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Otero-Romero S, Sánchez-Montalvá A, Vidal-Jordana A. Assessing and mitigating risk of infection in patients with multiple sclerosis on disease modifying treatment. Expert Rev Clin Immunol 2021; 17:285-300. [PMID: 33543657 DOI: 10.1080/1744666x.2021.1886924] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: The important development that the multiple sclerosis (MS) treatment field has experienced in the last years comes along with the need of dealing with new adverse events such as the increase risk of infections. In the shared therapeutic decision-making process, the MS expert neurologist should also balance the risks of specific infections under each particular treatment and be familiar with new mitigation strategies.Areas covered: In this review, the authors provide an up-to-date review of the infection risk associated with MS treatments with a specific focus on risk mitigating strategies. The search was conducted using Pubmed® database (2000 - present) to identify publications that reported infection rates and infection complications for each treatment (interferon beta, glatiramer acetate, teriflunomide, dimethyl fumarate, fingolimod, cladribine, natalizumab, alemtuzumab, rituximab, and ocrelizumab).Expert opinion: Since the emergence of the first natalizumab-related PML case, the arrival of new MS therapies has come hand in hand with new infectious complications. MS-specialist neurologist has to face new challenges regarding the management of immunosuppression-related infectious complications. The implementation of patient-centered management focus on preventive and mitigating strategies with a multidisciplinary approach should be seen in the future as a marker of excellence of MS management.
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Affiliation(s)
- Susana Otero-Romero
- Department of Preventive Medicine and Epidemiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Department of Infectious Diseases. Hospital Universitari Vall d'Hebron, International Health Program Catalan Institute of Health (PROSICS), Universitat Autònoma De Barcelona, Barcelona, Spain.,Micobacteria Infections Study Group (GEIM) of the Spanish Society of Infectious Diseases (SEIMC), Spain
| | - Angela Vidal-Jordana
- Department of Neurology-Neuroimmunology and Multiple Sclerosis Centre of Catalonia (Cemcat). Hospital Universitari Vall d'Hebron, Universitat Autònoma De Barcelona, Barcelona, Spain
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Zhao H, Zhou M, Zheng Q, Zhu M, Yang Z, Hu C, Xu L. Clinical features and Outcomes of Cryptococcemia patients with and without HIV infection. Mycoses 2021; 64:656-667. [PMID: 33609302 DOI: 10.1111/myc.13261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effects of cryptococcemia on patient outcomes in those with or without HIV remain unclear. METHODS One hundred and seventy-nine cryptococcemia patients were enrolled in this retrospective study. Demographic characteristics, blood test results and outcome were compared between the two groups. RESULTS The diagnosis time of Cryptococcus infection was 2.0(0-6.0) days for HIV-infected patients, 5.0 (1.5-8.0) days for HIV-uninfected patients (p = .008), 2.0 (1.0-6.0) days for cryptococcal meningitis (CM) patients and 6.0 (5.0-8.0) days for non-CM patients (p < .001). HIV infection [adjusted odds ratio (AOR) (95% confidence interval): 6.0(2.3-15.9)], CRP < 15 mg/L [AOR:3.7(1.7-8.1)) and haemoglobin > 110 g/L [AOR:2.5(1.2-5.4)] were risk factors for CM development. Forty-six (25.7%) patients died within 90 days. ICU stay [AOR:2.8(1.1-7.1)], hypoalbuminemia [AOR:2.7(1.4-5.3)], no anti-cryptococcal treatment [AOR:4.7(1.9-11.7)] and altered consciousness [AOR:2.4(1.0-5.5)] were independent risk factors for 90-day mortality in all patients. HIV infection did not increase the 90-day mortality of cryptococcemia patients when anti-Cryptococcus treatment was available. Non-Amphotericin B treatment [AOR:3.4(1.0-11.2)] was associated with 90-day mortality in HIV-infected patients, but age ≥ 50.0 years old [AOR:2.7(1.0-2.9)], predisposing disease [AOR:4.1(1.2-14.2)] and altered consciousness [AOR:3.7(1.1-12.9)] were associated with 90-day mortality in HIV-uninfected patients who accepted anti-Cryptococcus treatment. CONCLUSION HIV infection increased the incidence of CM rather than mortality in cryptococcemia patients. The predictive model was completely divergent in HIV-infected and HIV-uninfected patients, suggesting that novel strategies for diagnosis and treatment algorithms are urgently needed.
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Affiliation(s)
- Handan Zhao
- National Clinical Research Center for Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,College of Medicine, Zhejiang University, Hangzhou, China
| | - Minghan Zhou
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Qing Zheng
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Mingjian Zhu
- National Clinical Research Center for Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,College of Medicine, Zhejiang University, Hangzhou, China
| | - Zongxing Yang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou, China
| | - Caiqin Hu
- National Clinical Research Center for Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,College of Medicine, Zhejiang University, Hangzhou, China
| | - Lijun Xu
- National Clinical Research Center for Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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3
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Peri AM, Rossio R, Tafuri F, Benzecry V, Grancini A, Reda G, Bandera A, Peyvandi F. Atypical primary cutaneous cryptococcosis during ibrutinib therapy for chronic lymphocytic leukemia. Ann Hematol 2019; 98:2847-2849. [PMID: 31741032 DOI: 10.1007/s00277-019-03837-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/28/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Anna Maria Peri
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Via Francesco Sforza 32, Milan, Italy.
| | - Raffaella Rossio
- UOC Medicina Generale - Emostasi e Trombosi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Tafuri
- UOC Medicina Generale - Emostasi e Trombosi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Benzecry
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Anna Grancini
- Medical Laboratory of Clinical Chemistry and Microbiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Reda
- Hematology Department, Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Via Francesco Sforza 32, Milan, Italy.,Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Flora Peyvandi
- UOC Medicina Generale - Emostasi e Trombosi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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Abstract
Invasive fungal infections (IFI) are an emerging problem worldwide with invasive candidiasis and candidemia responsible for the majority of cases. This is predominantly driven by the widespread adoption of aggressive immunosuppressive therapy among certain patient populations (e.g., chemotherapy, transplants) and the increasing use of invasive devices such as central venous catheters (CVCs). The use of new immune modifying drugs has also opened up an entirely new spectrum of patients at risk of IFIs. While the epidemiology of candida infections has changed in the last decade, with a gradual shift from C. albicans to non-albicans candida (NAC) strains which may be less susceptible to azoles, these changes vary between hospitals and regions depending on the type of population risk factors and antifungal use. In certain parts of the world, the incidence of IFI is strongly linked to the prevalence of other disease conditions and the ecological niche for the organism; for instance cryptococcal and pneumocystis infections are particularly common in areas with a high prevalence of HIV disease. Poorly controlled diabetes is a major risk factor for invasive mould infections. Environmental factors and trauma also play a unique role in the epidemiology of mould infections, with well-described hospital outbreaks linked to the use of contaminated instruments and devices. Blastomycosis is associated with occupational exposure (e.g., forest rangers) and recreational activities (e.g., camping and fishing).The true burden of IFI is probably an underestimate because of the absence of reliable diagnostics and lack of universal application. For example, the sensitivity of most blood culture systems for detecting candida is typically 50 %. The advent of new technology including molecular techniques such as 18S ribosomal RNA PCR and genome sequencing is leading to an improved understanding of the epidemiology of the less common mould and dimorphic fungal infections. Molecular techniques are also providing a platform for improved diagnosis and management of IFI.Many factors affect mortality in IFI, not least the underlying medical condition, choice of therapy, and the ability to achieve early source control. For instance, mortality due to pneumocystis pneumonia in HIV-seronegative individuals is now higher than in seropositive patients. Of significant concern is the progressive increase in resistance to azoles and echinocandins among candida isolates, which appears to worsen the already significant mortality associated with invasive candidiasis. Mortality with mould infections approaches 50 % in most studies and varies depending on the site, underlying disease and the use of antifungal agents such as echinocandins and voriconazole. Nevertheless, mortality for most IFIs has generally fallen with advances in medical technology, improved care of CVCs, improved diagnostics, and more effective preemptive therapy and prophylaxis.
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Affiliation(s)
- David A Enoch
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK.
| | - Huina Yang
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
| | - Sani H Aliyu
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
| | - Christianne Micallef
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
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Schmalzle SA, Buchwald UK, Gilliam BL, Riedel DJ. Cryptococcus neoformans infection in malignancy. Mycoses 2016; 59:542-52. [PMID: 26932366 DOI: 10.1111/myc.12496] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/10/2016] [Accepted: 02/04/2016] [Indexed: 12/25/2022]
Abstract
Cryptococcosis is an opportunistic invasive fungal infection that is well described and easily recognised when it occurs as meningitis in HIV-infected persons. Malignancy and its treatment may also confer a higher risk of infection with Cryptococcus neoformans, but this association has not been as well described. A case of cryptococcosis in a cancer patient is presented, and all cases of coincident C. neoformans infection and malignancy in adults published in the literature in English between 1970 and 2014 are reviewed. Data from these cases were aggregated in order to describe the demographics, type of malignancy, site of infection, clinical manifestations, treatment and outcomes of cryptococcosis in patients with cancer. Haematologic malignancies accounted for 82% of cases, with lymphomas over-represented compared to US population data (66% vs. 53% respectively). Cryptococcosis was reported rarely in patients with solid tumours. Haematologic malignancy patients were more likely to have central nervous system (P < 0.001) or disseminated disease (P < 0.001), receive Amphotericin B as part of initial therapy (P = 0.023), and had higher reported mortality rates than those with solid tumours (P = 0.222). Providers should have heightened awareness of the possibility of cryptococcosis in patients with haematologic malignancy presenting with infection.
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Affiliation(s)
- Sarah A Schmalzle
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - Ulrike K Buchwald
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - Bruce L Gilliam
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - David J Riedel
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
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Mousset S, Buchheidt D, Heinz W, Ruhnke M, Cornely OA, Egerer G, Krüger W, Link H, Neumann S, Ostermann H, Panse J, Penack O, Rieger C, Schmidt-Hieber M, Silling G, Südhoff T, Ullmann AJ, Wolf HH, Maschmeyer G, Böhme A. Treatment of invasive fungal infections in cancer patients-updated recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 2013; 93:13-32. [PMID: 24026426 PMCID: PMC3889633 DOI: 10.1007/s00277-013-1867-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 07/29/2013] [Indexed: 11/28/2022]
Abstract
The Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) here presents its updated recommendations for the treatment of documented fungal infections. Invasive fungal infections are a main cause of morbidity and mortality in cancer patients undergoing intensive chemotherapy regimens. In recent years, new antifungal agents have been licensed, and agents already approved have been studied in new indications. The choice of the most appropriate antifungal treatment depends on the fungal species suspected or identified, the patient's risk factors (e.g., length and depth of neutropenia), and the expected side effects. This guideline reviews the clinical studies that served as a basis for the following recommendations. All recommendations including the levels of evidence are summarized in tables to give the reader rapid access to the information.
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Affiliation(s)
- Sabine Mousset
- Interdisziplinäres Zentrum für Palliativmedizin, Agaplesion Markus Krankenhaus, Wilhelm Epstein-Straße 4, 60431, Frankfurt, Germany,
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Affiliation(s)
- Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.
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Abstract
Outcomes of fungal infections in immunocompromised individuals depend on a complex interplay between host and pathogen factors, as well as treatment modalities. Problems occur when host responses to an infection are either too weak to effectively help eradicate the pathogen, or when they become too strong and are associated with host damage rather than protection. Immune reconstitution syndrome (IRS) can be generally defined as a restoration of host immunity in a previously immunosuppressed patient that becomes dysregulated and overly robust, resulting in host damage and sometimes death. IRS associated with opportunistic mycoses presents as new or worsening clinical symptoms or radiographic signs consistent with an inflammatory process that occur during receipt of an appropriate antifungal, and that cannot be explained by a newly acquired infection. Because there are currently no established tests or biomarkers for IRS, it can be difficult to distinguish from progression of the original infection, although culture and biomarkers for the fungal pathogen or infection are typically negative during diagnostic workup. IRS was originally characterized in human immunodeficiency virus-infected patients receiving antiretroviral therapy, but has subsequently been described in solid-organ transplant recipients, neutropenic patients, women in the postpartum period, and recipients of tumor necrosis factor-α inhibitor therapy. In each of these cases, recovery of the host's immunity during treatment of an initial infection results in a powerful proinflammatory environment that overshoots and leads to host damage. Optimal management of IRS has not been established at present, but often involves treatment with a corticosteroid or other anti-inflammatory compounds. This article uses a number of patient cases to explore the intricacies of diagnosing and managing a patient with IRS, as well as the other extreme, namely patients who are so immunocompromised without immune recovery that they essentially become breeding grounds for a wide range of opportunistic pathogens, often simultaneously.
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Affiliation(s)
- John R Perfect
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Mlinarić-Missoni E, Hagen F, Chew WHM, Važić-Babić V, Boekhout T, Begovac J. In vitro antifungal susceptibilities and molecular typing of sequentially isolated clinical Cryptococcus neoformans strains from Croatia. J Med Microbiol 2011; 60:1487-1495. [DOI: 10.1099/jmm.0.031344-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Emilija Mlinarić-Missoni
- Croatian National Institute of Public Health, Reference Centre for Diagnostics of Systemic Mycoses, Zagreb, Croatia
| | - Ferry Hagen
- Department of Internal Medicine and Infectious Diseases, University Medical Center, Utrecht, The Netherlands
- CBS Fungal Biodiversity Centre, Department of Yeast and Basidiomycete Research, Utrecht, The Netherlands
| | | | - Verica Važić-Babić
- Croatian National Institute of Public Health, Reference Centre for Diagnostics of Systemic Mycoses, Zagreb, Croatia
| | - Teun Boekhout
- Department of Internal Medicine and Infectious Diseases, University Medical Center, Utrecht, The Netherlands
- CBS Fungal Biodiversity Centre, Department of Yeast and Basidiomycete Research, Utrecht, The Netherlands
| | - Josip Begovac
- Department of Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
- University Hospital for Infectious Diseases, Zagreb, Croatia
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Badoux XC, Keating MJ, Wang X, O'Brien SM, Ferrajoli A, Faderl S, Burger J, Koller C, Lerner S, Kantarjian H, Wierda WG. Cyclophosphamide, fludarabine, alemtuzumab, and rituximab as salvage therapy for heavily pretreated patients with chronic lymphocytic leukemia. Blood 2011; 118:2085-93. [PMID: 21670470 DOI: 10.1182/blood-2011-03-341032] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Patients with relapsed chronic lymphocytic leukemia (CLL) and high-risk features, such as fludarabine refractoriness, complex karyotype, or abnormalities of chromosome 17p, experience poor outcomes after standard fludaradine-based regimens. Alemtuzumab is a chimeric CD52 monoclonal antibody with activity in CLL patients with fludarabine-refractory disease and 17p deletion. We report the outcome for 80 relapsed or refractory patients with CLL enrolled in a phase 2 study of cyclophosphamide, fludarabine, alemtuzumab, and rituximab (CFAR). All patients were assessed for response and progression according to the 1996 CLL-working group criteria. For the intention-to-treat analysis, the overall response rate was 65%, including 29% complete response. The estimated progression-free survival was 10.6 months and median overall survival was 16.7 months. Although we noted higher complete response in high-risk patients after CFAR compared with a similar population who had received fludarabine, cyclophosphamide, and rituximab as salvage therapy, there was no significant improvement in progression-free survival and overall survival appeared worse. CFAR was associated with a high rate of infectious complications with 37 patients (46%) experiencing a serious infection during therapy and 28% of evaluable patients experiencing late serious infections. Although CFAR produced good response rates in this highly pretreated high-risk group of patients, there was no benefit in survival outcomes.
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Current awareness: Pharmacoepidemiology and drug safety: Current Awareness. Pharmacoepidemiol Drug Saf 2009; 18:i-xvi. [DOI: 10.1002/pds.1655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Cryptococcus neoformans is an opportunistic fungal pathogen that causes central nervous system and pulmonary disease among immunocompromised patients. Recent studies highlight the high incidence of cryptococcosis among patients in certain resource-poor areas, where there is also a high incidence of AIDS. Despite the availability of antifungal agents with anticryptococcal activity, the mortality and treatment-failure rates associated with cryptococcosis remain unacceptably high. This article reviews current treatment strategies and the basis for these strategies, as well as prospects for future approaches to the treatment of cryptococcosis.
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Affiliation(s)
- Michele Ritter
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10461, USA
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