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.

Successful treatment of pulmonary invasive aspergillosis with voriconazole in patients who failed conventional therapy.

BACKGROUND: The incidence of fungal infections, including those due to Aspergillosis species has continued to increase in recent years. Invasive aspergillosis remains an important cause of morbidity and mortality, despite therapeutics interventions. PATIENTS AND METHODS: We reported five cases of invasive pulmonary aspergillosis treated with voriconazole failing to respond to conventional treatments. RESULTS: The clinical and radiological resolution of pulmonary aspergillosis reported in these cases following therapy with voriconazole is remarkable, considering the infections had proved refractory to standard antifungal therapies. Long-term therapy (in two cases > or = 1 year, in one case 6 months) was very well tolerated by patients who were unable to tolerate other antifungal agents. CONCLUSION: Therapy with voriconazole offers a new therapeutic option for otherwise difficult-to-treat infections and the potential to significantly improve the management of Aspergillosis infections.

Cefepime--assessment of its need at a tertiary care center.

OBJECTIVE: To assess the need and possible indications for a fourth-generation cephalosporin (cefepime). METHOD: A cohort study was carried out over a 17-month period in a 1500-bed Swiss university hospital. RESULTS: In 256 (22.6%) of the 1135 patients followed consecutively by our Infectious Diseases Division, cefepime could have been chosen as an alternative to other broad-spectrum antibiotics, including imipenem/cilastatin (n=94), ciprofloxacine (n=52) and ceftazidime (n=49). Considering the low price-strategy of the pharmaceutical company promoting this drug in Switzerland, there would have been considerable cost savings for the hospital pharmacy if cefepime had been used as first-line treatment in these occasions. Nevertheless, we could not observe any potential advantage of cefepime compared to already introduced broad-spectrum antibiotics, except that cefepime was effective against infections caused by Enterobacter spp. resistant to ceftazidime. CONCLUSION: We conclude that fourth-generation cephalosporins such as cefepime may be introduced into large hospitals only after careful assessment of their potential benefits and that consultation by an Infectious Diseases Division is useful when evaluating the need for new broad-spectrum antibiotics in the hospital setting.

[Therapeutic attitude in cyanide poisoning (author's transl)]. / Propositions thérapeutiques actuelles en cas d'intoxication par les cyanures.

According to experimental and clinical data, the present treatment of acute cyanide poisoning depends basically on: 1) Dicobaltetracemate in cases of occupational pathology to be given at the working area, to patients with giddiness or mental confusion, 2) Oxygen by assisted ventilation, associated to hydroxocobalamine and sodium thiosulfate, to be administered after admission (patients in coma or circulatory failure). Initial cardio-respiratory arrest requires immediate cardiac massage and assisted ventilation. The rapid cyanide metabolism makes useless the dialysis methods. Frequent complications as metabolic acidosis and acute pulmonary oedema respond to symptomatic treatment. If these therapeutic measures are rapidly applied in confirmed cyanide poisoning, the notion of lethal blood level should be reconsidered. Survivals have been observed with initial plasma levels of 6 mg/l.