Neosartorya udagawae pulmonary infection requiring a surgical treatment in a paediatric haematopoietic progenitor cell recipient

Neosartorya udagawae is a known cause of fungal infection in humans and animals. It is found to be more refractory to antifungal treatment in comparison to other Aspergillus species. With this report we present a case of proven invasive infection with Neosartorya udagawae in a child with chronic myeloid leukaemia after haematopoietic stem cell transplant. The patient received several lines of antifungal therapy including dual therapy appropriate to the antifungal susceptibility profile with progression of the invasive fungal disease requiring left lung upper lobe lobectomy. The case emphasizes the importance of early biopsy with antifungal susceptibility testing for targeted therapy and demonstrates the potential requirement for surgical management in addition to appropriate antifungal treatment.

Neonatal invasive candidiasis in low- and middle-income countries: Data from the NeoOBS study

Neonatal invasive candidiasis (NIC) has significant morbidity and mortality. Reports have shown a different profile of those neonates affected with NIC and of fluconazole-resistant Candida spp. isolates in low- and middle-income countries (LMICs) compared to high-income countries (HICs). We describe the epidemiology, Candida spp. distribution, treatment, and outcomes of neonates with NIC from LMICs enrolled in a global, prospective, longitudinal, observational cohort study (NeoOBS) of hospitalized infants <60 days postnatal age with sepsis (August 2018-February 2021). A total of 127 neonates from 14 hospitals in 8 countries with Candida spp. isolated from blood culture were included. Median gestational age of affected neonates was 30 weeks (IQR: 28-34), and median birth weight was 1270 gr (interquartile range [IQR]: 990-1692). Only a minority had high-risk criteria, such as being born <28 weeks, 19% (24/127), or birth weight <1000 gr, 27% (34/127). The most common Candida species were C. albicans (n = 45, 35%), C. parapsilosis (n = 38, 30%), and Candida auris (n = 18, 14%). The majority of C. albicans isolates were fluconazole susceptible, whereas 59% of C. parapsilosis isolates were fluconazole-resistant. Amphotericin B was the most common antifungal used [74% (78/105)], followed by fluconazole [22% (23/105)]. Death by day 28 post-enrollment was 22% (28/127). To our knowledge, this is the largest multi-country cohort of NIC in LMICs. Most of the neonates would not have been considered at high risk for NIC in HICs. A substantial proportion of isolates was resistant to first choice fluconazole. Understanding the burden of NIC in LMIC is essential to guide future research and treatment guidelines.

Nystatin is commonly prescribed as prophylaxis in children beyond the neonatal age

The indications for nystatin as prophylaxis or treatment are limited. In the PASOAP (Pediatric Antifungal Stewardship Optimizing Antifungal Prescription) study, high use of nystatin in hospitalized children beyond the neonatal age was observed. In this report, we present the data on nystatin use in infants and children ≥ 3 months who participated in the PASOAP study. Nystatin was prescribed mainly for prophylaxis. Congenital heart disease, cystic fibrosis, and chronic renal disease were the most commonly reported conditions in children receiving prophylactic nystatin. There is sparse evidence supporting the use of nystatin prophylaxis beyond neonates; trials in specific pediatric patient groups are required.

Disseminated Bisifusarium infection following toxic epidermal necrolysis in a child with B-cell acute lymphoblastic leukemia

Fusarium is a polyphyletic genus of plant pathogens, members of which can cause opportunistic human infections with varying superficial and systemic presentations, including disseminated infections which typically occur in immunocompromised patients and have a poor prognosis. Treatment is challenging due to intrinsic resistance to many antifungal agents, and antifungal susceptibility testing is therefore essential. Early suspicion, isolation of the organism, and prompt initiation of management are crucial to improving survival. We present a case of disseminated Bisifusarium infection following toxic epidermal necrolysis in a child with B-cell acute lymphoblastic leukemia, successfully treated with liposomal amphotericin B, voriconazole, flucytosine, and terbinafine.

Paediatric TB care in the United Kingdom

BACKGROUND: Care of patients with paediatric TB is delivered in a variety of settings by different clinicians in the United Kingdom. Paediatric practices vary in size. Guidelines on managing children with TB differ in recommendations. These factors contribute to variations in practice.OBJECTIVE: To describe practice among UK professionals caring for children exposed to or infected with TB, and their investigation and treatment.METHODS: From 81 NHS (National Health Service) clinical services, 114 individuals responded to a web-based questionnaire.RESULTS: We describe variation in several areas of practice, with important differences between smaller and larger centres. Most respondents go beyond National Institute for Health & Care Excellence guidance and screen child contacts of extrapulmonary TB. Most respondents would presume pulmonary TB exposed children aged under 2 years to be infected. They would not rely on immunological investigations to rule out infection. There was wide variety in approaches to microbiological diagnosis, and in the use of laboratory investigations to monitor treatment. Many respondents felt unclear on how to manage newborns exposed to TB, or children exposed to multidrug-resistant TB.CONCLUSION: These findings support the case for further developing regional networks providing evidence and consensus-based care for children with TB.

Serial (1-3)-beta-D-Glucan (BDG) monitoring shows high variability among premature neonates

This study aimed to characterize the baseline values and dynamics of serum (1,3)-Beta-D-Glucan (BDG) in neonates at high risk of neonatal invasive candidiasis (NIC); as well as to determine the effect of various clinical variables on these levels. Single center prospective cohort study was performed including 20 high-risk neonates (gestational age < 29 weeks and/or birth weight ≤ 1000 gr). Samples for BDG (Fungitell® assay) were obtained twice weekly during 6 weeks. Nineteen neonates were enrolled with a median gestational age of 25 weeks (IQR 24-27), median birth weight of 730 gr (IQR 650-810). None of the neonates was diagnosed with NIC. 190 serum samples were included. The median BDG value was 59 pg/ml (IQR 30-148), mean was 119 pg/ml (SD ± 154). A total of 42.1% (80/190) samples showed values ≥80 pg/ml, with all the neonates presenting at least one test above this cut-off. Neonatal age did not show an association with BDG levels. Exposure to steroids and the use of a heel prick as sampling method were associated with statistically significant higher BDG levels. The BDG levels showed high variability and in a significant proportion of samples values were above the threshold for positivity (e.g., ≥80 pg/ml) in the absence of NIC. The exposure to postnatal steroids and the heel prick as the method of blood sampling were associated with higher BDG levels.

LAY SUMMARY

Neonatal invasive candidiasis (NIC) presents high morbi-mortality. The diagnosis of NIC is often challenging. Blood cultures have limitations and better diagnostic tools are needed. Beta-D-glucan is a diagnostic marker which could be potentially used, although still more clinical data are required.

1162. Antifungal Use in Immunocompromised Children in Europe: a 12-week Multicenter Modified Point prevalence Study (CALYPSO)

Background

While antifungal consumption in immunocompromised patients appears high, data on children are limited. We analyzed antifungal use in hospitalized immunocompromised children across Europe in order to better organize a European pediatric antifungal stewardship programs (pAFS).

Methods

A multicenter 12-wk modified point-prevalence study was conducted. All patients hospitalized in hematology-oncology (HO) or bone marrow/solid organ transplant (BMT/SOT) units across Europe and receiving systemic antifungals were included. Data on ward demographics and policies were collected once at the beginning; weekly ward and patient data were prospectively collected during the 12-wk study period and entered in REDCap. Systemic antifungals administered were recorded (doses, duration, reason for administration or discontinuation).

Results

Twenty-one HO and 10 BMT/SOT units from 18 hospitals in 11 European countries participated in the study and 572 antifungal prescriptions were recorded. The most common underlying conditions were: 69% malignancy (81% hematologic, 19% solid tumors), 20% BMT, 6% hematologic diseases except malignancy and 4% primary immunodeficiency. Indication of antifungals was prophylaxis for 439 (77%) and treatment for 133 (23%) prescriptions (62 empirical, 43 pre-emptive, 28 targeted). Most common reasons for empirical, pre-emptive and targeted treatment were antibiotic-resistant febrile neutropenia (52%), abnormalities on chest-CT with/without positive galactomannan (72%) and candidiasis (82%), respectively. For targeted treatment, the most frequent pathogens were C. albicans (50%), C. parapsilosis (11%) and A. fumigatus (11%). Overall, fluconazole and liposomal amphotericin B were the most frequently prescribed agents both for prophylaxis (31% and 21%) and treatment (32% and 23%). However, in BMT patients the most frequently prescribed antifungal agents were fluconazole or micafungin for prophylaxis and caspofungin and voriconazole for treatment (Table).

Antifungal agents used per underlying condition

Conclusion

Most systemic antifungal prescribing across European HO and BMT/SOT units is for prophylaxis, and fluconazole is the main antifungal prescribed. Results from this multicenter study can be a first step to guide a Europe-wide pAFS.

Disclosures

Emmanuel Roilides, MD, PhD, ECMM (Research Grant or Support, Other Financial or Material Support, ECMM grant for this study)

Global Divergence of Antifungal Prescribing Patterns: Data From the Global Antimicrobial Resistance, Prescribing, and Efficacy in Neonates and Children Surveys

BACKGROUND

Globally, invasive fungal diseases (IFDs) have a significant impact in human health. With an increasing pediatric population at risk of IFD, effective antifungal drugs access and affordability should be ensured universally. The aim of our study was to characterize the global antifungal drug use in neonates and children and its variability between countries in different income groups.

METHODS

Data were extracted from the Global Antimicrobial Resistance, Prescribing and Efficacy in Neonates and Children Point Prevalence Survey project, consisting in 1 pilot and four 1-day Point Prevalence Survey between 2015 and 2017. The data had been entered through a study-specific web-based data collection tool.

RESULTS

From a total of 13,410 children included, 7.8% (1048/13,410) received at least 1 systemic antifungal drug: 9.5% (95% confidence interval: 8.9%-10.1%) in high income countries (HIC) versus 5.0% (95% confidence interval: 4.4%-5.6%) in low-middle income countries (LMIC) (P < 0.01). A significant proportion of patients on antifungals belonged to high-risk group for IFD (67.4%; 706/1048); most of these were managed in HIC (72.8%, P < 0.01). The likelihood of receiving antifungals being in high-risk group was higher in HIC compared with LMIC (ratio of 5.8 vs. 3.4, P < 0.01). Antifungal prophylaxis was more likely prescribed in HIC (67.2% vs. 30.4%, P < 0.01). Fluconazole was the most frequently prescribed drug. The proportional use of fluconazole was higher in LMIC compared with HIC.

CONCLUSIONS

A significant variability of antifungal prescribing patterns was observed. The proportional use of systemic antifungals was twice as high in HIC compared with LMIC. More detailed data on access and antifungal use in limited-resource settings should be explored.

Paediatric antimicrobial stewardship programmes in the UK's regional children's hospitals

A survey was conducted in UK regional children's hospitals with paediatric intensive care and paediatric infectious disease (PID) departments to describe the characteristics of paediatric antimicrobial stewardship (PAS) programmes. A structured questionnaire was sent to PAS coordinators. 'Audit and feedback' was implemented in 13 out of 17 centres. Microbiology-led services were more likely to implement antimicrobial restriction (75% vs 33% in PID-led services), to focus on broad-spectrum antibiotics, and to review patients with positive blood cultures. PID-led services were more likely to identify patients from e-prescribing or drug charts and review all antimicrobials. A PAS network has been established.