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Akinosoglou K, Rigopoulos EA, Papageorgiou D, Schinas G, Polyzou E, Dimopoulou E, Gogos C, Dimopoulos G. Amphotericin B in the Era of New Antifungals: Where Will It Stand? J Fungi (Basel) 2024; 10:278. [PMID: 38667949 PMCID: PMC11051097 DOI: 10.3390/jof10040278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
Amphotericin B (AmB) has long stood as a cornerstone in the treatment of invasive fungal infections (IFIs), especially among immunocompromised patients. However, the landscape of antifungal therapy is evolving. New antifungal agents, boasting novel mechanisms of action and better safety profiles, are entering the scene, presenting alternatives to AmB's traditional dominance. This shift, prompted by an increase in the incidence of IFIs, the growing demographic of immunocompromised individuals, and changing patterns of fungal resistance, underscores the continuous need for effective treatments. Despite these challenges, AmB's broad efficacy and low resistance rates maintain its essential status in antifungal therapy. Innovations in AmB formulations, such as lipid complexes and liposomal delivery systems, have significantly mitigated its notorious nephrotoxicity and infusion-related reactions, thereby enhancing its clinical utility. Moreover, AmB's efficacy in treating severe and rare fungal infections and its pivotal role as prophylaxis in high-risk settings highlight its value and ongoing relevance. This review examines AmB's standing amidst the ever-changing antifungal landscape, focusing on its enduring significance in current clinical practice and exploring its potential future therapeutic adaptations.
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Affiliation(s)
- Karolina Akinosoglou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Rio, Greece
| | | | - Despoina Papageorgiou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - Georgios Schinas
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - Eleni Polyzou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | | | - Charalambos Gogos
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - George Dimopoulos
- 3rd Department of Critical Care, Evgenidio Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
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2
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Agarwal R, Sehgal IS, Muthu V, Denning DW, Chakrabarti A, Soundappan K, Garg M, Rudramurthy SM, Dhooria S, Armstrong-James D, Asano K, Gangneux JP, Chotirmall SH, Salzer HJF, Chalmers JD, Godet C, Joest M, Page I, Nair P, Arjun P, Dhar R, Jat KR, Joe G, Krishnaswamy UM, Mathew JL, Maturu VN, Mohan A, Nath A, Patel D, Savio J, Saxena P, Soman R, Thangakunam B, Baxter CG, Bongomin F, Calhoun WJ, Cornely OA, Douglass JA, Kosmidis C, Meis JF, Moss R, Pasqualotto AC, Seidel D, Sprute R, Prasad KT, Aggarwal AN. Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses. Eur Respir J 2024; 63:2400061. [PMID: 38423624 PMCID: PMC10991853 DOI: 10.1183/13993003.00061-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics. METHODS An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively. RESULTS We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL-1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus-IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response. CONCLUSION We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Kathirvel Soundappan
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Darius Armstrong-James
- Faculty of Medicine, Department of Infectious Disease, Imperial College London, London, UK
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Jean-Pierre Gangneux
- Université Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail), UMR_S 1085, Rennes, France
- CHU Rennes, Laboratoire de Parasitologie-Mycologie, ECMM Excellence Center in Medical Mycology, Rennes, France
- National Reference Center on Mycoses and Antifungals (CNRMA LA-Asp C), Rennes, France
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University (NTU) and Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Helmut J F Salzer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine-Pneumology, Kepler University Hospital and Medical Faculty, Johannes Kepler University, Linz, Austria
| | | | - Cendrine Godet
- Université Paris Sorbonne, AP-HP, Hôpital Tenon, Service de Pneumologie et Oncologie Thoracique, Centre Constitutif Maladies Pulmonaires Rares Paris, Paris, France
| | | | - Iain Page
- NHS Lothian, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Parameswaran Nair
- McMaster University, McGill University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - P Arjun
- KIMS Hospital, Trivandrum, India
| | - Raja Dhar
- Department of Pulmonology, CK Birla Hospitals, Kolkata, India
| | - Kana Ram Jat
- Division of Pediatric Pulmonology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Joseph L Mathew
- Pediatric Pulmonology Division, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute, Lucknow, India
| | - Dharmesh Patel
- City Clinic and Bhailal Amin General Hospital, Vadodara, India
| | - Jayanthi Savio
- Department of Microbiology, St John's Medical College and Hospital, Bengaluru, India
| | - Puneet Saxena
- Pulmonary and Critical Care Medicine, Army Hospital (R&R), New Delhi, India
| | - Rajeev Soman
- Department of Infectious Diseases, Jupiter Hospital, Pune, India
| | | | - Caroline G Baxter
- Department of Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - William J Calhoun
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Oliver A Cornely
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Jo A Douglass
- University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | - Chris Kosmidis
- Division of Evolution, Infection and Genomics, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jacques F Meis
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
- Center of Expertise in Mycology Radboudumc/CWZ Nijmegen, Nijmegen, The Netherlands
| | - Richard Moss
- Center of Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Alessandro C Pasqualotto
- Molecular Biology Laboratory, Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Danila Seidel
- Department of Internal Medicine, University Hospital, Cologne, Germany
| | - Rosanne Sprute
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Excellence Center for Medical Mycology (ECMM), University of Cologne, Cologne, Germany
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Godet C, Brun AL, Couturaud F, Laurent F, Frat JP, Marchand-Adam S, Gagnadoux F, Blanchard E, Taillé C, Philippe B, Hirschi S, Andréjak C, Bourdin A, Chenivesse C, Dominique S, Mangiapan G, Murris-Espin M, Rivière F, Garcia G, Blanc FX, Goupil F, Bergeron A, Flament T, Priou P, Mal H, de Keizer J, Ragot S, Cadranel J. CT Imaging Assessment of Response to Treatment in Allergic Bronchopulmonary Aspergillosis in Adults With Bronchial Asthma. Chest 2024:S0012-3692(24)00261-7. [PMID: 38387646 DOI: 10.1016/j.chest.2024.02.026] [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: 11/18/2023] [Revised: 02/10/2024] [Accepted: 02/17/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND One of the major challenges in managing allergic bronchopulmonary aspergillosis remains consistent and reproducible assessment of response to treatment. RESEARCH QUESTION What are the most relevant changes in CT scan parameters over time for assessing response to treatment? STUDY DESIGN AND METHODS In this ancillary study of a randomized clinical trial (NebuLamB), patients with asthma with available CT scan and without exacerbation during a 4-month allergic bronchopulmonary aspergillosis exacerbation treatment period (corticosteroids and itraconazole) were included. Changed CT scan parameters were assessed by systematic analyses of CT scan findings at initiation and end of treatment. CT scans were assessed by two radiologists anonymized to the clinical data. Radiologic parameters were determined by selecting those showing significant changes over time. Improvement of at least one, without worsening of the others, defined the radiologic response. Agreement between radiologic changes and clinical and immunologic responses was likewise investigated. RESULTS Among the 139 originally randomized patients, 132 were included. We identified five CT scan parameters showing significant changes at end of treatment: mucoid impaction extent, mucoid impaction density, centrilobular micronodules, consolidation/ground-glass opacities, and bronchial wall thickening (P < .05). These changes were only weakly associated with one another, except for mucoid impaction extent and density. No agreement was observed between clinical, immunologic, and radiologic responses, assessed as an overall response, or considering each of the parameters (Cohen κ, -0.01 to 0.24). INTERPRETATION Changes in extent and density of mucoid impaction, centrilobular micronodules, consolidation/ground-glass opacities, and thickening of the bronchial walls were found to be the most relevant CT scan parameters to assess radiologic response to treatment. A clinical, immunologic, and radiologic multidimensional approach should be adopted to assess outcomes, probably with a composite definition of response to treatment. TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT02273661; URL: www. CLINICALTRIALS gov).
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Affiliation(s)
- Cendrine Godet
- Service de Pneumologie B et Transplantation pulmonaire, Université Paris Cité, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France.
| | | | - Francis Couturaud
- Université Brest, INSERM U1304-GETBO, CHU Brest, Département de Médecine Interne et Pneumologie, CIC INSERM 1412, CHU Brest, FCRIN INNOVTE, France; Département de Médecine Interne et Pneumologie, CHU Brest, France
| | - François Laurent
- Université Bordeaux, INSERM, CRCTB, U 1045, F-33000 Bordeaux, France
| | - Jean-Pierre Frat
- Médecine Intensive Réanimation, CHU Poitiers, Poitiers, France; Université Poitiers, INSERM, CIC 1402, IS-ALIVE, CHU Poitiers, Poitiers, France
| | - Sylvain Marchand-Adam
- Université François Rabelais, Tours, INSERM 1100, Tours, France; Service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France
| | - Frédéric Gagnadoux
- Service de Pneumologie et Allergologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Elodie Blanchard
- Service de Pneumologie, CHU Bordeaux site Haut Lévêque Pessac, France
| | - Camille Taillé
- Service de Pneumologie et Centre de Référence constitutif des Maladies Pulmonaires Rares, AP-HP Nord-Université Paris Cité, Hôpital Bichat, INSERM, UMR 1152, Paris, France
| | | | - Sandrine Hirschi
- Service de Pneumologie, Centre de Compétence des Maladies Pulmonaires Rares, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Claire Andréjak
- Service de Pneumologie, CHU Amiens Picardie, Amiens, France; Université Picardie Jules Verne, UR 4294, CHU Amiens Picardie, Amiens, France
| | - Arnaud Bourdin
- Université Montpellier, INSERM, CNRS, CHU Montpellier, PhyMed Exp, Montpellier, France
| | - Cécile Chenivesse
- Université Lille, CNRS, INSERM, CHU Lille, U1019 - UMR9017 - CIIL - Center for Infection and Immunity of Lille, F-5900 Lille, France; CRISALIS, F-CRIN Network, INSERM US015, Toulouse, France
| | | | | | - Marlène Murris-Espin
- Service de Pneumologie, CRCM adulte et Transplantation pulmonaire, Clinique des Voies Respiratoires, CHU de Toulouse, Hôpital Larrey, Toulouse, France
| | - Frédéric Rivière
- Service de Pneumologie, Centre Hospitalier Universitaire Côte de Nacre, Caen, France
| | - Gilles Garcia
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR-S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Assistance Publique - Hôpitaux de Paris, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - François-Xavier Blanc
- Nantes Université, CHU Nantes, INSERM, Service de Pneumologie, CIC 1413, l'institut du thorax, Nantes, France
| | | | - Anne Bergeron
- Division of Pulmonology, Geneva University Hospitals, Geneva, Switzerland
| | - Thomas Flament
- Service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France
| | - Pascaline Priou
- Service de Pneumologie et Allergologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Hervé Mal
- Service de Pneumologie B et Transplantation pulmonaire, Université Paris Cité, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Joe de Keizer
- Université Poitiers, INSERM, CIC-1402, Biostatistics, Poitiers, France, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France
| | - Stéphanie Ragot
- Université Poitiers, INSERM, CIC-1402, Biostatistics, Poitiers, France, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France
| | - Jacques Cadranel
- Service de Pneumologie et Oncologie Thoracique, Centre constitutif Maladies pulmonaires rares, Université Paris Sorbonne, Assistance Publique - Hôpitaux de Paris, Hôpital Tenon, Paris, France
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Agarwal R, Muthu V, Sehgal IS. Clinical Manifestation and Treatment of Allergic Bronchopulmonary Aspergillosis. Semin Respir Crit Care Med 2024; 45:114-127. [PMID: 38154470 DOI: 10.1055/s-0043-1776912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction to airway colonization by Aspergillus fumigatus in patients with asthma and cystic fibrosis. The pathophysiology of ABPA involves a complex interplay between the fungus and the host immune response, which causes persistent inflammation and tissue damage. Patients present with chronic cough, wheezing, and dyspnea due to uncontrolled asthma. Characteristic symptoms include the expectoration of brownish mucus plugs. Radiographic findings often reveal fleeting pulmonary infiltrates, bronchiectasis, and mucus impaction. However, the definitive diagnosis of ABPA requires a combination of clinical, radiological, and immunological findings. The management of ABPA aims to reduce symptoms, prevent disease progression, and minimize the future risk of exacerbations. The treatment approach involves systemic glucocorticoids or antifungal agents to suppress the inflammatory response or fungal growth and prevent exacerbations. Biological agents may be used in patients with severe disease or glucocorticoid dependence. This review provides an overview of the clinical manifestations and current treatment options for ABPA.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Arroyo-Urea EM, Lázaro-Díez M, Garmendia J, Herranz F, González-Paredes A. Lipid-based nanomedicines for the treatment of bacterial respiratory infections: current state and new perspectives. Nanomedicine (Lond) 2024; 19:325-343. [PMID: 38270350 DOI: 10.2217/nnm-2023-0243] [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] [Indexed: 01/26/2024] Open
Abstract
The global threat posed by antimicrobial resistance demands urgent action and the development of effective drugs. Lower respiratory tract infections remain the deadliest communicable disease worldwide, often challenging to treat due to the presence of bacteria that form recalcitrant biofilms. There is consensus that novel anti-infectives with reduced resistance compared with conventional antibiotics are needed, leading to extensive research on innovative antibacterial agents. This review explores the recent progress in lipid-based nanomedicines developed to counteract bacterial respiratory infections, especially those involving biofilm growth; focuses on improved drug bioavailability and targeting and highlights novel strategies to enhance treatment efficacy while emphasizing the importance of continued research in this dynamic field.
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Affiliation(s)
- Eva María Arroyo-Urea
- Instituto de Química Médica, Consejo Superior de Investigaciones Científicas (IQM-CSIC), C/ Juan de la Cierva, 3, 28006, Madrid, Spain
| | - María Lázaro-Díez
- Instituto de Agrobiotecnología, Consejo Superior de Investigaciones Científicas y Gobierno de Navarra (IdAB-CSIC), Av. de Pamplona, 123, 31192, Mutilva, Navarra, Spain
| | - Junkal Garmendia
- Instituto de Agrobiotecnología, Consejo Superior de Investigaciones Científicas y Gobierno de Navarra (IdAB-CSIC), Av. de Pamplona, 123, 31192, Mutilva, Navarra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Av. Monforte de Lemos, 3-5, 28029, Madrid, Spain
| | - Fernando Herranz
- Instituto de Química Médica, Consejo Superior de Investigaciones Científicas (IQM-CSIC), C/ Juan de la Cierva, 3, 28006, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Av. Monforte de Lemos, 3-5, 28029, Madrid, Spain
| | - Ana González-Paredes
- Instituto de Química Médica, Consejo Superior de Investigaciones Científicas (IQM-CSIC), C/ Juan de la Cierva, 3, 28006, Madrid, Spain
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Denning DW, Pfavayi LT. Poorly controlled asthma - Easy wins and future prospects for addressing fungal allergy. Allergol Int 2023; 72:493-506. [PMID: 37544851 DOI: 10.1016/j.alit.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 08/08/2023] Open
Abstract
Poorly controlled asthma is especially common in low resource countries. Aside from lack of access to, or poor technique with, inhaled beta-2 agonists and corticosteroids, the most problematic forms of asthma are frequently associated with both fungal allergy and exposure, especially in adults leading to more asthma exacerbations and worse asthma. The umbrella term 'fungal asthma' describes many disorders linked to fungal exposure and/or allergy to fungi. One fungal asthma endotype, ABPA, is usually marked by a very high IgE and its differential diagnosis is reviewed. Both ABPA and fungal bronchitis in bronchiectasis are marked by thick excess airway mucus production. Dermatophyte skin infection can worsen asthma and eradication of the skin infection improves asthma. Exposure to fungi in the workplace, home and schools, often in damp or water-damaged buildings worsens asthma, and remediation improves symptom control and reduces exacerbations. Antifungal therapy is beneficial for fungal asthma as demonstrated in nine of 13 randomised controlled studies, reducing symptoms, corticosteroid need and exacerbations while improving lung function. Other useful therapies include azithromycin and some biologics approved for the treatment of severe asthma. If all individuals with poorly controlled and severe asthma could be 'relieved' of their fungal allergy and infection through antifungal therapy without systemic corticosteroids, the health benefits would be enormous and relatively inexpensive, improving the long term health of over 20 million adults and many children. Antifungal therapy carries some toxicity, drug interactions and triazole resistance risks, and data are incomplete. Here we summarise what is known and what remains uncertain about this complex topic.
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Affiliation(s)
- David W Denning
- Manchester Fungal Infection Group, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK.
| | - Lorraine T Pfavayi
- Institute of Immunology & Infection Research, Ashworth Laboratories, School of Biological Sciences, University of Edinburgh, Edinburgh, UK
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7
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Agarwal R, Muthu V, Sehgal IS. Relationship between Aspergillus and asthma. Allergol Int 2023; 72:507-520. [PMID: 37633774 DOI: 10.1016/j.alit.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/28/2023] Open
Abstract
Fungal sensitization is highly prevalent in severe asthma. The relationship between fungus and asthma, especially Aspergillus fumigatus, has been the subject of extensive research. The ubiquitous presence of A. fumigatus, its thermotolerant nature, the respirable size of its conidia, and its ability to produce potent allergens are pivotal in worsening asthma control. Due to the diverse clinical manifestations of fungal asthma and the lack of specific biomarkers, its diagnosis remains intricate. Diagnosing fungal asthma requires carefully assessing the patient's clinical history, immunological tests, and imaging. Depending on the severity, patients with fungal asthma require personalized treatment plans, including inhaled corticosteroids and bronchodilators, and antifungal therapy. This review provides a comprehensive overview of the association between Aspergillus and asthma by reviewing the relevant literature and highlighting key findings. We discuss the diagnosis of various entities included in fungal asthma. We also debate whether newer definitions, including allergic fungal airway disease, offer any additional advantages over the existing ones. Finally, we provide the current treatment options for the individual entities, including A. fumigatus-associated asthma, severe asthma with fungal sensitization, and allergic bronchopulmonary mycoses.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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8
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Roboubi A, Audousset C, Fréalle É, Brun AL, Laurent F, Vitte J, Mortuaire G, Lefevre G, Cadranel J, Chenivesse C. Allergic bronchopulmonary aspergillosis: A multidisciplinary review. J Mycol Med 2023; 33:101392. [PMID: 37172543 DOI: 10.1016/j.mycmed.2023.101392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a rare disease characterized by a complex allergic inflammatory reaction of airways against Aspergillus affecting patients with chronic respiratory diseases (asthma, cystic fibrosis). Exacerbation is often the way to diagnose ABPA and marks its evolution by its recurrent character leading to cortico-requirement or long-term antifungal treatment. Early diagnosis allows treatment of ABPA at an initial stage, preventing recurrence of exacerbations and long-term complications, mainly represented by bronchiectasis. This review of the literature aims to present the current state of the art in terms of diagnosis and treatment of ABPA from a multidisciplinary perspective. As there is no clinical, biological nor radiological specific sign, diagnostic criteria are regularly revised. They are mainly based on the elevation of total and specific IgE against Aspergillus fumigatus and the presence of suggestive CT abnormalities such as mucoid impaction and consolidations. ABPA management includes eviction of mold and pharmacological therapy. Exacerbations are treated in first line with a moderate dose of oral corticosteroids. Azole antifungal agents represent an alternative for the treatment of exacerbations and are the preferential strategy to reduce the future risk of exacerbations and for corticosteroids sparing. Asthma biologics may be of interest; however, their place remains to be determined. Avoiding complications of ABPA while limiting the side effects of systemic drugs remains a major challenge of ABPA management. Several drugs, including new antifungals and asthma biologics, are currently being tested and may be useful in the future.
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Affiliation(s)
| | - Camille Audousset
- CHU Lille, Univ. Lille, CNRS, Inserm, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Lille, France
| | - Émilie Fréalle
- CHU Lille, Laboratoire de Parasitologie-Mycologie, Univ. Lille, ULR 4515-LGCgE, Laboratoire de Génie Civil et Géo-Environnement, Lille F-59000, France
| | - Anne-Laure Brun
- Hôpital Foch, Service de radiologie diagnostique et interventionnelle, Suresnes, France
| | - François Laurent
- Université de Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, INSERM U1045, CIC1401, CHU de Bordeaux, Pessac, France
| | - Joana Vitte
- Aix-Marseille Univ, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; Desbrest Institute of Epidemiology and Public Health IDESP, Univ Montpellier, INSERM UA 11, Montpellier, France
| | - Geoffrey Mortuaire
- CHU de Lille, Service d'ORL et de chirurgie cervico-faciale, Lille 59000, France; Université de Lille, Inserm, CHU de Lille, U1286, INFINITE-Institute for translational research in inflammation, Lille 59000, France
| | - Guillaume Lefevre
- Univ Lille, U1286 INFINITE - Lille Inflammation Research International Center, CHU Lille, Lille, France
| | - Jacques Cadranel
- Sorbonne Université, APHP-Hopital Tenon, GRC04 Theranoscan Sorbonne Université, Paris, France
| | - Cécile Chenivesse
- Univ. Lille, CHU Lille, CNRS, Inserm, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Lille, France; CRISALIS (Clinical Research Initiative in Severe Asthma: a Lever for Innovation & Science), F-CRIN Network, INSERM US015, Toulouse, France.
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Muthu V, Dhooria S, Sehgal IS, Prasad KT, Rudramurthy SM, Aggarwal AN, Chakrabarti A, Agarwal R. Nebulized amphotericin B for preventing exacerbations in allergic bronchopulmonary aspergillosis: A systematic review and meta-analysis. Pulm Pharmacol Ther 2023; 81:102226. [PMID: 37230237 DOI: 10.1016/j.pupt.2023.102226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 02/09/2023] [Accepted: 05/22/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Allergic bronchopulmonary aspergillosis (ABPA) is complicated by exacerbations in more than one-third of the subjects. Whether nebulized amphotericin B (NAB) therapy prevents ABPA exacerbations remains unclear. OBJECTIVES The primary objective of this systematic review and meta-analysis was to determine the frequency of subjects remaining exacerbation-free, one year after initiating NAB. The key secondary objectives were the time to first exacerbation and the safety of NAB therapy. METHODS We searched the PubMed and Embase databases for studies evaluating ≥5 subjects of ABPA managed with NAB. We report the pooled proportion of ABPA subjects remaining exacerbation free after one year. For the randomized controlled trials (RCTs), we estimate the pooled risk difference (RD) of exacerbation-free status at one year with NAB versus the control arm. RESULTS We included five studies for our analysis; three were observational (n = 28) and two RCTs (n = 160). The pooled proportion (95% confidence interval [CI]) of subjects remaining exacerbation free with NAB at one year was 76% (62-88). The pooled RD (95% CI) of an exacerbation-free status at one year was 0.33 (-0.12 to 0.78) and was not significantly different between the NAB and control arms. The time to first exacerbation was longer with NAB than with the standard therapy. No serious adverse events were reported with NAB. CONCLUSION NAB does not improve exacerbation-free status at one year; however, weak evidence suggests it delays ABPA exacerbations. More research using different dosing regimens is required.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Pulmonary Medicine, Doodhadhari Burfani Hospital, Haridwar, Uttarakhand, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Muthu V, Gogineni RR, Agarwal R, Prasad KT, Sehgal IS, Dhooria S, Aggarwal AN, Rudramurthy SM, Singh H, Garg M, Chakrabarti A. Treatment of pulmonary mucormycosis with adjunctive nebulized amphotericin B (MUCONAB trial): Results of an open-label randomized controlled trial. Mycoses 2023. [PMID: 37095064 DOI: 10.1111/myc.13591] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The role of nebulized amphotericin B (NAB) in managing pulmonary mucormycosis (PM) is unknown. METHODS In this open-label trial, we randomized PM subjects to receive either intravenous liposomal amphotericin B (control arm, 3-5 mg/kg/day) alone or along with nebulized amphotericin B deoxycholate (NAB, 10 mg twice a day, every alternate day). The primary outcomes were: (1) overall response ('success' [complete or partial response] or 'failure' [stable disease, progressive disease, or death]) at 6 weeks; and (2) the proportion of subjects with adverse events (AE). The key secondary outcome was 90-day mortality. We performed a modified intention-to-treat (mITT) analysis where we included only subjects receiving at least a single dose of NAB. RESULTS Fifteen and 17 subjects were randomized to the control and NAB arms; two died before the first dose of NAB. Finally, we included 30 subjects (15 in each arm; mean age 49.8 years; 80% men) for the mITT analysis. Diabetes mellitus (n = 27; 16/27 were COVID-19-associated PM) was the most common predisposing factor. The overall treatment success was not significantly different between the control and the NAB arms (71.4% vs. 53.3%; p = .45). Twenty-nine subjects experienced any AE, but none discontinued treatment. The 90-day mortality was not significantly different between the control (28.6%) and NAB arm (53.3%; p = .26). CONCLUSION Adjunctive NAB was safe but did not improve overall response at 6 weeks. A different dosing schedule or nebulized liposomal amphotericin B may still need evaluation. More research is needed to explore other treatment options for PM.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ratnakara Rao Gogineni
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Harkant Singh
- Department of Cardiovascular and thoracic surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Tackling the cytokine storm using advanced drug delivery in allergic airway disease. J Drug Deliv Sci Technol 2023. [DOI: 10.1016/j.jddst.2023.104366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
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12
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Moss RB. Severe Fungal Asthma: A Role for Biologics and Inhaled Antifungals. J Fungi (Basel) 2023; 9:jof9010085. [PMID: 36675906 PMCID: PMC9861760 DOI: 10.3390/jof9010085] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Allergic asthma has traditionally been treated with inhaled and systemic glucocorticosteroids. A continuum of allergic fungal airways disease associated with Aspergillus fumigatus colonization and/or atopic immune responses that encompasses fungal asthma, severe asthma with fungal sensitization and allergic bronchopulmonary aspergillosis is now recognized along a phenotypic severity spectrum of T2-high immune deviation lung disease. Oral triazoles have shown clinical, anti-inflammatory and microbiologic efficacy in this setting; in the future inhaled antifungals may improve the therapeutic index. Humanized monoclonal antibody biologic agents targeting T2-high disease also show efficacy and promise of improved control in difficult cases. Developments in these areas are highlighted in this overview.
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Affiliation(s)
- Richard B Moss
- Center of Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University School of Medicine, 770 Welch Road, Suite 350, Palo Alto, CA 94304, USA
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13
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Aspergillose: Vernebeltes liposomales Amphotericin-B zur Erhaltungstherapie? Pneumologie 2023. [DOI: 10.1055/a-1947-3950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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14
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Gangneux JP, Godet C, Denning DW. Allergic diseases and fungal exposome: Prevention is better than cure. Allergy 2022; 77:3182-3184. [PMID: 35822920 DOI: 10.1111/all.15436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/05/2022] [Accepted: 07/09/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Jean-Pierre Gangneux
- Univ Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Cendrine Godet
- Service de Pneumologie, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - David W Denning
- Manchester Fungal Infection Group, Core Technology Facility, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Sehgal IS, Dhooria S, Prasad KT, Muthu V, Aggarwal AN, Agarwal R. Comparative diagnostic accuracy of immunoprecipitation versus immunoassay methods for detecting A.fumigatus-specific IgG in allergic bronchopulmonary aspergillosis: a systematic review and meta-analysis. Mycoses 2022; 65:866-876. [PMID: 35757847 DOI: 10.1111/myc.13488] [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: 05/13/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The diagnostic accuracy of immunoassays versus immunoprecipitation methods for detecting A.fumigatus-specific IgG in patients with allergic bronchopulmonary aspergillosis (ABPA) complicating asthma remains unclear. METHODS We performed a systematic review to identify studies describing both the methods in the same ABPA subjects. We assessed study quality using the QUADAS-2 tool. We derived the relative sensitivity and specificity using the HSROC meta-regression model. We calculated the number-needed-to-test using an immunoassay to detect one additional positive test in ABPA. RESULTS Our search yielded 20 studies (796 ABPA, 929 controls). The studies had a high risk of bias. The summary estimates for sensitivity and specificity of immunoprecipitation methods were 68.6% (95% CI, 48.4-83.5) and 93.8% (95% CI, 83.6-97.8), while for immunoassays they were 85.2% (95% CI, 73.3-92.3) and 84.6% (95% CI, 76.0-90.5), respectively. The relative sensitivity and specificity of immunoassays compared to immunoprecipitation tests were 1.29 (95% CI, 1.1-1.6) and 0.91 (95% CI, 0.85-0.97), respectively. The automated immunoassays (1.77; 95% CI, 1.1-2.8) had better relative sensitivity than the manual (1.1; 95% CI, 1.02-1.18) assays compared to immunoprecipitation. The relative specificity of manual immunoassays (0.95; 95% CI, 0.91-0.99) was significantly lower, while that of automated (0.88; 95% CI, 0.77-1.0) assays was lower but not statistically different. One additional positive result was detected for every 6 (95% CI, 5-7) tests performed with immunoassay (versus immunoprecipitation). CONCLUSION Manual immunoassays have higher sensitivity and lower specificity, while automated immunoassays have higher sensitivity and similar specificity than immunoprecipitation methods for detecting A.fumigatus-IgG in patients with ABPA.
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Affiliation(s)
- Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Drew RH, Perfect JR. Conventional Antifungals for Invasive Infections Delivered by Unconventional Methods; Aerosols, Irrigants, Directed Injections and Impregnated Cement. J Fungi (Basel) 2022; 8:jof8020212. [PMID: 35205966 PMCID: PMC8879564 DOI: 10.3390/jof8020212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 12/10/2022] Open
Abstract
The administration of approved antifungals via unapproved formulations or administration routes (such as aerosol, direct injection, irrigation, topical formulation and antifungal-impregnated orthopedic beads or cement) may be resorted to in an attempt to optimize drug exposure while minimizing toxicities and/or drug interactions associated with conventional (systemic) administrations. Existing data regarding such administrations are mostly restricted to uncontrolled case reports of patients with diseases refractory to conventional therapies. Attribution of efficacy and tolerability is most often problematic. This review updates prior published summaries, reflecting the most recent data and its application by available prevention and treatment guidelines for invasive fungal infections. Of the various dosage forms and antifungals, perhaps none is more widely reported than the application of amphotericin B-containing aerosols for the prevention of invasive mold infections (notably Aspergillus spp.).
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Affiliation(s)
- Richard H. Drew
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC 27710, USA;
- College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA
- Correspondence: ; Tel.: +1-(919)681-6793; Fax: +1-(919)681-7494
| | - John R. Perfect
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC 27710, USA;
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