Invasive Aspergillosis In Neutropenic Patients Research Articles

Nationwide Trends and Outcomes in Neutropenic Acute Leukemia Patients with Invasive Aspergillosis

Background: Invasive aspergillosis (IA) is one of the most dreaded complications in neutropenic patients with hematologic malignancies; risk significantly increases with chemotherapy, particularly during induction. It dramatically worsens the overall prognosis of the underlying malignancy and predisposes patients to undergo secondary interventions, thereby prolonging the duration of treatment and hospital stay. While prophylactic antifungal therapy has remarkably lowered the rates of IA, it remains a persistent problem in cancer treatment. The primary objective of our study is to explore the risk factors of IA in neutropenic patients with acute leukemias and its role in hospital stay, in-hospital mortality, and hospitalization costs. Methods: The Nationwide Inpatient Sample (NIS) database was queried to include all adults with acute leukemia admitted from 2012 and 2017, whose course was complicated by neutropenia. Those with and without invasive aspergillosis were compared. T-test was used to compare means of continuous variables and chi-square test to compare proportions of categorical variables. Multivariable logistic regression was used to evaluate risk factors for aspergillosis, as well as, inpatient mortality. Statistical tests for trends of resource utilization across six years were performed. Results: A total of 141,835 admissions met the inclusion criteria, of which, 2.5% had aspergillosis. Mean age (55.4 years) and gender (male 55.5%) did not significantly differ in neutropenic patients with and without aspergillosis. AML accounted for a larger proportion of the aspergillosis group (84.3% vs 76.9%, p<0.0001). Rates of HSCT and inpatient chemotherapy were comparable in both groups. Those with aspergillosis had higher inpatient mortality (15.8% vs 7.1%, p<0.0001) and more frequently required ICU-level care (12.9% vs 5.4%, p<0.0001) Independent risk factors for the development of aspergillosis included: Black race, receiving treatment at a teaching hospital, AML (compared to ALL) and poor nutritional status. On multivariate analysis, aspergillosis conferred an increased risk of inpatient mortality (aOR 2.57, 95% CI: 2.08-3.19, p<0.001), longer length of hospital stay by 7.4 days (95% CI: 6.0 to 8.8 days, p<0.001) and higher hospitalization costs by $37k per admission (95% CI: $29k-44k, p<0.001). Rates of aspergillosis decreased from 2.9% in 2012 to 2.2% in 2017 (trend P=0.03). In neutropenic acute leukemia patients without aspergillosis, there has been an improvement in inpatient mortality (from 7.3% in 2012 to 6.0% in 2017, trend P <0.01), as well as, length of hospital stay (17.5 days in 2012 to 16.7 days in 2017, trend P=0.02). However, there was no significant change in mortality or resource utilization among those with aspergillosis. Conclusions: Aspergillosis represents a significant challenge in the management of hematological malignancies. There is a delicate interplay between neutropenia and IA, with neutropenic patients more susceptible to invasive fungal infections, and IA further contributing to neutropenia. The encouraging trend in decreasing prevalence along the years is reflective of more aggressive prophylactic antifungal usage in acute leukemias, with the revised IDSA guidelines for aspergillosis being a cornerstone. However, mortality and resource utilization remain unchanged despite advances in diagnosis and treatment of aspergillosis. This data highlights the importance of prophylactic antifungals and maintaining a high index of suspicion for IA in neutropenic acute leukemia and the need of early focused treatment to improve clinical outcomes. Disclosures No relevant conflicts of interest to declare.

Role of Aspergillus Galactomannan Antigen Test for the Screening of Invasive Aspergillosis in Patients with Hematological Malignancies

Background: Invasive aspergillosis (IA) is a leading cause of death among immunocompromised patients, particularly those with hematological malignancies. The use of galactomannan (GM) antigen as a biological marker for screening of IA in high-risk patients is attractive and non-invasive tool that detect evidence of IA prior to the appearance of clinical manifestations.
 Objectives: The aim of this study was to compare the diagnostic value of the conventional blood culture technique to the serological detection of GM antigen using ELISA for screening of IA in neutropenic patients with hematological malignancies.
 Methods: Forty patients with haematological malignancies from those admitted to the Clinical Oncology Department of Menoufia University Hospitals (MUH) were enrolled and classified to have either proven (5/40; 12.5%), probable (10/40; 25%) or possible (25/40; 62.5%) invasive aspergillosis based on the clinical criteria provided by the European Organization for research and treatment of Cancer (EORTC) and Mycoses Study Group (MSG). Blood samples were collected from all participants and subjected to conventional blood culture for isolation and identification of Aspergillus spp. ELISA technique was applied for serological detection of GM antigen in the patients’ serum samples.
 Results: The sensitivity, specificity, PPV(positive predictive value) and NPV (negative predictive value of GM antigen ELISA testing were 100%, 74%, 36% and 100% respectively for both proven and probable cases. On applying the principle of test in series (the patient is positive if positive in both culture and the GM test), the results were improved to 100% sensitivity, 100% specificity, 100% PPV, 100% NPV and 100% accuracy. Galactomannan antigen testing proved excellent sensitivity (80%) compared to other clinical features and radiological criteria for diagnosis of probable aspergillosis and proved to be a good negative test.
 Conclusion: With conjunction of clinical and radiological signs, Aspergillus GM test can assist physicians in the of diagnosis of IA in patients with hematological malignancies to allow initiation of effective antifungal therapy which is ultimately important in high-risk populations.

Use of Micafungin for the Management of a Cluster of Invasive Aspergillosis in Children with Cancer

Background: Progressive increase of the capacity to cure children with cancer makes their rescue from life-threatening infectious complications, such as invasive fungal infections, a compelling challenge. Local outbreak among patients at risk may occur, and the optimal strategy for their management, including prophylactic regimens, is not defined.
 Purpose: We describe our experience in the use of micafungin to break a cluster of invasive aspergillosis in children and adolescent with cancer.
 Methods: Since study start, all in-patients who had severe neutropenia (<500/mm3) received prophylaxis with micafungin (1 mg/kg; ≤50 mg) daily i.v. until discharge. Serial testing of galactomannan was used as screening test for invasive aspergillosis; lung computed tomography was performed in patients who tested positive at repeated assay.
 Results: Among 27 patients enrolled, one was excluded due to breakthrough invasive aspergillosis diagnosed on day 2. The remaining 26 patients were observed for a minimum of 90 days. Four patients had one positive galactomannan test; this was confirmed at second (but not at third) serial assay in a single patient. None of the patients developed invasive aspergillosis. The drug was very well tolerated, with no side effects related to micafungin administration. The total cost of the drug used for this “prophylaxis” in the study patients was €30.451, with a mean cost per patient of €1.133.
 Conclusions: “Prophylactic” use of micafungin was safe, feasible and turned out to be associated with breaking the cluster of invasive aspergillosis in neutropenic patients exposed to an environmental risk. The pharmaco-economic evaluation also turned to be highly favorable.

Performance of serum (1,3)‐ß‐d‐glucan screening for the diagnosis of invasive aspergillosis in neutropenic patients with haematological malignancies

We report our experience with the use of (1,3)-ß-d-glucan (BDG) screening for the diagnosis of invasive aspergillosis (IA) in neutropenic patients with haematological malignancies. The performance of BDG screening was assessed retrospectively in per patient and per sample analyses. Overall, 20 among 167 patients developed IA (12%). In the per patient analysis, BDG showed 60% sensitivity and 78% specificity when the criterion for positivity was the presence of at least one BDG value ≥80pg/mL. For 2 consecutive positive results, sensitivity decreased to 40%, while specificity increased to 93% and was similar to that of a positive galactomannan (GM; 90%). The highest specificity (97%) was observed for combined positivity of at least one BDG and at least one GM. In the per sample analysis, the specificity of BDG was 100% in the best scenario, 96% in the median scenario and 89% in the worst scenario. BDG became positive before GM in 33% of IA patients with both markers positive (n=12). Despite good specificity for 2 consecutive positive results, the BDG test offered unsatisfactory performance for the diagnosis of IA due to low sensitivity. The combination of BDG and GM showed the potential for increasing specificity.

Host immune status-specific production of gliotoxin and bis-methyl-gliotoxin during invasive aspergillosis in mice

Delayed diagnosis in invasive aspergillosis (IA) contributes to its high mortality. Gliotoxin (GT) and bis-methyl-gliotoxin (bmGT) are secondary metabolites produced by Aspergillus during invasive, hyphal growth and may prove diagnostically useful. Because IA pathophysiology and GT’s role in virulence vary depending on the underlying host immune status, we hypothesized that GT and bmGT production in vivo may differ in three mouse models of IA that mimic human disease. We defined temporal kinetics of GT and bmGT in serum, bronchoalveolar lavage fluid (BALF) and lungs of A. fumigatus-infected chronic granulomatous disease (CGD), hydrocortisone-treated, and neutropenic mice. We harvested lungs for assessment of fungal burden, histology and GT/bmGT biosynthetic genes’ mRNA induction. GT levels were higher in neutropenic versus CGD or steroid-treated lungs. bmGT was persistently detected only in CGD lungs. GT, but not bmGT, was detected in 71% of sera and 50% of BALF of neutropenic mice; neither was detected in serum/BALF of CGD or steroid-treated mice. Enrichment of GT in Aspergillus-infected neutropenic lung correlated with fungal burden and hyphal length but not induction of GT biosynthetic genes. In summary, GT is detectable in mouse lungs, serum and BALF during neutropenic IA, suggesting that GT may be useful to diagnose IA in neutropenic patients.

The Plasmair Decontamination System Is Protective Against Invasive Aspergillosis in Neutropenic Patients.

OBJECTIVE Invasive aspergillosis (IA) is a rare but severe infection caused by Aspergillus spp. that often develops in immunocompromised patients. Lethality remains high in this population. Therefore, preventive strategies are of key importance. The impact of a mobile air decontamination system (Plasmair, AirInSpace, Montigny-le-Bretonneux, France) on the incidence of IA in neutropenic patients was evaluated in this study. DESIGN Retrospective cohort study METHODS Patients with chemotherapy-induced neutropenia lasting 7 days or more were included over a 2-year period. Cases of IA were confirmed using the revised European Organization for Research and Treatment of Cancer (EORTC) criteria. We took advantage of a partial installation of Plasmair systems in the hematology intensive care unit during this period to compare patients treated in Plasmair-equipped versus non-equipped rooms. Patients were assigned to Plasmair-equipped or non-equipped rooms depending only on bed availability. Differences in IA incidence in both groups were compared using Fisher's exact test, and a multivariate analysis was performed to take into account potential confounding factors. RESULTS Data from 156 evaluable patients were available. Both groups were homogenous in terms of age, gender, hematological diagnosis, duration of neutropenia, and prophylaxis. A total of 11 cases of probable IA were diagnosed: 10 in patients in non-equipped rooms and only 1 patient in a Plasmair-equipped room. The odds of developing IA were much lower for patients hospitalized in Plasmair-equipped rooms than for patients in non-equipped rooms (P=.02; odds ratio [OR] =0.11; 95% confidence interval [CI], 0.00-0.84). CONCLUSION In this study, Plasmair demonstrated a major impact in reducing the incidence of IA in neutropenic patients with hematologic malignancies. Infect Control Hosp Epidemiol 2016;37:845-851.

Invasive aspergillosis in neutropenic patients during hospital renovation: effectiveness of mechanical preventive measures in a prospective cohort of 438 patients.

Aspergillus species are the main cause of invasive fungal disease for patients with severe and prolonged neutropenia. Building or renovation works have been shown as one of the major causes of outbreaks of aspergillosis. This study aimed to assess the effectiveness of introduction and adaptation by air sampling of mechanical preventive measures on the incidence of invasive pulmonary aspergillosis in neutropenic patients during hospital renovation. All of the patients admitted for prolonged and severe neutropenia during a renovation period from 2003 to 2008 were prospectively enrolled. Invasive pulmonary aspergillosis (IPA) cases were classified as possible, probable, and proven, according to the 2008 European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group criteria. The effectiveness of preventive measures was determined by air sampling. We recorded 705 hospitalizations for neutropenia concerning 438 patients. The majority of hospitalized neutropenic patients was treated for acute leukemia (38.3 %), followed by patients suffering from non-Hodgkin and Hodgkin lymphomas (33 %). The total cumulative incidence of probable and proven IPA was 4.1 %. Risk factors for developing IPA were underlying disease, treatment course at the time of hospitalization, and the mean duration of hospitalization and of neutropenia. In this prospective study, the incidence of invasive pulmonary aspergillosis did not increase in neutropenic patients during a renovation period because of efficient mechanical preventive measures systematically adjusted using the results of air sampling.

Clinical utility and prognostic value of galactomannan in neutropenic patients with invasive aspergillosis

Invasive aspergillosis (IA) is a major cause of morbidity and mortality in profoundly neutropenic patients. Delayed diagnosis and therapy may lead to poor outcomes. AimsThe objective of this study was to assess the performance characteristics of the galactomannan (GM) assay in serum and bronchoalveolar lavage specimens for the diagnosis of IA in neutropenic patients with hematological malignancies. We also evaluated the prognostic outcome. Patients and methodsA total of 1198 serum samples and 42 BAL from 235 neutropenic patients were tested with a GM elisa platelia test. We used Cox modeling of time to 6- and 12-week mortality for GM level at the time of diagnosis (GM0) and GM decay in the week following diagnosis in proven and probable IA patients with more than two GM values. ResultsThere were three proven, 55 probable, and four possible cases of IA. The sensitivity and specificity of the GM test were 96.8% and 82.4% respectively. In BAL samples, sensitivity was 86% and the specificity 93%. BAL GM was more sensitive than microscopy (22.2%) and BAL culture (38.9%). Among patients with proven/probable IA, serum and BAL GM were in agreement for 92.8% of paired samples. The hazard ratio (HR) of GM0 and 1-week GM decay per unit increase in Aspergillus enzyme immunoassay (EIA) was 1.044 (95% CI, 0.738 to 1.476) and 0.709 (95% CI, 0.236 to 2.130) respectively. ConclusionWe found good correlation between the GM0 and GM decay combination and outcome of IA patients. The GM is a useful tool for diagnosis and monitoring of IA.

Pandemic 2009 influenza A(H1N1) virus infection coinciding with invasive pulmonary aspergillosis in neutropenic patients

SIn patients receiving anti-neoplastic chemotherapy, the impact of influenza on the incidence of invasive pulmonary aspergillosis (IPA) remains unknown. We matched data of the Cologne Cohort of Neutropenic Patients (CoCoNut) with records from the Institute for Virology and compared the findings to historical data. During the pandemic, we diagnosed influenza A(H1N1) in five patients with malignancies and febrile neutropenia refractory to antibiotic therapy. Probable IPA was diagnosed in three of these patients on the grounds of typical computed tomography morphology and microbiological results. Three of five patients receiving remission-induction chemotherapy for acute myeloid leukaemia developed aspergillosis although receiving posaconazole prophylaxis. In the 3 years before the influenza pandemic, only 2/77 patients of this group developed infection. Infection with influenza A(H1N1) may increase the risk for invasive aspergillosis in neutropenic patients. Pulmonary aspergillosis is an important additional differential diagnosis in neutropenic influenza patients with pneumonia.

Identification and Characterization of Human Aspergillus Fumigatus-Specific Tr1-(Like) Cells

Abstract 181 Introduction:The ubiquitous mold Aspergillus fumigatus (A. fumigatus) induces two forms of pathogenesis: invasive aspergillosis in neutropenic patients and allergic aspergillosis in patients with chronic obstructive lung disease as well as in immunosuppressed patients. Mouse models of aspergillosis suggest that not only effector T cells (Teff) but also regulatory T cells (Treg) play a crucial role for the regulation of a protective T cell-mediated immunity to A. fumigatus. However, it is little-known about the involvement of Treg during A. fumigatus infection in humans. In order to develop new therapeutical strategies for the treatment of aspergillosis this project aims to understand the influence of regulatory T cells on A. fumigatus infection in humans.Material/Methods: A. fumigatus-specific CD4+ T cell clones were established from PBMC of healthy donors. Based on this clone pool Treg clones were identified due to their inability to proliferate in the absence of costimulation assessed by 3[H]-TdR incorporation as well as their Ag-specific cytokine production and phenotype determined by flow cytometry. Treg function was analyzed by their ability to suppress proliferation of autologous CD4+ T cells using CFSE dilution. Results:We identified A. fumigatus-specific T cell clones that exhibited marginal detectable proliferation after restimulation with immobilized anti-CD3 mAb in the absence of costimulation. However, these T cell clones vigorously proliferated in response to restimulation with their cognate antigen. A more detailed characterization showed that these suppressor T cell clones produced high amounts of IL-10 and moderate levels of IFN-gamma upon Ag-specific restimulation and expressed low amounts of Foxp3 but not Helios, a transcription factor that had recently been linked to natural occurring Treg. Most importantly, these T cell clones suppressed Ag-specific expansion of CD4+ Teff. This effect was contact-independent since suppression of Ag-specific CD4+ T cell expansion detected in transwell experiments was comparable to cocultures that enabled cellular-contact. Furthermore, anti-CD3/CD28-induced proliferation of naïve CD4+ T cells was not reduced in the presence of culture supernatants obtained from suppressor T cell clones after their antigen-specific restimulation in the absence of DCs. Conclusions:We identified for the first time A. fumigatus-specific CD4+ T cell clones with a Tr1(-like) IL-10+IFN-gamma+Foxp3lowHelios− phenotype. These cells suppressed expansion of A. fumigatus-specific Teff in an Ag-specific manner mediated by soluble factors released from Tr1(-like) cell clones. Since these factors did not affect CD4+ T cell proliferation in the absence of DCs our data suggest, that Tr1(-like) cell clones rather negatively regulate the stimulatory capacity of DCs leading to a reduced expansion of Ag-specific CD4+ T cells. Therefore these Tr1(-like) cells might play a protective role during A. fumigatus infection in humans. Thus, adoptive transfer of A. fumigatus-specific Treg could be useful to enhance protective immunity in patients with chronic A. fumigatus infection. Disclosures:Topp:Micromet: Consultancy, Honoraria.

Twenty-nine cases of invasive aspergillosis in neutropenic patients

Introduction Invasive aspergillosis is a life-threatening infectious complication in hematological patients undergoing immunosuppressive chemotherapy. Patients and methods We report 29 cases of invasive aspergillosis diagnosed in the Sousse Farhat Hached hospital Hematology unit, Tunisia, between 2002 and 2010. Results The most frequent disease (65.5%) was acute myeloid leukemia. All patients were severely neutropenic (< 500/mm 3, mean duration = 27 days). Pulmonary invasive aspergillosis was suggested in 28 (96.5%) cases. The most frequent respiratory signs were cough (64.3%), chest pain (53.6%), and hemoptysis (50%). The chest X-ray showed suggestive lesions in 60.7% of cases. CT scans revealed nodules with cavitation in 65% of cases, a halo sign in 20% of cases, and nodules in 15% of cases. Galactomannan antigenemia was positive in 88%, mycological examination positive in 51.6%, and seroconversion was noted in 35.7% of the cases. Invasive pulmonary aspergillosis was classified, according to EORTC/MSG criteria, as probable in 26 cases, possible in one case, and proven in one case. Aspergillus flavus was the dominant species in pulmonary invasive aspergillosis accounting for 73.7% of isolates. Extrapulmonary involvement was suggested in 39.3% of cases, the most frequent were sinusitis and brain abscess. Primary cutaneous aspergillosis was observed in one case. The overall mortality rate was 64.2%; the 12-week survival rate was 71.4%. Conclusion Our results are correlated to published data. A. flavus was the most frequent species in our region.

Chronic Granulomatous Disease: Lessons from a Rare Disorder

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency with X-linked or autosomal recessive inheritance involving defects in genes encoding phox proteins, which are the subunits of the phagocyte NADPH oxidase. This results in failure to produce superoxide anion and downstream antimicrobial oxidant metabolites and to activate antimicrobial proteases. Affected patients are susceptible to severe, life-threatening bacterial and fungal infections and excessive inflammation characterized by granulomatous enteritis resembling Crohn's disease and genitourinary obstruction. Early diagnosis of CGD and rapid treatment of infections are critical. Prophylaxis with antibacterial and mold-active antifungal agents and the administration of interferon-γ has significantly improved the natural history of CGD. Currently, the only cure is allogeneic hematopoietic cell transplant (HCT), although there remains controversy as to which patients with CGD should get a transplant. Allele-based HLA typing of alternative donors, improved supportive care measures, and use of reduced toxicity conditioning have resulted in event-free survival (EFS) of at least 80% even with an unrelated donor and even better when the patient has no active infections/inflammation. Gene correction of CGD would eliminate the risks of graft-versus-host disease (GVHD) and the immunoablative chemotherapy required for allogeneic HCT. Based on gene therapy trials in patients with SCID-X1, ADA-SCID, and the early experience with CGD, it is clear that at least some degree of myeloablation will be necessary for CGD as there is no inherent selective growth advantage for gene-corrected cells. Current efforts for gene therapy focus on use of lentivector constructs, which are thought to be safer from the standpoint of insertional mutagenesis and more efficient in transducing hematopoietic stem cells (HSCs).

Pathogen-Specific DNA Enrichment Does Not Increase Sensitivity of PCR for Diagnosis of Invasive Aspergillosis in Neutropenic Patients

PCR assays designed for the diagnosis of invasive aspergillosis (IA) in high-risk patients have to detect minute amounts of target DNA to reach sufficient analytical sensitivity to be of clinical use. This prospective study assessed the use of a novel strategy for selective pathogen DNA enrichment for enhancing the performance of diagnostic PCR in a direct comparison with a highly sensitive in-house quantitative PCR (qPCR) assay and the galactomannan enzyme-linked immunosorbent assay (ELISA). Surprisingly, and in contrast to experience with other patient groups, the novel protocol for selective pathogen DNA enrichment did not enhance but instead significantly impaired sensitivity. This could be explained by the small amounts of host DNA in the specimens, which were derived mostly from severely neutropenic patients. In the qPCR assay, positive samples required an average of 43.5 amplification cycles (range, 39.2 to 50) for detection in the in-house PCR. Repetitive testing of selected samples showed test positivity to be variable, most likely due to the small amounts of target DNA. Despite this, the in-house protocol proved helpful in the diagnosis of IA, detecting 2 out of 3 patients with probable IA and 10 out of 19 patients with possible IA. Our results underline the necessity for diagnostic PCR protocols that help diagnose IA to be highly sensitive and show that selective pathogen DNA enrichment using affinity purification may not be useful in severely neutropenic patients.

Report from the 4th Advances Against Aspergillosis Conference

Traditionally, the patients believed to be at highest risk of invasive aspergillosis (IA) are those who are neutropenic due to chemotherapy for hematological malignancy or those undergoing allogeneic hematopoietic stem cell transplantation. However, emerging data show that other patients are vulnerable to IA, even though some are not classically immunocompromised. These include: solid organ transplant recipients; patients with TB, chronic obstructive pulmonary disease and patients in the intensive care unit for other reasons. The conference highlighted the diagnostic and therapeutic challenges facing physicians treating this diverse group, not least of which include the unreliable estimates of IA incidence due to poor surveillance and inadequate data collection. Moreover, although there is now considerable experience of IA in neutropenic patients, much less is known about the management of those who are non-neutropenic. Nevertheless, approaches that have proven effective in neutropenic patients may also benefit others in this growing population. The meeting, attended by more than 500 delegates from almost 50 countries, also provided the opportunity to hear how basic scientific research may improve the understanding of the pathogenic mechanisms and therapy of IA.

Early Diagnosis of Invasive Aspergillosis in Neutropenic Patients. Comparison between Serum Galactomannan and Polymerase chain Reaction

Invasive aspergillosis (IA) is a major cause of morbidity and mortality in profoundly neutropenic patients, so early diagnosis is mandatory. Consecutive patients with hematological malignancies undergoing intensive chemotherapy were screened for IA with two different methods which were compared. From October 2000 to August 2003 we tested 1311 serum samples from 172 consecutive patients with a polymerase chain reaction assay and between April 2005 and April 2008 we tested 806 serum samples from 169 consecutive patients with a Galactomannan (GM) test. Bronchoalveolar (BAL) samples were obtained whenever the patient's condition allowed and tested with either method. The serum PCR assay had a sensitivity of 75.0% and a specificity of 91.9% and the serum GM assay had a sensitivity of 87.5% and a specificity of 93.1%, (P > 0.05). The presence of two or more consecutive positive serum samples was predictive of IA for both assays. BAL GM/PCR was positive in some patients without serum positivity and in patients with 2 or more positive serum GM/PCR. No significant differences between the 2 serum tests were found. The GM assay has the advantage of being standardized among several laboratories and is incorporated in the criteria established by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycosis Study Group (EORTC/MSG), however is much more expensive. BAL GM and PCR sampling aids in IA diagnosis but needs further validation studies to differentiate between colonization and true infection in cases where serum GM or PCR are negative.

Characterization and identification of proteases secreted by Aspergillus fumigatus using free flow electrophoresis and MS

Early diagnosis of life-threatening invasive aspergillosis in neutropenic patients remains challenging because current laboratory methods have limited diagnostic sensitivity and/or specificity. Aspergillus species are known to secrete various pathogenetically relevant proteases and the monitoring of their protease activity in serum specimens might serve as a new diagnostic approach.For the characterization and identification of secreted proteases, the culture supernatant of Aspergillus fumigatus was fractionated using free flow electrophoresis (Becton Dickinson). Protease activity of separated fractions was measured using fluorescently labeled reporter peptides. Fractions were also co-incubated in parallel with various protease inhibitors that specifically inhibit a distinct class of proteases e.g. metallo- or cysteine-proteases. Those fractions with high protease activity were further subjected to LC-MS/MS analysis for protease identification. The highest protease activity was measured in fractions with an acidic pH range. The results of the 'inhibitor-panel' gave a clear indication that it is mainly metallo- and serine-proteases that are involved in the degradation of reporter peptides. Furthermore, several proteases were identified that facilitate the optimization of reporter peptides for functional protease profiling as a diagnostic tool for invasive aspergillosis.

Risk factors for invasive aspergillosis in neutropenic patients with hematologic malignancies

Risk factors for invasive aspergillosis (IA) are incompletely identified and may undergo changes due to differences in medical practice. A cohort of 189 consecutive, adult patients with neutropenia hospitalized in the hemato-oncology ward of the University hospital Berne between 1995 and 1999 were included in a retrospective study to assess risk factors for IA. In total, 45 IA cases (nine proven, three probable, 33 possible), 11 patients with refractory fever and 133 controls were analyzed. IA cases had more often acute leukemia or myelodysplastic syndrome (MDS) (88 vs 38%, P < 0.001) and a longer duration of neutropenia (mean 20.6 vs 9.9 days, P < 0.001). They also had fewer neutropenic episodes during the preceding 6 months (mean 0.42 vs 1.03, P < 0.001), that is, confirmed (82%) and probable (73%) IA occurred most often during the induction cycle. A short time interval ( < or = 14 days) between neutropenic episodes increased the risk of IA four-fold (P = 0.06). Bacteremia, however, was not related to the number of preceding neutropenic episodes. Therefore, neutropenic patients with leukemia or MDS have the highest risk of IA. The risk is highest during the first induction cycle of treatment and increases with short-time intervals between treatment cycles.

Clinical evaluation of the adverse effects of voriconazole in the management of hemopoeitic stem cell transplant patients

Fungal infection is one of the most important causes of morbidity and mortality in hemopoeitic stem cell transplant (HSCT) recipients. The growing incidence of fungal infection is related to several factors including prolonged granulocytopenia, use of broad-spectrum antibiotics, conditioning regimens, and use of immunosuppression to avoid graft-versus-host disease. Amphotericin B with or without 5-flucytosine is considered the standard therapy for acute candidiasis with fluconazole as an alternative. Amphotericin B is also the first-line therapy for invasive aspergillosis in neutropenic patients. However nephrotoxicity is a major side effect of amphothericin B, particularly in patients with HSCT needing cyclosporine concurrently with amphotericin B. Both of these drugs are nephrotoxic and impaired renal function may be observed. Even with the development of the liposomal formulations of amphotericin B, there is still about a 20% risk of nephrotoxicity. Possible liposomal amphotericin B-induced nephrogenic diabetes insipidus has also been reported. Third generation triazoles have become available and have broadened the spectrum of effects against invasive aspergillosis. The efficacy of voriconazole (VRC) in the treatment of invasive aspergillosis in patients with acute myeloid leukemia undergoing HSCT has been reported. However there is no report regarding the adverse effects of VRC in the management of HSCT patients (PubMed Jan. 2001-Oct. 2003). Therefore we conducted this retrospective study to assess the adverse effects of VRC in HSCT patients (Jan. 2002 to Oct. 2003) and to evaluate the safety of the empiric use of VRC in HSCT patients. A total of 31 patients post HSCT received VRC. The characteristics of the patients are shown in table.1. All adverse events and laboratory abnormalities during treatment and follow-up were recorded and their relationship to VRC was determined. There were two patients with mild elevation in liver function tests not necessitating discontinuation of VRC with spontaneous normalization of liver function tests while on VRC. There was one patient with confusion, noted three days after the initiation of VRC while on narcotics. The confusion resolved upon discontinuing VRC and adjusting narcotics. VRC was not restarted due to resolution of fever and engraftment. Unlike prior reports we did not observe any skin rashes or visual disturbances. Our experience confirms the safety and tolerability of VRC in HSCT patients. TableNumber of patients31Mean age (range)48 (25–65)SexMale 24 (77%), Female 7 (23%)Underlying diseaseAML 11 (36%), NHL 7 (22%), HD 4 (13%), MM 4 (13%), ALL 3 (10%), CML 1 (3%), Germ cell 1 (3%)Type of HSCTAuto 28 (90%), Allo 3 (10%)Mean days of neutropeina (range)19 (7–57)Route of VRC administrationPO 15 (49%), IV 10 (32%), IV+PO 6 (19%)Dose of VRC400mg q12hr for two doses then 200mg q 12hrMean days of VRC administration (range)13 (2–45)Adverse effectsElevation of LFT’s 2 (6%), Confusion 1 (3%)HSCT, hemopoietc stem cell transplant; VRC, voriconazole; AMI, acute myeloid leukemia; CML, chronic myeloid leukemia; ALL, acute lymphoid leukemia; MM, multiple myeloma; HD, Hodgkin’s disease; NHL, non-Hodgkin’s lymphoma; LFT, liver function test.

Treatment of Documented and Suspected Neutropenia-Associated Invasive Fungal Infections

Factors such as the intensification of anti-tumor regimens have enhanced both the depth and length of neutropenia and endorsed severe deficiencies in other immune systems. As a result, the risk of fungal infections has increased substantially. Clinicians should be aware of the possibility to enable a timely diagnosis because many of the problems in the management of invasive fungal infections during neutropenia are as much the consequence of diagnostic shortcomings as of lack of therapeutic options. About 7% of all febrile episodes during neutropenia can ultimately be attributed to fungi, Candida and Aspergillus species being the paramount pathogens. Although the data in favor of prophylactic use of antifungals are not convincing, prophylaxis is still recommended in an attempt to protect particularly high-risk patients. Fluconazole still appears a suitable agent in recipients of a bone marrow transplant. Given the paucity of data, reappraisal of the value of empirical antifungal therapy is warranted. Amphotericin B with or without 5-flucytosine is considered the standard therapy for acute candidiasis with fluconazole as an alternative. Amphotericin B is also first-line therapy for invasive aspergillosis in neutropenic patients; lipid-based formulations are recommended for patients who develop nephrotoxity. Recovery of the granulocytes and other immune systems has shown to be of critical importance in the management of all invasive fungal infections.

Invasive aspergillosis in neutropenic patients: rapid neutrophil recovery is a risk factor for severe pulmonary complications.

In invasive aspergillosis, the duration of neutropenia is an accepted risk factor, and recovery from neutropenia is generally associated with a favourable outcome. However, the rapidity of granulocyte recovery may rarely be associated with adverse sequelae. The purpose of this study was to define the relationship between neutrophil (polymorphonuclear, PMN) recovery after chemotherapy-induced bone marrow aplasia and the occurrence of severe pulmonary complications (haemoptysis, pneumothorax and death) in patients with haematological malignancies who developed invasive fungal pneumonias. Twenty consecutive patients were retrospectively studied; eight of them had developed pulmonary events between 5 and 11 days after neutrophil recovery that followed deep neutropenia (PMN < 100 microL-1). Five patients had haemoptysis (one of these also had pneumothorax) and three had pneumothorax. According to the multiplicative logistic model, the odds of occurrence of a pulmonary event increased significantly with increasing PMN count on the fifth day (P < 0.001). Five of the eight patients who had pulmonary complications died. Also, the risk of death was larger in the presence of rapid neutrophil recovery, although the difference was not statistically significant (P = 0.111). Analysis of clinical and laboratory data showed that the risk of pulmonary complications significantly increased when the neutrophil concentration was > 4500 microL-1 on day 5 after deep granulocyte neutropenia (PMN < 100 microL-1). There was no correlation between pulmonary complications, dosage of amphotericin B and deaths. The occurrence of life-threatening complications in patients with invasive fungal pneumonia is closely related to rapid PMN recovery.