Epidemiology Of Invasive Fungal Infections Research Articles

Emerging trends of invasive yeast infections and azole resistance in Beijing intensive care units

Invasive fungal infections pose a substantial threat to patients in healthcare settings globally. Recent changes in the prevalence of fungal species and challenges in conducting reference antifungal susceptibility testing emphasize the importance of monitoring fungi and their antifungal resistance. A two-phase surveillance project was conducted in Beijing, China, involving 37 centers across 12 districts, from January 2012 to December 2013 and from January 2016 to December 2017. We found that the proportion of Candida albicans in intensive care units (ICUs) during 2016–2017 exhibited a significant decline compared to the 2012–2013 period, although it remained the most predominant pathogen. In contrast, the prevalence of Nakaseomyces glabratus (formerly Candida glabrata) and Candida tropicalis notably increased during the two-phase surveillance. The high prevalence of C. tropicalis and its resistance to azole drugs posed a serious threat to patients in ICUs. The pathogens causing invasive fungal infections in Beijing were relatively sensitive to echinocandins. While C. albicans continued to exhibit susceptibility to azoles, the resistance and growth rates of C. tropicalis towards azoles were particularly prominent. Concerns were raised due to the emergence of multiple, short-term isolates of Clavispora lusitaniae and Candida parapsilosis complex in neonatal ICUs, given their similarity in antifungal susceptibilities. Such occurrences point towards the potential for transmission and persisting presence of these pathogens within the ICU environment. Our study complements existing data on the epidemiology of invasive fungal infections. It is imperative to exercise cautious medication management for ICU patients in Beijing, paying particular attention to azole resistance in C. tropicalis.

2716. Epidemiology of invasive fungal infection in pediatric liver transplant recipients: A retrospective, single-center study, 2012-2022

Abstract Background Studies on liver transplant (LT) recipients have reported an incidence of invasive fungal infection (IFI) ranging from 2.5 to 5%; however, antifungal prophylaxis has not yet been approved by the Ministry of Food and Drug Safety in Korea. We investigated the incidence of early-onset IFI and its characteristics in pediatric LT recipients in Korea, and also explored the risk factors for IFIs. Methods This is a retrospective, single-center study on children (< 19 years of age) who have undergone LT from 2012 to 2022 at Severance Hospital, Korea. IFI was defined as the detection of fungus in sterile fluid, tissue, and/or blood with symptoms of a fungal infection. Superficial fungal infection and colonization on the skin or urine were excluded. The primary outcome is the occurrence of IFI within 90 days of LT. The logistic regression method was used to analyze the risk factors for IFI. Results A total of 104 LT children were included, among whom 6 received multiple transplantations, resulting in 111 LT cases. 42% (n = 44) were male, and the median age at LT was 4.0 years of age (IQR 1.0–11.0). Two thirds of the patients received LT due to biliary atresia (n = 69, 66%), and the remaining were diagnosed with acute liver failure (n = 17, 16%), miscellaneous causes (n = 11, 11%), and so on (n = 7, 7%). Antifungal prophylaxis, except nystatin gargle, was done in 12.8% of recipients. IFI was identified in 19 patients (18%), and due to five multiple IFI events per patient, a total of 23 IFI events were noted at a median time of 16.5 days after LT (IQR 10-38). 87% of the pathogens detected were Candida species (C. albicans 40%, C. parapsilosis 35%, C. auris 15%), and Aspergillus fumigatus (13%). Antifungal susceptibility patterns are described in Table 1. The risk of IFI was significantly increased in those who underwent acute re-transplantation, postoperative intervention, or surgery due to bleeding, vascular, and bile duct complications (OR = 4.6; 95% CI, 1.5–13.6; P = 0.006) 8) and renal replacement therapy (OR=3.2; 95% CI, 1.1-8.8; P=0.028).Table.Antifungal susceptibility patterns of identified pathogens according to Clinical and Laboratory Standards Institute (CLSI). a Number of cases identified with the fungal pathogen b Antifungal susceptibility testing has to be additionally requested, so it was not performed in all cases. c 1 case had a fluconazole-resistant C.parapsilosis strain with intermediate resistance to other antifungal agents (MIC: fluconazole 32, micafungin 2, caspofungin 2, voriconazole 0.12, amphotericin B 0.5). d CLSI does not provide a tentative MIC breakpoint for voriconazole and other second generation azoles, but that of fluconazole may be considered as a surrogate. Conclusion The incidence of early IFI after LT in Korean children is considerable; therefore, universal antifungal prophylaxis is necessary. High-risk IFI patients, such as those undergoing reoperation, intervention, or renal replacement therapy, require attention and close monitoring. Disclosures All Authors: No reported disclosures

Epidemiology of invasive fungal infection in pediatric liver transplant recipients: a retrospective single-center study 2012–2022

Epidemiology of invasive fungal infection in pediatric liver transplant recipients: a retrospective single-center study 2012–2022

Availability of Systemic Antifungals in Africa: A Comparative Study between North Africa and West Africa

Introduction. Due to the lack of systemic antifungals (SAs), many invasive fungal infections (IFIs) do not yet benefit from effective treatment in Africa. Yet, fungi are a major threat to human health. This study aimed to assess the availability of SAs and compare this availability between West Africa (WA) and North Africa (NA). Materials and methods. The information processed was obtained during the same period between February and June 2021 in Senegal, Mauritania, and Côte d’Ivoire as well as in Morocco and Tunisia. In WA, data were received from wholesale drug suppliers and private pharmacies while in NA, the data were those available on the websites of the pharmacy and drug directorates. Results. All classes of SAs were available. However, this availability was not uniform depending on location, whether in WA or NA. Fluconazole and itraconazole were the only SA available in WA. In NA, all classes of SAs have been found, particularly in Morocco, while flucytosine was the only molecule absent in Tunisia. Conclusion. NA is ahead of WA as regards the burden of IFIs both diagnostically and in the availability of SAs. Studies on the epidemiology of IFIs in Africa, particularly in WA, are limited. The partial data available highlight that IFIs are not negligible, though these may be underestimated. Thus, a network based on the directory of African pharmacy and drug directorates must be set up and run in collaboration with the national laboratory directorates for the harmonization of procedures in order to reduce morbidity and mortality related to IFIs.

Novel Antifungals and Aspergillus Section Terrei with Potpourri Susceptibility Profiles to Conventional Antifungals.

The epidemiology of invasive fungal infections (IFIs) is currently changing, driven by aggressive immunosuppressive therapy, leading to an expanded spectrum of patients at risk of IFIs. Aspergillosis is a leading cause of IFIs, which usually affects immunocompromised patients. There are a limited number of antifungal medications available for treating IFIs, and their effectiveness is often hindered by rising resistance rates and practical limitations. Consequently, new antifungals, especially those with novel mechanisms of action, are increasingly required. This study assessed the activity of four novel antifungal agents with different mechanisms of activity, namely, manogepix, rezafungin, ibrexafungerp, and olorofim, against 100 isolates of Aspergillus section Terrei, containing amphotericin-B (AmB)-wildtype/non-wildtype and azole-susceptible/-resistant strains, according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) method. In general, all tested agents showed potent and consistent activity against the tested isolates, exhibiting geometric mean (GM) and minimum effective concentration (MEC)/minimum inhibitory concentration (MIC) ranges, respectively, as follows: manogepix (0.048 mg/L, 0.032-0.5 mg/L), rezafungin (0.020 mg/L, 0.016-0.5 mg/L), ibrexafungerp (0.071 mg/L, 0.032-2 mg/L), and olorofim (0.008 mg/L, 0.008-0.032 mg/L). In terms of MIC90/MEC90, olorofim had the lowest values (0.008 mg/L), followed by rezafungin (0.032 mg/L), manogepix (0.125 mg/L), and ibrexafungerp (0.25 mg/L). All the antifungals tested demonstrated promising in vitro activity against Aspergillus section Terrei, including A. terreus as well as azole-resistant and AmB-non-wildtype cryptic species.

Microbial and clinical epidemiology of invasive fungal rhinosinusitis in hospitalized COVID-19 patients, the divergent causative agents.

Since COVID-19 spread worldwide, invasive fungal rhinosinusitis (IFRS) has emerged in immunocompromised patients as a new clinical challenge. In this study, clinical specimens of 89 COVID-19 patients who presented clinical and radiological evidence suggestive of IFRS were examined by direct microscopy, histopathology, and culture, and the isolated colonies were identified through DNA sequence analysis. Fungal elements were microscopically observed in 84.27% of the patients. Males (53.9%) and patients over 40 (95.5%) were more commonly affected than others. Headache (94.4%) and retro-orbital pain (87.6%) were the most common symptoms, followed by ptosis/proptosis/eyelid swelling (52.8%), and 74 patients underwent surgery and debridement. The most common predisposing factors were steroid therapy (n=83, 93.3%), diabetes mellitus (n=63, 70.8%), and hypertension (n=42, 47.2%). The culture was positive for 60.67% of the confirmed cases, and Mucorales were the most prevalent (48.14%) causative fungal agents. Different species of Aspergillus (29.63%) and Fusarium (3.7%) and a mix of two filamentous fungi (16.67%) were other causative agents. For 21 patients, no growth was seen in culture despite a positive result on microscopic examinations. In PCR-sequencing of 53 isolates, divergent fungal taxons, including 8 genera and 17 species, were identified as followed: Rhizopus oryzae (n=22), Aspergillus flavus (n=10), A. fumigatus (n=4), A. niger (n=3), R. microsporus (n=2), Mucor circinelloides, Lichtheimia ramosa, Apophysomyces variabilis, A. tubingensis, A. alliaceus, A. nidulans, A. calidoustus, Fusarium fujikuroi/proliferatum, F. oxysporum, F. solani, Lomentospora prolificans, and Candida albicans (each n=1). In conclusion, a diverse set of species involved in COVID-19-associated IFRS was observed in this study. Our data encourage specialist physicians to consider the possibility of involving various species in IFRS in immunocompromised and COVID-19 patients. In light of utilizing molecular identification approaches, the current knowledge of microbial epidemiology of invasive fungal infections, especially IFRS, may change dramatically.

Candida species associated with urinary tract infections

Around the world, candidemia is becoming more common. In the past thirty years, a number of factors, including the AIDS epidemic, an increase in the number of patients receiving immune-suppressive therapy for transplantation, and an increase in the use of antibiotics in hospital settings and even in the community, have changed the epidemiology of invasive fungal infections in general and candidemia in particular. Usage of broad-spectrum antibiotics, cancer treatment, Candida species colonization of mucosal surfaces and broad-spectrum use antifungal. Five species of the Candida genus are in charge of causing Urinary Tract Infections (UTIs): Candida albicans, C. glabrata, C. parapsilosis, C. tropicalis, and C. krusei. The key to managing candidemia episodes is early diagnosis and appropriate therapy.

Epidemiology of Invasive Fungal Infections in Solid Organ Transplant Recipients: an Indian Perspective.

Purpose of ReviewThis review summarizes the available Indian data on epidemiology of invasive fungal infections (IFI) in recipients of solid organ transplants (SOT). The epidemiology is further compared with studies from other parts of the world for each SOT type.Recent FindingsThe available studies on Indian epidemiology of IFI in SOT are scarce, though the number of SOTs performed in India have increased tremendously in recent years. The limited data from India present a distinct spectrum of infection in transplant recipients with high incidence of mucormycosis. During COVID-19 outbreak, IFI rate increased and renal transplant recipients acquired mucormycosis earlier than previous studies.SummaryMaximum data on IFI was available from renal transplant recipients, wherein mucormycosis was the predominant IFI in Indian patients in contrast to invasive candidiasis in majority countries. The other IFIs had varied spectrum. With the increasing number of SOTs being performed and the already persisting high burden of IFI in India, there is an urgent need of larger prospective studies on epidemiology of IFI in transplant recipients.

Epidemiology of Invasive Fungal Infections in Solid Organ Transplant Recipients: a North American Perspective

Epidemiology of Invasive Fungal Infections in Solid Organ Transplant Recipients: a North American Perspective

Antifungal Resistance and the Role of New Therapeutic Agents.

Purpose of ReviewAdvances in health care over time have led to an evolution in the epidemiology of invasive fungal infections. There is an increasing concern for antifungal resistance and emergence of less common fungal species for which optimal therapies are not well defined. The purpose of this review is to describe mechanisms of antifungal resistance and to evaluate the modern role of new and investigational antifungals.Recent FindingsIsavuconazole and ibrexafungerp represent the two newest antifungal agents. Evidence from in vivo and in vitro studies has been published recently to help define their place in therapy and potential roles in treating resistant fungi. Isavuconazole is a broad-spectrum triazole antifungal with evidence to support its use in invasive aspergillosis and mucormycosis. Its utility in treating voriconazole-resistant Candida should be confirmed with susceptibility testing if available. Ibrexafungerp is an oral glucan synthase inhibitor with little cross-resistance among currently available antifungals, including echinocandins. It is a promising new agent for invasive candidiasis, including azole-resistant Candida species, and in combination therapy with voriconazole for aspergillosis. Multiple antifungals, some with novel mechanisms, are in development, including rezafungin, oteseconazole, olorofim, fosmanogepix, and opelconazole.SummaryBoth isavuconazole and ibrexafungerp are welcome additions to the arsenal of antifungals, and the prospect of more antifungal options in the future is encouraging. Such an array of antifungals will be important as antifungal resistance continues to expand alongside evolving medical practices. However, managing resistant fungal infections will grow in complexity as the unique role of each new agent is defined.

Molecular mechanisms of acquired antifungal drug resistance in principal fungal pathogens and EUCAST guidance for their laboratory detection and clinical implications.

The increasing incidence and changing epidemiology of invasive fungal infections continue to present many challenges to their effective management. The repertoire of antifungal drugs available for treatment is still limited although there are new antifungals on the horizon. Successful treatment of invasive mycoses is dependent on a mix of pathogen-, host- and antifungal drug-related factors. Laboratories need to be adept at detection of fungal pathogens in clinical samples in order to effectively guide treatment by identifying isolates with acquired drug resistance. While there are international guidelines on how to conduct in vitro antifungal susceptibility testing, these are not performed as widely as for bacterial pathogens. Furthermore, fungi generally are recovered in cultures more slowly than bacteria, and often cannot be cultured in the laboratory. Therefore, non-culture-based methods, including molecular tests, to detect fungi in clinical specimens are increasingly important in patient management and are becoming more reliable as technology improves. Molecular methods can also be used for detection of target gene mutations or other mechanisms that predict antifungal drug resistance. This review addresses acquired antifungal drug resistance in the principal human fungal pathogens and describes known resistance mechanisms and what in-house and commercial tools are available for their detection. It is emphasized that this approach should be complementary to culture-based susceptibility testing, given the range of mutations, resistance mechanisms and target genes that may be present in clinical isolates, but may not be included in current molecular assays.

Epidemiology and Antifungal Susceptibility Patterns of Invasive Fungal Infections (IFIs) in India: A Prospective Observational Study.

The epidemiology of invasive fungal infections (IFI) is ever evolving. The aim of the present study was to analyze the clinical, microbiological, susceptibility, and outcome data of IFI in Indian patients to identify determinants of infection and 30-day mortality. Proven and probable/putative IFI (defined according to modified European Organization for Research and Treatment of Cancer/Mycoses Study Group and AspICU criteria) from April 2017 to December 2018 were evaluated in a prospective observational study. All recruited patients were antifungal naïve (n = 3300). There were 253 episodes of IFI (7.6%) with 134 (52.9%) proven and 119 (47%) probable/putative infections. There were four major clusters of infection: invasive candidiasis (IC) (n = 53, 20.9%), cryptococcosis (n = 34, 13.4%), invasive aspergillosis (IA) (n = 103, 40.7%), and mucormycosis (n = 62, 24.5%). The significant risk factors were high particulate efficiency air (HEPA) room admission, ICU admission, prolonged exposure to corticosteroids, diabetes mellitus, chronic liver disease (CLD), acquired immunodeficiency syndrome (AIDS), coronary arterial disease (CAD), trauma, and multiorgan involvement (p < 0.5; odds ratio: >1). The all-cause 30-day mortality was 43.4% (n = 110). It varied by fungal group: 52.8% (28/53) in IC, 58.8% (20/34) in cryptococcosis, 39.8% (41/103) in IA, and 33.9% (21/62) in mucormycosis. HEPA room, ICU admission for IC; HEPA rooms, diabetes mellitus for cryptococcosis; hematological malignancies, chronic kidney disease (CKD), sepsis, galactomannan antigen index value ≥1 for IA and nodules; and ground glass opacities on radiology for mucormycosis were significant predictors of death (odds ratio >1). High minimum inhibitory concentration (MIC) values for azoles were observed in C. albicans, C. parapsilosis, C. glabrata, A. fumigatus, A. flavus, R. arrhizus, R. microsporus, and M. circinelloides. For echinocandin, high MIC values were seen in C. tropicalis, C. guillermondii, C. glabrata, and A. fumigatus. This study highlights the shift in epidemiology and also raises concern of high MICs to azoles among our isolates. It warrants regular surveillance, which can provide the local clinically correlated microbiological data to clinicians and which might aid in guiding patient treatment.

GET THE MUNKII OFF YOUR BACK! A RARE BLACK MOLD CAPRONIA MUNKII CAUSING INVASIVE FUNGAL INFECTION IN AN IMMUNOCOMPROMISED INDIVIDUAL

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Individuals receiving chemotherapy or undergoing transplantation are increasingly susceptible to invasive fungal infections. They are commonly caused by opportunistic pathogens like Aspergillus and Candida and are associated with high morbidity and mortality. Such individuals are also susceptible to invasive mold infections. We present a rare case of a black mold Capronia munkii causing cavitary lung lesions in a patient with NHL. CASE PRESENTATION: A 65-year-old female with non-Hodgkin's Lymphoma, CNS lymphoma treated with chemotherapy and autologous stem cell transplant five years ago, had progression of disease last year. She began Ibrutinib therapy for her lymphoma. She was admitted to the hospital for altered mental status due to progression of CNS disease. She developed worsening respiratory failure during hospitalization requiring intubation and mechanical ventilation. She was empirically treated with intravenous vancomycin and piperacillin-tazobactam. Her initial infectious workup and lumbar puncture was negative. Computed tomography (CT) of her chest showed new diffuse ground glass opacities.Bronchial wash was notable for black mold Capronia munkii. She was started on Voriconazole and Amphotericin B. Repeat CT chest showed improving opacities with increasing apical cystic lesions. Respiratory failure can be attributed to mold infection in the lung, immunotherapy-induced pneumonitis and organizing pneumonia. After multiple failed spontaneous breathing trials and septic shock necessitating vasopressors, she was transitioned to comfort care and subsequently expired. DISCUSSION: Capronia munkii is a saprotrophic yeast commonly found on decaying plant matter. There is a lack of clinical information on this mold in literature. It is closely related phylogenetically to Exophiala dermatides which is a neurotrophic black mold. It typically causes a non-specific granulomatous inflammatory response. The host responses are highly variable, and include pulmonary cyst formation and tissue necrosis. The patient's immunosuppression and cystic lesions on CT scan make invasive black mold infection likely. Biopsy of the cavitary lesions to determine the presence of mold would have been confirmatory. The lack of response to anti-fungal treatment reiterates the high mortality associated with this rare infection. CONCLUSIONS: Invasive fungal infections have become more prevalent due to increasing number of individuals undergoing transplantation or receiving aggressive immunosuppression and chemotherapy. Early diagnosis and prompt treatment of uncommon pathogens like black mold with appropriate azole and caspofungin antibiotics is essential to prevent poor outcomes. Newer molecular techniques such as 18S ribosomal RNA PCR and genome sequencing have led to improved diagnosis.Treatment algorithms should be adapted to accommodate changing epidemiologies and anti-fungal drug resistance patterns. REFERENCE #1: Bassetti M, Bouza E. Invasive mould infections in the ICU setting: complexities and solutions. J Antimicrob Chemother. 2017 Mar 1;72(suppl_1):i39-i47. doi: 10.1093/jac/dkx032. PMID: 28355466. REFERENCE #2: Enoch DA, Yang H, Aliyu SH, Micallef C. The Changing Epidemiology of Invasive Fungal Infections. Methods Mol Biol. 2017;1508:17-65. doi: 10.1007/978-1-4939-6515-1_2. PMID: 27837497. REFERENCE #3: Badiee P, Hashemizadeh Z. Opportunistic invasive fungal infections: diagnosis & clinical management. Indian J Med Res. 2014 Feb;139(2):195-204. PMID: 24718393; PMCID: PMC4001330. DISCLOSURES: No relevant relationships by Padmastuti Akella, source=Web Response No relevant relationships by Saira Imran, source=Web Response No relevant relationships by Shashank Nuguru, source=Web Response

The Antifungal Pipeline: Fosmanogepix, Ibrexafungerp, Olorofim, Opelconazole, and Rezafungin.

The epidemiology of invasive fungal infections is changing, with new populations at risk and the emergence of resistance caused by the selective pressure from increased usage of antifungal agents in prophylaxis, empiric therapy, and agriculture. Limited antifungal therapeutic options are further challenged by drug–drug interactions, toxicity, and constraints in administration routes. Despite the need for more antifungal drug options, no new classes of antifungal drugs have become available over the last 2 decades, and only one single new agent from a known antifungal class has been approved in the last decade. Nevertheless, there is hope on the horizon, with a number of new antifungal classes in late-stage clinical development. In this review, we describe the mechanisms of drug resistance employed by fungi and extensively discuss the most promising drugs in development, including fosmanogepix (a novel Gwt1 enzyme inhibitor), ibrexafungerp (a first-in-class triterpenoid), olorofim (a novel dihyroorotate dehydrogenase enzyme inhibitor), opelconazole (a novel triazole optimized for inhalation), and rezafungin (an echinocandin designed to be dosed once weekly). We focus on the mechanism of action and pharmacokinetics, as well as the spectrum of activity and stages of clinical development. We also highlight the potential future role of these drugs and unmet needs.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40265-021-01611-0.

Evolución de la infección fúngica invasora en los últimos 30 años

Clinical mycology is in continuous development. The appearance of new clinical guidelines has made it possible to improve the approach to opportunistic fungal infections, especially in immunosuppressed patients (oncohematological and/or transplant recipients). At the same time, the development of new diagnostic tools and new antifungals with a greater spectrum of action and fewer side effects have led to faster diagnoses and treatments that are more effective. Along with these advances, there has been a change in the epidemiology of invasive fungal infection (IFI), with the appearance of new patients (e.g., COPD, liver cirrhosis, post-influenza) and new microorganisms (Candida auris, Lomentospora prolificans, mucorales), and resistant fungi (isolates of Aspergillus resistant to azoles) which the clinician must take into account when choosing the treatment of a patient with an IFI. In this paper we will briefly review the advances in recent decades and the emerging problems.

A 5-Year Review of Invasive Fungal Infection at an Academic Medical Center.

Background: Invasive fungal infection (IFI) is one of the most common nosocomial infections. However, data on the epidemiology of IFI and susceptibility to antifungal agents in China are quite limited, and in particular, no current data exist on the microbiological, and clinical characteristics of IFI patients in Northeast China.Objectives: The purpose of this study was to provide a retrospective review of the clinical characteristics, laboratory test results, and risk factor predictions of inpatients diagnosed with IFI. Multivariate regression analysis was used to assess prognostic factors associated with the mortality of these patients.Methods: We retrospectively analyzed the results from 509 patients with IFI extracted from the First Hospital of China Medical University from January 2013 to January 2018.Results: Neutrophil numbers, total bilirubin, length of stay in the ICU, renal failure, use of immunosuppressants within the past 30 days, stomach tube placement and septic shock were risk factors for death from IFI. Recent surgery (within 2 weeks) and drainage tube placement did not increase mortality in these IFI patients. Increased serum levels of PCT (AUC 0.601, 95% CI 0.536–0.665, P = 0.003) and CRP (AUC 0.578, 95% CI 0.512–0.644, P = 0.020) provided effective predictors of 30-day mortality rates.Conclusions: We report for the first time epidemiological data on invasive fungal infections in Northeast China over the past 5 years. Despite the limited available clinical data, these findings will greatly aid clinical health care workers with regard to the identification, prevention, and treatment of IFI in hospitalized patients.

Breakthrough invasive fungal infections: Who is at risk?

The epidemiology of invasive fungal infections (IFIs) in immunocompromised individuals has changed over the last few decades, partially due to the increased use of antifungal agents to prevent IFIs. Although this strategy has resulted in an overall reduction in IFIs, a subset of patients develop breakthrough IFIs with substantial morbidity and mortality in this population. Here, we review the most significant risk factors for breakthrough IFIs in haematology patients, solid organ transplant recipients, and patients in the intensive care unit, focusing particularly on host factors, and highlight areas that require future investigation.

Update on invasive fungal infections in the Middle Eastern and North African region.

In the recent years, the epidemiology of invasive fungal infections (IFIs) has changed worldwide. This is remarkably noticed with the significant increase in high-risk populations. Although surveillance of such infections is essential, data in the Middle Eastern and North African (MENA) region remain scarce. In this paper, we reviewed the existing data on the epidemiology of different IFIs in the MENA region. Epidemiological surveillance is crucial to guide optimal healthcare practices. This study can help to guide appropriate interventions and to implement antimicrobial stewardship and infection prevention and control programs in countries.

How can we optimise antifungal use in a solid organ transplant centre? Local epidemiology and antifungal stewardship implementation: A single-centre study.

We aimed to implement and to assess the impact of the antifungal stewardship programme (AFSp) on prescription appropriateness of antifungals, management and outcomes of candidaemia patients, and antifungal consumption and costs at our solid organ transplant (SOT) institute. Local epidemiology of invasive fungal infections (IFIs) from 2009 to 2017 was analysed in order to prepare an effective AFSp, implemented in January 2018. It included suspension of empirical antifungal prescriptions after 72hours (antifungal time-out), automated alert and infectious disease (ID) consult for empirical prescriptions and for every patient with IFI, and indication for step-down to oral fluconazole when possible. We used process measures and results measures to assess the effects of the implemented programme. The ASFp led to significant improvements in selection of the appropriate antifungal (40.5% in pre-AFS vs 78.6% in post-AFS), correct dosing (51.2% vs 79.8%), correct length of treatment (55.9% vs 75%) and better management of patients with candidaemia. Analysis of prescribed empirical antifungal revealed that defined daily doses (DDDs) per 100 patient days decreased by 36.7% in 2018 compared to the average of pre-AFSp period, with important savings in costs. This AFSp led to a better use of antifungal drugs in terms of appropriateness and consumption, with stable clinical and microbiological outcomes in patients with IFI.

Characteristics and risk factors for mortality of invasive non-Aspergillus mould infections in patients with haematologic diseases: A single-centre 7-year cohort study.

SummarySince mould‐active azole prophylaxis has become a standard approach for patients with high‐risk haematologic diseases, the epidemiology of invasive fungal infections (IFIs) has shifted towards non‐Aspergillus moulds. It was aimed to identify the epidemiology and characteristics of non‐Aspergillus invasive mould infections (NAIMIs). Proven/probable NAIMIs developed in patients with haematologic diseases were reviewed from January 2011 to August 2018 at Catholic Hematology hospital, Seoul, Korea. There were 689 patients with proven/probable invasive mould infections; of them, 46 (47 isolates) were diagnosed with NAIMIs. Fungi of the Mucorales order (n = 27, 57.4%) were the most common causative fungi, followed by Fusarium (n = 9, 19.1%). Thirty‐four patients (73.9%) had neutropenia upon diagnosis of NAIMIs, and 13 (28.3%) were allogeneic stem cell transplantation recipients. The most common site of NAIMIs was the lung (n = 27, 58.7%), followed by disseminated infections (n = 8, 17.4%). There were 23.9% (n = 11) breakthrough IFIs, and 73.9% (n = 34) had co‐existing bacterial or viral infections. The overall mortality at 6 and 12 weeks was 30.4% and 39.1%, respectively. Breakthrough IFIs (adjusted hazards ratio [aHR] = 1.99, 95% CI: 1.3‐4.41, P = .031) and surgical treatment (aHR = 0.09, 95% CI: 0.02‐0.45, P = .003) were independently associated with 6‐week overall mortality. NAIMIs were not rare and occur as a complex form of infection often accompanied by breakthrough/mixed/concurrent IFIs and bacterial or viral infections. More active diagnostic efforts for NAIMIs are needed.