Management of patients with SARS-CoV-2 infections with focus on patients with chronic lung diseases (as of 10 January 2022) : Updated statement of the Austrian Society of Pneumology (ASP).

The Austrian Society of Pneumology (ASP) launched a first statement on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in May 2020, at a time when in Austria 285 people had died from this disease and vaccinations were not available. Lockdown and social distancing were the only available measures to prevent more infections and the breakdown of the health system. Meanwhile, in Austria over 13,000 patients have died in association with a SARS-CoV­2 infection and coronavirus disease 2019 (COVID-19) was among the most common causes of death; however, SARS-CoV­2 has been mutating all the time and currently, most patients have been affected by the delta variant where the vaccination is very effective but the omicron variant is rapidly rising and becoming predominant. Particularly in children and young adults, where the vaccination rate is low, the omicron variant is expected to spread very fast. This poses a particular threat to unvaccinated people who are at elevated risk of severe COVID-19 disease but also to people with an active vaccination. There are few publications that comprehensively addressed the special issues with SARS-CoV­2 infection in patients with chronic lung diseases. These were the reasons for this updated statement. Pulmonologists care for many patients with an elevated risk of death in case of COVID-19 but also for patients that might be at an elevated risk of vaccination reactions or vaccination failure. In addition, lung function tests, bronchoscopy, respiratory physiotherapy and training therapy may put both patients and health professionals at an increased risk of infection. The working circles of the ASP have provided statements concerning these risks and how to avoid risks for the patients.

Management of patients with SARS-CoV-2 infections and of patients with chronic lung diseases during the COVID-19 pandemic (as of 9 May 2020) : Statement of the Austrian Society of Pneumology (ASP).

The coronavirus disease 2019 (COVID-19) pandemic is currently a challenge worldwide. In Austria, a crisis within the healthcare system has so far been prevented. The treatment of patients with community-acquired pneumonia (CAP), including SARS-CoV­2 infections, should continue to be based on evidence-based CAP guidelines during the pandemic; however, COVID-19 specific adjustments are useful. The treatment of patients with chronic lung diseases has to be adapted during the pandemic but must still be guaranteed.

Diagnosing filamentous fungal infections in immunocompromised patients applying computed tomography-guided percutaneous lung biopsies: a 12-year experience.

BACKGROUND: Invasive fungal diseases (IFD) are an important cause of morbidity and mortality in immunocompromised patients, and early diagnosis and management are a challenge. We evaluated the clinical utility of computed tomography (CT)-guided percutaneous lung biopsies in diagnosing IFD. METHODS: Between 2003 and 2014, we analyzed 2671 CT-guided lung biopsies, from which 157 were IFD associated; we aimed to determine microbiological-based diagnostic accuracy of calcofluor white staining (CFWS), culture, Aspergillus antigen detection (GM), broad-range fungal PCR, and Aspergillus PCR per sample. RESULTS: 127 (81%) specimens were microscopically positive for any fungal elements, 30 (19%) negative. Aspergillus and non-Aspergillus like hyphae were obtained in 85 (67%) and 42 (33%) specimens, respectively. CFWS positivity was defined as proof of infection. Sensitivity, specificity, and positive (PPV) and negative predictive (NPV) values for CT scan were 100, 44, 80, and 100%, for Aspergillus PCR 89, 58, 88, and 58%, for broad-range fungal PCR 90, 83, 95, and 90%, and for GM 94, 83, 95, and 90%. The most common CT features were patchy opacifications with central necrosis (78%) or cavern defects (50%), less common were air bronchograms (39%) or ground glass halos (39%), and all other features were rare. The overall pneumothorax rate subsequent to biopsy was 19%, but in only 2% of all cases the placement of a chest tube was indicated. One case of fatal air embolism occurred. CONCLUSIONS: CT-guided lung biopsies have high diagnostic accuracy in terms of microscopic examination, and complication rates are low. Molecular-based and antigen tests applied on fungal hyphae-positive specimens showed comparable results.

Bronchoalveolar Lavage Fluid (1,3)ß-D-Glucan for the Diagnosis of Invasive Fungal Infections in Solid Organ Transplantation: A Prospective Multicenter Study.

BACKGROUND: Prompt diagnosis of invasive fungal infections (IFI) remains a challenge. (1,3)ß-D-glucan detection in bronchoalveolar lavage (BAL) fluid by Fungitell assay aims to further improve upon the test's utility by directly applying it to specimens from the target organ. METHODS: A prospective multicenter analysis of the Fungitell assay was performed on BAL and serum samples obtained from nonselected solid-organ transplantation patients suffering from probable, proven or no IFI according to the revised criteria of the European Organisation for Research and Treatment of Cancer / Mycosis Study Group. RESULTS: Two hundred thirty-three BAL and 109 serum specimens from 135 patients with proven, probable, or no IFI were tested. Based on a 100 pg/mL: cutoff per test sensitivity, specificity, positive and negative predictive values were 79.2%, 38.5%, 27.6%, and 86.3% in BALs and 79.2%, 81.8%, 69.2%, and 83.1% in sera investigated. CONCLUSIONS: The accuracy of the (1,3)ß-D-glucan test is marginal so that its utility as a clinical test for early diagnosis of IFI is questionable in the lung transplant population. Although the high negative predictive value of the Fungitell assay in both, BALs and sera, may support exclusion of pulmonary IFI in solid-organ transplantation patients, the low positive predictive value limits its utility as a screening tool for early diagnosis of IFI.

Single time point measurement by C2 or C3 is highly predictive in cyclosporine area under the curve estimation immediately after lung transplantation.

BACKGROUND: The two h post-dose cyclosporine (CsA) concentration has been advocated as the optimal time point measurement for CsA area under the curve (AUC) estimation after solid organ transplantation. The aim of the study was to investigate whether intensified CsA monitoring is necessary, or if a single time point measurement is accurate to estimate the AUC in the very early period following lung transplantation (LuTX). METHODS: Within the first two wk following transplantation, daily AUCs were calculated by serial CsA measurements at zero, one, two, three, four, and six h (C0-C6) in 12 consecutive lung transplant recipients. Correlation of single CsA measurements and AUC as well as linear regression analysis was performed to evaluate the most predictive single CsA blood level regarding the AUC. RESULTS: A total of 606 CsA concentration measurements were performed and the 101 corresponding AUCs were calculated for each patient. Mean AUC was 3443 +/- 1451 microg/L. C0: 361 +/- 118 microg/L, C1: 481 +/- 231 microg/L, C2: 682 +/- 314 microg/L, C3: 715 +/- 347 microg/L, C4: 658 +/- 271 microg/L, C6: 571 +/- 260 microg/L. The correlation of CsA serum levels with AUC was the lowest at trough levels (C0) with a correlation coefficient (r = 0.31) and highest at three h (C3: r = 0.89) and two h (C2: r = 0.88). CONCLUSIONS: Similar to a stable post-transplant period, CsA trough levels turned out to have poor correlation with the corresponding AUC early after LuTX. The highest correlation of C3 with the AUC may be explained by delayed intestinal resorption immediately post-operative, however C2 is a peer parameter. Optimum AUCs and corresponding C2 or C3 levels in the immediate post-operative phase however remain to be determined.

Combined CMV prophylaxis improves outcome and reduces the risk for bronchiolitis obliterans syndrome (BOS) after lung transplantation.

BACKGROUND: The benefit of cytomegalovirus (CMV) hyperimmune globuline in preventing CMV infection after lung transplantation still remains unclear. The aim of this study was to investigate the effect of combined prophylaxis using ganciclovir (GAN) and CMV hyperimmune globulin (CMV-IG) on CMV infection, CMV disease, survival and its role in preventing Bronchiolitis obliterans syndrome (BOS). METHODS: A consecutive series of 68 CMV high-risk lung transplant recipients (D+/R-, D+/R+), who had a minimum follow-up of 1 year posttransplant were analyzed. Thirty patients (44.1%) received single GAN prophylaxis for 3 months (control group) and 38 recipients (55.9%) received GAN together with CMV-IG 7 times during the first postoperative month (study group). Median follow-up was 16.5 months in the control and 23.8 months in the study group (P = 0.54). RESULTS: Five CMV-related deaths (16.7%) occurred in the control group (P = 0.014). Fifteen recipients suffered from CMV pneumonitis and three patients had CMV syndrome. In the control group, 13 recipients (43.3%) suffered from clinically manifested CMV disease compared to 5 (13.2%) in the study group (P = 0.007). Additionally, recipient survival was significantly better in the study group (P = 0.01). One year freedom from CMV affection was 52.1% in the control and 71.5% in the study group (P = 0.027). Three-year freedom from BOS was significantly higher in the study group (54.3% vs. 82%, P = 0.024). CONCLUSIONS: In CMV high risk patients, additional CMV-IG administration seems to be effective to reduce CMV-related morbidity and to avoid CMV-related mortality. Reduced incidence of BOS may result from improved CMV prevention, although randomized trials are warranted.