Noninvasive Testing and Surrogate Markers in Invasive Fungal Diseases

Invasive fungal infections continue to increase as at-risk populations expand. The high associated morbidity and mortality with fungal diseases mandate the continued investigation of novel antifungal agents and diagnostic strategies that include surrogate biomarkers. Biologic markers of disease are useful prognostic indicators during clinical care, and their use in place of traditional survival end points may allow for more rapid conduct of clinical trials requiring fewer participants, decreased trial expense, and limited need for long-term follow-up. A number of fungal biomarkers have been developed and extensively evaluated in prospective clinical trials and small series. We examine the evidence for these surrogate biomarkers in this review and provide recommendations for clinicians and regulatory authorities.

Global guideline for the diagnosis and management of the endemic mycoses: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology

The global burden of the endemic mycoses (blastomycosis, coccidioidomycosis, emergomycosis, histoplasmosis, paracoccidioidomycosis, sporotrichosis, and talaromycosis) continues to rise yearly and these infectious diseases remain a leading cause of patient morbidity and mortality worldwide. Management of the associated pathogens requires a thorough understanding of the epidemiology, risk factors, diagnostic methods and performance characteristics in different patient populations, and treatment options unique to each infection. Guidance on the management of these infections has the potential to improve prognosis. The recommendations outlined in this Review are part of the "One World, One Guideline" initiative of the European Confederation of Medical Mycology. Experts from 23 countries contributed to the development of these guidelines. The aim of this Review is to provide an up-to-date consensus and practical guidance in clinical decision making, by engaging physicians and scientists involved in various aspects of clinical management.

1077. Infectious complications after second allogeneic hematopoietic cell transplant (allo-HCT) in adult patients with hematological malignancies

Background

A 2nd allo-HCT is received by some adults after relapse of their underlying malignancy, development of a second malignancy, or graft failure. Few studies have reported on infectious complications in adults given a 2nd HCT

Methods

This is a retrospective review of infectious complications and overall mortality of 60 adult patients who received a 2nd HCT from Jan. 2010 - Dec. 2015. Data were collected for 2 years post-HCT for each patient. Infections were separated into < 30 days (d) post-HCT, 30-100d post-HCT, and >100d post-HCT.

Results

Mean age at 2nd HCT was 49+13; 60% were men. The most common reason for the 1st HCT was acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) (73%,n= 44) The 2nd HCT was for relapse of original malignancy (62%,n=37), graft failure (27%,n=16), and new malignancy (10%,n=6). The 2nd HCT was received a median of 344d (range 29-8248) after 1st HCT. Neutrophil engraftment occurred by 13+4d in 50/60 patients.

Fifty-eight patients (97%) had at least one infection during the study period. A total of 183 infections were reported: 75 (41%) were < 30d, 56 (31%) 30-100d, and 52 (28%) >100d post-HCT. Bacterial infections, primarily C. difficile, vancomycin-resistant Enterococcus, and coagulase (-) Staphylococcus caused 90 (49%) infections and were seen throughout the post-HCT period. Viral infections, predominantly CMV and BK virus, caused 60 (33%) of infections, peaking at 30-100d post-HCT. Only 19 (10%) infections were fungal, most of which were mold infections and occurred >30d post-HCT.

Thirty-nine (65%) patients died by 2 years post-HCT, 27 within the first year. Cause of death was infection in 16 (41%), graft failure, relapse, or GVHD in 16 (41%), other in 7 (18%). At < 30d post-HCT, 5 deaths (71%) were from infection 4 of which were bacterial. At 30-100d post-HCT, 6/9 (69%) deaths were from relapse/graft failure/GVHD. All 6 deaths from fungal infections were >100d post-HCT. Bacterial Infections and engraftment failure within 100d post-HCT were associated with increased mortality (p .05 and < .001, respectively).

Conclusion

All but 2 patients receiving a 2nd allo-HCT developed an infection. Most deaths at < 30d post-HCT were from infection. Overall 2-year mortality was 65% and 41% of deaths were related to infection.

Disclosures

Marisa H. Miceli, MD, FIDSA, SCYNEXIS, Inc. (Advisor or Review Panel member)

Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium

BACKGROUND

Invasive fungal diseases (IFDs) remain important causes of morbidity and mortality. The consensus definitions of the Infectious Diseases Group of the European Organization for Research and Treatment of Cancer and the Mycoses Study Group have been of immense value to researchers who conduct clinical trials of antifungals, assess diagnostic tests, and undertake epidemiologic studies. However, their utility has not extended beyond patients with cancer or recipients of stem cell or solid organ transplants. With newer diagnostic techniques available, it was clear that an update of these definitions was essential.

METHODS

To achieve this, 10 working groups looked closely at imaging, laboratory diagnosis, and special populations at risk of IFD. A final version of the manuscript was agreed upon after the groups' findings were presented at a scientific symposium and after a 3-month period for public comment. There were several rounds of discussion before a final version of the manuscript was approved.

RESULTS

There is no change in the classifications of "proven," "probable," and "possible" IFD, although the definition of "probable" has been expanded and the scope of the category "possible" has been diminished. The category of proven IFD can apply to any patient, regardless of whether the patient is immunocompromised. The probable and possible categories are proposed for immunocompromised patients only, except for endemic mycoses.

CONCLUSIONS

These updated definitions of IFDs should prove applicable in clinical, diagnostic, and epidemiologic research of a broader range of patients at high-risk.

Evaluation of targeted versus universal prophylaxis for the prevention of invasive fungal infections following lung transplantation

BACKGROUND

Antifungal prophylaxis to prevent invasive fungal infections (IFI) is widely used following lung transplantation, but the optimal strategy remains unclear. We compared universal with targeted antifungal prophylaxis for effectiveness in preventing IFI.

METHODS

Adult patients who underwent lung transplantation at the University of Michigan from /1 July 2014-31 December 2017 were studied for 18 months post-transplant. Universal prophylaxis consisted of itraconazole with or without inhaled liposomal amphotericin B. Using specific criteria, targeted prophylaxis was given with voriconazole for patients at risk for invasive pulmonary aspergillosis (IPA) and with fluconazole or micafungin for patients at risk for invasive candidiasis. Risk factors, occurrence of proven/probable IFI, and mortality were analyzed for the two prophylaxis cohorts.

RESULTS

Of 105 lung transplant recipients, 84 (80%) received a double lung transplant, and 38 (36%) of patients underwent transplant for pulmonary fibrosis. Fifty-nine (56%) patients received universal antifungal prophylaxis, and 46 (44%), targeted antifungal prophylaxis. Among 20 proven/probable IFI, there were 14 IPA, 4 invasive candidiasis, 1 cryptococcosis, and 1 deep sternal mold infection. Six (10%) IFI occurred in the universal prophylaxis cohort and 14 (30%) in the targeted prophylaxis cohort. Five of 6 (83%) IFI in the universal prophylaxis cohort, compared with 9/14 (64%) in the targeted prophylaxis cohort, were IPA Candida infections occurred only in the targeted prophylaxis cohort. The development of IFI was more likely in the targeted prophylaxis cohort than the universal prophylaxis cohort, HR = 4.32 (1.51-12.38), P = .0064.

CONCLUSIONS

Universal antifungal prophylaxis appears to be more effective than targeted antifungal prophylaxis for prevention of IFI after lung transplant.

Performance of the (1,3)-Beta-D-Glucan Assay on Bronchoalveolar Lavage Fluid for the Diagnosis of Invasive Pulmonary Aspergillosis

Detection of (1,3)-beta-D-glucan (BDG), a component of the cell wall of many fungi, was studied in bronchoalveolar lavage fluid (BALF) as a possible aid for the diagnosis of proven/probable invasive pulmonary aspergillosis (IPA). BDG was measured on stored BALF from 13 patients with EORTC/MSGERC defined proven/probable IPA and 26 matched control patients without IPA. The median BALF BDG was 80 pg/mL (range < 45-8240 pg/mL) in the IPA cohort and 148 pg/mL (range < 45-5460 pg/mL) in the non-IPA cohort. Using a positive cutoff of ≥ 80 pg/mL, sensitivity was 54% and specificity was 38%. Higher cutoff values led to improvement in specificity but a dramatic decrease in sensitivity. ROC/AUC analysis was unable to identify an optimal cutoff value at which test performance was enhanced: AUC 0.43, 95% CI 0.24-0.63. When the BDG assay was performed on BALF, neither sensitivity nor specificity was sufficient for use in the diagnosis of IPA.

Long-term Outcomes of Patients With Fungal Infections Associated With Contaminated Methylprednisolone Injections

Background

The largest health care–associated infection outbreak in the United States occurred during 2012–2013. Following injection of contaminated methylprednisolone, 753 patients developed infection with a dematiaceous mold, Exserohilum rostratum. The long-term outcomes of these infections have not been described.

Methods

This retrospective cohort study of 440 of a total of 753 patients with proven or probable Exserohilum infection evaluated clinical and radiographic findings, antifungal therapy and associated adverse effects, and outcomes at 6 weeks, 3, 6, 9, and 12 months after diagnosis. Patients were grouped into 4 disease categories: meningitis with/without stroke, spinal or paraspinal infections, meningitis/stroke plus spinal/paraspinal infections, and osteoarticular infections.

Results

Among the 440 patients, 223 (51%) had spinal/paraspinal infection, 82 (19%) meningitis/stroke, 123 (28%) both, and 12 (3%) osteoarticular infection. Of 82 patients with meningitis/stroke, 18 (22%) died; among those surviving, 87% were cured at 12 months. Only 7 (3%) of 223 patients with spinal/paraspinal infection died, but at 12 months, 68% had persistent or worsening pain and only 47% were cured. For the 123 patients with both meningitis/stroke and spinal/paraspinal infection, 10 (8%) died, pain persisted in 72%, and 52% were cured at 12 months. Only 37% of those with osteoarticular infection were cured at 12 months. Adverse events from antifungal therapy were noted at 6 weeks in 71% of patients on voriconazole and 81% on amphotericin B.

Conclusions

Fungal infections related to contaminated methylprednisolone injections culminated in death in 8% of patients. Persistent pain and disability were seen at 12 months in most patients with spinal/paraspinal infections.

Ketoconazole Pharmacokinetics in Continuous Ambulatory Peritoneal Dialysis

Ketoconazole, a new oral drug, has minimal toxicity and a broad spectrum of antifungal activity. To determine its usefulness in fungal peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD), we carried out nine pharmacokinetic studies in five patients on CAPD. Serum levels of ketoconazole in CAPD patients were lower than in normal controls, and some patients did not appear to absorb the drug. We did not detect ketoconazole in the peritoneal fluid of any patient, even in the presence of peritoneal inflammation. One should not use this agent in the treatment of fungal peritonitis at daily doses of 400 mg or less because such a dose achieves only poor peritoneal fluid concentrations.

Continuous ambulatory peritoneal dialysis (CAPD) has become an attractive alternative to hemodialysis for many patients with chronic renal failure. However, a major drawback with this technique is peritonitis (1). Although most of these infections are due to staphylococci (I), fungal peritonitis appears to be increasing as experience with CAPD grows (2,3). The treatment of such peritonitis is hampered by the poor penetration of amphotericin B into the peritoneal fluid (2), chemical peritonitis when amphotericin B is instilled directly into the cavity (3), and the limited spectrum of activity of flucytosine -a drug which readily penetrates into the peritoneal fluid (4).

Ketoconazole is less toxic than amphotericin B and easier to administer and it has a much broader antifungal spectrum than flucytosine. The value of ketoconazole in fungal peritonitis remains to be established, and we have only limited data concerning its penetration into the peritonal cavity (2, 5). In this study we assessed the serum and peritoneal-fluid levels of ketoconazole in patients on CAPD.

Blastomycosis

Blastomycosis is a serious fungal disease of humans and other mammals caused by environmentally acquired infection with geographically restricted, thermally dimorphic fungi belonging to the genus Blastomyces. The genetic and geographic diversity of these pathogens is greater than previously appreciated. In addition to Blastomyces dermatitidis and the cryptic species Blastomyces gilchristii, which cause blastomycosis in mid-western and various eastern areas of North America, atypical blastomycosis is occasionally caused by Blastomyces helicus in western parts of North America and Blastomyces percursus in Africa. Blastomycosis is acquired by inhalation of the conidia that are produced in the mold phase; in the lungs, temperature-dependent transformation occurs to the yeast phase. In this form, the organism is phagocytized by macrophages and can spread hematogenously to various organs causing disseminated infection. Pulmonary disease is most common and varies from mild, self-limited infection to severe, potentially fatal adult respiratory distress syndrome. Disseminated infection is manifested primarily by skin lesions, but many other organs can be involved. Diagnosis is established by growth of the organism in culture; however, a tentative diagnosis can be made quickly by histopathological identification of the classic yeast form in tissues or by finding Blastomyces antigen in urine or serum. Blastomycosis is treated initially with amphotericin B when the disease is severe, involves the central nervous system, or the host is immunosuppressed. Itraconazole is recommended for primary therapy in mild-to-moderate infection and for step-down therapy after initial amphotericin B treatment. Voriconazole and posaconazole can be used for patients in whom itraconazole is not tolerated.

Invasive Genitourinary Aspergillosis in a Patient with Chronic Lymphocytic Leukemia Treated with Venetoclax: Case Report and Review of the Literature

Novel targeted pharmacotherapies have ushered in a new era in the management of chronic lymphocytic leukemia (CLL). Postmarketing surveillance indicates that some of these agents are associated with unexpected increases in opportunistic infections. In this report, we present a case of primary genitourinary invasive aspergillosis in a patient with CLL treated with venetoclax. We briefly review both genitourinary aspergillosis and infection risks associated with venetoclax treatment for CLL.

1736. Evaluation of Targeted vs. Universal Antifungal Prophylaxis (AP) for Invasive Fungal Infections (IFI) After Lung Transplant (LTx)

Background

LTx patients (pt) are at increased risk for IFI. Systemic AP is widely used, but the optimal strategy remains unclear. Our LTx program changed from universal to targeted AP in July 2016; we compared outcomes between the 2 strategies.

Methods

All adult pt who underwent LTx at U. Michigan from July 1, 2014 to December 31, 2017 were studied for 18 mo post-LTx. Universal AP consisted of itraconazole (itra) ± inhaled liposomal amphotericin-B (iAmB) for 6 months. Pt received targeted AP with voriconazole for 3 months if they had a history of pre-LTx Aspergillus colonization or invasive pulmonary aspergillosis (IPA); 14 days of a yeast-active azole was given if donor or recipient had Candida colonization at the time of LTx. All other pt received no AP. Demographics, LTx characteristics, occurrence of proven/probable IFI defined by EORTC/MSG criteria, and mortality data were recorded.

Results

Of 105 LTx patients, 73 (70%) were men and 84 (80%) received a double LTx. The most common indication for LTx was idiopathic pulmonary fibrosis (38, 36%). Of 59 pt receiving universal AP, 36 (61%) received itra, and 23 (39%) received itra+iAmB; outcomes did not differ between these 2 regimens. Of 46 patients in the targeted AP cohort, 10 (22%) received antifungals based on predefined criteria. Overall, 19 proven/probable IFI occurred: 14 IPA, 3 invasive Candida infections, 1 Cryptococcus pneumonia, and 1 mold wound infection. IFI occurred in 5 patients (8%) in universal AP group vs. 13 patients (28%) in targeted AP group, P = .008. All but 1 IFI in the targeted AP group occurred among pt for whom antifungals were not recommended or given. IPA occurred in 4 patients (7%) in universal AP group and 9 patients (20%) in targeted AP group, P = 0.05; Candida infections occurred only among patients in the targeted AP cohort. Time to IFI was similar between the 2 AP strategies with the majority occurring <180 days post-LTx (median 109 days). Death occurred in 11 patients (8 in the universal AP cohort and 3 in the targeted AP cohort, P = .34); no deaths were related to IFI.

Conclusion

When compared with universal AP, targeted AP strategy was associated with a significant increase in IFI post-LTx. Universal AP for 6 months appears to be more effective than our targeted AP strategy for prevention of IFI post-LTx.

Disclosures

Marisa H. Miceli, MD, FIDSA, Astellas: Advisory Board, Research Grant; Scynexis: Research Grant.

Clinical application of Aspergillus lateral flow device in bronchoalveolar lavage fluid of patients with classic risk factors for invasive pulmonary aspergillosis

BACKGROUND

The diagnosis of invasive pulmonary aspergillosis (IPA) remains challenging. We evaluated the performance characteristics of a newly formatted Aspergillus lateral flow test, AspLFD, in bronchoalveolar lavage (BAL) fluid from patients with classic risk factors for IPA.

METHODS

Prospectively banked BAL samples from 14 patients with proven or probable IPA defined by EORTC/MSG criteria and 28 BAL samples from age-matched high-risk patients without IPA were tested with AspLFD according to manufacturer's directions. Results were read by two independent observers, and test performance was calculated.

RESULTS

Age, gender and underlying risk factors, except for neutropenia and haematological malignancy, were similar between IPA cases and controls. Seven patients (50%) in the IPA group received a mould-active agent within 5 days prior to bronchoscopy compared with only three patients (11%) in the control group, P = .004. Of 14 patients with proven/probable IPA, AspLFD was positive in 3 and negative in 9; two tests yielded invalid results. All 28 control patients had a negative AspLFD test. AspLFD showed low sensitivity (25%, 95% CI: 5.5% to 57.2%), but high specificity (100%. (95% CI: 87.7% to 100%).

CONCLUSIONS

A positive AspLFD test in BAL fluid of patients with classic risk factors for IPA could be useful to support the diagnosis of proven/probable IPA because of its high specificity. However, as a stand-alone test for IPA, the use of AspLFD is limited by low sensitivity.

Central Nervous System Infection with Other Endemic Mycoses: Rare Manifestation of Blastomycosis, Paracoccidioidomycosis, Talaromycosis, and Sporotrichosis

The central nervous system (CNS) is not a major organ involved with infections caused by the endemic mycoses, with the possible exception of meningitis caused by Coccidioides species. When CNS infection does occur, the manifestations vary among the different endemic mycoses; mass-like lesions or diffuse meningeal involvement can occur, and isolated chronic meningitis, as well as widely disseminated acute infection that includes the CNS, are described. This review includes CNS infection caused by Blastomyces dermatitidis, Paracoccidioides brasiliensis, Talaromyces marneffei, and the Sporothrix species complex. The latter is not geographically restricted, in contrast to the classic endemic mycoses, but it is similar in that it is a dimorphic fungus. CNS infection with B. dermatitidis can present as isolated chronic meningitis or a space-occupying lesion usually in immunocompetent hosts, or as one manifestation of widespread disseminated infection in patients who are immunosuppressed. P. brasiliensis more frequently causes mass-like intracerebral lesions than meningitis, and most often CNS disease is part of disseminated infection found primarily in older patients with the chronic form of paracoccidioidomycosis. T. marneffei is the least likely of the endemic mycoses to cause CNS infection. Almost all reported cases have been in patients with advanced HIV infection and almost all have had widespread disseminated infection. Sporotrichosis is known to cause isolated chronic meningitis, primarily in immunocompetent individuals who do not have Sporothrix involvement of other organs. In contrast, CNS infection in patients with advanced HIV infection occurs as part of widespread disseminated infection.

Infectious Complications After Umbilical Cord Blood Transplantation for Hematological Malignancy

Background

Umbilical cord blood transplant (UCBT) is used for patients who do not have a matched donor, but engraftment often takes longer than with a standard allogeneic transplant, likely increasing the risk for infection. We characterized specific infections and outcomes in adults undergoing UCBT at our 2 centers.

Methods

All adults who underwent UCBT between January 1, 2006 and December 31, 2015 were included. Infectious episodes from 6 months before to 2 years after UCBT were reviewed.

Results

Fifty-seven patients underwent UCBT; 47 had neutrophil engraftment. A total of 179 infectious episodes occurred in 55 patients, 73 (41%) within 30 days post-UCBT. Viruses caused 85 (47%) infections. Cytomegalovirus caused 32 infectious episodes and was most common from day 30 to 100. Human herpesvirus 6 occurred in 28 episodes, was most common within 30 days, and caused 1 death. Bacteria were responsible for 82 (46%) infections, most commonly bacteremias due to Staphylococcus spp, Enterococcus spp, and Enterobacteriaceae. Of 11 invasive fungal infections, 9 were aspergillosis, 4 of which were fatal. Overall mortality was 56% in the first year. Thirteen deaths were from infection; 11 occurred in the first 100 days and 7 in the first 30 days post-UCBT. Of 10 patients who never engrafted, 9 died, 6 from infection, within 100 days post-UCBT.

Conclusions

Infectious complications were common after UCBT, especially in the first 30 days. Deaths from viral infections were fewer than expected. Delayed engraftment and nonengraftment continue to convey increased risk for fatal bacterial and fungal infections post-UCBT.

2040. Clinical Application of Aspergillus Lateral Flow Device (AspLFD) in Bronchoalveolar Lavage (BAL) Fluid of Patients with Classic Risk Factors for Invasive Pulmonary Aspergillosis (IPA)

Background

IPA causes high morbidity and mortality in immunocompromised patients, but diagnosis remains challenging. A newly formatted AspLFD targets specific Aspergillus antigen JF5, but reported results for this test are variable. We evaluated the performance characteristics of this new AspLFD in BAL fluid of patients with IPA.

Methods

Samples tested were from patients with classic risk factors for IPA defined by EORTC/MSG criteria and that had been prospectively banked in our BAL repository. Each case of IPA identified was matched to two high-risk control patientst without IPA or other invasive fungal infection. Samples were thawed, vortexed, centrifuged, and 100 μL of supernatant was applied to the AspLFD. Results were interpreted at 15 minutes as +, ++, +++, or negative by three independent, blinded observers. Test characteristics, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

Results

Samples from 14 patients with proven/probable IPA by EORTC/MSG criteria and 28 control patients without IPA were tested. Median age was 58 (range 22–87); 28 were men. Age and gender distribution were similar between cases and controls. Among IPA cases, 9 were on T cell depleting agents, 4 on high-dose steroids, and 3 had prolonged neutropenia. Among non-IPA controls, risk factors were T-cell depleting agents (17), high-dose steroids (11), and stem cell transplant (2). Of the 14 patients with IPA, AspLFD was positive in 3, negative in 9; in 2, the internal control line did not display and these were considered invalid. Of 6 patients receiving an azole, three had a positive AspLFD test. AspLFD was negative for all 28 BAL in the non-IPA group. AspLFD showed low sensitivity (25%) and high specificity (100%); PPV was 100% and NPV was 75%. Accuracy of the test was 77.5%.

Conclusion

A positive AspLFD test in BAL of patients with classic risk factors for IPA could be useful for ruling in proven/probable IPA because of its high specificity. However, the use of AspLFD as a screening test for IPA is limited by its poor sensitivity.

Disclosures

All authors: No reported disclosures.

2042. Clinical Application of AspID PCR Alone and in Combination with Aspergillus Lateral Flow Device (AspLFD) in Bronchoalveolar Lavage (BAL) Fluid of Patients with Classic Risk Factors for Invasive Pulmonary Aspergillosis (IPA)

Background

Methods

Results

Conclusion

Disclosures

1542. Infectious Complications in Patients Following Umbilical Cord Blood Transplant (UCBT) for Hematologic Malignancy

Background

UCBT can be performed in pt with hematologic malignancies who do not have a matched donor, but engraftment often takes longer than with a standard allogeneic stem cell transplant. Delayed engraftment can increase the risk for infections, but characteristics of specific infections & outcomes have not been well characterized in adults undergoing UCBT.

Methods

All adults who underwent UCBT between January 1, 2006 and January 1, 2016 at our two centers were included. Infectious episodes within 6 months before and up to 2 years after UCBT were reviewed.

Results

Fifty-seven patients underwent UCBT. Mean age was 43 ± 14 years, and 34 patients were women. Thrity-nine (60%) had acute leukemia. Only 47 patients had neutrophil engraftment. One hundred and seventy-nine infectious episodes occurred in 55 patients, 73 (41%) within 30 days post-UCBT. Viruses caused 85 (47%) infections. HHV-6 occurred in 28 episodes, 24 of which were viremia alone, and was most common within 30 days of UCBT. One patient died of HHV-6 encephalitis. CMV caused 32 infectious episodes, 24 of which were viremia only, was most common from Days 30–100, and caused no deaths. BK viruria occurred in 18 episodes. Bacteria were responsible for 82 (46%) infections; most common were bacteremias due to Staphylococcus, van-R Enterococcus and Enterobacteriaceae. Three patients had mycobacterial infections, two of which were fatal. Of 11 invasive fungal infections (IFI), nine were invasive aspergillosis, of which four were fatal. Overall mortality was 56% in the first year, including 13 deaths from infection. Eleven of these 13 infections occurred in the first 100 days post-UCBT and seven of them in the first 30 days. Patients who died within 100 days were significantly more likely to have had IFI (P = 0.04) or infection with VRE (P = 0.03) or Enterobacteriaceae (P = 0.03) within 30 days after UCBT. Among the 10 patients who never had neutrophil engraftment, nine died within 100 days post-UCBT, six from infection.

Conclusion

Infectious complications were common after UCBT, especially in the first 30 days. Deaths from viral infections were fewer than expected, most likely because of increased screening and prophylaxis for CMV infections. Delayed engraftment and nonengraftment continue to convey increased risk for fatal bacterial and fungal infections post-UCBT.

Disclosures

All authors: No reported disclosures.

971. Breakthrough Invasive Fungal Infections (IFI) in Acute Leukemia (AL) Patients Receiving Antifungal Prophylaxis

Background

A major challenge in patients with AL receiving chemotherapy is to decrease the risk of IFI during the prolonged neutropenic period. Even with antifungal prophylaxis, the incidence of breakthrough IFI can be as high as 14%. Our objectives were to determine the incidence of all IFI and breakthrough IFI, to define risk factors associated with IFI, and to assess outcomes.

Methods

Single-center retrospective cohort analysis of all adult patients admitted to the University of Michigan for AL from January 1, 2010 to December 31, 2013. Chart review determined co-morbidities, chemotherapy regimens, antifungal prophylaxis, occurrence of IFI as determined by EORTC/MSG criteria, and outcomes. Chi-square, Fischer’s, ANOVA, and binary logistic regression tests were performed when appropriate.

Results

Of 363 patients, all but 4 had acute myeloid leukemia (AML); 124 had a stem cell transplant (SCT). A total of 103 (28%) had proven (n = 13), probable (n = 22), or possible (n = 68) IFI. Considering only those 35 patients who had proven or probable IFI, the only risk factor for development of IFI by logistic regression analysis was IFLAG chemotherapy (P = .006). Mold infections occurred in 27 patients: Aspergillus (19), Mucorales (5), both Aspergillus and Mucorales (1), Alternaria (1), and Scedosporium (1). Additionally, 5 patients had invasive candidiasis and 3 had Pneumocystis. Eighteen of 35 patients (51%) had breakthrough IFI while on posaconazole suspension (6), fluconazole (5), micafungin (5) or voriconazole (2). Factors significantly associated with breakthrough IFI were SCT (P = .04), neutrophils <500, ≥10 days at diagnosis (P = .002) and prophylaxis with posaconazole suspension (P = .003). Twelve-week mortality in proven and probable IFI was 31% (11/35). Nine of 11 deceased patients had breakthrough IFI; 8 of whom (5 with mold IFI and 3 with invasive candidiasis) died of the fungal infection.

Conclusion

Patients receiving chemotherapy for AL remain at risk for IFI despite the the use of antifungal prophylaxis. In our study, prophylaxis with posaconazole suspension was found to be an independent risk factor for breakthrough IFI. Mortality was high among patients with breakthrough IFI.

Disclosures

All authors: No reported disclosures.

Manifestations and outcomes of nocardia infections: Comparison of immunocompromised and nonimmunocompromised adult patients

Nocardia is a ubiquitous environmental pathogen that causes infection primarily following inhalation into the lungs. It is generally thought to cause infection primarily in immunocompromised patients, but nonimmunocompromised individuals are also at risk of infection. We sought to compare risk factors, clinical manifestations, diagnostic approach, treatment, and mortality in immunocompromised and nonimmunocompromised adults with nocardiosis.We studied all adults with culture-proven Nocardia infection at a tertiary care hospital from 1994 to 2015 and compared immunocompromised with nonimmunocompromised patients. The immunocompromised group included patients who had a solid organ transplant, hematopoietic cell transplant (HCT), hematological or solid tumor malignancy treated with chemotherapy in the preceding 90 days, inherited immunodeficiency, autoimmune/inflammatory disorders treated with immunosuppressive agents, or high-dose corticosteroid therapy for at least 3 weeks before the diagnosis of nocardiosis.There were 112 patients, mean age 55 ± 17 years; 54 (48%) were women. Sixty-seven (60%) were immunocompromised, and 45 (40%) were nonimmunocompromised. The lung was the site of infection in 54 (81%) immunocompromised and 25 (55%) nonimmunocompromised patients. Pulmonary nocardiosis in immunocompromised patients was associated with high-dose corticosteroids, P = .002 and allogeneic HCT, P = .01, and in nonimmunocompromised patients with cigarette smoking, bronchiectasis, and other chronic lung diseases, P = .002.Cavitation occurred only in the immunocompromised group, P < .001. Disseminated infection was more common in the immunocompromised, P = .01, and was highest in solid organ transplant recipients, P = .007. Eye infection was more common in nonimmunocompromised patients, P = .009. Clinical signs and symptoms did not differ significantly between the 2 groups. The initial treatment for most patients in both groups was trimethoprim-sulfamethoxazole with or without a carbapenem. All-cause 1-year mortality was 19%; 18 (27%) immunocompromised and 3 (7%) nonimmunocompromised patients died, P = .01.Immunocompromised patients with nocardiosis had more severe disease and significantly higher mortality than nonimmunocompromised patients, but clinical presentations did not differ.

Cytomegalovirus infections in lung and hematopoietic cell transplant recipients in the Organ Transplant Infection Prevention and Detection Study: A multi-year, multicenter prospective cohort study

BACKGROUND

Most studies of post-transplant CMV infection have focused on either solid organ or hematopoietic cell transplant (HCT) recipients. A large prospective cohort study involving both lung and HCT recipients provided an opportunity to compare the epidemiology and outcomes of CMV infections in these 2 groups.

METHODS

Patients were followed up for 30 months in a 6-center prospective cohort study. Data on demographics, CMV infections, tissue-invasive disease, recurrences, rejection, and immunosuppression were recorded.

RESULTS

The overall incidence of CMV infection was 83/293 (28.3%) in the lung transplant group and 154/444 (34.7%) in the HCT group (P = .0706). Tissue-invasive CMV disease occurred in 8/83 (9.6%) of lung and 6/154 (3.9%) of HCT recipients with CMV infection, respectively (P = .087). Median time to CMV infection was longer in the lung transplant group (236 vs 40 days, P < .0001), likely reflecting the effects of prophylaxis vs preemptive therapy. Total IgG levels of < 350 mg/dL in lung recipients and graft vs host disease (GvHD) in HCT recipients were associated with increased CMV risk. HCT recipients had a higher mean number of CMV episodes (P = .008), although duration of viremia was not significantly different between the 2 groups. CMV infection was not associated with reduced overall survival in either group.

CONCLUSIONS

Current CMV prevention strategies have resulted in a low incidence of tissue-invasive disease in both lung transplant and HCT, although CMV viremia is still relatively common. Differences between the lung and HCT groups in terms of time to CMV and recurrences of CMV viremia likely reflect differences in underlying host immunobiology and in CMV prevention strategies in the modern era.

Epidemiology and outcomes of Clostridium difficile infection in allogeneic hematopoietic cell and lung transplant recipients

BACKGROUND

Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described.

METHODS

We performed a prospective, multicenter study of CDI within 365 days post-allogeneic HCT or lung transplantation. Data were collected via patient interviews and medical chart review. Participants were followed weekly in the 12 weeks post-transplant and while hospitalized and contacted monthly up to 18 months post-transplantation.

RESULTS

Six sites participated in the study with 614 total participants; 4 enrolled allogeneic HCT (385 participants) and 5 enrolled lung transplant recipients (229 participants). One hundred and fifty CDI cases occurred within 1 year of transplantation; the incidence among lung transplant recipients was 13.1% and among allogeneic HCTs was 31.2%. Median time to CDI was significantly shorter among allogeneic HCT than lung transplant recipients (27 days vs 90 days; P = .037). CDI was associated with significantly higher mortality from 31 to 180 days post-index date among the allogeneic HCT recipients (Hazard ratio [HR] = 1.80; P = .007). There was a trend towards increased mortality among lung transplant recipients from 120 to 180 days post-index date (HR = 4.7, P = .09).

CONCLUSIONS

The epidemiology and outcomes of CDI vary by transplant population; surveillance for CDI should continue beyond the immediate post-transplant period.

Therapeutic drug monitoring and use of an adjusted body weight strategy for high-dose voriconazole therapy

Objectives

A high-dose 12 mg/kg/day (6 mg/kg twice daily) voriconazole regimen was recommended by the CDC to treat patients injected with contaminated methylprednisolone acetate that caused a multi-state fungal outbreak in 2012-13. Therapeutic drug monitoring results of this unique regimen are unknown, as is the most appropriate dosing weight for obese patients. We evaluated voriconazole trough measurements for this dosing scheme, as well as the use of adjusted body weight dosing for obese patients.

Methods

Voriconazole trough levels were analysed in obese (BMI ≥35 kg/m 2 ) and non-obese (BMI <35 kg/m 2 ) patients who were given initial therapy with 12 mg/kg/day.

Results

Of 138 patients, the first steady-state voriconazole troughs were supratherapeutic (>5 mg/L) in 65 (47%) patients, therapeutic (2-5 mg/L) in 57 (41%) patients and subtherapeutic (<2 mg/L) in 16 (12%) patients. Twenty-three patients had pre-steady-state dose decreases due to supratherapeutic levels, with subsequent first steady-state troughs in the therapeutic ( n  =   17) and subtherapeutic ( n  =   6) categories. Voriconazole doses >11 and >8 mg/kg/day produced mainly first steady-state supratherapeutic troughs in 44 obese and 94 non-obese patients, respectively. An initial 12 mg/kg/day was progressively lowered to a median maintenance dose of 8.5 mg/kg/day in the obese and 8.6 mg/kg/day in the non-obese.

Conclusions

A high-dose voriconazole regimen produced initial supratherapeutic troughs that required dose adjustment downward by nearly 30%. Adjusted body weight dosing in obese patients resulted in a similar maintenance dose to total body weight dosing in the non-obese, and appears to be a sensible dosing strategy for these patients.

A Mycoses Study Group International Prospective Study of Phaeohyphomycosis: An Analysis of 99 Proven/Probable Cases

Background

Phaeohyphomycosis is infection caused by dematiaceous, or darkly pigmented, fungi. The spectrum of disease is broad, and optimal therapy remains poorly defined. The Mycoses Study Group established an international case registry of patients with proven/probable phaeohyphomycosis with the goal of improving the recognition and management of these infections.

Methods

Patients from 18 sites in 3 countries were enrolled from 2009-2015. Cases were categorized as local superficial, local deep (pulmonary, sinus, osteoarticular infections), and disseminated infections. End points were clinical response (partial and complete) and all-cause mortality at 30 days and end of follow-up.

Results

Of 99 patients, 32 had local superficial infection, 41 had local deep infection, and 26 had disseminated infection. The most common risk factors were corticosteroids, solid organ transplantation, malignancy, and diabetes. Cultures were positive in 98% of cases. All-cause mortality was 16% at 30 days and 33% at end of follow-up, and 18 of 26 (69%) with dissemination died. Itraconazole was most commonly used for local infections, and voriconazole was used for more severe infections, often in combination with terbinafine or amphotericin B.

Conclusions

Phaeohyphomycosis is an increasingly recognized infection. Culture remains the most frequently used diagnostic method. Triazoles are currently the drugs of choice, often combined with other agents. Further studies are needed to develop optimal therapies for disseminated infections.

Testing the performance of a prototype lateral flow device using bronchoalveolar lavage fluid for the diagnosis of invasive pulmonary aspergillosis in high-risk patients

The diagnosis of invasive pulmonary aspergillosis (IPA) increasingly relies on non-culture-based biomarkers in bronchoalveolar lavage (BAL) fluid. The Aspergillus lateral flow device (LFD) is a rapid immunoassay that uses a novel Aspergillus monoclonal antibody to gain specificity. The objective of the study is to compare specificity and sensitivity of the prototype LFD and the galactomannan (GM) enzyme immunoassay in BAL fluid in high-risk patients. A total of 114 BAL samples from 106 patients at high risk for IPA were studied: 8 patients had proven/probable IPA, 16 had possible IPA and 82 did not have IPA. In patients with proven/probable IPA, specificity of LFD was 94% and GM was 89%; sensitivity of LFD was 38% and GM was 75%. Negative predictive value (NPV) for LFD was 94% and for GM was 98%; positive predictive value (PPV) was 38% for both tests. The use of anti-mould prophylaxis did not affect specificity but resulted in decreased NPV of both LFD and GM. Union and intersection analysis showed no improvement in the performance by using both tests. Among patients at risk for IPA, the diagnostic performance of LFD and GM in BAL fluid appears comparable; specificity is high, but sensitivity of both LFD and GM is poor.

Daptomycin nonsusceptible vancomycin resistant Enterococcus bloodstream infections in patients with hematological malignancies: risk factors and outcomes

Daptomycin is typically the treatment of choice for vancomycin resistant Enterococcus (VRE) bloodstream infections (BSI) in patients with hematological malignancies, but increasingly daptomycin nonsusceptible VRE are being reported. We reviewed our experience with daptomycin nonsusceptible VRE BSI among patients with hematological malignancies. We compared risk factors and outcomes of 20 patients with daptomycin nonsusceptible VRE BSI (case patients) with 40 matched control patients with daptomycin susceptible VRE BSI. Case patients had more complications (6/20 vs. 2/40, p = .013); all-cause mortality was similar in both groups. By multivariable analysis, only prior daptomycin exposure within 90 days was significantly associated with daptomycin nonsusceptible VRE BSI (odds ratio 26.71; p < .0001). In 25% of case patients, all of whose VRE isolates had an initial minimum inhibitory concentration (MIC) of 4 μg/mL, nonsusceptibility developed during treatment, raising the question of whether higher doses of daptomycin should be used for VRE BSI in hematology patients.

Infections in Hematopoietic Cell Transplant Recipients: Results From the Organ Transplant Infection Project, a Multicenter, Prospective, Cohort Study

Background

Infection is a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT). Our object was to better define the epidemiology and outcomes of infections after HCT.

Methods

This was a prospective, multicenter cohort study of HCT recipients and conducted from 2006 to 2011.

The study included 4 US transplant centers and 444 HCT recipients. Data were prospectively collected for up to 30 months after HCT using a standardized data collection tool.

Results

The median age was 53 years, and median follow up was 413 (range, 5–980) days. The most common reason for HCT was hematologic malignancy (87%). The overall crude mortality was 52%. Death was due to underlying disease in 44% cases and infection in 21%. Bacteremia occurred in 231 (52%) cases and occurred early posttransplant (median day 48). Gram-negative bloodstream infections were less frequent than Gram-positive, but it was associated with higher mortality (45% vs 13%, P = .02). Clostridium difficile infection developed in 148 patients (33%) at a median of 27 days post-HCT. There were 53 invasive fungal infections (IFIs) among 48 patients (11%). The median time to IFI was 142 days. Of 155 patients with cytomegalovirus (CMV) infection, 4% had CMV organ involvement. Varicella zoster infection (VZV) occurred in 13 (4%) cases and was disseminated in 2. Infection with respiratory viruses was seen in 49 patients. Pneumocystis jirovecii pneumonia was rare (1%), and there were no documented cases of nocardiosis, toxoplasmosis, endemic mycoses, or mycobacterial infection. This study lacked standardized antifungal and antiviral prophylactic strategies.

Conclusions

Infection remains a significant cause of morbidity and mortality after HCT. Bacteremias and C difficile infection are frequent, particularly in the early posttransplant period. The rate of IFI is approximately 10%. Organ involvement with CMV is infrequent, as are serious infections with VZV and herpes simplex virus, likely reflecting improved prevention strategies.

Effect of underlying immune compromise on the manifestations and outcomes of group A streptococcal bacteremia

BACKGROUND

Group A streptococcal bloodstream infection is the most common presentation of invasive group A streptococcal disease. We sought to determine the impact of immunosuppression on severity of disease and clinical outcomes.

METHODS

This retrospective review of 148 patients with at least one positive blood culture for Streptococcus pyogenes from 1/2003 to 3/2013 compared immunocompromised patients with those with no immunocompromise in regards to development of severe complications and mortality.

RESULTS

Twenty-five patients (17%) were immunocompromised; 123 were not. Skin and soft tissue infection occurred in 60% of immunocompromised vs. 38% of non-immunocompromised patients, p = .04. Necrotizing fasciitis and septic shock were significantly more common in immunocompromised patients, p < .0001 and .028, respectively. Mortality at 30 days was 32% in immunocompromised patients vs. 16% in non-immunocompromised patients, p = .05.

CONCLUSION

Patients who are immunocompromised are more likely to develop necrotizing fasciitis and septic shock as complications of group A streptococcal bacteremia and have a higher mortality rate than patients who are not immunocompromised.

Risk Factors and Outcomes of Invasive Fungal Infections in Allogeneic Hematopoietic Cell Transplant Recipients

Allogeneic hematopoietic cell transplant (HCT) recipients are at increased risk of invasive fungal infections (IFI), which are associated with a high mortality rate. We evaluated the impact of IFI in allogeneic HCT patients. In total, 541 consecutive allogeneic HCT recipients were included. The cumulative incidence of any IFI and mold infections at 1-year post-HCT was 10 and 7%, respectively. Median times to IFI and mold infection were 200 and 210 days, respectively. There was a trend toward fewer IFI and mold infections in the last several years. Both acute graft-versus-host disease (GVHD) (OR 1.83, p = 0.05) and corticosteroid duration (OR 1.0, p = 0.026) were significantly associated with increased risk of IFI, acute GVHD (OR 2.3, p = 0.027) emerged as the most important association with mold infections. Any IFI [HR 4.1 (2.79-6.07), p < 0.0001] and mold infections [HR 3.34 (2.1-5.1), p < 0.0001] were independently associated with non-relapse mortality (NRM). This association persisted in the setting of both acute and chronic GVHD. Corticosteroid treatment for >90 days was also significantly associated with higher NRM [HR 1.9 (1.3-2.6), p < 0.0001]. This study highlights the impact of IFI on NRM among HCT patients. The decrease in number of IFI and mold infections over the last several years may reflect the benefit of prophylaxis with mold-active antifungal agents.

Executive Summary: Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Staphylococcus aureus Nasal Colonization in a Nursing Home: Eradication With Mupirocin

Recent reports have emphasized an increase in both infection and colonization with methicillin-resistant Staphylococcus aureus (MRSA) in institutionalized older patients. We studied whether or not local treatment with mupirocinointment could eliminate nasal colonization with S aureus. A total of 102 patients in a Veterans Administration nursing home were screened for S aureus nasal colonization. Thirty-nine patients (38.2%) were colonized, 18 with methicillin-sensitive Saureus (MSSA) and 21 with MRSA. Almost half of all colonized patients were in the most dependent functional category and there was a significant association of MRSA colonization, but not MSSA colonization, with poor functional status. Colonized patients were treated with mupirocin ointment applied to the anterior nares twice daily for seven days. After treatment, MSSA persisted in only two patients and MRSA in only one patient; thus, nasal colonization was eliminated in 91.4% of colonized patients. At one month and two months follow-up, 11 patients became transiently recolonized and three became persistently recolonized with S aureus. Mupirocin was well tolerated with no side effects noted. Mupirocin ointment may be useful in controlling nasal colonization with S aureus in the nursing home setting.

Enterococcal Infections: An Increasing Problem in Hospitalized Patients

We studied 157 episodes of infection or colonization with enterococci in 122 patients over a six-month period. One hundred twelve episodes (71.3%) occurred in patients over age 60 years. The most common sites for isolation of enterococci were the urinary tract, and bone and soft tissue. Nosocomial acquisition of enterococci occurred in 74.7% of all infections, and an additional 21% of episodes occurred in patients who had been transferred from another hospital or were regularly seen in the clinic. The overall mortality was 19.6%; 71.4% of those with bacteremia died. Enterococci appear to be significant pathogens, especially in older men in veterans' acute care hospitals and nursing home care units.

The Upside of Bias: A Case of Chronic Meningitis Due to Sporothrix Schenckii in an Immunocompetent Host

Chronic meningitis of unknown etiology is a vexing illness for patients and clinicians. Identification of the correct pathogen can be challenging and time consuming, leading to delays in appropriate treatment. Although Sporothrix schenckii is a recognized and treatable cause of chronic meningitis, neurologists and infectious diseases physicians may not regularly evaluate for Sporothrix infection. We describe an immunocompetent patient with chronic meningitis who partially responded to empiric fluconazole. Prompted by a recent culture-confirmed case of meningeal sporotrichosis, we tested for S schenckii antibodies from the cerebrospinal fluid, which were positive. His clinical and functional status improved, and the S schenckii antibody titer decreased with itraconazole therapy. Clinicians should consider S schenckii in the differential diagnosis for chronic meningitis, even in immunocompetent patients, particularly when the clinical picture does not respond to standard empiric therapy.

Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Blastomycosis

Blastomycosis is an endemic fungal infection due to Blastomyces dermatitidis that most commonly causes pneumonia; but the organism can disseminate to any organ system, most commonly the skin, bones/joints, and genitourinary tract. Both immunocompetent and immunocompromised persons can be infected, but more severe disease occurs in the immunocompromised. Blastomycosis can be diagnosed by culture, direct visualization of the yeast in affected tissue, and/or antigen testing. Treatment course and duration depend on severity of illness. For mild to moderate pulmonary disease the treatment is itraconazole. For severe blastomycosis, lipid formulation amphotericin B is given, followed by step-down therapy with itraconazole.

Voriconazole: How to Use This Antifungal Agent and What to Expect

Voriconazole is an important agent in the antifungal armamentarium. It is the treatment of choice for invasive aspergillosis, other hyaline molds, and many brown-black molds. It is also effective for infections caused by Candida species, including those that are fluconazole resistant, and for infections caused by the endemic mycoses, including those that occur in the central nervous system. It has the advantage of being available in both an intravenous and an oral formulation that is well absorbed. Drawbacks to the use of voriconazole are that it has unpredictable, nonlinear pharmacokinetics with extensive interpatient and intrapatient variation in serum levels. Some of the adverse effects seen with voriconazole are related to high serum concentrations, and, as a result, therapeutic drug monitoring is essential when using this agent. Drug-drug interactions are common, and possible interactions must be sought before voriconazole is prescribed. With prolonged use, newly described adverse effects, including periostitis, alopecia, and development of skin cancers, have been noted.

Complications of Candidemia in ICU Patients: Endophthalmitis, Osteomyelitis, Endocarditis

Bloodstream infection with Candida species is not uncommon in the intensive care unit setting and has the potential to distribute organisms to many different organ systems causing secondary infections, such as endophthalmitis, osteomyelitis, and endocarditis. In some patients, these types of infections become manifested shortly after the episode of candidemia. In others, especially vertebral osteomyelitis, weeks pass before the diagnosis is entertained. Endophthalmitis should be sought by a retinal examination in all patients early after an episode of candidemia. Both osteomyelitis and endocarditis are less common complications of candidemia than endophthalmitis. In patients who manifest symptoms or signs suggesting these infections, magnetic resonance imaging and transesophageal echocardiography, respectively, are extremely helpful diagnostic tests. Newer approaches to the treatment of these infections allow the use of better tolerated, safer antifungal agents. Endophthalmitis is often treated with fluconazole or voriconazole, and the echinocandins are increasingly used, instead of amphotericin B, as initial therapy for osteomyelitis and endocarditis before step-down therapy to oral azole agents.

Invasive Aspergillosis: Epidemiology, Clinical Aspects, and Treatment

Invasive aspergillosis remains an often fatal, difficult-to treat infection in immunocompromised patients. Patients not classically defined as immunocompromised, especially those in an intensive care unit setting, also develop invasive aspergillosis. Clinical clues suggesting angioinvasion and radiographic modalities, especially computed tomographic scans, combined with newer non-culture-based diagnostic techniques, have allowed earlier recognition of invasive aspergillosis. Although mortality remains high, it has greatly decreased over the past 15 years. Voriconazole has supplanted amphotericin B, with its various toxicities, as primary treatment for invasive aspergillosis. Combination therapy with voriconazole and an echinocandin for initial therapy, based on results from a recent controlled clinical trial, could become the standard of care in high-risk patients.