Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline.

The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.

Improved Standardization of the Bio-Rad Platelia Aspergillus Galactomannan Antigen Sandwich Enzyme Immunoassay Using the DS2 (Dynex) Enzyme-Linked Immunosorbent Assay (ELISA) Processing System.

The galactomannan enzyme immunoassay (GM-EIA) is widely utilized for the diagnosis of invasive aspergillosis (IA). There is inconsistent reproducibility of results between centers when the assay is processed manually. Automation of EIAs can reduce variation. This study investigated the semiautomation of the GM-EIA on the DS2 (Dynex) platform in the following three stages: (i) DS2 GM-EIA method validation with experimental samples, (ii) DS2 retesting of case-defined clinical samples, and (iii) a 12-month audit of DS2 GM-EIA performance. In stage i, Bland-Altman analysis demonstrated a reduced variance between optical density index (ODI) values for samples processed on two DS2 platforms (mean difference, -0.02; limits of agreement [LOA], -0.19 to 0.14) compared with the variance between samples processed manually and on a DS2 platform (mean difference, 0.02; LOA, -0.25 to 0.3). In stage ii, 100% (14/14 samples) qualitative agreement was observed for serum samples from patients with IA, with no significant change in the ODI values when samples were processed on the DS2 platform. A significant decrease in ODI values was observed for control serum samples on the DS2 platform (difference, 0.01; P = 0.042). In stage iii, a significant reduction in the frequency of equivocal results, from 5.56% (136/2,443 samples) to 1.56% (15/961 samples), was observed after DS2 automation (difference, 4.0%; 95% confidence interval [CI], 2.7 to 5.2%; P < 0.01), with an equivalent increase in negative results. This study demonstrates that GM-EIA automation may reduce intersite variability. Automation does not have an impact on the repeatability of truly positive results but contributes to a reduction in false-positive (equivocal) GM-EIA results, reducing the need to retest a significant proportion of samples.

Fusarium dimerum infection in a stem cell transplant recipient treated successfully with voriconazole.

We report the first case, to our knowledge, of a proven Fusarium dimerum soft-tissue infection in a stem cell transplant recipient treated successfully with voriconazole. There is a well-documented increase in the incidence, diversity and antifungal resistance of invasive mould infections in the immunocompromised patient population. The management of these infections is changing as new, more efficacious and less toxic antifungal agents become available. We present the case of a 19-year-old female diagnosed with a proven F. dimerum soft-tissue infection of the foot and possible pulmonary infection with the same organism 10 days following a sibling allogeneic stem cell transplant for severe aplastic anaemia. The infection developed despite treatment with 3 mg/kg AmBisome for a concurrent chest infection. She was treated successfully with voriconazole.

The community prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in older people living in their own homes: implications for treatment, screening and surveillance in the UK.

Methicillin-resistant Staphylococcus aureus (MRSA) predominantly affects those over 65 years old. There may be a substantial pool of older people with MRSA in the community. We studied the prevalence in one London general practice, screening 258 older people living in their own home. MRSA (E-MRSA 15) was found in two participants (0.78%). Past history of MRSA was the only significant risk factor. The results of this and other studies suggest that national guidelines recommending early discharge for MRSA carriers have not resulted in widespread community acquisition amongst elderly people living in their own home. Community antibiotic policies for skin and soft-tissue infection do not require amendment. Patients with previous MRSA should be isolated and screened on admission especially to high-risk units.

Epidemiology of candidaemia in Europe: results of 28-month European Confederation of Medical Mycology (ECMM) hospital-based surveillance study.

In order to update the epidemiological and mycological profile of candidaemia in Europe, the European Confederation of Medical Mycology conducted a prospective, sequential, hospital population-based study from September 1997 to December 1999. A total of 2,089 cases were documented by 106 institutions in seven European countries. Rates of candidaemia ranging from 0.20 to 0.38 per 1,000 admissions were reported. Candida albicans was identified in 56% of cases. Non-albicans Candida species were most frequently isolated from patients with haematological malignancies (65%). With increasing age, an increasing incidence of Candida glabrata was seen. The 30-day mortality rate was 37.9%. The survey results underline the burden of candidaemia in a wide range of patient populations, confirm the importance of non- albicans species, and provide baseline data for future surveillance studies at a European level.

Treatment failure in invasive aspergillosis: susceptibility of deep tissue isolates following treatment with amphotericin B.

OBJECTIVES: To determine whether treatment failure in invasive aspergillosis (IA) is the result of resistance of Aspergillus spp. isolates to amphotericin B. METHODS: Six Aspergillus fumigatus and six Aspergillus flavus isolates cultured from deep tissue biopsies in 11 patients with haematological malignancies during 1991-1998 were tested. A method based on the NCCLS M38-A broth microdilution method, with colorimetric determination of MICs, was used to determine the MICs of amphotericin B and itraconazole. RESULTS: All A. fumigatus isolates were susceptible to amphotericin B (MIC 0.25-0.5 mg/L), as were three A. flavus isolates (MIC 1 mg/L), but three were less susceptible (MIC 2 mg/L). All isolates were susceptible to itraconazole (MIC 0.125-0.25 mg/L). All patients had been treated with amphotericin B, having received a median of 12 days of treatment when the tissue was obtained. CONCLUSION: The difficulty in treating IA may not be because of the susceptibility of the isolates, but because of poor penetration of antifungal agents into infected tissue. Aspergillus spp. invade blood vessels causing thrombosis and tissue infarction, and therefore it may be difficult for antifungal drugs to exceed MICs in infected tissues. This highlights the need for different treatment strategies, such as surgery and the administration of cytokines.

Toxoplasmosis in bone marrow transplantation: a report of two cases and systematic review of the literature.

Toxoplasma infection represents a rare but often fatal complication in bone marrow transplant (BMT) recipients. We report two cases of toxoplasmosis: one of successfully treated cerebral toxoplasmosis after peripheral blood stem cell transplantation, and a fatal case of pulmonary toxoplasmosis in a BMT recipient. We have systematically reviewed the 110 published cases of toxoplasmosis following BMT. We analyzed the pre-transplant and clinical features of BMT recipients developing toxoplasmosis, together with the diagnostic procedures used and treatment given. By univariate and multivariate statistical analysis we analyzed the risk factors for diagnosis (during life vs post-mortem) and Toxoplasma-related mortality. Ante-mortem diagnosis was made in 47% of cases. Site of infection (P = 0.02; odds ratio 10.8), presence of symptoms at onset (P = 0.01) and conditioning regimen (P = 0.04) were factors influencing whether the diagnosis was made before or after death. Overall mortality rate was 80% and that attributed to toxoplasmosis was 66%. Variables influencing outcome were: site of infection (P = 0.02; odds ratio 5.28), day of onset (P = 0.04) and conditioning regimen (P = 0.04). Underlying disease (P = 0.02; odds ratio 9.45), among patients diagnosed before death, was the most significant factor influencing outcome.

Oral ciprofloxacin plus colistin: prophylaxis against bacterial infection in neutropenic patients. A strategy for the prevention of emergence of antimicrobial resistance.

Following a 2-year study, the combination of oral ciprofloxacin and colistin has been used continuously for 10 years without the emergence of resistance. During a 2-year period (1987-1989), we compared ciprofloxacin + colistin (CIP + COL) with neomycin + colistin (NEO + COL) in a randomized trial--combinations chosen because of the potential for prophylaxis of Gram-negative infection by ciprofloxacin, with colistin given to reduce the risk of emergence of resistance. Sixty-four patients with similar demographics in each arm were evaluable for efficacy analysis. Patients on CIP + COL had a significantly lower proportion of neutropenic days with fever (P < 0.001) and neutropenic days on intravenous antibiotics (P < 0.001) than patients on NEO + COL. A total of 54 (15 bacteriologically documented) pyrexial episodes occurred in patients on CIP + COL and 77 (41 bacteriologically documented) in patients on NEO + COL. Only two Gram-negative bacterial infections occurred in the CIP + COL arm compared with 16 in the NEO + COL arm. No Staphylococcus aureus infections occurred in the CIP + COL group compared with 10 in the other patients. Two CIP-resistant Gram-negative bacilli were isolated from patients on CIP + COL compared with 13 NEO-resistant Gram-negative bacilli from patients on NEO + COL. Following a subsequent decade of unchanged use of this prophylactic strategy in neutropenic patients, a 2-year follow-up study between 1 January 1998 and 31 December 1999 showed 66 significant infections during 700 [corrected] neutropenic episodes. Thirty-five of the 111 (31%) isolates were ciprofloxacin-resistant, involving 5% of the neutropenic episodes [corrected].

The combination of oral amphotericin B with azoles prevents the emergence of resistant Candida species in neutropenic patients.

The role of antifungal prophylaxis remains controversial and concerns exist that the use of azoles may potentiate the emergence of resistant Candida species. We used a strategy of combining the latest azole/triazole with oral amphotericin B to reduce this risk. We analysed data on Candida colonization and candidaemia in neutropenic patients from four prophylaxis periods (1985/6: ketoconazole and amphotericin B suspension; 1991/2 & 1997: fluconazole and amphotericin B suspension; 1998/9: itraconazole) to look for evidence of the emergence of potentially resistant species. Overall, the percentage of patients colonized with Candida fell significantly (69.3%, 57.5%, 43.2% and 46%, respectively, P < 0.001) due to a decrease in colonization with C. albicans (49%, 23.1%, 22.2% and 25.2%, respectively, P < 0.001). However, in 1998/9, increased colonization, particularly with C. glabrata in the lower gastrointestinal tract, was noted to coincide with the omission of oral amphotericin B. Despite an increasing population of 'high risk' patients, the incidence of candidaemia has not changed significantly (2%, 1.4%, 1.2% and 2% respectively). However, species causing candidaemia have changed, with resistant organisms now predominating. Our findings support the use of azole prophylaxis although, in view of the trends noted when itraconazole was used alone, we would recommend the additional use of oral amphotericin B.

Infrequency of pulmonary microbial colonisation prior to respiratory disease in HIV-infected individuals.

To determine whether organisms are present in the HIV-infected lung prior to clinical respiratory disease, a cross-sectional bronchoscopic comparative analysis of 39 asymptomatic HIV-positive subjects and 31 healthy controls with 2-year prospective bronchoscopic monitoring of the HIV study group was performed. Pathological examination of bronchoalveolar lavage (BAL) fluid using standard microbiological techniques was undertaken. Organisms were recovered from similar numbers of HIV-positive and control subjects (7 of 39 and 3 of 31) and comprised predominantly scanty growths of bacteria. Five subjects developed respiratory disease during follow-up. Repeat BAL was performed in 11 asymptomatic HIV-positive patients; no relationship was found between the organisms isolated at the two procedures. The findings suggest that the asymptomatic HIV-positive lung is not a frequent site of either microbial colonisation or subclinical infection. This has implications for the understanding of the pathogenesis of HIV-related pulmonary disease.

Management of invasive pulmonary aspergillosis in hematology patients: a review of 87 consecutive cases at a single institution.

Eighty-seven patients with hematologic malignancies and invasive pulmonary aspergillosis (IPA) were identified between 1982 and 1995. Of these, 39 underwent lung resection on the basis of radiological detection of at least 1 lesion with imaging suggestive of aspergillosis (LISA). IPA was confirmed histologically in 35. The presence of LISA had 90% positive predictive value for IPA. The actuarial survival at 2 years was 36% for 37 patients treated surgically, 20% for 12 patients with unresected LISA but no cultures of Aspergillus species, and 5% for 21 patients diagnosed only by isolation of Aspergillus from respiratory secretions. Analysis by proportional hazard models showed a significant independent negative association between the radiological appearance of LISA and death from all causes. Relapsed hematologic disease was independently significantly associated with death. Age, sex, surgery, previous bone marrow transplantation, or Aspergillus isolation were not independent predictors of death. IPA presenting as LISA carries a relatively good prognosis, possibly explaining the better survival of patients undergoing surgery for such lesions.

Fatal invasive cerebral Absidia corymbifera infection following bone marrow transplantation.

A 56-year-old dairy farmer received a fully HLA matched unrelated donor marrow transplant for high risk CML in chronic phase. His early post-transplant course was complicated by a series of massive intracerebral bleeds and by sepsis related to a malignant otitis externa. The microbial pathogen isolated from ear swabs was found to be Absidia corymbifera, but CT scan at the time showed no intracerebral extension. Despite neutrophil engraftment and aggressive antifungal management he succumbed. Autopsy revealed invasion of Absidia into the brain from the ear. We speculate that colonisation by Absidia resulted from occupational exposure.

An evaluation of the cost-effectiveness of using CHROMagar for yeast identification in a routine microbiology laboratory.

CHROMagar, a chromogenic differential culture medium, is claimed to facilitate the isolation and presumptive identification of certain clinically important yeast species, e.g., Candida albicans. This study evaluated the cost-effectiveness and time advantage of using it in comparison with Sabouraud dextrose agar (SDA). Three possible pathways, each of which included the use of one or both media, were compared in a routine laboratory. A total of 21 yeast isolates was cultured from 298 clinical samples from neutropenic and AIDS patients. An overall sensitivity of 95.2% was observed for each medium and primary isolation on CHROMagar was found to be 100% sensitive and 100% specific for C. albicans. For identification purposes, after initial culture the use of CHROMagar provided the most economical and least time-consuming method. Direct inoculation on to CHROMagar is recommended for blood cultures when yeast cells are seen on microscopy and where early appropriate therapy is imperative.

The epidemiology and prevention of invasive aspergillosis.

Over the past two decades, the incidence of invasive aspergillosis (IA) has risen inexorably. This is almost certainly the consequence of the more widespread use of aggressive cancer chemotherapy regimens, the expansion of organ transplant programmes and the advent of the acquired immunodeficiency syndrome (AIDS) epidemic. Despite the development of new approaches to therapy, IA still remains a life-threatening infection in immunocompromised patients and is the most important cause of fungal death in cancer patients. It is clear that the prevention of severe fungal infection by the use of effective infection control measure should be the priority of the teams involved in managing at-risk patients. The evidence from clinical and molecular epidemiological studies is reviewed and current thinking on sources and routes of transmission of the organism are discussed. Our increasing understanding of these has led to the development of a variety of environmental and general strategies for the prevention of IA. It is anticipated that these, coupled with the use of prophylactic antifungal agents active against Aspergillus spp., will have a significant impact upon the morbidity and mortality associated with this infection.

Cytokine release and mitogenic activity in the viridans streptococcal shock syndrome.

Viridans streptococci are a heterogeneous group of Gram-positive bacteria that are normal inhabitants of the mouth, upper gastrointestinal tract and oropharynx. These organisms are typically thought of as of low virulence, classically as the cause of infective endocarditis, although recently they have been implicated in serious infections in other settings. In particular, viridans group streptococci have been described as responsible for the alpha-streptococcal shock syndrome in neutropenic patients. The mechanism by which viridans streptococci cause bacteraemia associated with adult respiratory distress syndrome (ARDS) in these patients has not been elucidated. Using enzyme-linked immunosorbent assays, we compared the ability of cell-free bacterial supernatants derived from commensal and clinical strains of viridans streptococci to induce the pro-inflammatory cytokines tumour necrosis factor alpha (TNF-alpha), tumour necrosis factor beta (TNF-beta) and interleukin 8 (IL-8) from human peripheral blood mononuclear cells (PBMC) in vitro. Supernatants of clinical isolates induced significantly more TNF-beta (P < 0.002) and IL-8 (P < 0.001) than did supernatants from commensal strains. The increased production of IL-8 by the clinical strains may be of importance in view of the role of IL-8 in the pathogenesis of the acute respiratory distress syndrome (ARDS), one of the principal clinical features of the alpha-streptococcal shock syndrome.

Guidelines for the investigation of invasive fungal infections in haematological malignancy and solid organ transplantation. British Society for Medical Mycology.

Invasive fungal infections are increasing in incidence and now affect as many as 50% of neutropenic/bone marrow transplant patients and 5 to 20% of solid organ transplant recipients. Unfortunately, many of the diagnostic tests available have a low sensitivity. The guidelines presented here have been produced by a working party of the British Society for Medical Mycology in an attempt to optimise the use of these tests. The yield of fungi from blood cultures can be increased by ensuring that at least 20 ml of blood are taken for aerobic culture, by using more than one method of blood culture, and by employing terminal subculture if continuous monitoring systems are used with a five-day incubation protocol. Skin lesions in febrile neutropenic patients should be biopsied and cultured for fungi. The detection of galactomannan in blood or urine is of value in diagnosing invasive aspergillosis only if tests are performed at least twice weekly in high-risk patients. Antigen detection tests for invasive candidiasis are less valuable. Computed tomography scanning is particularly valuable in diagnosing invasive pulmonary fungal infection when the chest radiograph is negative or shows only minimal changes. Bronchoalveolar lavage is most useful in patients with diffuse changes on computed tomography scan. The major advances in the diagnosis of invasive fungal infection in patients with haematological malignancy or solid organ transplantation have been in the use of imaging techniques, rather than in the development of new mycological methods in the routine laboratory.

Disseminated infection due to Cylindrocarpon lichenicola in a patient with acute myeloid leukaemia.

We describe what is to our knowledge the first reported case of disseminated infection due to Cylindrocarpon. The presumed source was athlete's foot, a condition with which this fungus has previously been associated. Diagnosis was made by needle aspiration of a cutaneous lesion. Radiographic evidence of pulmonary involvement was present. The infection resolved following marrow regeneration and treatment with amphotericin B. Correct identification of Cylindrocarpon may be useful in guiding antifungal therapy.

Empirical antifungal therapy in febrile neutropenic patients: current status.

Empirical antifungal therapy has become established as standard practice in hematology and oncology units over the past decade and its use is increasing. A number of agents have been evaluated and intravenous amphotericin B has emerged as the drug of choice. Evidence of its benefit is limited and only clearly demonstrated in patients not receiving prior antifungal prophylaxis. However, although there have been improvements in the diagnosis of invasive fungal infections, it has been well shown that many patients who die during periods of neutropenia succumb to undiagnosed fungal infection, and also, if treatment is to be effective, it should be started as soon as possible after the onset of infection. Better targeting of antifungal prophylaxis (or preemptive therapy) and empirical therapy may now be possible and standard empirical therapy needs to be reevaluated in the light of changes in the underlying immune status of neutropenic patients and the development of new antifungal agents for prophylaxis and treatment.