Division of Hematology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
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Lin R, Xu X, Li Y, Sun J, Fan Z, Jiang Q, Huang F, Zhou H, Nie D, Guo Z, Mao Y, Xiao Y, Liu Q. Comparison of long-term and short-term administration of itraconazole for primary antifungal prophylaxis in recipients of allogeneic hematopoietic stem cell transplantation: a multicenter, randomized, open-label trial. Transpl Infect Dis 2014; 16:286-94. [PMID: 24593273 DOI: 10.1111/tid.12192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/19/2013] [Accepted: 09/07/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal agents and duration of primary antifungal prophylaxis in recipients of allogeneic hematopoietic stem cell transplantation (allo-HSCT) remain a matter of discussion. OBJECTIVE Our objective was to compare the efficacy and safety of long-term and short-term administration of itraconazole (ITCZ) for primary antifungal prophylaxis in allo-HSCT recipients. METHODS This multicenter, randomized, open-label pilot study was performed in 4 transplant centers in China. Recipients of allo-HSCT without a history of invasive fungal disease (IFD) were randomly assigned to the long-term or the short-term arm. Randomization was carried out by a center computer system. Intravenous ITCZ was given to the patients in both study arms with a loading dose of 400 mg/day for 2 days followed by 200 mg/day until day +14 or when the white blood cell count was >1.0 × 10(9) /L, and then switched to oral ITCZ solution; prophylaxis was continued until day +30 post transplantation in the short-term arm or until day +90 in the long-term arm. The trough serum concentrations of ITCZ also were measured. The primary study endpoint was the incidence of IFD (proven, probable, and possible) within day +90 post transplantation. RESULTS A total of 128 recipients were enrolled in this study; 59 of them were randomized to the long-term arm and 62 were randomized to the short-term arm, forming the modified intent-to-treat (mITT) set. The incidence of IFD within day +90, the primary endpoint, was not significantly different between the 2 arms for the mITT set (6.78% in the long-term arm vs. 6.45% in the short-term arm, P = 0.94), or for the per-protocol set (6.90% in the long-term arm vs. 6.67% in the short-term arm, P = 0.96). From day +30 to day +90, the incidence of IFD was 0% and 6.45%, respectively, in the patients with long-term and short-term prophylaxis for the mITT set (P = 0.11). The mean trough serum concentrations of ITCZ was maintained at >500 ng/mL throughout administration. The incidences of withdrawal because of drug-related adverse events in patients with long-term and short-term prophylaxis were 6.78% and 0%, respectively (P = 0.05). CONCLUSIONS Long-term and short-term administration of ITCZ both seemed effective in preventing IFD in recipients of allo-HSCT. Further study with large sample size should be performed to evaluate this result. ITCZ shows the same pharmacokinetics in recipients of allo-HSCT as in non-recipients.
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Affiliation(s)
- R Lin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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12
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Hakim H, Shenep JL. Managing fungal and viral infections in pediatric leukemia. Expert Rev Hematol 2014; 3:603-24. [DOI: 10.1586/ehm.10.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Dellacasa CM, Busca A, Audisio E, Marmont F, Barbui AM, Falda M, De Rosa FG, Frairia C, Allione B, D’Ardia S, Aydin S, Pecoraro C, Manetta S, Vitolo U. Prevention of invasive fungal infections in patients with acute myeloid leukaemia: results of a single centre retrospective observational study with the use of posaconazole versus conventional mould-active azoles. J Chemother 2013; 26:315-20. [DOI: 10.1179/1973947813y.0000000142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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14
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Dahlin JL, Sinville R, Solberg J, Zhou H, Han J, Francis S, Strasser JM, John K, Hook DJ, Walters MA, Zhang Z. A cell-free fluorometric high-throughput screen for inhibitors of Rtt109-catalyzed histone acetylation. PLoS One 2013; 8:e78877. [PMID: 24260132 PMCID: PMC3832525 DOI: 10.1371/journal.pone.0078877] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 09/17/2013] [Indexed: 11/19/2022] Open
Abstract
The lysine acetyltransferase (KAT) Rtt109 forms a complex with Vps75 and catalyzes the acetylation of histone H3 lysine 56 (H3K56ac) in the Asf1-H3-H4 complex. Rtt109 and H3K56ac are vital for replication-coupled nucleosome assembly and genotoxic resistance in yeast and pathogenic fungal species such as Candida albicans. Remarkably, sequence homologs of Rtt109 are absent in humans. Therefore, inhibitors of Rtt109 are hypothesized as potential and minimally toxic antifungal agents. Herein, we report the development and optimization of a cell-free fluorometric high-throughput screen (HTS) for small-molecule inhibitors of Rtt109-catalyzed histone acetylation. The KAT component of the assay consists of the yeast Rtt109-Vps75 complex, while the histone substrate complex consists of full-length Drosophila histone H3-H4 bound to yeast Asf1. Duplicated assay runs of the LOPAC demonstrated day-to-day and plate-to-plate reproducibility. Approximately 225,000 compounds were assayed in a 384-well plate format with an average Z' factor of 0.71. Based on a 3σ cut-off criterion, 1,587 actives (0.7%) were identified in the primary screen. The assay method is capable of identifying previously reported KAT inhibitors such as garcinol. We also observed several prominent active classes of pan-assay interference compounds such as Mannich bases, catechols and p-hydroxyarylsulfonamides. The majority of the primary active compounds showed assay signal interference, though most assay artifacts can be efficiently removed by a series of straightforward counter-screens and orthogonal assays. Post-HTS triage demonstrated a comparatively small number of confirmed actives with IC50 values in the low micromolar range. This assay, which utilizes five label-free proteins involved in H3K56 acetylation in vivo, can in principle identify compounds that inhibit Rtt109-catalyzed H3K56 acetylation via different mechanisms. Compounds discovered via this assay or adaptations thereof could serve as chemical probes or leads for a new class of antifungals targeting an epigenetic enzyme.
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Affiliation(s)
- Jayme L. Dahlin
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
- Medical Scientist Training Program, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
| | - Rondedrick Sinville
- Institute for Therapeutics Discovery & Development, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Jonathan Solberg
- Institute for Therapeutics Discovery & Development, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Hui Zhou
- Department of Biochemistry and Molecular Biology, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
| | - Junhong Han
- Department of Biochemistry and Molecular Biology, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
| | - Subhashree Francis
- Institute for Therapeutics Discovery & Development, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Jessica M. Strasser
- Institute for Therapeutics Discovery & Development, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Kristen John
- Institute for Therapeutics Discovery & Development, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Derek J. Hook
- Institute for Therapeutics Discovery & Development, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Michael A. Walters
- Institute for Therapeutics Discovery & Development, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Zhiguo Zhang
- Department of Biochemistry and Molecular Biology, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
- * E-mail:
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Yeh TC, Liu HC, Wang LY, Chen SH, Liang DC. Invasive fungal infection in children undergoing chemotherapy for cancer. ACTA ACUST UNITED AC 2013; 27:141-7. [PMID: 17565811 DOI: 10.1179/146532807x192516] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND In children with cancer, invasive fungal infection is a serious complication of anticancer therapy. Successful treatment is a major challenge for clinical oncologists. METHODS The records of all episodes of invasive fungal infection occurring in children with cancer undergoing chemotherapy at Mackay Memorial Hospital, Taipei between January 1987 and October 2005 were reviewed. The following were documented: general characteristics, clinical presentation, predisposing factors, pathogens, antifungal treatment, association with anticancer therapy and outcome. We endeavoured to preserve renal function by administration of new antifungal agents. Anticancer therapy was given as soon as possible after diagnosis and the dose of chemotherapeutic agents was adjusted as required to prevent unduly prolonged interruption of chemotherapy and minimise the risk of leukaemia relapse. RESULTS Twenty-six patients with 29 episodes of invasive fungal infection were reviewed. Candida species were the leading pathogens (14/29) followed by Aspergillus species (11/29). In six episodes there was both visceral dissemination and fungaemia. In 23/29 patients, antibiotic therapy preceded fungal infection with a median of 11 days. Three children died from extensive fungal infection and four from progression of malignancy; the remainder survived with a median follow-up of 40 months (range 12-233). The actuarial 12-month survival rate was 87%; in patients with invasive candidiasis and aspergillosis the rates were 75% and 100%, respectively. CONCLUSIONS In children with cancer, most invasive fungal infections can be treated successfully. Current antifungal prophylaxis should protect patients from fungal infection.
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Affiliation(s)
- Ting-Chi Yeh
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
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Peterson L, Ostermann J, Rieger H, Ostermann H, Rieger CT. Posaconazole prophylaxis - impact on incidence of invasive fungal disease and antifungal treatment in haematological patients. Mycoses 2013; 56:651-8. [DOI: 10.1111/myc.12086] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 03/21/2013] [Accepted: 04/14/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Lisa Peterson
- Klinikum der Universität München Großhadern; Medizinische Klinik und Poliklinik III; München
| | - Julia Ostermann
- Institut für Sozialmedizin; Epidemiologie und Gesundheitsökonomie, Charité - Universitätsmedizin Berlin; Berlin
| | - Heidi Rieger
- Klinikum der Universität München Großhadern; Medizinische Klinik und Poliklinik III; München
| | - Helmut Ostermann
- Klinikum der Universität München Großhadern; Medizinische Klinik und Poliklinik III; München
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Badior M, Trigo F, Eloy C, Guimarães JE. Mucor Infection: Difficult Diagnosis. Clin Drug Investig 2013; 33 Suppl 1:S19-21. [DOI: 10.1007/s40261-012-0014-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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18
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Flowers CR, Seidenfeld J, Bow EJ, Karten C, Gleason C, Hawley DK, Kuderer NM, Langston AA, Marr KA, Rolston KVI, Ramsey SD. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2013; 31:794-810. [PMID: 23319691 DOI: 10.1200/jco.2012.45.8661] [Citation(s) in RCA: 284] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To provide guidelines on antimicrobial prophylaxis for adult neutropenic oncology outpatients and on selection and treatment as outpatients of those with fever and neutropenia. METHODS A literature search identified relevant studies published in English. Primary outcomes included: development of fever and/or infections in afebrile neutropenic outpatients and recovery without complications and overall mortality in febrile neutropenic outpatients. Secondary outcomes included: in afebrile neutropenic outpatients, infection-related mortality; in outpatients with fever and neutropenia, defervescence without regimen change, time to defervescence, infectious complications, and recurrent fever; and in both groups, hospital admissions, duration, and adverse effects of antimicrobials. An Expert Panel developed guidelines based on extracted data and informal consensus. RESULTS Forty-seven articles from 43 studies met selection criteria. RECOMMENDATIONS Antibacterial and antifungal prophylaxis are only recommended for patients expected to have < 100 neutrophils/μL for > 7 days, unless other factors increase risks for complications or mortality to similar levels. Inpatient treatment is standard to manage febrile neutropenic episodes, although carefully selected patients may be managed as outpatients after systematic assessment beginning with a validated risk index (eg, Multinational Association for Supportive Care in Cancer [MASCC] score or Talcott's rules). Patients with MASCC scores ≥ 21 or in Talcott group 4, and without other risk factors, can be managed safely as outpatients. Febrile neutropenic patients should receive initial doses of empirical antibacterial therapy within an hour of triage and should either be monitored for at least 4 hours to determine suitability for outpatient management or be admitted to the hospital. An oral fluoroquinolone plus amoxicillin/clavulanate (or plus clindamycin if penicillin allergic) is recommended as empiric therapy, unless fluoroquinolone prophylaxis was used before fever developed.
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Jamalian A, Shams-Ghahfarokhi M, Jaimand K, Pashootan N, Amani A, Razzaghi-Abyaneh M. Chemical composition and antifungal activity of Matricaria recutita flower essential oil against medically important dermatophytes and soil-borne pathogens. J Mycol Med 2012; 22:308-15. [DOI: 10.1016/j.mycmed.2012.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 09/05/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
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Canadian clinical practice guidelines for invasive candidiasis in adults. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2012; 21:e122-50. [PMID: 22132006 DOI: 10.1155/2010/357076] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Candidemia and invasive candidiasis (C/IC) are life-threatening opportunistic infections that add excess morbidity, mortality and cost to the management of patients with a range of potentially curable underlying conditions. The Association of Medical Microbiology and Infectious Disease Canada developed evidence-based guidelines for the approach to the diagnosis and management of these infections in the ever-increasing population of at-risk adult patients in the health care system. Over the past few years, a new and broader understanding of the epidemiology and pathogenesis of C/IC has emerged and has been coupled with the availability of new antifungal agents and defined strategies for targeting groups at risk including, but not limited to, acute leukemia patients, hematopoietic stem cell transplants and solid organ transplants, and critical care unit patients. Accordingly, these guidelines have focused on patients at risk for C/IC, and on approaches of prevention, early therapy for suspected but unproven infection, and targeted therapy for probable and proven infection.
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Tragiannidis A, Dokos C, Lehrnbecher T, Groll AH. Antifungal Chemoprophylaxis in Children and Adolescents with Haematological Malignancies and Following Allogeneic Haematopoietic Stem Cell Transplantation. Drugs 2012; 72:685-704. [DOI: 10.2165/11599810-000000000-00000] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Karthaus M. Prophylaxis and treatment of invasive aspergillosis with voriconazole, posaconazole and caspofungin: review of the literature. Eur J Med Res 2011; 16:145-52. [PMID: 21486728 PMCID: PMC3352070 DOI: 10.1186/2047-783x-16-4-145] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Major progress for the management of invasive aspergillosis has come from the introduction of new antifungals since the late 1990s. Although mortality of invasive aspergillosis remains as high as 30-50%. Backbone of management are prophylaxis, early diagnosis and early initiation of antifungals for reduction of invasive aspergillosis related mortality. Randomized trials have been undertaken for the prophylaxis as well as treatment of invasive aspergillosis in the last two decades. Posaconazole is recommended for prophylaxis against aspergillosis in patients treated for acute myelogenous leukemia, myelodysplastic syndrome or patients with graft versus host disease after allogeneic transplantation. Efficacy has been shown for first-line therapy of invasive aspergillosis with voriconazole and liposomal amphotericin B. Gastrointestinal resorption for the azoles posaconazole, voriconazole and itraconazole differ considerably. While oral voriconazole resportion is reduced when taken with food, posaconazole has to be taken with fatty food for optimal intestinal resorption. Beside all advances in the management of invasive aspergillosis important questions remain unresolved. This article reviews the current state of prophylaxis and treatment of invasive aspergillosis and points out clinicians unmet needs.
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Affiliation(s)
- M Karthaus
- Klinikum Neuperlach, Oskar-Maria-Graf Ring, Munich, Germany.
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Karthaus M, Hentrich M. Wait and see or rush and switch? New questions for the management of patients with febrile neutropenia receiving antifungal prophylaxis. Mycoses 2011; 54 Suppl 1:1-6. [PMID: 21126265 DOI: 10.1111/j.1439-0507.2010.01978.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Infections are a major threat for patients with haematological malignancies after intensive myelosuppressive chemotherapy. The severity and extent of neutropenia are considered a major risk factor for infections in these patients. Antibacterial treatment for patients with febrile neutropenia was standardised in the late 1990s with no further significant improvements within the last decade. Major progress in febrile neutropenia has come from the advent of new antifungals since the late 1990s. Lipid-based amphotericin B, third-generation azoles and the introduction of echinocandins allow a safer and effective treatment of invasive fungal infections. The mortality rate of invasive fungal infection is as high as 30-100% and a definitive diagnosis by culture may take too long. Thus, early diagnosis and early initiation of antifungal therapy remain important for the reduction of mortality rates. In the last two decades, randomised trials on prophylaxis and empirical therapy of invasive fungal infections were undertaken. Both primary prophylaxis and empirical therapy of invasive fungal infection proved effective. However, important questions remain unanswered. This article points out the clinicians view on unmet needs for patients with suspected invasive fungal infections after a decade of well-designed randomised trials for prevention of invasive fungal infections. Should we wait and see what happens in febrile neutropenic patients on antifungal prophylaxis or under empirical treatment or should we rush and switch antifungal treatment?
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Affiliation(s)
- Meinolf Karthaus
- Cancer Center Munich South, Städtisches Klinikum München, Klinikum Neuperlach und Harlaching, München, Germany.
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Effectiveness of Systemic Antifungal Prophylaxis in Patients With Neutropenia After Chemotherapy: A Meta-Analysis of Randomized Controlled Trials. Clin Ther 2010; 32:2316-36. [DOI: 10.1016/j.clinthera.2011.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2010] [Indexed: 11/17/2022]
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Imataki O, Kubota Y, Ohnishi H, Kitanaka A, Ishida T, Tanaka T. Medical cost analysis for antifungal prophylaxis in neutropenic patients with hematological malignancies: a systematic simulation analysis. Support Care Cancer 2010; 19:1657-65. [PMID: 20830490 DOI: 10.1007/s00520-010-0998-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Accepted: 08/23/2010] [Indexed: 11/25/2022]
Abstract
GOALS OF WORK We assessed the medical costs of different antifungal agents for prophylaxis of invasive fungal infections in neutropenic patients in Japan with a cost simulation model designed for the study. PATIENTS AND METHODS We used probabilities of prophylaxis failure, possible cases for empiric therapy, probable proportions of infections caused by fungus species among prophylaxis failure patients, and incidence of adverse events caused by any reason, based on systematic analysis of previously reported randomized trials identified by a computerized search of the PubMed database. Antifungal agents were limited to oral fluconazole, oral itraconazole, micafungin, and liposomal amphotericin B. The range of the expected medical cost was simulated as a sensitivity analysis using 95% of confidence interval of a mean. MAIN RESULTS Fifteen studies were identified for our analysis. The prophylactic efficacy was comparable between the four agents. The simulated expected cost for invasive fungal infection prophylaxis and treatment of the infection was $1,035.74 when oral itraconazole was used for prophylaxis, $1,552.81 with oral fluconazole, $2,245.96 with micafungin, and $3,028.10 with liposomal amphotericin B. The total cost including treatment cost for adverse events related to each drug was $2,742.14, $3,547.91, $3,034.57, and $3,028.10, respectively. This result was confirmed in a sensitivity analysis in which IFI incidence and therapy duration were tested as parameters. CONCLUSIONS Our analysis results suggest that oral itraconazole is the most cost-effective prophylactic antifungal agent for invasive fungal infections in neutropenic patients with hematological malignancies, and this result was robust by sensitivity analysis.
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Affiliation(s)
- Osamu Imataki
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan.
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Hammond SP, Marty FM, Bryar JM, DeAngelo DJ, Baden LR. Invasive fungal disease in patients treated for newly diagnosed acute leukemia. Am J Hematol 2010; 85:695-9. [PMID: 20652970 DOI: 10.1002/ajh.21776] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Invasive fungal disease (IFD) is a significant cause of morbidity and mortality in patients undergoing treatment for acute leukemia (AL). Antifungal prophylactic strategies are associated with significant toxicities and cost. We performed a retrospective study of the incidence and risk factors for IFD among patients newly diagnosed with and treated for AL between January 1, 2004 and July 1, 2006. Patient follow up concluded January 1, 2007. Among 231 patients with newly diagnosed AL, 31 (13.4%) developed IFD by the end of follow up, 24 (10.4%) of whom developed IFD within the first 100 days after diagnosis of AL. The cumulative probability of developing IFD was 5.9% by 30 days and 11.1% at 100 days after AL diagnosis. Patients who had persistent leukemia after an initial course of induction chemotherapy were significantly more likely to develop IFD than those who did not have evidence of persistent leukemia (14/65 (21.5%) vs. 15/148 (10.1%), P = 0.03). In a time-dependent Cox model, the adjusted hazard ratio for developing IFD within the first 100 days of AL diagnosis based on the number of days of neutropenia in that period was 4.85 (95% confidence interval: 1.52, 15.4). Those patients with more days of neutropenia in the first 100 days after AL diagnosis, such as those who did not achieve remission after a first course of induction chemotherapy, were more likely to develop IFD.
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Affiliation(s)
- Sarah P Hammond
- Division of Infectious Diseases, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Lalla RV, Latortue MC, Hong CH, Ariyawardana A, D'Amato-Palumbo S, Fischer DJ, Martof A, Nicolatou-Galitis O, Patton LL, Elting LS, Spijkervet FKL, Brennan MT. A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer 2010; 18:985-92. [PMID: 20449755 DOI: 10.1007/s00520-010-0892-z] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 04/22/2010] [Indexed: 01/12/2023]
Abstract
PURPOSE The aims of this systematic review were to determine, in patients receiving cancer therapy, the prevalence of clinical oral fungal infection and fungal colonization, to determine the impact on quality of life and cost of care, and to review current management strategies for oral fungal infections. METHODS Thirty-nine articles that met the inclusion/exclusion criteria were independently reviewed by two calibrated reviewers, each using a standard form. Information was extracted on a number of variables, including study design, study population, sample size, interventions, blinding, outcome measures, methods, results, and conclusions for each article. Areas of discrepancy between the two reviews were resolved by consensus. Studies were weighted as to the quality of the study design, and recommendations were based on the relative strength of each paper. Statistical analyses were performed to determine the weighted prevalence of clinical oral fungal infection and fungal colonization. RESULTS For all cancer treatments, the weighted prevalence of clinical oral fungal infection was found to be 7.5% pre-treatment, 39.1% during treatment, and 32.6% after the end of cancer therapy. Head and neck radiotherapy and chemotherapy were each independently associated with a significantly increased risk for oral fungal infection. For all cancer treatments, the prevalence of oral colonization with fungal organisms was 48.2% before treatment, 72.2% during treatment, and 70.1% after treatment. The prophylactic use of fluconazole during cancer therapy resulted in a prevalence of clinical fungal infection of 1.9%. No information specific to oral fungal infections was found on quality of life or cost of care. CONCLUSIONS There is an increased risk of clinically significant oral fungal infection during cancer therapy. Systemic antifungals are effective in the prevention of clinical oral fungal infection in patients receiving cancer therapy. Currently available topical antifungal agents are less efficacious, suggesting a need for better topical agents.
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Affiliation(s)
- Rajesh V Lalla
- University of Connecticut Health Center, Farmington, CT 06030, USA.
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Torres A, Serrano J, Rojas R, Martín V, Martín C, Tabares S, Molina JR, Capote M, Martínez F, Gómez P, Sánchez-García J. Voriconazole as primary antifungal prophylaxis in patients with neutropenia after hematopoietic stem cell transplantation or chemotherapy for acute myeloid leukemia. Eur J Haematol 2010; 84:271-3. [DOI: 10.1111/j.1600-0609.2009.01367.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Nemerovski CW, Mackler ER, DePestel DD, Collins CD, Welch KS, Stevenson JG. Drug costs and utilization after implementation of a posaconazole prophylaxis protocol in adults with acute myelogenous leukemia. Am J Health Syst Pharm 2010; 67:295-9. [PMID: 20133535 DOI: 10.2146/ajhp090101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Drug costs and utilization after implementation of a posaconazole prophylaxis protocol in adults with acute myelogenous leukemia (AML) were studied. METHODS Adult patients who initiated induction or reinduction chemotherapy for the treatment of AML between December 1, 2006, and March 31, 2008, at a tertiary care hospital were included in this retrospective cohort study. Patients were divided into two groups: preprotocol (treated before June 1, 2007) and postprotocol (treated on or after June 1, 2007). Medical charts, including pharmacy and laboratory data, were reviewed for all patients. Outcomes measured included antifungal and antibacterial drug costs and utilization and total pharmacy costs. RESULTS A total of 66 patients were evaluated (33 in each group). Baseline characteristics, except patient age, were similar between groups. Each group incurred similar costs and utilized resources for similar periods of time as evidenced by similar lengths of stay, duration of neutropenia, and mortality. Antibacterial costs, total pharmacy costs, and other utilization outcomes were also similar between the two groups. Alterations to antifungal management strategy occurred more often in the postprotocol group (33% versus 58%, p = 0.048). CONCLUSION Implementation of a posaconazole protocol did not significantly alter antifungal or antibacterial drug costs or utilization or total pharmacy costs. Prophylactic posaconazole was frequently changed to alternative antifungal therapy due to an adverse drug event, perceived lack of efficacy, avoidance of a drug interaction, or inability to tolerate oral intake.
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Affiliation(s)
- Carrie W Nemerovski
- University of Michigan Hospitals and Health Centers (UMHHC), Ann Arbor, MI, USA.
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Pagano L, Caira M, Valentini CG, Posteraro B, Fianchi L. Current therapeutic approaches to fungal infections in immunocompromised hematological patients. Blood Rev 2010; 24:51-61. [PMID: 20056300 DOI: 10.1016/j.blre.2009.11.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Invasive fungal infections are significant causes of morbidity and mortality in patients with hematological malignancies. Patients with acute myeloid leukemia and those who have undergone allogeneic hematopoietic stem cell transplantation are at especially high risk. Various fungal agents are responsible for this complication, but Aspergillus spp. and Candida spp. are the most frequently isolated micro-organisms; less commonly, infections could be caused by Zygomycetes or other rare molds or yeasts. Several new systemically-administered antifungal agents have been approved for clinical use since 2001; these agents include liposomal amphotericin B, voriconazole, caspofungin, and posaconazole, and they represent a major advance in antifungal therapy and have improved the prognosis of patients with hematological malignancies. This review focuses on therapeutic aspects of the management of fungal infections in hematological patients.
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Affiliation(s)
- Livio Pagano
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy.
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Pharmacokinetic and Toxicokinetic Studies of Potential Antifungal Compounds, KAF-200522 and KAF-200522 · HCl, in Animal Models. Lab Anim Res 2010. [DOI: 10.5625/lar.2010.26.4.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Antifungal Effects of New Synthetic Materials, KAF-200522 and KAF-200522-HCl, on in vitroand in vivoModels. Lab Anim Res 2010. [DOI: 10.5625/lar.2010.26.4.353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Vehreschild JJ, Rüping MJGT, Steinbach A, Cornely OA. Diagnosis and treatment of fungal infections in allogeneic stem cell and solid organ transplant recipients. Expert Opin Pharmacother 2009; 11:95-113. [DOI: 10.1517/14656560903405639] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Hütter G, Ganepola S, Thiel E, Blau IW. Correlation between the incidence of nosocomial aspergillosis and room reconstruction of a haematological ward. J Infect Prev 2009. [DOI: 10.1177/1757177409350235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) represents ~ a major cause of morbidity and mortality in patients I with impaired function of the immune system such as in patients with acute myeloid leukaemia (AML). We investigated the in uence of the patients’ room occu- pancy and the sanitary facilities with regard to the inci- dence of IPA after reconstruction of a haematological ward. This is a retrospective cohort-control study in patients with newly diagnosed AML. Thirty ve patients were treated before and 28 patients in the time after the reconstruction works. The median time of neutropenia was 18.5 days vs. 19.5 days. Twelve patients before and 11 patients after the reconstruction developed IPA (p = 0.794). The incidence of IPA did not decrease after a reduction in the patients’ occupancy and improvement of the sanitary equipment. This study emphasises the presumed importance of optimal physical barriers, e.g. air ltration and/or antimycotic prophylaxis in high-risk patients.
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Affiliation(s)
- G. Hütter
- Medical Department Hematology, Oncology, Charité Campus Benjamin Franklin, Hindenburgdamm 30, D-12203 Berlin, Germany,
| | - S. Ganepola
- Medical Department Hematology, Oncology, Charité Campus Benjamin Franklin, Hindenburgdamm 30, D-12203 Berlin, Germany
| | - E. Thiel
- Medical Department Hematology, Oncology, Charité Campus Benjamin Franklin, Hindenburgdamm 30, D-12203 Berlin, Germany
| | - IW Blau
- Medical Department Hematology, Oncology, Charité Campus Benjamin Franklin, Hindenburgdamm 30, D-12203 Berlin, Germany
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Rueping MJGT, Vehreschild JJ, Cornely OA. Invasive candidiasis and candidemia: from current opinions to future perspectives. Expert Opin Investig Drugs 2009; 18:735-48. [PMID: 19426121 DOI: 10.1517/13543780902911440] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Candida spp. are the fourth most common cause of nosocomial bloodstream infections in the United States, as well as the single most important cause of opportunistic fungal infections worldwide. A delayed diagnosis of invasive candidiasis and/or inadequate treatment choice is associated with high mortality rates and prolonged hospital stays. Even though the antifungal armamentarium has been broadened significantly over the last years, the best options for diagnosing and treating invasive candidiasis still remain a matter of discussion. In this article we present and analyze current evidence on the epidemiology, diagnostic methods and treatment options of invasive candidiasis, with a focus on results from randomized clinical trials. Finally, the reader is provided with a brief overview on promising clinical trial designs and antifungals that might shape the treatment of invasive candidiasis in the years to come.
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Affiliation(s)
- Maria J G T Rueping
- Clinical Trials Unit Infectious Diseases II and Clinical Trials Center Cologne, Kerpener Strasse 62, Koeln, Germany
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Maschmeyer G. The changing face of febrile neutropenia-from monotherapy to moulds to mucositis. Prevention of mould infections. J Antimicrob Chemother 2009; 63 Suppl 1:i27-30. [PMID: 19372178 DOI: 10.1093/jac/dkp084] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Isolation of patients at risk of invasive mould infection might be suitable for the reduction of invasive aspergillosis or zygomycosis, if combined with high-efficiency particulate air filtration. Prophylactic wearing of filtering masks of N95 or FFP2 standards has not yet been demonstrated to be efficacious in reducing invasive mould infections outside of scenarios with excessive contamination of room air by fungal spore-loaded dust. The oral broad-spectrum antifungal azoles posaconazole and voriconazole offer protection against invasive Aspergillus infections in severely neutropenic leukaemia patients and allogeneic haematopoietic stem cell transplant recipients; however, their routine use might result not only in considerable side effects, but also in the spread of multi-azole-resistant Aspergillus species, so that careful selection of suitable high-risk patient populations is mandatory.
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Affiliation(s)
- Georg Maschmeyer
- Department of Haematology and Oncology, Klinikum Ernst von Bergmann, Potsdam 14467, Germany.
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Harnicar S, Adel N, Jurcic J. Modification of vincristine dosing during concomitant azole therapy in adult acute lymphoblastic leukemia patients. J Oncol Pharm Pract 2009; 15:175-82. [PMID: 19282418 DOI: 10.1177/1078155208101959] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Vincristine is an important component in the treatment of acute lymphoblastic leukemia (ALL) and is now the backbone of therapy in the induction and consolidation phases of this disease. Proper dosing of vincristine is required to maximize disease control while avoiding toxicity. The gastrointestinal toxicity of vincristine such as decreased peristalsis can potentially be increased if the CYP 3A4 enzyme is inhibited. This interaction may become more prevalent with increasing use of CYP 3A4 inhibitors such as the azole antifungals. Since azoles are increasingly being used for prophylaxis and treatment of fungal infections in this patient population, an assessment of vincristine dosing and toxicity is the first step to constructing guidelines for the coadministration of these agents. METHODS ALL patients !18 years of age receiving vincristine-based therapy from August 2003 through December 2007 with or without azole therapy were included. Data was collected using electronic patient medical records and the pharmacy system (RxTFC). Information was entered into a database for this retrospective study. Patients were separated into two arms; vincristine with azoles and vincristine only. Patient demographic information, chemotherapy regimen, vincristine-induced symptoms, and concurrent strong CYP 3A4 inhibitors and inducers were collected. RESULTS A total of 50 patients received vincristine of which 29 (58%) had concurrent azole therapy. No patients received concurrent major CYP 3A4 inhibitors and the baseline characteristics were similar between groups. Vincristine dosing modifications were more common in the azole group (58.6 vs. 23.8%; p = 0.02). The mean dose reduction of vincristine when combined with an azole was 46.5%. Symptoms of decreased peristalsis were more common in patients receiving azoles (65.5 vs. 28.6%; p = 0.019) and on average occurred after the second vincristine dose. Symptoms occurred in 50, 75, and 66.6% of patients receiving fluconazole, voriconazole, and posaconazole, respectively. Patients were more likely to have an incomplete course of vincristine when receiving azole therapy (48.3 vs. 9.5%; p = 0.004). CONCLUSION Caution should be used with the coadministration of vincristine and azoles. It is recommended that institutional guidelines be developed to standardize care for patients receiving vincristine with azole therapy. Potential measures to avoid this interaction include revisiting azole prophylaxis in this patient group and being judicious in azole selection.
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Affiliation(s)
- Stephen Harnicar
- Department of Pharmacy, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Slobbe L, Boersma E, Rijnders BJ. Tolerability of prophylactic aerosolized liposomal amphotericin-B and impact on pulmonary function: Data from a randomized placebo-controlled trial. Pulm Pharmacol Ther 2008; 21:855-9. [DOI: 10.1016/j.pupt.2008.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 09/10/2008] [Accepted: 09/17/2008] [Indexed: 10/21/2022]
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Effect of liver and kidney function on migafungin disposition in patients with hematologic malignancies. Eur J Drug Metab Pharmacokinet 2008; 33:191-8. [DOI: 10.1007/bf03191118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rijnders B, Cornelissen J, Slobbe L, Becker M, Doorduijn J, Hop W, Ruijgrok E, Löwenberg B, Vulto A, Lugtenburg P, de Marie S. Aerosolized Liposomal Amphotericin B for the Prevention of Invasive Pulmonary Aspergillosis during Prolonged Neutropenia: A Randomized, Placebo‐Controlled Trial. Clin Infect Dis 2008; 46:1401-8. [DOI: 10.1086/586739] [Citation(s) in RCA: 199] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2008; 62:5-34. [PMID: 18445577 PMCID: PMC7110234 DOI: 10.1093/jac/dkn162] [Citation(s) in RCA: 236] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
These evidence-based guidelines have been produced after a systematic literature review of a range of issues involving prevention, diagnosis and treatment of hospital-acquired pneumonia (HAP). Prevention is structured into sections addressing general issues, equipment, patient procedures and the environment, whereas in treatment, the structure addresses the use of antimicrobials in prevention and treatment, adjunctive therapies and the application of clinical protocols. The sections dealing with diagnosis are presented against the clinical, radiological and microbiological diagnosis of HAP. Recommendations are also made upon the role of invasive sampling and quantitative microbiology of respiratory secretions in directing antibiotic therapy in HAP/ventilator-associated pneumonia.
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Maschmeyer G, Haas A. The epidemiology and treatment of infections in cancer patients. Int J Antimicrob Agents 2008; 31:193-7. [PMID: 17703922 DOI: 10.1016/j.ijantimicag.2007.06.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 06/13/2007] [Indexed: 11/20/2022]
Abstract
Significant changes in the epidemiology of infectious complications in cancer patients have emerged during the past decade. Among blood culture isolates from febrile neutropenic patients, Gram-positive pathogens have become predominant, and an increasing spread of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci must be taken into consideration. Risk factors such as indwelling venous catheters or chemotherapy-induced mucosal damage are associated with an increased incidence of Gram-positive infections. Invasive fungal infections, particularly invasive aspergillosis, have become most important in severely neutropenic patients and are associated with fatality rates of 40-60%. The use of nucleoside analogues and the CD52-antibody alemtuzumab induce a long-lasting lymphopenia facilitating the occurrence of opportunistic infections specifically caused by viruses and fungi. In elderly patients undergoing intensive myelosuppressive chemotherapy, infectious complications may be managed as successfully as in younger patients by appropriate antimicrobial therapy. The broad use of fluoroquinolones for antibacterial prophylaxis in neutropenic patients may lead to very high resistance rates among Gram-negative bacilli such as E. coli. In patients given moxifloxacin for infection prevention, unacceptably large numbers of Clostridium difficile-associated enterocolitis have been reported.
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Affiliation(s)
- Georg Maschmeyer
- Klinikum Ernst von Bergmann, Department of Hematology and Oncology, Charlottenstrasse 72, D-14467 Potsdam, Germany.
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Cornely OA, Böhme A, Reichert D, Reuter S, Maschmeyer G, Maertens J, Buchheidt D, Paluszewska M, Arenz D, Bethe U, Effelsberg J, Lövenich H, Sieniawski M, Haas A, Einsele H, Eimermacher H, Martino R, Silling G, Hahn M, Wacker S, Ullmann AJ, Karthaus M. Risk factors for breakthrough invasive fungal infection during secondary prophylaxis. J Antimicrob Chemother 2008; 61:939-46. [DOI: 10.1093/jac/dkn027] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Cordonnier C, Mohty M, Faucher C, Pautas C, Robin M, Vey N, Monchecourt F, Mahi L, Ribaud P. Safety of a weekly high dose of liposomal amphotericin B for prophylaxis of invasive fungal infection in immunocompromised patients: PROPHYSOME Study. Int J Antimicrob Agents 2008; 31:135-41. [DOI: 10.1016/j.ijantimicag.2007.10.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 09/25/2007] [Accepted: 10/01/2007] [Indexed: 11/30/2022]
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Will resistance in fungi emerge on a scale similar to that seen in bacteria? Eur J Clin Microbiol Infect Dis 2008; 27:327-34. [PMID: 18204870 DOI: 10.1007/s10096-007-0451-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Accepted: 12/18/2007] [Indexed: 01/26/2023]
Abstract
Growing numbers of patients receive azoles as prophylaxis or treatment for invasive fungal infections, begging the question of whether emergence of resistance will occur, as has been seen with bacteria. This review examines resistance pathways shared by bacteria and fungi, including alteration and overproduction of drug targets, changes in biosynthetic pathways, and enhanced drug efflux, and assesses whether such commonalities predict increased resistance to azoles. Important differences exist between the two kingdoms, including little, if any, horizontal transfer of extrachromosomal material across fungal species and a longer fungal generation time, thereby slowing vertical transfer of mutant traits. Further, no enzymatic modulation or inactivation of azoles has been reported in fungi. The newer broad-spectrum azoles posaconazole and voriconazole are active against the vast majority of yeasts and moulds and are likely to prevent the emergence of inherently resistant strains. Therefore, the likelihood for an explosion of fungal resistance is relatively low.
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Vehreschild JJ, Böhme A, Buchheidt D, Arenz D, Harnischmacher U, Heussel CP, Ullmann AJ, Mousset S, Hummel M, Frommolt P, Wassmer G, Drzisga I, Cornely OA. A double-blind trial on prophylactic voriconazole (VRC) or placebo during induction chemotherapy for acute myelogenous leukaemia (AML). J Infect 2007; 55:445-9. [PMID: 17822770 DOI: 10.1016/j.jinf.2007.07.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 07/06/2007] [Accepted: 07/10/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Invasive fungal infections remain a frequent cause of morbidity and mortality in long-term neutropenic patients. The availability of tolerable broad-spectrum antifungals like voriconazole stimulated the discussion about optimal timing of antifungal therapy. We conducted a trial to analyze the efficacy and safety of voriconazole in the prevention of lung infiltrates during induction chemotherapy for acute myelogenous leukaemia (AML). METHODS This was a prospective, randomised, double-blind, placebo-controlled phase III trial in AML patients undergoing remission induction chemotherapy. Oral voriconazole 200 mg twice daily or placebo was administered until detection of a lung infiltrate or end of neutropenia. Primary efficacy parameter was the incidence of lung infiltrates until day 21 after initiation of chemotherapy. Secondary objectives were incidence of infections, length of stay in hospital, time to antifungal treatment, time to first fever, and drug safety. RESULTS A total of 25 patients were randomly assigned to receive voriconazole (N=10) or placebo (N=15). Incidence of lung infiltrates until day 21 was 0 (0%) in the voriconazole and 5 (33%) in the placebo group (P=0.06). Average length of stay in hospital was shorter in the voriconazole group (mean 31.9 days) than in the placebo group (mean 37.3 days, P=0.09). Four patients were diagnosed with hepatosplenic candidiasis until a 4 week follow-up, all in the placebo group (P=0.11). Adverse events and toxicity did not differ between the two treatment groups. The trial was stopped prematurely when another trial demonstrated reduced mortality by antifungal prophylaxis with posaconazole, thus rendering further randomisation against placebo unethical. CONCLUSION In AML patients undergoing induction chemotherapy, prophylactic oral voriconazole 200 mg twice daily resulted in trends towards reduced incidences of lung infiltrates and hepatosplenic candidiasis. Voriconazole was safe and well tolerated.
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Affiliation(s)
- Jörg J Vehreschild
- Klinikum der Universität zu Köln, Klinik I für Innere Medizin, Studienzentrum Infektiologie II, 50937 Köln, Germany
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Maschmeyer G, Haas A, Cornely OA. Invasive aspergillosis: epidemiology, diagnosis and management in immunocompromised patients. Drugs 2007; 67:1567-601. [PMID: 17661528 DOI: 10.2165/00003495-200767110-00004] [Citation(s) in RCA: 279] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Morbidity and mortality caused by invasive Aspergillus infections are increasing. This is because of the higher number of patients with malignancies treated with intensive immunosuppressive therapy regimens as well as their improved survival from formerly fatal bacterial infections, and the rising number of patients undergoing allogeneic haematopoietic stem cell or organ transplantation. Early initiation of effective systemic antifungal treatment is essential for a successful clinical outcome in these patients; however, clinical clues for diagnosis are sparse and early microbiological proof of invasive aspergillosis (IA) is rare. Clinical diagnosis is based on pulmonary CT scan findings and non-culture based diagnostic techniques such as galactomannan or DNA detection in blood or bronchoalveolar lavage samples. Most promising outcomes can be expected in patients at high risk for aspergillosis in whom antifungal treatment has been started pre-emptively, backed up by laboratory and imaging findings. The gold standard of systemic antifungal treatment is voriconazole, which has been proven to be significantly superior to conventional amphotericin B and has led to a profound improvement of survival rates in patients with cerebral aspergillosis. Liposomal amphotericin B at standard dosages appears to be a suitable alternative for primary treatment, while caspofungin, amphotericin B lipid complex or posaconazole have shown partial or complete response in patients who had been refractory to or intolerant of primary antifungal therapy. Combination therapy with two antifungal compounds may be a promising future strategy for first-line treatment. Lung resection helps to prevent fatal haemorrhage in single patients with pulmonary lesions located in close proximity to larger blood vessels, but is primarily considered for reducing the risk of relapse during subsequent periods of severe immunosuppression. Strict reverse isolation appears to reduce the incidence of aspergillosis in allogeneic stem cell transplant recipients and patients with acute myeloid leukaemia undergoing aggressive anticancer therapy. Well designed, prospective randomised studies on infection control measures effective to prevent aspergillosis are lacking. Prophylactic systemic antifungal treatment with posaconazole significantly improves survival and reduces IA in acute myeloid leukaemia patients and reduces aspergillosis incidence rates in patients with intermediate-to-severe graft-versus-host reaction emerging after allogeneic haematopoietic stem cell transplantation. Voriconazole prophylaxis may be suitable for prevention of IA as well; however, the results of large clinical trials are still awaited.
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Affiliation(s)
- Georg Maschmeyer
- Department of Internal Medicine, Hematology and Oncology, Klinikum Ernst von Bergmann, Potsdam, Germany.
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Abstract
The four main classes of antifungal drugs are the polyenes, azoles, allylamines and echinocandins. Clinically useful "older" agents include topical azole formulations (for superficial yeast and dermatophyte infections), first-generation triazoles (fluconazole and itraconazole, for a range of superficial and invasive fungal infections), amphotericin B formulations (for a broad range of invasive fungal infections) and terbinafine (for dermatophyte infections). Clinically important "newer" agents include members of the echinocandin class (eg, caspofungin) and second-generation triazoles (eg, voriconazole and posaconazole). Voriconazole and posaconazole have broad-spectrum activity against yeasts and moulds, including Aspergillus species. Posaconazole is the only azole drug with activity against zygomycete fungi. Caspofungin and the other echinocandins are effective in treating Candida and Aspergillus infections. The azoles are relatively safe, but clinicians should be aware of drug-drug interactions and adverse effects, including visual disturbances (with voriconazole), elevations in liver transaminase levels, and skin rashes. Caspofungin has minimal adverse effects. Combination antifungal therapy may be appropriate in selected patients with invasive fungal infections, but is empiric and driven by individual physician practice.
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Affiliation(s)
- Sharon C A Chen
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia.
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