RESUMO
The fusariosis is an opportunistic mycosis caused by Fusarium spp. Its clinical presentation depends on the immunological status of the host, especially in patients with hematooncological diseases, whose manifestations vary from localized to invasive fungal infections. Skin or blood culture helps to guide combined antifungal treatment with amphotericin B and voriconazole. Here, we present 13 cases in a period of eleven years of patients with cancer who developed disseminated fusariosis and their outcomes, together with a review of the related literature. In this series of cases, mortality was 61.5 % (8/13), despite the use of the antifungal. Out of the 13 cases, 11 had hematological neoplasia and 2 solid neoplasia. The most determinant risk factor was profound neutropenia. Skin involvement and positive blood cultures in most cases allowed combined treatment prescription. Persistent febrile neutropenia associated with skin lesions, onychomycosis, nodules, or lung masses lead to suspicion of Fusarium spp. fungal invasive infection. The aim of this series of cases is to remind healthcare professionals that oncological patients with deep and persistent febrile neutropenia can develop fusariosis.
La fusariosis es una micosis oportunista producida por Fusarium spp. Su presentación clínica depende del estado inmunológico del huésped, especialmente, el de aquellos con enfermedades hematooncológicas, cuyas manifestaciones varían desde formas localizadas hasta infección fúngica invasora. El cultivo de piel o de sangre permite orientar el tratamiento antifúngico combinado con anfotericina B y voriconazol. Se presentan 13 casos de pacientes con cáncer en un periodo de once años que desarrollaron fusariosis diseminada; asimismo, se hizo con una revisión extensa de la literatura. En esta serie de casos, la mortalidad fue del 61,5 % (8/13), a pesar del uso del antifúngico. De los 13 pacientes, 11 tenían neoplasia hematológica y 2 neoplasia sólida. El factor de riesgo más importante fue la neutropenia profunda. El compromiso de la piel y los hemocultivos positivos facilitaron la prescripción del tratamiento combinado en la mayoría de los casos. La neutropenia febril persistente asociada a lesiones cutáneas, la onicomicosis, los nódulos o las masas pulmonares permitieron sospechar una infección fúngica invasora por Fusarium spp. El objetivo de la presentación de esta serie de casos es recordar el diagnóstico de fusariosis a la comunidad médica en contacto con pacientes oncológicos, con neutropenia febril profunda y persistentes.
Assuntos
Neutropenia Febril , Fusariose , Neoplasias , Humanos , Fusariose/tratamento farmacológico , Fusariose/etiologia , Antifúngicos/uso terapêutico , Pesquisa , Neoplasias/complicaçõesRESUMO
Fungemia caused by Geotrichum spp. is rare and highly lethal. The Instituto Nacional de Cancerología in Bogotá reported just two cases: one in the period 2001-2007 and the other in 2012-2018. This type of infection is more common in any kind of immunocompromised patients, so it can occur in those with hematological malignancies. Here we present the case of a 27-year-old man, diagnosed with acute lymphoblastic leukemia in relapse and admitted with polyarthralgia for five days, febrile neutropenia, nonabscessed cellulitis, and bacteremia due to methicillin-sensitive Staphylococcus aureus. The patient received therapy with oxacillin and cefepime, but the febrile neutropenia persisted. A new set of blood cultures was taken, and antifungal treatment was started because of the suspicion of invasive fungal infection. Arthroconidia were identified in blood cultures and Geotrichum spp. was confirmed using matrix-assisted laser desorption-ionization mass spectrometry. The antifungal treatment was adjusted with amphotericin B deoxycholate for 14 days and voriconazole for four weeks, and after a prolonged stay, the patient was discharged. Although the incidence of fungemia caused by Geotrichum spp. is low, it must be considered in patients with hematological malignancies and persistent febrile neutropenia despite the broadspectrum antimicrobial treatment. The confirmation of fungemia causing agents, with proteomic tools such as the mentioned mass spectrometry, allows treatment adjustment and decreases complications, hospital stay, and mortality.
La fungemia por Geotrichum spp. es poco frecuente y altamente letal. En el Instituto Nacional de Cancerología de Bogotá solo se han reportado dos casos: uno entre el 2001 y el 2007, y el otro entre el 2012 y el 2018. Este tipo de infección es más común en pacientes con algún grado de compromiso del sistema inmunitario, por lo que puede presentarse en pacientes con neoplasias hematológicas malignas. Se presenta el caso de un hombre de 27 años con recaída de leucemia linfoblástica aguda, que ingresó con poliartralgias de cinco días de duración. También cursaba con neutropenia febril, celulitis sin abscesos y bacteriemia por Staphylococcus aureus resistente a la meticilina para lo cual recibió terapia con oxacilina y cefepime. Sin embargo, persistía la neutropenia febril por lo que se sospechó una infección fúngica invasora. Se tomó un nuevo set de hemocultivos y se inició tratamiento antifúngico. En los hemocultivos se identificaron artroconidias y mediante espectrometría de masas por láser de matriz asistida de ionización-desorción se confirmó la presencia de Geotrichum spp. Se ajustó el tratamiento antifúngico con deoxicolato de anfotericina B por 14 días y voriconazol por cuatro semanas. Luego de una estancia prolongada se le dio de alta. Aunque la incidencia de la fungemia por Geotrichum spp. es baja, en pacientes con neoplasias hematológicas malignas debe considerarse en el contexto de una neutropenia febril que es persistente a pesar del tratamiento antimicrobiano de amplio espectro.
Assuntos
Neutropenia Febril , Fungemia , Geotricose , Neoplasias Hematológicas , Leucemia-Linfoma Linfoblástico de Células Precursoras , Masculino , Humanos , Adulto , Fungemia/diagnóstico , Fungemia/tratamento farmacológico , Antifúngicos/uso terapêutico , Proteômica , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicações , Neutropenia Febril/tratamento farmacológicoRESUMO
Los pacientes con malignidades hematológicas tienen un riesgo más alto de hospitalización, admisión a cuidado crítico y muerte cuando contraen COVID-19. En este grupo se ha propuesto la vacunación y los refuerzos para disminuir el riesgo de complicaciones. Sin embargo, es posible ver una pobre respuesta humoral y celular a las vacunas. En esta revisión se presenta la evidencia sobre la respuesta a la vacunación, poniendo de presente algunas patologías y tratamientos que pueden disminuirla de forma significativa. Los pacientes con neoplasias hematológicas se deben considerar en riesgo de complicaciones, incluso después de haber sido vacunados de forma completa y haber recibido los refuerzos. Se debe mantener la vigilancia de forma estrecha después de haber sido vacunados y evaluar la posibilidad de otras estrategias (medicamentos, anticuerpos monoclonales) para la prevención o el manejo de COVID-19.
Patients with hematological malignancies have a higher risk of hospital admission, critical care and death when they suffer from COVID-19. In this group of patients, vaccination and boosters have been proposed to mitigate the risk of complications. However, it is possible to observe a diminished rate of humoral and cellular response. In this review, evidence is shown about the response to COVID-19 vaccination, considering some specific pathologies and treatments that can affect such response in a significant account. Patients with malignant neoplasm must be considered at risk of COVID-19 complications, even after a complete vaccine schedule and boosters. Surveillance must be maintained after vaccination over these patients and other strategies must be considered (drugs, monoclonal antibodies) for prevention and management of COVID-19.
Assuntos
Humanos , Neoplasias Hematológicas/imunologia , COVID-19/prevenção & controle , Fatores de Risco , Terapia de Imunossupressão , Hospedeiro Imunocomprometido , Neoplasias Hematológicas/complicações , Neoplasias Hematológicas/tratamento farmacológico , Vacinas contra COVID-19/imunologia , SARS-CoV-2/imunologia , COVID-19/complicações , Antineoplásicos/efeitos adversosRESUMO
Patients with cancer have a higher risk of severe bacterial infections. This study aims to determine the frequency, susceptibility profiles, and resistance genes of bacterial species involved in bacteremia, as well as risk factors associated with mortality in cancer patients in Colombia. In this prospective multicenter cohort study of adult patients with cancer and bacteremia, susceptibility testing was performed and selected resistance genes were identified. A multivariate regression analysis was carried out for the identification of risk factors for mortality. In 195 patients, 206 microorganisms were isolated. Gram-negative bacteria were more frequently found, in 142 cases (68.9%): 67 Escherichia coli (32.5%), 36 Klebsiella pneumoniae (17.4%), and 21 Pseudomonas aeruginosa (10.1%), and 18 other Gram-negative isolates (8.7%). Staphylococcus aureus represented 12.4% (n = 25). Among the isolates, resistance to at least one antibiotic was identified in 63% of them. Genes coding for extended-spectrum beta-lactamases and carbapenemases, blaCTX-M and blaKPC, respectively, were commonly found. Mortality rate was 25.6% and it was lower in those with adequate empirical antibiotic treatment (22.0% vs. 45.2%, OR: 0.26, 95% CI: 0.1-0.63, in the multivariate model). In Colombia, in patients with cancer and bacteremia, bacteria have a high resistance profile to beta-lactams, with a high incidence of extended-spectrum beta-lactamases and carbapenemases. Adequate empirical treatment diminishes mortality, and empirical selection of treatment in this environment of high resistance is of key importance.
RESUMO
La fungemia por Geotrichum spp. es poco frecuente y altamente letal. En el Instituto Nacional de Cancerología de Bogotá solo se han reportado dos casos: uno entre el 2001 y el 2007, y el otro entre el 2012 y el 2018. Este tipo de infección es más común en pacientes con algún grado de compromiso del sistema inmunitario, por lo que puede presentarse en pacientes con neoplasias hematológicas malignas. Se presenta el caso de un hombre de 27 años con recaída de leucemia linfoblástica aguda, que ingresó con poliartralgias de cinco días de duración. También cursaba con neutropenia febril, celulitis sin abscesos y bacteriemia por Staphylococcus aureus resistente a la meticilina para lo cual recibió terapia con oxacilina y cefepime. Sin embargo, persistía la neutropenia febril por lo que se sospechó una infección fúngica invasora. Se tomó un nuevo set de hemocultivos y se inició tratamiento antifúngico. En los hemocultivos se identificaron artroconidias y mediante espectrometría de masas por láser de matriz asistida de ionización-desorción se confirmó la presencia de Geotrichum spp. Se ajustó el tratamiento antifúngico con deoxicolato de anfotericina B por 14 días y voriconazol por cuatro semanas. Luego de una estancia prolongada se le dio de alta. Aunque la incidencia de la fungemia por Geotrichum spp. es baja, en pacientes con neoplasias hematológicas malignas debe considerarse en el contexto de una neutropenia febril que es persistente a pesar del tratamiento antimicrobiano de amplio espectro. La identificación de los agentes causantes de fungemias con herramientas de proteómica, como la espectrometría de masas mencionada, permite ajustar el tratamiento dirigido y reducir las complicaciones, la estancia hospitalaria y la mortalidad.
Fungemia caused by Geotrichum spp. is rare and highly lethal. The Instituto Nacional de Cancerología in Bogotá reported just two cases: one in the period 2001-2007 and the other in 2012-2018. This type of infection is more common in any kind of immunocompromised patients, so it can occur in those with hematological malignancies. Here we present the case of a 27-year-old man, diagnosed with acute lymphoblastic leukemia in relapse and admitted with polyarthralgia for five days, febrile neutropenia, non- abscessed cellulitis, and bacteremia due to methicillin-sensitive Staphylococcus aureus. The patient received therapy with oxacillin and cefepime, but the febrile neutropenia persisted. A new set of blood cultures was taken, and antifungal treatment was started because of the suspicion of invasive fungal infection. Arthroconidia were identified in blood cultures and Geotrichum spp. was confirmed using matrix-assisted laser desorption-ionization mass spectrometry. The antifungal treatment was adjusted with amphotericin B deoxycholate for 14 days and voriconazole for four weeks, and after a prolonged stay, the patient was discharged. Although the incidence of fungemia caused by Geotrichum spp. is low, it must be considered in patients with hematological malignancies and persistent febrile neutropenia despite the broadspectrum antimicrobial treatment. The confirmation of fungemia causing agents, with proteomic tools such as the mentioned mass spectrometry, allows treatment adjustment and decreases complications, hospital stay, and mortality.
Assuntos
Leucemia-Linfoma Linfoblástico de Células Precursoras , Geotricose , Anfotericina B , Fungemia , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , VoriconazolRESUMO
La fusariosis es una micosis oportunista producida por Fusarium spp. Su presentación clínica depende del estado inmunológico del huésped, especialmente, el de aquellos con enfermedades hematooncológicas, cuyas manifestaciones varían desde formas localizadas hasta infección fúngica invasora. El cultivo de piel o de sangre permite orientar el tratamiento antifúngico combinado con anfotericina B y voriconazol. Se presentan 13 casos de pacientes con cáncer en un periodo de once años que desarrollaron fusariosis diseminada; asimismo, se hizo con una revisión extensa de la literatura. En esta serie de casos, la mortalidad fue del 61,5 % (8/13), a pesar del uso del antifúngico. De los 13 pacientes, 11 tenían neoplasia hematológica y 2 neoplasia sólida. El factor de riesgo más importante fue la neutropenia profunda. El compromiso de la piel y los hemocultivos positivos facilitaron la prescripción del tratamiento combinado en la mayoría de los casos. La neutropenia febril persistente asociada a lesiones cutáneas, la onicomicosis, los nódulos o las masas pulmonares permitieron sospechar una infección fúngica invasora por Fusarium spp. El objetivo de la presentación de esta serie de casos es recordar el diagnóstico de fusariosis a la comunidad médica en contacto con pacientes oncológicos, con neutropenia febril profunda y persistentes.
The fusariosis is an opportunistic mycosis caused by Fusarium spp. Its clinical presentation depends on the immunological status of the host, especially in patients with hemato-oncological diseases, whose manifestations vary from localized to invasive fungal infections. Skin or blood culture helps to guide combined antifungal treatment with amphotericin B and voriconazole. Here, we present 13 cases in a period of eleven years of patients with cancer who developed disseminated fusariosis and their outcomes, together with a review of the related literature. In this series of cases, mortality was 61.5 % (8/13), despite the use of the antifungal. Out of the 13 cases, 11 had hematological neoplasia and 2 solid neoplasia. The most determinant risk factor was profound neutropenia. Skin involvement and positive blood cultures in most cases allowed combined treatment prescription. Persistent febrile neutropenia associated with skin lesions, onychomycosis, nodules, or lung masses lead to suspicion of Fusarium spp. fungal invasive infection. The aim of this series of cases is to remind healthcare professionals that oncological patients with deep and persistent febrile neutropenia can develop fusariosis.
Assuntos
Fusarium , Anfotericina B , Fungemia , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , VoriconazolRESUMO
Previous research has determined that the required doses for treating febrile neutropenia with vancomycin are higher than the doses used conventionally. These recommendations have been made considering pharmacotherapeutic goals based on minimum concentration (Cmin) between 15-20 mg/L. This study was developed to evaluate dose recommendations based on the achievement of a target consisting of ratio of area under the curve over minimum inhibitory concentration (AUC24h/MIC) ≥400 in this population of individuals. This study was conducted in a referral hospital for cancer treatment, study participants received vancomycin doses of 1g every 12 h in 2-4-h infusions. Vancomycin was described by a two-compartment pharmacokinetic model with clearance dependent on the estimated glomerular filtration rate. Simulations were performed taking into account a reduced version of the model to establish the influence of controllable and non-controllable variables on the probability of achieving several PK-PD targets. A dose of 2.5g/day in patients with estimated glomerular filtration rate (eGFR) between 80 and 122mL/min/1.73m2 was adequate to achieve the pharmacotherapeutic target. A discrepancy was found between AUC-based and Cmin-based PK/PD indices, the former being affected by the dose and creatinine clearance while the latter highly influenced by the interval between doses.
RESUMO
Resumen La neumonía sigue siendo una de las principales causas de consulta y de hospitalización a la que, además de su un alto impacto en términos de morbilidad y mortalidad, se suma la actual problemática de resistencia a los antimicrobianos, por lo que establecer directrices que permitan su adecuado diagnóstico y tratamiento es de gran importancia para obtener mejores desenlaces clínicos y promover un uso racional de antibióticos en estos pacientes. La presente guía de práctica clínica (GPC) contiene recomendaciones basadas en la evidencia para el diagnóstico y tratamiento de la neumonía adquirida en la comunidad en adultos, las cuales fueron realizadas mediante el proceso de adaptación de GPC basadas en la evidencia para el contexto colombiano.
Abstract Pneumonia continues to be one of the main causes of consultation and hospitalization to which, besides its high impact on morbidity and mortality, the current problem of antimicrobial resistance is added; thus, establishing guidelines that allow its adequate diagnosis and treatment is of great importance to obtain better clinical outcomes and promote a rational use of antibiotics in these patients. This clinical practice guideline (CPG) contains evidence-based recommendations for the diagnosis and treatment of community-acquired pneumonia in adult population; these recommendations were made by means of the process of adaptation of evidence-based CPGs for the Colombian context.
RESUMO
Introducción. La enfermedad de Chagas es una parasitosis endémica en Latinoamérica transmitida por triatominos. Está asociada a factores de riesgo como la pobreza y la ruralidad. Después de la infección aguda, un tercio de los pacientes presenta compromiso del corazón, el aparato digestivo o el sistema nervioso central, en tanto que los dos tercios restantes no presentan este tipo de compromiso secundario. La inmunosupresión farmacológica rompe el equilibrio entre el sistema inmunitario y el parásito, lo cual favorece su reactivación. Caso clínico. Se presenta el caso de un hombre de 58 años procedente de un área rural colombiana, con diagnóstico de mieloma múltiple resistente a los fármacos de primera línea de tratamiento, que requirió un nuevo esquema de quimioterapia y consolidación con trasplante autólogo de células madre. Después del trasplante, presentó neutropenia febril. Los estudios microbiológicos iniciales fueron negativos. En el frotis de sangre periférica, se demostraron tripomastigotes y se diagnosticó enfermedad de Chagas aguda posterior al trasplante. Se inició el tratamiento con benznidazol. La evolución del paciente fue satisfactoria. Conclusiones. La serología positiva para Chagas previa a un trasplante obliga a descartar la reactivación de la enfermedad en caso de neutropenia febril. Se requieren más estudios para determinar las herramientas que permitan estimar la probabilidad de reactivación de la enfermedad y decidir sobre la mejor opción de relación entre costo, riesgo y beneficio de la terapia profiláctica.
Introduction: Chagas disease is an endemic parasitic infection in Latin America transmitted by triatomines. It is associated with risk factors such as poverty and rurality. After acute infection, a third of patients will present target organ involvement (heart, digestive tract, central nervous system). The remaining two thirds remain asymptomatic throughout their life. Pharmacological immunosuppression breaks the balance between the immune system and the parasite, favoring its reactivation. Clinical case: We present the case of a 58-year-old man from a Colombian rural area with a diagnosis of multiple myeloma refractory to the first line of treatment who required a new chemotherapy scheme and consolidation with autologous stem cell transplant. During the post-transplant period, he suffered from febrile neutropenia. Initial microbiological studies were negative but the peripheral blood smear evidenced trypomastigotes in blood. With a diagnosis of acute Chagas disease in a post-transplant patient, benznidazole was started. The evolution of the patient was satisfactory. Conclusions: Positive serology prior to transplantation makes it necessary to rule out reactivation of the pathology in the setting of febrile neutropenia. More studies are required to determine tools for estimating the probability of reactivation of the disease and defining the best cost-risk-benefit relation for the prophylactic therapy.
Assuntos
Doença de Chagas , Transplante de Células-Tronco Hematopoéticas , Doenças Parasitárias , Trypanosoma cruzi , Terapia de Imunossupressão , Neutropenia Febril , Mieloma MúltiploRESUMO
Invasive fungal disease (IFD) is a condition affecting immunosuppressed and critically ill patients. Recently there has been an increase in the amount of patients at risk for IFD, which implies an increase in the prescription of antifungal agents as prophylactic, pre-emptive or empiric therapy. Some studies evaluating appropriateness of antifungal prescription have shown that inappropriate formulations reach 72%, exposing patients to side effects, pharmacological interactions and rising costs. Some groups have recommended many interventions to control and make a rational use of antimicrobials, into strategies known as "antimicrobial stewardship", these interventions are useful also for antifungal agents and it has been named "antifungal stewardship". Here we present a narrative review of the scientific literature showing published articles about appropriate use of antifungal agents and the experience of some centers after implementing antifungal stewardship programs.
Assuntos
Antifúngicos/administração & dosagem , Antifúngicos/efeitos adversos , Gestão de Antimicrobianos/métodos , Prescrição Inadequada/prevenção & controle , Infecções Fúngicas Invasivas/tratamento farmacológico , Monitoramento de Medicamentos , Humanos , Hospedeiro Imunocomprometido , Prescrição Inadequada/estatística & dados numéricos , Infecções Fúngicas Invasivas/diagnósticoRESUMO
Resumen La enfermedad fúngica invasora (EFI) es una entidad que afecta pacientes inmunocomprometidos y críticamente enfermos. En los últimos años, el número de pacientes con riesgo de presentarla viene en aumento, con el consecuente incremento de la formulación de antifúngicos de manera profiláctica, anticipada o empírica. Algunos estudios que evaluaron el uso adecuado de antifúngicos han mostrado que hasta 72% de las formulaciones pueden ser inapropiadas, exponiendo a los pacientes al riesgo de efectos adversos e interacciones medicamentosas, con mayores costos de la atención. Se han recomendado diferentes intervenciones para el control y el uso racional de antimicrobianos, conocidas como "antimicrobial stewardship", las que se pueden aplicar al uso de antifúngicos denominándose "antifungal stewardship"". Se presenta una revisión de la literatura médica sobre el uso apropiado de antifúngicos y el impacto de la implementación de programas de optimización del uso de estos medicamentos en algunos centros.
Invasive fungal disease (IFD) is a condition affecting immunosuppressed and critically ill patients. Recently there has been an increase in the amount of patients at risk for IFD, which implies an increase in the prescription of antifungal agents as prophylactic, pre-emptive or empiric therapy. Some studies evaluating appropriateness of antifungal prescription have shown that inappropriate formulations reach 72%, exposing patients to side effects, pharmacological interactions and rising costs. Some groups have recommended many interventions to control and make a rational use of antimicrobials, into strategies known as "antimicrobial stewardship", these interventions are useful also for antifungal agents and it has been named "antifungal stewardship". Here we present a narrative review of the scientific literature showing published articles about appropriate use of antifungal agents and the experience of some centers after implementing antifungal stewardship programs.
Assuntos
Humanos , Prescrição Inadequada/prevenção & controle , Infecções Fúngicas Invasivas/tratamento farmacológico , Gestão de Antimicrobianos/métodos , Antifúngicos/administração & dosagem , Antifúngicos/efeitos adversos , Hospedeiro Imunocomprometido , Monitoramento de Medicamentos , Prescrição Inadequada/estatística & dados numéricos , Infecções Fúngicas Invasivas/diagnósticoRESUMO
Objetivos: El tratamiento actual de las neoplasias busca mejorar la sobrevivencia mediante la aplicación de esquemas de quimioterapia intensificada, que produce una neutropenia más profunda y duradera, que favorece el desarrollo de infecciones bacterianas y micóticas invasoras. Este artículo resume las recomendaciones de una guía para el diagnóstico y tratamiento de las infecciones bacterianas y micóticas en pacientes oncológicos mayores de 15 años con neutropenia febril posquimioterapia de alto riesgo. Métodos: Guía de práctica clínica basada en la evidencia. Se realizó la definición de preguntas clínicas, la búsqueda sistemática de literatura, la evaluación crítica de la evidencia y la formulación de recomendaciones. Se desarrolló una evaluación económica sobre la eficiencia de dos esquemas diferentes de tratamiento antimicótico. Resultados: El presente documento incluye recomendaciones para el diagnóstico de infecciones bacterianas y micóticas en paciente con neutropenia, el uso de profilaxis antibiótica y antimicótica, el tratamiento antibiótico empírico, y el tratamiento antimicótico empírico y anticipado en pacientes mayores de 15 años, acorde con la microbiología del contexto colombiano. Conclusiones: La implementación oportuna de las recomendaciones de la guía acorde con el contexto clínico de cada paciente debe contribuir a mejorar la supervivencia y morbilidad infecciosa de los pacientes con neutropenia febril derivada de la quimioterapia.
Objective: Current cancer treatment is intended to improve survival by implementing intensified chemotherapy strategies, which increases the likelihood of neutropenia and favors the development of bacterial and invasive fungal infections. This paper summarizes clinical practice guideline recommendations for the diagnosis and treatment of bacterial and fungal infections in patients older than 15 years with febrile neutropenia after high risk chemotherapy. Methods: Evidence-based clinical practice guideline. A set of clinical questions was defined, a literature search performed, critical appraisal of the evidence, as the development of recommendations. An economic assessment was carried out on two alternative schemes for fungal therapy. Results: This article includes recommendations for the diagnosis of bacterial and fungal infections in neutropenic patients, prophylaxis for bacterial and fungal infections, empiric antimicrobial treatment, empiric and anticipated antifungal therapy in patients over 15 years, according to the microbiology setting in Colombia. Conclusions: Timely implementation of these recommendations according to each clinical context, should contribute to improve survival and reduce infection-derived morbidity in patients with chemotherapy-induced febrile neutropenia.
Assuntos
Humanos , Adolescente , Pacientes , Tratamento Farmacológico , Neutropenia Febril Induzida por Quimioterapia , Infecções Fúngicas Invasivas , Micoses , Infecções Bacterianas , AntibioticoprofilaxiaRESUMO
Las infecciones necrosantes de tejidos blandos presentan altas tasas de mortalidad. Estas se han relacionado con diferentes causas, incluidas las enfermedades neoplásicas. En la literatura se ha descrito infección necrosante especialmente en pacientes con neoplasias del tracto gastrointestinal bajo. La presentación de este caso clínico tiene como objetivo recordar a los médicos de urgencias la pertinencia de considerar este diagnóstico en pacientes con neoplasias de colon y recto en estadio avanzado y presentar una breve revisión de la literatura.
Necrotizing soft tissue infections have high mortality rates. These infections have been linked to various causes, including those related to neoplastic diseases. The literature has described necrotizing particularly in patients with malignancies of the colon and rectum. The presentation of this case is intended to remind emergency physicians to consider this diagnosis in patients with advanced-stage gastrointestinal tract tumors and to present a brief review of the literature.
Assuntos
Humanos , Masculino , Adulto , Fasciite Necrosante , Neoplasias Retais , Pele/imunologia , Neoplasias do Colo , Infecções dos Tecidos Moles , Serviços Médicos de EmergênciaRESUMO
OBJECTIVE: To assess cost-effectiveness of antifungal treatment on patients with persistent fever neutropenia: empiric antifungal therapy (EAT) vs. anticipated antifungal therapy (AAT). METHODS: A decision model was performed to evaluate the cost-effectiveness of antifungal treatment strategies in patients with febrile neutropenia not responding to a broad spectrum antibiotic treatment. The strategies included were: 1) EAT with amphotericin B deoxycholate; 2) EAT with liposomal amphotericin B; 3) EAT with caspofungin; and 4) AAT with voriconazole and amphotericin B deoxycholate or liposomal amphotericin B or caspofungin in patients who initiate treatment despite having negative CT scan and galactomannan or fail to voriconazole. Effectiveness was measured as the number of deaths averted. Cost-effectiveness and incremental cost-effectiveness ratios were calculated. Deterministic and probabilistic sensitivity analyzes were performed. RESULTS: EAT with Amphotericin B deoxycholate was the least expensive and least effective strategy. The EAT with caspofungin was the most effective. The cost per death averted for caspofungin when compared with amphotericin B deoxycholate was $17,011,073.83, which would indicate that this strategy would be cost-effective for the country if the willingness to pay per death averted is equal to or greater than this value. EAT with liposomal amphotericin B and AAT with voriconazole were dominated by AET with caspofungin, which is less costly and more effective. CONCLUSIONS: EAT with caspofungin would be cost-effective for Colombia if the threshold per death averted is greater to $18.000.000. If the threshold is lesser the EAT with amphotericin B deoxycholate would be the election.
RESUMO
El género Aspergillus es ubicuo en la naturaleza y de distribución universal. Por esta razón, el contacto con este hongo incluye hospederos inmunocompetentes e inmunosuprimidos. La vía aérea es la forma más frecuente de adquirir este hongo y sus manifestaciones clínicas y localización topográfica se relacionan con la interacción del hongo y la capacidad inmunológica del hospedero. La principal manifestación clínica de este hongo es a nivel respiratorio, con un impacto muy importante en mortalidad y morbilidad, especialmente en el paciente inmunosuprimido. Los pacientes con tumores hematológicos, trasplantes de corazón, pulmón y con sida son más susceptibles de presentar invasión tisular y vascular por este hongo, que en tales casos se manifiesta como Aspergilosis Invasora (AI). La AI ofrece dificultades diagnósticas en el hospedero inmunosuprimido por lo que en este grupo de pacientes el uso de métodos de diagnóstico no invasores permite guiar el abordaje terapéutico. En la actualidad se dispone de medicamentos antifúngicos del grupo de los azoles (voriconazol) y de las equinocandinas (caspofungina) que han mejorado el resultado de la AI. En este artículo se actualiza la literatura en cuanto al diagnóstico y tratamiento de la AI.
The genus Aspergillus is ubiquitous in nature and has universal distribution; for this reason contact with this fungus includes immunocompetent and non-immunocompetent hosts. The most common form of acquiring this fungus is through air, and its clinical manifestations and topographic location correspond to the interaction of the fungus and its host's immune capacity. The main clinical manifestation of this fungus is a breathing condition and has a very significant impact on mortality and morbidity, especially in non-immunocompetent patients. Patients with haematological malignancies, heart or lung transplant surgeries, and AIDS are the most susceptible to present tissue and vascular invasion by this fungus in the form of invasive aspergillosis (IA). The IA presents diagnostic difficulties in non-immunocompetent hosts; therefore using non-invasive diagnosis methods for this group of patients offers therapeutic approach guidance. Antifungal drugs such as azoles (voriconazole) and echinocandins (caspofungin), that have improved the AI group results, are available nowadays. This article updates the literature on AI diagnosis and treatment.