Transcript 25th ECCMID - MediPrint

ESCMID
EuropEan SoCIEty of ClInICal
MICrobIology anD InfECtIouS DISEaSES
Selected literature
25th
ECCMID
EuropEan CongrESS of ClInICal MICrobIology
anD InfECtIouS DISEaSES
Copenhagen, Denmark • 25 - 28 april 2015
Emergency on Invasive Fungal Infections
A cura del Professor Giuseppe Gentile
Tutti i poster e abstract sono riportati nella forma originale e sono reperibili online all’indirizzo:
http://www.escmid.org/research_projects/eccmid. La selezione scelta e i commenti sono a cura del prof. Gentile
selected literature
25th
ECCMID
EuropEAn CongrEss of CliniCAl MiCrobiology
AnD infECtious DisEAsEs
Copenhagen, Denmark • 25 - 28 April 2015
Emergency on Invasive Fungal Infections
A cura del Professor Giuseppe Gentile
IndIce
Introduzione
5
Giuseppe Gentile
EP015 - Poster
Treatment of Invasive Aspergillosis in Patients with Acute Myeloid Leukaemia and
Acute Lymphoblastic Leukaemia: A Pharmacoeconomic Evaluation of Liposomal
Amphotericin B, Voriconazole and Caspofungin
6
S.M. Heimann, L. Scherkenbach, O.A. Cornely, M.J. Vehreschild, H. Wisplinghoff, B. Franke, J.J. Vehreschild (Germany)
EV0062 - Abstract e Poster
Muscle penetration of liposomal Amphotericin B (L-AmB) and Posaconazole (Pos)
in burn patients with mucormycosis
10
Christophe Padoin, Quentin Ressaire, Alexandre Alanio, Veronique Maurel, Axelle Ferry, Sabri Soussi,
Mourad Benyamina, Blandine Denis, Marc Guibert, Alexandre Mebazaa, Marc Chaouat, Matthieu Legrand (France)
P0235 - Abstract e Poster
Delay of Antifungal Therapy Influences the Outcome of Invasive Aspergillosis
in Experimental Models of Infections
14
Francesco Barchiesi, Daniele Giannini, Gianfranco Greganti, Ester Manso (Italy)
P1258 - Abstract e Poster
A trend analysis of candidaemia caused by Candida glabrata in Belgium:
drug resistance and antifungal consumption
18
B. Goemaere, K. Lagrou, A. Ingenbleek, M. Goossens, K. Latour, B. Catry, M. Hendrickx, P. Becker (Belgium)
P1282 - Abstract e Poster
Emerging azole-resistant invasive aspergillosis at a tertiary Dutch Intensive Care Unit
22
J. van Paassen, A. Russcher, A. W. in ‘t Veld –van Wingerden, P.E. Verweij, E.J. Kuijper (St. Radboud)
P1283 - Abstract e Poster
Occurrence of azole resistant Aspergillus fumigatus in environmental samples
from Italian regions
A.M. Tortorano, A. Prigitano, M.C. Esposto (Italy)
26
P0212 - Abstract
News on antifungal prophylaxis and therapy
Protection against azole-resistant Aspergillus fumigatus in an immunosuppressed
model of murine pulmonary aspergillosis following short course liposomal
amphotericin B therapy
30
J. Olson, J. Adler-Moore (USA)
O184 - Abstract
Invasive fungal infections: what is new?
Surveillance and antifungal susceptibility of mixed invasive aspergillosis over
a 13-year period
32
T. Pelaez Garcia, G. Rocio, Á. Ana, A. Oiahane, G. Sara, M. Emilia, B. Emilio (Spain)
P1090 - Abstract
Improving fungal diagnostics
Performance of Aspergillus PCR, multifungal DNA microarray, galactomannan,
1,3-beta-D-glucan and Aspergillus azole resistance PCR for diagnosis of invasive
fungal infections in haematological patients
34
T. Boch, B. Spiess, O.A. Cornely, J.J. Vehreschild, P. Rath, J. Steinmann, W.J. Heinz, J. Hahn, S.W. Krause,
M. Kiehl, G. Egerer, M. Koldehoff, M. Klein, F. Nolte, S. Will, N. Merker, W. Hofmann, D. Buchheidt,
M. Reinwald (Germany)
P1222 - Abstract
Invasive fungal infections in immunocompromised patients
Breakthrough of fungal infections in allogeneic stem cell transplanted
patients in antifungal prophylaxis
36
T. Pelaez Garcia, G. Rocio, Á. Ana, A. Oiahane, G. Sara, M. Emilia, B. Emilio (Spain)
P1256 - Abstract
Invasive candidiasis
A decade of nation-wide fungaemia surveillance in Denmark:
current status and major trends
M.C. Arendrup, R.H. Jensen, H.K. Johansen, J.D. Knudsen, L.E. Lemming, B.L. Røder, F.S. Rosenvinge,
L. Kristensen, L. Nielsen, B. Olesen, E. Dzajic, P. Kjældgård, H.C. Schønheyder (Denmark)
38
IntroduzIone
I
l Congresso Europeo della Società di Microbiologia Clinica e di Malattie Infettive (ECCMID) si è
tenuto dal 25 al 28 aprile 2015 a Copenhagen, Danimarca, e ha visto la presenza di oltre 10.000
partecipanti provenienti sia da molti paesi Europei che da tutto il mondo.
Sono stati presentati studi su ogni aspetto delle infezioni, sia nell’ambito della ricerca di base che
della ricerca clinica, sia studi riguardanti vecchie infezioni sia quelli che hanno cercato di
approcciare le infezioni più recenti ed emergenti.
Per quanto riguarda le infezioni fungine è stato possibile selezionare, tra i molti e interessanti studi
presentati, quelli riguardanti l’epidemiologia, quelli sui nuovi gruppi di pazienti a rischio, sui nuovi
test diagnostici, sulla farmacoeconomia, e sull’emergenza di specie fungine resistenti a farmaci
antifungini usualmente utilizzati. Inoltre, degli studi scelti sono evidenziate le principali
caratteristiche e viene dedicato un commento che consente di valutarne i risultati alla luce della
letteratura più recente e rilevante.
Professor Giuseppe Gentile
Dipartimento di Biotecnologie Cellulari ed Ematologia
“Sapienza”, Università di Roma
5
treatment of invasive Asp
A pharmacoec
Ep015
1
University Hospital of Cologne,
Abstract
Introduction
Objectives: Invasive aspergillosis (IA) is among the most frequent
complications of high-risk patients with underlying haematological diseases. In case of failure of antifungal therapy, the disease
may progress to life-threatening illness, resulting in high treatment costs.
Methods: Patients treated at the University Hospital of Cologne between 2006 and 2012 for a haematological disease and who developed a possible, probable, or proven IA according to EORTC/MSG
criteria were included into analysis. Based on data extracted from
the Cologne Cohort of Neutropenic Patients (CoCoNut), an evaluation of direct treatment costs was performed. Analysis was split
into patients receiving liposomal amphoptericin B (LAmB), voriconazole (VCZ), or caspofungin (CFG). The following cost factors were
analyzed from the German societal perspective: treatment on general ward and intensive care unit, anti-infective treatment, diagnostic measures, radiological findings, and laboratory tests. Costs
were expressed in EUR (€), year 2013 values. Discounting of costs
was performed with an annual discount rate of 5%.
Results: We identified 166 patients with underlying haematological
disease who were treated with LAmB, VCZ, or CFG due to IA. Onehundred and five patients (63.3%) had AML or ALL as primary underlying disease and were included into pharmacoeconomic analysis.
Thirty-five patients (33.3%) were treated with LAmB, 31 (29.5%) with
VCZ and 39 (37.1%) with CFG, whereby distribution of treatment with
LAmB, VCZ, and CFG due to possible, probable, or proven IA was as
follows: 31 (88.6%), 3 (8.6%) and 1 (2.9%); 29 (93.5%), 2 (6.5%),
and 0 (0%); 33 (84.6%), 4 (10.3%) and 2 (5.1%). Patients in the
LAmB, VCZ, and CFG group had a mean overall length of stay of 55.6
days (95%CI: 48.7–62.6), 56.5 days (95%CI: 46.8–66.1) and 53.9
days (95%CI: 44.7–63.0, P= 0.907), were neutropenic for 22.8 days
(95% CI: 16.5–29.2), 25.5 days (95% CI: 18.9–32.1) and 22.2 days
(95% CI: 17.8–26.7, P= 0.571) and were treated with LAmB, VCZ,
and CFG for 20.8 days (95% CI: 16.5–25.1), 24.0 days (95%CI: 16.7–
31.4) and 21.3 days (95% CI: 17.0–25.6, P= 0.749). Treatment of patients in the LAmB, VCZ, and CFG group caused in mean overall daily
treatment costs of € 700 (95%CI: 624 – 777), € 617 (95%CI: 530 –
705) and € 691 (95%CI: 621 – 762, P= 0.272) and mean overall
treatment costs of € 39,556 (95%CI: 32,940 – 46,171), € 33,847
(95%CI: 26,552 – 41,142) and € 36,404 (95%CI: 30,514 – 42,294,
P= 0.517). Twenty-nine (82.9%), 27 (87.1) and 32 (82.1%) patients
in the LAmB, VCZ, and CFG group survived hospitalization.
Conclusion: Our pharmacoeconomic evaluation shows comparable results in length of treatment, treatment costs, and outcome
of AML and ALL patients with IA treated with LAmB, VCZ, and CFG.
Choice of antifungal did not appear to be a main cost driver of
overall treatment costs.
• Immunocompromised patients with hematological underlying
diseases (such as AML and ALL) are at high risk to develop an
invasive aspergillosis (IA) [1,2].
• These nosocomial infections are associated with high morbidity
and mortality rates [3,4].
• Recent studies described the high treatment costs of IA [5,6].
• Especially the treatment in intensive care unit and the treatment with
innovative antifungal agents resulted in high treatment costs [5,6].
• From the health economic point of view, controversy exists
about cost-effectiveness of antifungal treatment in possible,
probable and proven IA.
• We performed a pharmacoeconomic evaluation in a German
tertiary care hospital to analyze the impact of antifungal drug
choice with liposomal amphotericin B (LAmB), voriconazole
(VCZ) and caspofungin (CFG) in IA.
Methods I
First aim of our analysis was to identify all patients with hematological underlying diseases who developed a possible, probable
or proven IA according to revised EORTC/MSG criteria [7]. We
therefore included patients who were treated at the Department
I of Internal Medicine of the University Hospital of Cologne (UHC)
between 2006 and 2012 with the following key inclusion criteria:
• All male or female patients who developed a possible, probable
or proven IA [7] while being neutropenic.
• Antifungal treatment due to IA with LAmB, VCZ or CFG.
Methods II
Patients with AML and ALL were included into our pharmacoeconomic
evaluation. Data documentation was performed by using the Cologne
Cohort of Neutropenic Patients (CoCoNut; ClinicalTrials.gov:
NCT01821456), a prospective cohort study assessing clinical data of patients with hemato-oncological underlying diseases treated at the UHC.
For our pharmacoeconomic evaluation only direct medical treatment costs were included:
• Treatment on general ward
• Treatment on intensive care unit
• Mechanical ventilation
• Diagnostic measures
• Radiological findings
• Laboratory tests
• Antiinfective treatment (antifungals, antibiotics, antivirals)
6
pergillosis in patients with Acute Myeloid leukaemia and Acute ly
conomic Evaluation of liposomal Amphotericin b, Voriconazole and
S.M. Heimann1, L. Scherkenbach1, O.A. Cornely1, M.J. Vehreschild1, H. Wisplinghoff2, B. Franke1, J.J. Vehreschild1
, Department I of Internal Medicine, Cologne, Germany; 2University Hospital of Cologne, Institute for Medical Microbiology, Immunology a
All direct medical treatment costs were calculated based on the
German Diagnosis Related Groups (G-DRG), the official German
reimbursement system since 2003 [8] and the WEBAPO®LAUERTaxe, a database offering comprehensive information about pharmaceutical products [9]. All costs are expressed in EURO (€),
year 2013 values. Due to the observed time timeframe of more
than one year, discounting of costs was performed with an annual
rate of 5% as recommended by national guidelines [10, 11]. Indirect costs were disregarded due to the severity of the underlying diseases. Statistical analysis was performed by IBM SPSS
Statistics software, for Windows version 21.0 (IBM Corp., Armonk, NY, USA).
Results I – Patients characteristics
Group →
Item ↓
Age; median (range)
Gender; no. female (%)
BMI; mean (95% CI)
Underlying Disease:
• AML (%)
• ALL (%)
Type of IA [7]:
• Possible (%)
• Probable (%)
• Proven (%)
Duration on general ward (days);
mean (95% CI)
Duration on intensive care unit (days);
mean (95% CI)
Duration of neutropenia (days);
mean (95% CI)
Duration of mechanical ventilation (hours);
mean (95% CI)
Duration of group-specific antifungal
treatment (days); mean (95% CI)
Hospitalization survived (%)
LAmB-group
(n=35)
VCZ-group
(n=31)
CFG-group
(n=39)
P*
56 (21 – 80)
15 (42.9)
25.1 (23.6 – 26.6)
54 (24 – 85)
20 (64.5)
26.7 (23.6 – 26.6)
56 (21 – 72)
19 (48.7)
25.7 (24.5 – 26.8)
0.719
0.673
0.868
0.638
33 (94.3)
2 (5.7)
25 (80.6)
6 (19.4)
33 (84.6)
6 (15.4)
0.251
31 (88.6)
3 (8.6)
1 (2.9)
29 (93.5)
2 (6.5)
0 (0)
33 (84.6)
4 (10.3)
2 (5.1)
50.8 (43.8 – 57.8)
54.6 (45.2 – 63.9)
49.1 (40.2 – 57.9)
0.481
4.8 (1.8 – 7.9)
1.9 (0.6 – 3.2)
4.8 (1.4 – 8.2)
0.425
22.8 (16.5 – 29.2)
25.5 (18.9 – 32.1)
22.2 (17.8 – 26.7)
0.571
80.5 (12.1 – 148.8)
18.5 (-3.1 – 40.1)
69.6 (7.6 – 131.7)
0.591
20.8 (16.5 – 25.1)
29 (82.9)
24.0 (16.7 – 31.4)
27 (87.1)
21.3 (17.0 – 25.6)
32 (82.1)
0.749
0.710
*single factor analysis of variance (ANOVA) -test
Results II – Cost calculation
Group →
Item ↓
Overall treatment costs in €;
mean (95% CI)
Treatment costs for group-specific antifungal
agent in €; mean (95% CI)
Overall treatment costs per day in €;
mean (95% CI)
LAmB-group
(n=35)
VCZ-group
(n=31)
CFG-group
(n=39)
P*
39,556
(32,940 – 46,171)
7,916
(5,673 – 10,158)
700
(624 – 777)
33,847
(26,552 – 41,142)
5,593
(3,686 – 7,500)
617
(530 – 705)
36,404
(30,514 – 42,294)
10,668
(7,812 – 13,524)
691
(621 – 762)
0.517
*single factor analysis of variance (ANOVA) -test
7
0.477
0.272
ymphoblastic leukaemia:
d Caspofungin
and Hygiene, Cologne, Germany
45000
40000
35000
30000
706
2619
9217
10000
5000
Overall an bio cs
11378
Overall an myco cs (LAmB,
VCZ, CFG)
Laboratory test
7368
6844
15000
243
3021
12094
25000
20000
Overall an virals
414
3335
799
1655
5227
Radiological findings
900
1028
Diagnos c measures
4257
1215
1497
1871
4215
9634
9877
10392
LAmB-group
VCZ-group
CFG-group
Intensive care unit
General ward
€0
References & Funding
Conclusion
[1] Bohme A. et al. Treatment of invasive fungal infections in cancer patients--recommendations
of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Annals of hematology (2009). [2] Perfect JR. et al. Update on epidemiology of
and preventive strategies for invasive fungal infections in cancer patients. Clin Infect Dis (2014).
[3] Herbrecht R. et al. Indications and outcomes of antifungal therapy in French patients with
haematological conditions or recipients of haematopoietic stem cell transplantation. J Antimicrob
Chemother (2012). [4] Pagano L. et al. The epidemiology of fungal infections in patients with
hematologic malignancies: the SEIFEM-2004 study. Haematologica (2006). [5] Baddley JW. et
al. Aspergillosis in Intensive Care Unit (ICU) patients: epidemiology and economic outcomes. BMC
Infect Dis (2013). [6] Rieger CT. et al. Treatment cost of invasive fungal disease (Ifd) in patients
with acute myelogenous leukaemia (Aml) or myelodysplastic syndrome (Mds) in German hospitals. Mycoses (2012). [7] De Pauw et al. Revised definitions of invasive fungal disease from the
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. Clin Infect Dis (2008). [8] Institute for the Hospital Remuneration
System. Institute for the Hospital Remuneration System - German Diagnosis Related Groups.
http://www.g-drg.de/cms/. [9] LAUER-FISCHER Taxe. WEBAPO Lauer Taxe. http://www2.lauerfischer.de/produkte/lauer-taxe/lauer-taxe/. [10] Schulenburg et al. German recommendations
on health economic evaluation - Third and updated version of the Hanover Consensus. Gesundh
ökon Qual manag (2007). [11] Institute for Quality and Efficiency in Health Care. Methods for
health economic evaluation. https://www.iqwig.de/en/methods/methods_papers/health_economic_evaluation.3022.html.
Our pharmacoeconomic evaluation analyses the impact of antifungal drug choice on outcome and direct treatment costs
of IA. Antifungal treatment regimens with LAmB, VCZ and CFG
shows comparable results with respect to overall hospital
length of stay, duration of antifungal treatment and survival
of hospitalization.
Furthermore, no significant differences could be shown concerning overall direct treatment costs, group-specific antifungal treatment costs and overall treatment costs per day.
Overall antifungal treatment was the most important cost
driver in our analysis with an amount of almost 1/3 of overall
direct treatment costs.
The limitations of our study should be mentioned as well. We
cannot rule out that other comorbidities may have influenced
the calculated overall costs, although we tried to include only
infection-related cost factors.
Further pharmacoeconomic evaluation are warranted to analyze the impact of the increase of rare invasive fungal infections and antifungal resistance.
This study was supported by an unrestricted research grant from Gilead Sciences GmbH, Germany.
It was designed, planned, and performed by the academic authors and students of the UHC.
8
Key points
L’aspergillosi invasiva (A.I.) rappresenta, ancora oggi, una frequente complicanza infettiva per i pazienti con
malattie ematologiche ad alto rischio. Nel caso di fallimento della terapia fungina, l’infezione può progredire
fino a morte del paziente producendo, inoltre, elevati costi per il suo trattamento.
Sono stati inclusi, nello studio, pazienti con malattie ematologiche osservati tra il 2006 e il 2012 che
sviluppavano una A.I. (secondo i criteri EORTC: possible, probable, or proven).
Sono stati analizzati i seguenti costi: trattamento in una corsia generale e in una terapia intensiva, trattamento
antiinfettivo, test diagnostici, radiologici e di laboratorio. I costi sono stati espressi in euro relativi all’anno 2013.
Nelle valutazioni è stato considerato uno sconto annuale del 5%.
Sono stati trattati con Amfotericina B liposomiale (L-AmB), voriconazolo (VCZ), o caspofungina (CFG) 166 pazienti
con malattie ematologiche e con A.I.; 105 pazienti (63,3%) avevano malattie ematologiche come la leucemia
mieloide acuta (AML) o leucemia linfatica acuta (ALL) e sono stati inclusi in questa analisi farmacoeconomica.
Sono stati trattati con L-AmB, 35 pazienti (33,3%) 31 pazienti (29,5%) con VCZ e 39 (37,1%) con CFG.
I pazienti che avevano ricevuto L-AmB, VCZ e CFG mostravano una lunghezza media di ricovero
rispettivamente di 55,6 giorni, 56,5 giorni e 53,9 giorni.
I pazienti sono stati trattati con L-AmB, VCZ e CFG rispettivamente per 20,8 giorni, 22,4 giorni e 21,3 giorni.
Il costo medio giornaliero dei pazienti trattati con L-AmB ,VCZ e CFG era rispettivamente di 732 euro, 654
euro, e 717 euro (differenze non statisticamente significative).
Il costo medio totale dei trattamenti (L-AmB,VCZ e CFG ) era di 41.312 euro, 35.805 euro e 38.157 euro
(differenze non statisticamente significative).
Sono sopravvissuti nel periodo di ospedalizzazione, l’82,9%, l’87,1% e l’82,1% dei pazienti trattati,
rispettivamente, con L-AmB ,VCZ e CFG.
Le valutazioni farmacoeconomiche di questo studio mostrano risultati confrontabili per quanto riguarda la
lunghezza e i costi del trattamento e la prognosi dei pazienti con malattie ematologiche affetti da A.I. e trattati
con L-AmB , VCZ e CFG. La scelta dei farmaci antifungini non sembra essere uno dei principali determinanti
del costo complessivo dei trattamenti antifungini.
Commento
Gli studi di farmacoeconomia applicati alla terapia di gravi infezioni fungine che colpiscono pazienti
affetti da malattie oncoematologiche consentono di ottimizzare il valore e la qualità delle cure e della
gestione di malati così complessi. Complessivamente, in questo studio, la scelta dei farmaci antifungini
non sembra essere stato uno dei principali determinanti del costo complessivo dei trattamenti
antifungini. Tuttavia, uno dei limiti delle analisi di farmacoeconomia è la scarsa generalizzazione ed
applicazione a paesi diversi da quello in cui è stato generato lo studio.
9
EV0062 - ePoster Viewing
Antimicrobials: antimicrobial pK/pD, pharmacogenomics, pharmacoeconomics and general
pharmacology, drug interaction studies.
Muscle penetration of liposomal Amphotericin b (l-Amb) and posaconazole (pos) in burn
patients with mucormycosis
C. Padoin, Q. Ressaire, A. Alanio, V. Maurel, A. Ferry, S. Soussi, M. Benyamina, B. Denis, M. Guibert, A. Mebazaa,
M. Chaouat, M. Legrand
Objectives: Mucormycosis is an opportunistic infection which occurs in patients with impaired host defenses
or diabetes mellitus. In burn patients, mucormycosis more often involve the burn wound. First line
chemotherapy of mucormycosis includes high-dose Liposomal Amphotericin B (L-AmB). Association with
posaconazole has also been proposed. The objective of this study was to measure muscle and plasma
concentrations of L-AmB and posaconazole (Pos) in burn patients.
Methods: Plasma and tissue were collected simultaneously. Levels were measured in plasma and muscle of
three burn patients admitted to our burn intensive care unit WITH severe burn injuries (total body surface
area 60, 96 an 85% respectively), all with multiple organ failure who had been treated with L-AmB 10 mg/kg
once daily for respectively 15, 15 and 12 days and Pos 400 mg oral suspension twice daily. Weighed tissues
were homogenized in water using a Polytron for 2.5 min over an ice bath. Plasma and muscle
concentrations of L-AmB and Pos were assayed using validated liquid chromatography method. The limits
of quantification (LOQ) were 0.1 mg/L for both, AmB and POS.
Results: Plasma AmB concentrations were 2.1, 2.6 and 4.6 mg/L for patient 1, 2 and 3 respectively. Tissue
AmB concentrations were 41.8 and 17.7 μg/g for patient 1, 50.2; 30.7 μg/g for patient 2 and 81.3 μg/g for
patient 3. The AmB concentration in muscle was approximately 8 to 18 times higher than in plasma. POS
plasma concentrations were < limit of quantification (LOQ) for patients 1 and 3 and 0.3 mg/L for patient 2. Pos
tissue concentrations were all < LOQ.
Conclusion: Liposomal AmB displayed high penetration into muscle. Muscle tissue concentrations were
approximately 10-20 fold higher than those in plasma. Very low plasma Pos concentrations demonstrate altered
Pos bioavability in these patients. Therapeutic drug monitoring of POS is therefore mandatory for burn patients.
10
Muscle penetration of liposomal Amphote
in burn patients w
EV0062
Christophe Padoin1, Quentin Ressaire2, Alexandre Alanio3, Veronique Maurel2, Axelle Ferry2, Sabri Soussi2, M
HUPSSD - Avicenne, Toxicology Laboratory1, Bobigny, France; GH St-Louis-Lariboisière, Burn
Université Paris Did
Objectives
mitted to our burn intensive care unit with severe burn injuries
(total body surface area 60, 96 an 85% respectively). All patients with multiple organ failure had been treated with LAmB 10 mg/kg once daily for respectively 15, 15 and 12 days
and Pos 400 mg oral suspension twice daily. Weighed tissues
were homogenized in water using a Polytron for 2.5 min over
an ice bath. Plasma and muscle concentrations of L-AmB and
Pos were assayed using validated liquid chromatography method. The limits of quantification (LOQ) were 0.1 mg/L for
both, AmB and POS.
Mucormycosis is an opportunistic infection which occurs in
patients with impaired host defenses or diabetes mellitus. In
burn patients, mucormycosis more often involve the burn
wound. First line chemotherapy of mucormycosis includes
high-dose Liposomal Amphotericin B (L-AmB). Association with
posaconazole has also been proposed.
The objective of this study was to measure muscle and
plasma concentrations of LAmB and posaconazole in burn
patients.
Results
Methods
Three patients were diagnosed with proven invasive subcutaneous mucormycosis due to Mucor circinelloides. Results
are summarised in Table 1.
Plasma and tissue were collected simultaneously. Levels were
measured in plasma and muscle of three burn patients ad-
L-AmB
Conc
Patient 1
Patient 2
Patient 3
Plasma (mg/L)
Pos
Tissues ( g/g)
Plasma (mg/L)
41,8
<LOQ
17,8
<LOQ
50,2
0,28
30,7
0,32
81,3
<LOQ
2,1
2,6
4,6
LOQ: Limit Of Quantification
11
Tissues ( g/g)
<LOQ
<LOQ
<LOQ
ericin b (l-Amb) and posaconazole (pos)
with mucormycosis
Mourad Benyamina2, Blandine Denis4, Marc Guibert2, Alexandre Mebazaa2, Marc Chaouat2, Matthieu Legrand2
n Unit2, Parasitology-Mycology Laboratory3, Department of Infectious Diseases4, Paris, France
derot5, Paris, France
Conclusion
fold higher than those in plasma. Very low plasma Pos
concentrations demonstrate altered Pos bioavability in
these patients. Therapeutic drug monitoring of POS is therefore mandatory for burn patients.
Liposomal AmB displayed high penetration into muscle.
Muscle tissue concentrations were approximately 10-20
12
Key points
La mucormicosi è un’infezione opportunistica che colpisce pazienti con difese immunitarie deficitarie o
affetti da diabete mellito. Nei pazienti ustionati la mucormicosi spesso coinvolge la ferita ustionata. La
terapia di prima linea della mucormicosi comprende dosi elevate di L-AmB; mentre l’associazione con il
posaconazolo è in fase di definizione.
L’obiettivo dello studio è stato quello di misurare le concentrazioni di L-AmB e Pos nei muscoli e nel
plasma dei pazienti ustionati.
Plasma e tessuti sono stati prelevati simultaneamente da 3 pazienti ustionati, gravi e con multiple
insufficienze d’organo. I pazienti sono stati trattati con 10 mg/Kg di L-AmB una volta al giorno e con Pos
400 mg, sospensione orale due volte al giorno.
Le concentrazioni plasmatiche di L-AmB oscillavano tra 2,1 e 4,6 mg/L, mentre le concentrazioni nei tessuti
erano tra 17,7 Ug/G e 81,3 Ug/G.
La concentrazione di L-AmB nei muscoli era approssimativamente 8 -18 volte più elevata rispetto al plasma.
Le concentrazioni di Pos nel plasma oscillavano tra il limite inferiore di quantizzazione e 0,3 mg/l, mentre le
concentrazioni tessutali erano inferiori al limite di quantizzazione.
In questo studio L-AmB ha mostrato un’elevata penetrazione nei muscoli e la relativa concentrazione era 1020 volte più elevata della concentrazione osservata nel plasma. Le concentrazioni di Pos, molto basse nel
plasma, dimostravano un’alterata biodisponibiltà di questo farmaco nei pazienti ustionati. Il monitoraggio dei
livelli terapeutici di Pos è necessario nei pazienti ustionati.
Commento
La maggior parte delle infezioni da mucormicosi è osservata in pazienti con deficit immunitari o affetti da
diabete mellito. Tuttavia, la diagnosi di infezioni da mucormicosi in individui ustionati o traumatizzati è
riportata in letteratura con maggiore frequenza rispetto al passato (Schaal JV et al. Epidemiology of
filamentous fungal infection in burned patients: a French retrospective study. Burns 2015;41:853-63.
Lelievre L. et al. Post traumatic mucormycosis: a nationwide study in France and review of the literature.
Medicine 2014;93:395-404). Anche se questo studio è stato condotto solo su 3 pazienti, la valutazione, in
vivo, delle concentrazioni dei farmaci attualmente indicati da linee guida vigenti per il trattamento della
mucormicosi, nei muscoli e nel plasma dei pazienti ustionati è un risultato di rilievo. Si rendono necessari
ulteriori studi clinici sulle infezioni da Mucor in questo ambito al fine di ridurre l’elevata mortalità correlata
a questa infezione.
13
P0235 - Paper Poster Session I
news on antifungal prophylaxis and therapy
Delay of Antifungal therapy influences the outcome of invasive Aspergillosis in
Experimental Models of infections
F. Barchiesi, D. Giannini, G. Gianfranco, E. Manso
Objectives: The aim of the present study was to evaluate the effects of delay the antifungal therapy on the
outcome of invasive aspergillosis (IA) due to A. fumigatus in experimental models of infections.
Methods: A clinical isolate of A. fumigatus susceptible to both amphotericin B (AMB, median MIC 0.5 μg/ml)
and micafungin (MICA, median MEC 0.03 μg/ml) was used in all experiments. Two models of infections were
investigated in CD1 immunosuppressed female mice: disseminated infection (DI) performed by given the
conidia intravenously and pulmonary infection (PI) by given the conidia intranasally. 24 h (early therapy, ET) and
48 h (delayed therapy, DT) postinfection, the mice were given placebo, MICA, liposomal-AMB (L-AMB), and
MICA plus L-AMB (Combo). Each drug was utilized at low (3 mg/kg/day) and high (10 mg/kg/day) doses.
Therapy was given for three consecutive days. Drug efficacy was assessed either by survival analysis (15 days
of observation) or tissue burden experiments (kidney and lung in DI and PI models, respectively). In tissue
burden the mice were euthanized 24 h after the last dose of the drug and tissue CFUs were determined.
Histology studies were also performed. Survivals were plotted as Kaplan-Meier curves and analyzed by log rank
(due to multiple comparison, a P < 0.008 was considered statistically significant). CFUs/organ/mouse were
analyzed by one-way Anova followed by the Tukey's test corrected for multiple comparison (a P <0.05 was
considered statistically significant).
Results: In ET of DI model either L-AMBI (P = 0.0024) or MICA (P = 0.0031) given at 3 mg were effective against
the control at prolonging the survival. Combo was more effective than control (P <0.0001), more effective than
L-AMBI (P = 0.0005) but not more effective than MICA alone (P = 0.02). In DT, the only regimen which prolonged
the survival was Combo (P = 0.005). When drug doses, singly and in combination, were increased at 10 mg, all
regimens were effective at prolonging the survival following ET (P <0.0001). In DT experiments, only MICA (P =
0.001) and Combo (P = 0.0026) were effective. PI was conducted with drugs given at 3 mg. In both ET and DT
experiments only Combo was more effective than control at prolonging the survival (P = 0.007 in ET, P = 0.004
in DT). In ET of tissue burden experiments each single regimen given at 3 mg was effective in DI model, while
only L-AMB and Combo were effective in PI model. Conversely, in DT no regimen was effective.
Conclusion: The delay onset of therapy is deleterious in experimental models of IA either in terms of survival
than in terms of fungal burden. A combination approach seems to be a good therapeutic option when therapy is
started late.
14
Delay of Antifungal therapy influ
Aspergillosis in Experime
p0235
Francesco Barchiesi, Daniele Giannin
Clinica Malattie Infettive, Università Politecnica delle Marche, Az
Objectives
Figure 1. Survival curves of mice infected intravenously (A,B,C,D) or in
conidia/mouse and treated with placebo (circle), L-AMB (square), MICA
Both drugs, alone or in combination, were given at 3 (A,B,E,F) or 10 (C,
(early therapy; A,C,E) or 48 h (delayed therapy; B,D,F) postinfection.
The aim of the present study was to evaluate the effects of delaythe
antifungal therapy in the outcome of invasive aspergillosis (IA) due to
A. fumigatus in experimental models of infections.
100
Methods
A
Percent survival
80
A clinical isolate of A. fumigatus susceptible to both amphotericin B
(AMB, median MIC 0.5 µg/ml) and micafungin (MICA, median MEC 0.03
µg/ml) was used in all experiments.
Two models of infections were investigated in CD1 immunosuppressed female mice: disseminated infection (DI) performed by given the
conidia intravenously and pulmonary infection (PI) by given the conidia intranasally. 24 h (early therapy, ET) and 48 h (delayed therapy,
DT) postinfection, the mice were given placebo, MICA, liposomal-AMB
(L-AMB), and MICA plus L-AMB (Combo). Each drug was utilized at
low (3 mg/kg/day) and high (10 mg/kg/day) doses. Therapy was given
for three consecutive days.
Drug efficacy was assessed either by survival analysis (15 days) or tissue
burden experiments (kidney in DI model). In tissue burden, the mice were
euthanized 24 h after the last dose of the drug and the CFUs were determined.
Survivals were plotted as Kaplan-Meier curves and analyzed by log rank
(due to multiple comparison, a P < 0.008 was considered statistically
significant). CFUs/organ/mouse were analyzed by one-way Anova followed by the Tukey's test corrected for multiple comparison. A P <0.05
was considered statistically significant.
60
40
20
0
0
100
5
10
Days post-infection
15
C
Percent survival
80
60
40
20
0
0
Results
5
10
15
Days post-infection
In ET (Fig. 1A) of DI model either L-AMBI (P = 0.0024) or MICA (P = 0.0031)
given at 3 mg were effective against the control. Combo was more effective than control (P <0.0001), more effective than L-AMBI (P = 0.0005)
but not more effective than MICA alone (P = 0.02). In DT, the only regimen
which prolonged the survival was Combo (P = 0.005, Fig. 1B). When drug
doses, singly and in combination, were increased at 10 mg, all regimens
were effective at prolonging the survival following ET (Fig. 1C, P <0.0001).
In DT experiments (Fig. 1D), only MICA (P = 0.001) and Combo (P =
0.0026) were effective.
PI was conducted with drugs given at 3 mg. In both ET and DT experiments (Fig. 1E and 1F, respectively) only Combo was more effective than
control (P = 0.007 in ET, P = 0.004 in DT).
In ET of tissue burden experiments all regimens given at 3 mg were effective against the controls (Fig. 2A). Conversely, in DT no regimen was
effective (Fig. 2B).
E
100
Percent survival
80
60
40
20
0
0
15
5
10
Days post-infection
15
uences the outcome of invasive
ental Models of infections
ni, Gianfranco Greganti, Ester Manso
zienda Ospedaliero-Universitaria, Ospedali Riuniti, Ancona, Italy
tranasally (E,F) with of 1x105 (A,B,C,D), 1x104 (E,F) A. fumigatus
(triangle), and combination of L-AMB plus MICA (upper base triangle).
,D) mg/kg/day for three consecutive days. Therapy was started 24 h
100
Figure 2. Tissue burden of mice infected intravenously with
approximately 7x105 A. fumigatus conidia/mouse and treated with
placebo (circle), L-AMB, MICA, and combination of L-AMB plus
MICA (Combo). Both drugs, alone or in combination, were given at
3 mg/kg/day for three consecutive days. Therapy was started 24 h
(early therapy; A) or 48 h (delayed therapy; B) postinfection.
B
103
A
CFUs Kidney tissue
Percent survival
80
60
40
20
0
5
10
Days post-infection
15
103
CFUs Kidney tissue
D
Percent survival
80
60
40
20
0
5
10
Days post-infection
Control
L-Amb
Mica
Combo
L-Amb
Mica
Combo
B
102
101
0
Control
Conclusions
15
1. Either Mica or L-Ambi are effective in infections due to A. fumigatus.
2. No antagonism between drugs has been evidenced; on the contrary
a trends toward a potentiation of single drug regimen was seen, mainly
when each single drug is used at low dose.
3. The delay onset of therapy is deleterious in experimental model of IA
either in terms of survival than in terms of reducing the fungal burden.
4. Combination therapy seems to be a good therapeutic option when
therapy is started late.
F
100
80
Percent survival
101
100
0
100
102
60
40
References
20
Marr KA, Boeckh M, Carter RA, et al. 2004. Combination antifungal therapy for invasive
aspergillosis. Clin Infect Dis 39:797-802.
Caillot D, Thiebaut A, Herbrecht R, et al. 2007. Liposomal amphotericin B in combination
with caspofungin for invasive aspergillosis in patients with hematologic malignancies: a
randomized pilot study (Combistrat trial). Cancer 110:2740-2746.
Kontoyiannis DP, Ratanatharathorn V, Young JA, et al. 2009. Micafungin alone or in combination with other systemic antifungal therapies in hematopoietic stem cell transplant
recipients with invasive aspergillosis. Transpl Infect Dis 11:89-93.
0
0
5
10
Days post-infection
15
16
Key points
L’obiettivo dello studio è stato quello di valutare gli effetti della terapia antifungina iniziata tardivamente in relazione
alla prognosi dell’aspergillosi invasiva causata da Aspergillus fumigatus in modelli di studio sperimentali.
È stato usato un ceppo di A. fumigatus sensibile sia ad amfotericina B che alla micafungina. Sono stati usati due
modelli di infezione in topi da esperimento: un modello di infezione disseminata ed un modello di infezione polmonare.
La terapia precoce è stata somministrata 24 ore dopo l’inizio dell’infezione, mentre la terapia tardiva è stata
somministrata 48 ore dopo l’inizio dell’infezione. In entrambi i modelli, sono stati somministrati placebo, micafungina,
amfotericina B liposomiale, oppure micafungina + amfotericina B liposomiale (terapia di combinazione).
L’efficacia dei farmaci è stata valutata sia attraverso l’analisi della sopravvivenza dei topi e sia analizzando il
quantitativo di infezione fungina presente nei reni e nei polmoni.
Nel modello di infezione disseminata trattata precocemente, sia amfotericina B liposomiale sia micafungina
somministrati alla dose di 3 mg erano capaci di prolungare la sopravvivenza dei topi.
La terapia di combinazione è stata più efficace del placebo, più efficace di amfotericina B liposomiale ma non più
efficace del trattamento di micafungina da sola.
Nel modello di terapia tardiva, l’unico farmaco che ha prolungato la sopravvivenza era la terapia di combinazione.
Nel modello di terapia precoce, incrementando le dosi dei farmaci, usati da soli o in combinazione, alle dosi di 10
mg, tutti gli schemi erano efficaci nel prolungare la sopravvivenza.
Negli esperimenti di terapia ritardata solo micafungina o la terapia di combinazione erano efficaci.
In entrambi i modelli di terapia precoce e ritardata, solo la somministrazione della combinazione dei farmaci era più
efficace rispetto al controllo, nel prolungare la sopravvivenza.
Nel modello di terapia precoce, la valutazione del quantitativo di infezione fungina presente nei tessuti mostrava che
ogni singolo farmaco era efficace nel trattamento dell’infezione disseminata, mentre solo la terapia con amfotericina
B liposomiale e la terapia di combinazione erano efficaci nel modello di infezione polmonare. Al contrario, per i topi
che ricevevano la terapia ritardata, nessun farmaco era efficace.
Ritardare l’inizio della terapia antifungina è deleterio nei modelli sperimentali di Aspergillosi invasiva sia in termini di
sopravvivenza che in termini di quantità di infezione fungina presente nei tessuti. La combinazione di farmaci
sembra essere una buona opzione terapeutica quando la terapia antifungina è iniziata tardivamente.
Commento
La somministrazione precoce e tempestiva della terapia antifungina a pazienti immunodepressi è considerata
un aspetto rilevante e strategico per ottenere il controllo di gravi infezioni fungine come quelle da Aspergillus
spp. e da Mucor spp. Lo studio di Barchiesi F. et al., condotto in animali da esperimento infettati da
Aspergillus fumigatus, dimostra che la somministrazione in combinazione di farmaci antifungini sembra
essere una opzione terapeutica migliore rispetto alla monoterapia anche quando la terapia antifungina è
iniziata tardivamente. Immaginando di traslare i dati di questo studio sperimentale nella pratica clinica, si
apprezza la difficoltà di porre diagnosi precoci di infezioni fungine invasive, considerando la mancanza di
manifestazioni cliniche specifiche, la limitazione di esami culturali, molecolari e sierologici che
complessivamente conducono al ritardo dell’inizio della terapia antifungina. L’estensione di questi dati
sperimentali nell’ambito clinico sarà senz’altro un aspetto di rilievo per la gestione di infezioni ancora gravate
da elevate morbilità e mortalità per i pazienti immunodepressi.
17
P1258 - Paper Poster Session VI
invasive candidiasis
A trend analysis of candidaemia caused by Candida glabrata in belgium: drug resistance
and antifungal consumption
B. Goemaere, K. Lagrou, A. Ingenbleek, M. Goossens, K. Latour, B. Catry, M. Hendrickx, P. Becker
Objectives: The prevalence of candidaemia caused by C. glabrata over a 12-years period (2004-2015) in a
Belgian hospital is investigated, together with the resistance of C. glabrata and antifungal consumption in
Belgium. A deeper knowledge is attained in both the acquisition and spreading efficiency of resistance and its
underlying mechanisms in C. glabrata. Risk factors, associated with the rise in both the prevalence of
candidaemia and the resistance of C. glabrata are identified.
Methods: A set of unrelated bloodstream isolates of C. glabrata from the University Hospitals Leuven is
analysed as a study population, in collaboration with the BCCM/IHEM fungal collection. Antifungal
susceptibilities are determined by applying the EUCAST guidelines. The isolates are genotyped using the
multilocus variable-number tandem repeat analysis (MLVA) method. An overview of the antifungal consumption
in all acute care hospitals and large chronic care hospitals (>150 beds) is given by the national surveillance of
antimicrobial consumption since 2007.
Results: To date, the susceptibilities to amphotericin B, triazoles and echinocandins were determined for 106
isolates (2008-2013). Among the 84 fluconazole-resistant isolates, 7 were resistant to anidulafungin. Out of the
22 fluconazole susceptible-dose dependent isolates, 4 exhibited reduced susceptibility to one or more
echinocandins. To understand the phylogenetic and phenotypic relatedness of the isolates, MLVA analyses
using 4 microsatellite markers were performed and revealed the occurrence of about 20 different genotypes out
of the 75 isolates already analysed. Concerning the antifungal consumption in Belgium, the use of triazoles has
declined from 2007 until 2012 (median: from 23.13 to 19.24 DDD/1000 patient-days for non-teaching hospitals
and from 75.04 to 60.66 DDD/1000 patient days for teaching hospitals) while consumption of echinocandins
has risen (median: from 0.46 to 0.66 DDD/1000 patient-days for non-teaching hospitals and from 3.45 to 5.5
DDD/1000 patient days for teaching hospitals). In university hospitals delivering more specialized cares,
consumption of triazoles and echinocandins was respectively up to 3 and 7 times higher in comparison to nonteaching hospitals.
Conclusion: Preliminary results suggest that echinocandin resistance is increasing, including among
fluconazole-resistant isolates. Although triazoles (especially fluconazole) are still the most commonly used
antifungal agents, echinocandins are increasingly utilized as they are now recommended as first line therapy to
treat infections (including candidaemia) caused by potentially triazoles-resistant species. Future work will allow
to trace the mutations that cause resistance and identify the predominant mechanisms, together with the
determination of the associated risk factors.
18
p1258
A trend analysis of candidaemia caus
drug resistance and an
B. Goemaere1, K. Lagrou2, A. Ingenbleek3, M. Goosse
1
BCCM/IHEM fungal collection, Mycology and Aerobiology Laboratory, Scientific Institute of Public Health (WIV-ISP), Brussels, Belgi
3
Department of Public Health & Surveillance, Scientific Institute of Public Health (WIV-ISP), Brussels, Belgium
Introduction
Results
- Candida glabrata is an opportunistic pathogen that can cause
invasive bloodstream infections in humans.
- In recent years, the proportion of candidaemia due to C. glabrata
has been increasing in Northern Europe and the United States.
- Candida glabrata candidaemia is more common in elderly immunocompromised patients than in other populations.
- Candida glabrata shows an increased azole resistance and even a
decreased susceptibility towards echinocandins in certain regions.
- There is a lack of recent surveillance studies in Belgium.
- Over a period of 11 years, a total number of 731 patients were
affected by a candidaemia in the University Hospitals Leuven,
of which 172 (23.5%) were infected by C. glabrata.
- Candida glabrata ranked each year as the second most common cause of candidaemia in the University Hospitals Leuven
The evolution of fluconazole resistance in C. glabrata bloodstream
isolates from the University Hosptials Leuven (2004-2014).
Purpose
- Investigate the number of candidaemia episodes per year and
the proportion caused by C. glabrata.
- Determine the antifungal resistance of C. glabrata, causing candidaemia over an 11-years period (2004-2014) in the Belgian
University Hospitals Leuven.
- Better understand both the acquisition and dissemination of antifungal resistance in C. glabrata.
- Obtain insight into the antifungal consumption in all Belgian
acute and chronic care hospitals (>150 beds) since 2007.
Methods
MStree: the size of the circles, each corresponding to a VNTR profile,
indicates the number of isolates belonging to that profile. The thickness
of the lines is proportional to the similarity between the profiles.
- 172 independent (i.e. originating from different patients; first
isolate per episode) C. glabrata bloodstream isolates were collected over a period of 11 years (2004-2014) at the University
Hospitals Leuven and analysed as a study population, in collaboration with the BCCM/IHEM fungal collection.
- Antifungal susceptibilities were determined by applying the EUCAST EDef 7.2 guidelines for the following antifungal agents:
amphotericin B, fluconazole, itraconazole, voriconazole, anidulafungin, caspofungin and micafungin.
- A multilocus variable-number tandem repeat analysis (multilocus VNTR analysis) was performed to characterize the diversity
and relationships at a micro-evolutionary level of the C. glabrata
isolates by using 3 microsatellite markers (Cg4, Cg6 and
Cg10)*. Afterwards, the phylogenetic relationships were estimated by a minimum-spanning tree (MStree) analysis.
- An overview of the antifungal consumption since 2007 in all Belgian acute and chronic care hospitals (>150 beds) is given by the
national surveillance of antimicrobial consumption (www.nsih.be).
A differentiation is made between teaching and nonteaching hospitals. Results are calculated at the ATC-level 4 (chemical subgroup) and displayed in DDD/1000 patient days (www.whocc.no).
fluconazole susceptible-dose dependent
fluconazole resistant
*(Grenouillet et al. (2007). J. Clin. Microbiol. 45, 3781-3784)
19
sed by Candida glabrata in belgium:
ntifungal consumption
ens3, K. Latour3, B. Catry3, M. Hendrickx1, P. Becker1
ium; 2Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium;
(Belgium), after C. albicans.
- The multilocus VNTR analysis revealed 15 alleles for the Cg4
locus, 12 alleles for Cg6 and 14 alleles for Cg10. The combination of alleles from the 3 microsatellite regions generated 63
different genotypes, of which the phylogenetic relationships
were estimated by a MStree.
- The MStree also maps the resistance to fluconazole. The latter
is dispatched within the entire tree.
- 21 C. glabrata isolates (12.2%) showed resistance to fluconazole while others were susceptible-dose dependent.
- 1 isolate (0.6%) showed resistance to anidulafungin and another isolate showed resistance to micafungin.
- Concerning the antifungal consumption in Belgium, the use of
triazoles first declined between 2007 and 2009, before increasing since 2010, especially in teaching hospitals. The consumption of echinocandins has risen since its introduction.
- In university hospitals, which deliver more specialized care, consumption of triazoles and echinocandins was respectively up to
3 and 7 times higher in comparison to non-teaching hospitals.
The number and the percentage of candidaemia cases in the University
Hospitals Leuven (2004-2014) caused by Candida glabrata in
comparison to the number of cases caused by Candida species.
The use of triazoles in Belgian hospitals.
Conclusions
- In the MStree, no correlation was visualised between genotypically similar isolates and fluconazole susceptibility. The latter
is dispatched within the MStree, indicating that the resistance
appeared not via spread in the population but several times
independently.
- Despite an increased fluconazole resistance in C. glabrata, only
12.2% of all C. glabrata isolates showed resistance to fluconazole, while 1.2% showed a reduced susceptibility to echinocandins. This is in contrast with the rise of both fluconazole and
echinocandin resistance in some other European countries.
Since echinocandin exposure can cause echinocandin resistance, these results may be related by the fact that, in Belgium,
echinocandin drugs might be less used due to limited reimbursement conditions.
- Future work will include VNTR analysis of 3 extra microsatellite
regions in order to improve discrimination and to define subpopulations. Moreover, since antifungal resistance in C. glabrata can
be acquired through different molecular changes, sequencing and
q-RT-PCR analyses will trace respectively the mutations and the
upregulated gene regions that cause resistance and determine
the predominant mechanisms. Finally, the analysis of epidemiological data will identify risk factors associated with a rise in both
the prevalence of candidaemia and the resistance in C. glabrata.
The use of echinocandins in Belgian hospitals.
Acknowledgments: we kindly thank Pfizer, Astellas and Merck
to provide us with echinocandin drugs.
20
Key points
Lo studio è stato condotto in un ospedale Belga; sono state analizzate la prevalenza di candidemia di
Candida glabrata, la resistenza di C. glabrata a farmaci antifungini e il consumo di farmaci antifungini lungo
un periodo di 12 anni (2004-2015). Inoltre sono stati valutati alcuni fattori clinici potenzialmente associati
con l’incremento della prevalenza di candidemia e della resistenza di C. glabrata.
La sensibilità ai farmaci antifungini è stata valutata usando il sistema EUCAST. Lo studio genotipico degli
isolati fungini è stato eseguito mediante la multilocus variable-number tandem repeat analysis (MLVA). I dati
riguardanti il consumo dei farmaci antifungini di tutti gli ospedali del Belgio con più di 150 letti sono stati
forniti dal Sistema Nazionale di Sorveglianza.
La sensibilità dei ceppi di C. glabrata è stata testata nei confronti di amfotericina B, degli azoli e delle
echinocandine.
Di 84 ceppi resistenti al fluconazolo, 7 erano resistenti alla anidulafungina. Di 22 ceppi sensibili al
fluconazolo (dose-dipendente), 4 ceppi mostravano una ridotta sensibilità verso una o più echinocandine.
Le analisi filogenetiche e fenotipiche dei ceppi analizzati, hanno rivelato la presenza di 20 differenti genotipi
in 75 ceppi di C. glabrata analizzati.
Per quanto concerne l’uso di farmaci antifungini in Belgio è stata osservata una riduzione dell’uso di azoli a
partire dal 2007 fino al 2012, mentre il consumo di echinocandine è stato incrementato. Negli ospedali
universitari il consumo di azoli e di echinocandine era incrementato, rispettivamente, fino a 3 e 7 volte in
confronto agli ospedali non universitari.
I risultati suggeriscono che la resistenza alle echinocandine è in incremento, inclusi i ceppi fluconazoloresistenti. Benché gli azoli, specialmente fluconazolo, siano ancora i farmaci antifungini più comunemente
usati, le echinocandine sono utilizzate con maggior frequenza poiché, allo stato attuale, sono
raccomandate come farmaci di prima linea per il trattamento di infezioni fungine (inclusa la candidemia)
causate da funghi potenzialmente resistenti agli azoli.
Commento
Candida glabrata possiede una ridotta sensibilità intrinseca a fluconazolo e può essere causa fino al 30%
degli episodi di candidemia documentati nei programmi di sorveglianza basati su popolazioni generali. I
soggetti anziani, quelli residenti nel Nord Europa e gli individui affetti da cancro sembrano essere
maggiormente a rischio di sviluppare candidemie da Candida glabrata (Aredrup MC. Update on antifungal
resistance in Aspergillus and Candida. Clin Microbiol Infect 2014;20(Suppl.6):42-48). Nel poster presentato al
Congresso, gli autori hanno mostrato i dati riguardanti 731 pazienti con candidemia, di questi, 172 (23,5%)
avevano una candidemia da Candida glabrata. In particolare, solo il 12% di tutti i ceppi di Candida glabrata
era resistente a fluconazolo, mentre l’1,2% mostrava una ridotta sensibilità alle echinocandine; questi aspetti
sono in contrasto ai dati riguardanti altri paesi Europei dove la resistenza a fluconazolo ed echinocandine è in
aumento. Si ritiene che l’incremento del consumo delle echinocandine possa essere potenzialmente correlato
alla esposizione di farmaci antifungini tra i quali anche le echinocandine, farmaci molto usati in Belgio
soprattutto negli ospedali universitari rispetto a quelli non universitari.
21
P1282 - Paper Poster Session VI
Antifungal susceptibility
Emerging azole-resistant invasive aspergillosis at a Dutch intensive Care unit
J. van Paassen, A. Russcher, A. in t Veld - van Wingerden, E. Kuijper
Introduction: Resistance to anti-fungal therapy with azoles is emerging (1) and data regarding the incidence of
invasive aspergillosis (IA) at the Intensive care unit (ICU) is scarce (2). Due to difficulty in culturing Aspergillus
species in vitro, the incidence of azole-resistance is even more uncertain. Moreover, evidence is growing for
increasing IA in non-traditional hosts. Due to unawareness of uncommon hosts, diagnostic delay, and suboptimal
treatment due to resistance, IA at the ICU is associated with high mortality. We aimed to investigate the prevalence
of resistant IA in at our ICU, investigate patient characteristics associated with resistant IA and evaluate current
diagnostic and therapeutic strategies.
Methods: We conducted a single-centre retrospective cohort study. All ICU-patients receiving therapy with azoles
or amfotericine-B for suspected IA from January 2010 to December 2013 were eligible. Host factors, CT reports,
microbiology results, mortality and use of prophylactic antifungal therapy were extracted from patient records.
Results: 136 patients were included; 38 of these patients had positive cultures with Aspergillus (28%, table 1). 10
of the positive Aspergillus cultures were resistant for itraconazol and voriconazol in a 4-well MIC-test, a resistance
incidence of 26%. In 5 of 10 patients with an azole-resistant IA, the resistance pattern was known only post-mortal.
Table 1. Patient-Characteristics.
Patient-characteristics
Mean age (range)
Underlying disease n(%)
- hematological malignancy/stem cell transplant
- solid organ transplant
- other
EORTC/MSG diagnosis n (%)
- proven
- probable
- unclassified
Azole pre-treatment
Azole-resistant n=10 (%)
52 (24-69)
Azole-susceptible n=28 (%)
58 (1-85)
6 (60)
1 (10)
3 (30)
14 (50)
2 (8)
12 (42)
0 (0)
5 (50)
5 (50)
4 (40)
2 (7)
15 (54)
11 (40)
8 (28)
% 90-day mortality
Most patients were stem cell transplantation recipients or
Figure 1. 90-days mortality.
patients with chronic steroid use. 5 of 28 patients (18%)
with an azole-sensitive IA had no common host factor. In
the azole-resistant group, 40% of patients received azoleprohpylaxis before diagnosis, compared to 29% in the
azole-sensitive group. 90-days mortality in the patients
with an azole-resistant IA was 100% compared to 80% in
the patients with an azole-sensitive infection (figure 1.)
Conclusions: Our results show a high azole-resistance IA
prevalence in the ICU, associated with high mortality. No
risk factors for developing resistant strains can be learned
from this study. Resistance rates might be overestimated
as resistant isolates are perhaps more likely to be cultured
when azole therapy is already instituted at the time of
sampling. Current changing patterns of IA call for
development of adequate ICU criteria for diagnosis, development of rapid resistance tests and knowledge of local
resistance rate to guide therapeutic decisions.
References: 1. Van der Linden J.W.M., et al. Aspergillus due to voriconazole highly resistant Aspergillus fumigatus and recovery of genetically related
resistant isolates from domiciles. CID 2013;57:513-520. 2. Meersseman W., et al Invasive aspergillosis in the intensive care unit. CID 2007;45:205-216.
22
p1282
Emerging azole-resistant invasive aspergill
J. van Paassen1, A. Russcher2, A. W. in ‘t Veld
1
Department of Intensive Care, Leiden University Medical Center; 2De
3
Department of medical Microbiology, Nijme
Introduction
Results
Azole resistance is emerging and complicates treatment of
patients with invasive aspergillosis (IA). A two-years survey
at various departments in 6 hospitals in The Netherlands revealed an overall prevalence rate of azole resistance in 6.8%
of 921 Aspergillus isolates 1.
At the intensive care (ICU), non traditional hosts are increasingly recognized as susceptible for IA. The incidence of
azole resistance at the ICU is unknown, though very important since high azole-resistance incidence might change diagnostic and therapeutic regimens.
The aim of this study was to determine prevalence of azole
resistant IA at the ICU and to find risk-factors.
From 2010-2013, 136 out of 9121 admitted ICU patients (15
per 1000 admissions) received antifungal treatment for suspected IA.
In 38 (28%) patients A. fumigatus could be cultured and 10
(26%) isolates revealed azole-resistance. The resistance mechanisms consisted of TR 34 /LR98H and TR 46 /T289A/Y121F
mutations. Azole resistance prevalence at ICU is higher (Fisher
Figure 1. Case Selection.
Methods
Design: Single-center retrospective observational cohort
study 2010-2013.
Study population: All ICU-patients, regardless their age,
treated with antifungal therapy for IA were included. Exclusion criteria were: antifungal prophylaxis only or therapy for
non-aspergillusfungal infections.
26%
Resistance
Patient identification: Patients were traced by running a
query on the patient data management system (PDMS ® ) for
voriconazole and/or amphotericin B.
Figure 2. 90-days mortality.
% 90-day mortality
Data Collection: Demographic data, clinical course, Radiological data and microbiological laboratory results were extracted
from digital patients records (PDMS® -Chipsoft/EZIS -GLIMS.
All aspergillus isolates were sent to Nijmegen for susceptibility
tests, both phenotypically and genetically using. Azole resistance was defined as a MIC-value >2 mg/mL for itraconazoleand/or voriconazole, using Eucast criteria.
Endpoints: Primary endpoints were prevalence of -and mortality due to resistant IA in LUMC ICU. Secondary endpoints
were to identify risk factors for the presence of azole-resistance, such as underlying illness, prior prophylactic azole
exposure.
23
losis at a tertiary Dutch intensive Care unit
d – van Wingerden1, P.E. Verweij3, E.J. Kuijper2
epartment of Medical Microbiology, Leiden University Medical Centre;
egen University Medical Centre, St. Radboud
late, as opposed to 79% in patients with a susceptible isolate.
In 6 of 10 patients with a resistant isolate, results of susceptibility tests were available before therapy with amphotericin
B was initiated.
In 9 of 10 patients with resistant A. fumigatus,death was directly attributable to IA; 1 patient died as a result of liver failure. In the azole susceptible patient group incidence of IA
attributable death was lower (30%).
Exact, p=0.06) compared to other departments In the same
study period: 24/170 isolates (14%).
As shown in table 1, most of the patients with IA at ICU were
haematological patients, and some were treated with azoles
earlier, but no specific risk factors for developing azole-resistant IA were identified.
Figure 2 shows the crude 90-day mortality rates in various patients groups. Mortality was 100% in patients with a resistant isoTable 1. Patient characteristics in relation to susceptibility.
Mean age (range)
Underlying disease n (%)
- Haematological/SCT
- Solid organ Transplant
- Other
Prior azole exposure
Bal results
- BAL available
- GMN positive
EORTC/MSGcriteria
- Proven
- Probable
- Unclassified
ICU criteria (Blot 2 )
- Proven
- Putative
- Colonization
Azole resistant n=10 (%)
52 (24-69)
Azole susceptible n=28 (%)
58 (1-85)
6 (60)
1(10)
3 (30)
4 (40)
14 (50)
2 (7)
12 (43)
11 (39)
10 (100)
9 (90)
22 (79)
20 (71)
0
5 (50)
5 (50)
2 (7)
15 (54)
11 (39)
0
10 (100)
0
2 (7)
22 (79)
4 (14)
Conclusions
• Reconsideration of empirical anti fungal regimen at ICU in
the presence of resistance.
• Diagnostic tools for early detection of azole-resistance.
1. High prevalence of azole-resistance at ICU: 26%.
2. High mortality rates in azole resistant aspergillosis: -overall
mortality of 100% -attributable death due to IA in 90%.
3. No specific patient characteristics to identify azole resistance.
References
1. Van der Linden J.W.M, et al., Aspergillosis due to Voriconazole Highly Resistant Aspergillus fumigatus and Recovery of Genetically Related Resistant
Isolates From Domiciles. CID 2013;57:513-520.
2. Blot SI, et al. A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients. Intensive Care Med 2007;33:1694-703.
What is needed:
• Surveillance to assess local azole-resistance rates.
24
Key points
I dati riguardanti l’incidenza di aspergillosi invasive nelle terapie intensive sono scarsi. In aggiunta i dati
sull’incidenza della resistenza di Aspergillus spp. agli azoli sono resi ancora più incerti vista la difficoltà di
isolare l’Aspergillus in vitro.
Obiettivo dello studio: determinare la prevalenza di aspergillosi invasiva (A.I.) in una unità di terapia
intensiva, identificare le caratteristiche cliniche dei pazienti associate con A.I. resistente agli azoli e valutare
l’impatto delle strategie diagnostiche e terapeutiche in questo ambito.
Studio di coorte retrospettivo monocentrico, condotto tra il 2010 e il 2013.
Sono stati inclusi nello studio 136 pazienti di cui 38 avevano culture positive per Aspergillus (28%).
L’incidenza della resistenza a itraconazolo e voriconazolo è stata del 26% e in 5 dei 10 pazienti con A.I.
resistente ad azolo; il risultato della resistenza è stato acquisito solo post-mortem.
Cinque di 28 pazienti (18%) con A.I. azolo-sensibile non avevano i tipici fattori dell’ospite immunocompresso
utilizzati per diagnosticare l’infezione secondo i criteri EORTC. Nel gruppo di A.I. azolo-resistenti, il 40% dei
pazienti riceveva profilassi con azoli prima della diagnosi, in confronto al 29% del gruppo azolo-sensibile.
La mortalità, dopo 90 giorni dalla diagnosi di A.I. azolo-resistente, è stata del 100% in confronto all’80%
della mortalità osservata nei pazienti con infezione sensibie agli azoli.
Nella nostra terapia intensiva è stata documentata un’elevata prevalenza di A.I. azolo-resistente, associata
ad un elevato tasso di mortalità. Non sono stati identificati fattori di rischio per lo sviluppo di ceppi
resistenti.
Commento
Le attuali conoscenze sugli aspetti microbiologici e clinici della resistenza agli azoli di Aspergillus fumigatus
sono ancora preliminari. A tal proposito, lo studio condotto in una terapia intensiva olandese è molto
originale e clinicamente rilevante. È importante sottolineare che questi dati sono stati ottenuti in una terapia
intensiva di un paese con una elevata prevalenza ambientale, di ceppi di Aspergillus fumigatus azoloresistente (van Ingen J. et al. Azole, polyene, and echinocandin MIC distributions for wild-type, TR34/L98H
and TR46/Y121F/T289A Aspergillus fumigatus isolates in the Netherlands. J Antimicrob Chemother
2015;70:178-181). I risultati mostrano chiaramente sia l’elevata incidenza di resistenza agli azoli (26%) che
l’elevata mortalità (100%) associata alla aspergillosi invasiva azolo-resistente. La gestione clinica di infezioni
gravate da una mortalità così elevata non è stata ancora codificata da studi clinici ad hoc e, per tale motivo,
alcuni esperti hanno pubblicato una opinione a riguardo (Verweij P.E. et al. International expert opinion on
the management of infection caused by azole-resistant Aspergillus fumigatus. Drug Resistance Updates.
2015;21-22:30-40. doi: 10.1016/j.drup.2015.08.001) suggerendo, lì dove la resistenza ambientale fosse
>10%, una terapia iniziale composta da amfotericina B liposomiale o dalla combinazione di voriconazolo più
una echinocandina.
25
P1283 - Paper Poster Session VI
Antifungal susceptibility
occurrence of azole resistant Aspergillus fumigatus in environmental samples from italian regions
A.M. Tortorano, A. Prigitano, M.C. Esposto
Azole resistance in Aspergillus fumigatus is now recognized as an emerging problem worldwide. The development
of azole resistance may be environmentally driven because of the massive use of azole fungicides in agriculture and
the mechanism of resistance is mostly related to the mutation TR34/ L98H in the gene Cyp51A.
The presence of azole resistant A. fumigatus strains in the environment was documented in a previous study
conducted in Northern Italy (Eurosurv. 2014;19:20747). The aim of this study was to enlarge the survey to other
Italian regions.
Methods: Soil samples, treated according to previously described methods (Appl Environ Microbiol 2009;75:4053),
were plated on agar medium with and without itraconazole (4 mg/L) and incubated at 37° and 42°C for 72 hours.
One A. fumigatus isolate from each soil sample grown in presence of itraconazole was tested for antifungal
susceptibility to itraconazole, posaconazole and voriconazole by EUCAST broth microdilution method. Sequencing
of Cyp51A genes was performed in resistant isolates.
Results: A total of 122 soil samples collected between May and November 2014 from 41 sites located in 7 Italian
regions (Piemonte, Friuli-Venezia Giulia, Toscana, Marche, Puglia, Calabria e Sicilia) covering North, Centre, South
and island were analysed. A. fumigatus itraconazole resistant isolates (few or several colonies) grew from 25 out of
122 screened samples (20.5%), covering all the sampled regions. The resistant isolates were from different
cultivations (treated or officially not treated with azole fungicides), namely crops of vegetables (8), wheat (1), olive
trees (5), vineyard (3), apple orchard (3), oranges (2) and other fruits (3). All the isolates, except two, were resistant
or intermediate to all the tested azole.
The sequencing of Cyp51A genes, up to now performed in 17 isolates, confirmed that the resistance is associated
with the TR34/L98H mutation in 16 isolates and with the G54E mutation in one isolate. This last isolate, isolated in
Tuscany from crop of vegetable, was susceptible to voriconazole.
Conclusions: The occurrence of resistance in several geographic distinct sites shows that environmental
resistance associated with TR34/L98H mutation is spread all over our Country.
26
occurrence of azole resistant Aspergillus fumigat
p1283
A.M. Tortorano, A. Pri
Dipartimento Scienze Biomediche per la Sa
Introduction and objectives
Figure 1. Italian regions involved in the study of 2011-12 and
of 2014 and number of positive/screened samples.
Azole resistance in Aspergillus fumigatus is now recognized
as an emerging problem worldwide. The development of
azole resistance may be environmentally driven because of
the massive use of azole fungicides in agriculture and the
mechanism of resistance is mostly related to the mutation
TR34/ L98H in the gene Cyp51A.
The presence of azole resistant A. fumigatus strains in the
environment was documented in a previous study conducted
in Northern Italy (1).
The aim of this study was to enlarge the survey to other Italian regions.
Materials and methods
Soil samples, treated according to previously described methods (2), were plated on agar medium with and without itraconazole (4 mg/L) and incubated at 37° and 42°C for 72 hours.
One A. fumigatus isolate from each soil sample grown in presence of itraconazole was tested for antifungal susceptibility
to itraconazole, posaconazole and voriconazole by EUCAST
broth microdilution method.
Sequencing of Cyp51A genes was performed in resistant isolates.
n 2011-12
n 2014
Results
A total of 125 soil samples collected between May and November 2014 from 41 sites located in 7 Italian regions covering North, Centre, South and island were analysed.
A. fumigatus itraconazole resistant isolates (few or several colonies) grew from 25 out of 122 screened samples (20.5%),
covering ali the sampled regions (Fig. 1).
The resistant isolates were from different cultivations (treated or officially not treated with azole fungicides) (Fig. 2).
All the isolates, except two, were resistant or intermediate
to ali the tested azoles (Fig. 3).
Resistance is associated with thefollowing mutations in the
gene Cyp51A:
TR34/L98H
G54E
➡
➡
Figure 2. Samples with susceptible and resistant isolates.
30
N. of samples
25
20
15
10
5
0
24 isolates
1 isolate
(voriconazole susceptible)
n Susceptible
n Resistant
27
tus in environmental samples from italian regions
igitano, M.C. Esposto
alute, Università degli Studi di Milano, Italy
Figure 3. Azole MICs distribution of itraconazole resistant isolates.
25
Itraconazole
Voriconazole
N. of isolates
20
Posaconazole
15
10
5
0
0.12
0.25
0.5
1
2
MIC (mg/L)
4
8
16
Conclusions
References
The occurrence of resistant isolates in several geographic
distinct sites shows that environmental resistance associated
with TR34/L98H mutation is spread ali over our Country.
1) A. Prigitano et al., Euro Surveill. 2014 Mar 27;19:20747.
2) E. Snelders et al., Appi.Environ.Microbiol 2009;75:4053.
28
Key points
Attualmente, la resistenza di Aspergillus fumigatus agli azoli è considerata un problema emergente e non
ancora completamente definito in tutto il mondo.
La resistenza agli azoli può essere di origine ambientale in seguito all’uso massivo di azoli in agricoltura e il
meccanismo di resistenza è principalmente dovuto alla mutazione TR 34/L98H del gene CYP 51A.
La presenza nell’ambiente di ceppi di A. fumigatus resistenti agli azoli è stata documentata in un
precedente studio condotto nell’Italia del Nord (Eurosurv 2014;19:20747).
L’obiettivo di questo studio è stato quello di estendere la sorveglianza ad altre regioni italiane.
Nel 2014, 122 campioni ambientali sono stati prelevati da 41 siti localizzati in 7 regioni italiane (Piemonte,
Friuli-Venezia Giulia, Toscana, Marche, Puglia, Calabria e Sicilia).
Ceppi di A. fumigatus resistenti a itraconazolo sono stati identificati in 25 di 122 campioni (20,5%) analizzati
e presenti in tutte le regioni esaminate. Tutti i ceppi isolati, tranne 2, erano resistenti o intermedi a tutti gli
azoli testati.
Il sequenziamento dei geni CYP 51A, ad oggi eseguito su 17 ceppi isolati, confermava che la resistenza era
associata con la mutazione TR34 /L98H (16 isolati) e con la mutazione G54E in 1 ceppo isolato.
La presenza di ceppi di A. fumigatus resistente agli azoli, in alcune zone geografiche italiane, mostra che la
resistenza ambientale, associata con la mutazione TR34 /L98H, è diffusa in tutto il nostro Paese.
Commento
La resistenza di Aspergillus fumigatus agli azoli è considerata un problema emergente e rilevante sia dal
punto di vista epidemiologico che da quello clinico. Sulla base di evidenze scientifiche sempre più
numerose e metodologicamente adeguate, si ritiene che l’esposizione ambientale ad azoli fungicidi usati in
agricoltura rappresenti la spinta all’emergenza di ceppi di Aspergillus fumigatus resistenti agli azoli. Più
frequentemente sono state osservate resistenze ad alcuni o a tutti gli azoli testati, meno frequentemente ad
un solo azolo. Nella maggior parte dei casi, la resistenza agli azoli è dovuta alla mutazione del codone 98
del gene cyp51A, in combinazione con un 34-bp tandem repeat nella regione promoter di questo gene. I
ceppi portatori di queste alterazioni sono diffusi nell’ambiente e anche in ospedali situati in alcuni paesi
europei, oltre che in India, in Africa, in Australia e in altri paesi nel mondo (van der Linden JWM, et al.
Prospective multicenter international surveillance of azole resistance in Aspergillus fumigatus. Emerg Infect
Dis 2015;21:1041-1044). I dati di questo studio italiano confermano la presenza nell’ambiente di ceppi di
Aspergillus fumigatus resistenti agli azoli in tutte le 7 regioni analizzate. Sarà importante estendere la
sorveglianza ambientale a tutte le regioni italiane e determinare la rilevanza clinica dei ceppi di Aspergillus
fumigatus azolo-resistente isolati dai pazienti.
29
P0212 - Paper Poster Session I
news on antifungal prophylaxis and therapy
protection against azole-resistant Aspergillus fumigatus in an immunosuppressed model of
murine pulmonary aspergillosis following short course liposomal amphotericin b therapy
J. Olson, J. Adler-Moore
Objectives: The increasing incidence of azole resistance amongst Aspergillus species necessitates testing of nonazole drugs for treating aspergillosis. In previous published work liposomal amphotericin B (AmBisome®, AmBi) was
shown to be effective in treating systemic aspergillosis caused by azole resistant Aspergillus fumigatus. In the
present study we report the results comparing voriconazole (Vfend®, Vori) and AmBi efficacy in azole resistant
pulmonary aspergillosis.
Methods: Swiss Webster mice (6 weeks old) were immunosuppressed day -3, 0 and +2 with 6 mg/kg triamcinolone
given intraperitoneally. On day of challenge (d0), mice (n = 17/group) were sedated and 5.9 x 10ex6 A. fumigatus
spores (strain V29, MIC = 1.25 μg/ml AmBi, 64 μg/ml Vori) applied intranasally. Two hours post-challenge mice
were treated intravenously (IV) daily for 3 days with 5 or 10 mg/kg AmBi qd, 40 mg/kg Vori PO bid, or 5% dextrose
in water (D5W) IV qd. Additional groups of mice received 5 or 10 mg/kg AmBi IV qd for 3 days followed by 40
mg/kg Vori PO bid for 3 more days. Bronchoalveolar lavage (BAL) and lungs were collected 8h (AmBi) or 12h (Vori)
post challenge (7 mice/group) for determination of fungal burden, drug concentration (lungs) and cytokine levels
(lungs). Remaining mice (n=10/group) were followed for survival.
Results: Mice given either 5 or 10 mg/kg AmBi (+/-Vori) had significantly prolonged survival (50-60%) versus mice
treated with Vori monotherapy or D5W (0% survival) (p < 0.001). Although significant weight loss was observed in
all treatment groups in the first few days post-challenge, overall weight loss was significantly lower for mice given
10 mg/kg AmBi versus all other groups (p < 0.006) with significantly less disease signs in mice treated with 10
mg/kg AmBi versus 5 mg/kg AmBi (p = 0.031). Lung fungal burden was significantly lower in mice treated with
either dose of AmBi compared to Vori or D5W (p = 0.0006); no difference in the fungal burden was seen in the BAL.
Amphotericin B levels in the lungs of AmBi treated mice (65-80 μg/g) were significantly higher compared to Vori
levels (2 μg/g) (p = 0.017). No differences in cytokine levels (IL-1alpha, IL-1beta, IL-4, IL-6, IL-10, IL-12 (p70), IFNgamma, and TNF-alpha) were detected amongst any of the groups.
Conclusions: Only three days of AmBi treatment was sufficient to significantly reduce a pulmonary aspergillosis
infection caused by an azole-resistant strain of A. fumigatus with high levels of AmBi, but not Vori, in the infected
lungs. These data suggest that if the azole susceptibility of the causative agent is unknown, initiating treatment with
AmBi is a reasonable clinical approach.
30
Key points
In precedenti studi l’amfotericina B liposomiale (AMBI) è stata mostrata essere efficace per il trattamento
sistemico di aspergillosi causata da A. fumigatus resistente agli azoli.
In questo studio si riportano i risultati inerenti all’efficacia di voriconazolo (VORI) e AMBI per il trattamento
dell’aspergillosi polmonare resistente agli azoli.
AMBI alla dose di 5-10 mg/Kg* (+/- VORI) ha significativamente prolungato la sopravvivenza (50-60%) dei
topi di esperimento in confronto a topi trattati con VORI in monoterapia (0% sopravvivenza).
Il quantitativo di infezione fungina osservato nei polmoni era significativamente inferiore nei topi trattati con
AMBI confrontato a quello osservato nei topi trattati con VORI; tuttavia non è stata osservata nessuna
differenza nel quantitativo di infezione fungina misurato nel BAL.
I livelli di AMBI osservati nei polmoni dei topi erano significativamente più elevati ai livelli di VORI.
Non è stata osservata alcuna differenza, tra i due gruppi di topi, per quanto riguarda i livelli di citochine
esaminate (IL-1alfa ,IL1 Beta, IL-4,IL-6,IL-10,IL-12,IFN-gamma e TNF-alfa).
Solo 3 giorni di trattamento con AMBI erano sufficienti per ridurre significativamente il danno da
Aspergillosi polmonare causato da un ceppo di A. fumigatus azolo-resistente. Nei polmoni dei topi infettati
sono stati documentati elevati livelli di AMBI ma non di VORI.
Questi dati suggeriscono che se la sensibilità agli azoli non è nota, iniziare il trattamento con AMBI
rappresenta un approccio clinico ragionevole.
Commento
Lo studio condotto in animali da esperimento ha dimostrato l’efficacia di amfotericina B liposomiale per il
trattamento di aspergillosi polmonare resistente agli azoli. Lo studio ha mostrato l’efficacia di elevate dosi di
amfotericina B liposomiale (5-10 mg/Kg)* nel prolungare significativamente la sopravvivenza degli animali e
nel ridurre il quantitativo di infezione fungina presente nei polmoni dei topi esaminati. Gli autori dello studio
propongono di iniziare il trattamento con amfotericina B liposomiale nel caso in cui la sensibilità agli azoli
non sia nota, sottolineando che in soli 3 giorni di terapia era stata raggiunta nei polmoni una significativa
riduzione dell’infezione. I risultati di questo studio confermano ed estendono i risultati ottenuti in altri studi
condotti in animali da esperimento (Seyedmojtaba S. et al. Pharmacodynamics and dose-response
relationship of liposomal amphotericin B against different azole-resistant Aspergillus fumigatus isolates in a
murine model of disseminated aspergillosis. Antimicrobial Agents Chemother 2013;57:1866-1871). È
auspicabile che ulteriori studi clinici confermino i risultati ottenuti in animali da esperimento.
*Trattamento empirico della neutropenia febbrile. La dose giornaliera raccomandata è 3 mg/kg. Trattamento delle micosi. La terapia è normalmente articolata con
una dose giornaliera di 1,0 mg/kg aumentata progressivamente fino a 3,0 mg/kg, se necessario. Dosaggi più alti possono essere richiesti per la mucormicosi.
31
O184 - 2-hour Oral Session
invasive fungal infections: what is new?
surveillance and antifungal susceptibility of mixed invasive aspergillosis over a 13-year period
T. Pelaez Garcia, G. Rocio, Á. Ana, A. Oiahane, G. Sara, M. Emilia, B. Emilio
Objectives: Invasive Aspergillosis (IA) is usually considered a monofungal disease and a single Aspergillus species is
commonly reported as the causative agent. IA purportedly caused by 2 or more filamentous fungi (mixed infections)
is uncommon. Failure in antifungal therapy of IA may be due to intrinsic or secondary resistance and co-infection by
2 or more filamentous fungi (mixed infections). We retrospectively evaluated the incidence, epidemiology and
antifungal susceptibility of mixed IA in a general hospital over 13 years (2000-2012).
Methods: The clinical reports of patients with a positive culture were studied. Mixed IA was diagnosed based on
EORTC criteria and when two or more different moulds were recovered simultaneously from the same sample. The
prevalence of cryptic species was also tested. Antifungal susceptibility to amphotericin B, itraconazole,
voriconazole, posaconazole, caspofungin, anidulafungin and micafungin was obtained using CLSI M38-A2. Cyp51A
gene was sequenced in A. fumigatus isolates with high azoles MICs.
Results: We studied 1105 Aspergillus species isolates from 910 patients (749 colonized [82%] and 161 [18%] with
proven/probable IA). Of these, 152 (16.7%) had 2 or more filamentous fungi. In the colonized patients, 647 (86%)
had only 1 species of Aspergillus and 102 (14%) had >1 species. Among patients with IA, 112 (70%) were infected
by a single species and 49 (30%) by >1 species. The percentage of mixed IA during the study period increased
from 0% to 53.3%. The combinations causing IA were: A. fumigatus + Aspergillus spp. (59.2%), A. fumigatus +
other filamentous fungi (16.4%), 3 Aspergillus spp. (12.2%), 2 Aspergillus spp. + other filamentous fungi (8.2%) and
2 Aspergillus spp. (4%). The 4 dominant mixed IA were: A. fumigatus + A. flavus (27.1%), A. fumigatus + A. terreus
(14.5%), A. fumigatus + Scedosporium spp. (10.4%), and A. fumigatus + A. niger (6.25%). During the study period,
10 patients (5.8%) presented IA caused by azole-resistant cryptic species (9 were also mixed). The percentage of
IA caused by cryptic species increased from 0% to 20%, with A. lentulus being the most common. Most patients
with IA caused by cryptic species had a poor prognosis. During the last 4 years of the study, 4 patients (3 IA)
harboured azole-resistant A. fumigatus ‘sensu stricto’.
Conclusions: Our results confirm that the incidence of mixed IA (29%) was much higher than reported in the
literature. The percentage of mixed IA caused by cryptic species increased significantly during the study period.
Mixed IA due to resistant Aspergillus isolates will have a profound impact on morbidity and mortality, with a
consequent increase in healthcare costs.
Acknowledgements: This study was partially supported by GILEAD and FIS PI13/02783.
32
Key points
Usualmente l’aspergillosi invasiva (A.I.) è considerata una malattia infettiva dovuta a un singolo fungo e una
singola specie di Aspergillus spp. è frequentemente riportata come l’agente causale. Si ritiene che A.I.
causate da 2 o più funghi filamentosi (infezioni miste) non siano frequenti. Tuttavia il fallimento dei farmaci
antifungini nel trattamento di A.I. potrebbe essere dovuta a fattori intrinseci, a resistenze acquisite o a
coinfezioni dovute a 2 o più funghi filamentosi.
In uno studio retrospettivo condotto in un periodo di 13 anni (2000-2012) sono stati valutati l’incidenza,
l’epidemiologia e la sensibilità ad antifungini delle A.I. miste.
A.I. miste sono state diagnosticate sulla base dei criteri EORTC e quando 2 o più funghi filamentosi erano
simultaneamente identificati nello stesso campione esaminato.
Sono state studiate 1.105 specie di Aspergillus spp. isolate da 910 pazienti; di questi pazienti 161 (18%)
avevano una A.I. proven/probable. Inoltre 152 pazienti (16,7%) avevano una A.I. caratterizzata da 2 o più
funghi filamentosi.
Tra i pazienti con A.I. 112 (70%) erano infetti da una singola specie di Aspergillus e 49 (30%) da più di una
specie.
La percentuale di A.I. miste, osservate durante il periodo di studio, era incrementata dallo 0% fino al 53,3%.
Le combinazioni di funghi che più frequentemente causavano A.I. erano: A. fumigatus + Aspergillus spp.
(59,2 %), A. fumigatus + altri funghi filamentosi (16,4%).
Le A.I. miste più frequentemente identificate erano causate dalla combinazione tra A. fumigatus + A. flavus
(27,1%) e da A. fumigatus + A. terreus (4,5%).
Durante il periodo di studio 10 pazienti (5,8%) presentavano una A.I. causata da specie azolo-resistenti
criptiche. La percentuale di A.I. prodotta da specie criptiche è incrementata durante il periodo di studio da
0 al 20%. Molti pazienti con A.I. causate da specie criptiche hanno avuto una prognosi sfavorevole.
Durante gli ultimi 4 anni dello studio 4 pazienti (3 A.I.) avevano un’infezione da A. fumigatus azoloresistente.
I nostri risultati confermano che l’incidenza di A.I. mista (29%) è stata molto più elevata di quella riportata in
letteratura. Le A.I. miste causate da ceppi di Aspergillus resistenti potrebbero avere un impatto notevole
sulla morbilità e mortalità dei pazienti con un conseguente incremento dei costi.
Commento
Questo studio retrospettivo condotto in un periodo di oltre 10 anni su oltre 900 pazienti e su 1105 specie di
Aspergillus isolati mostra in modo convincente che l’incidenza di aspergillosi invasive miste (causate da 2 o
più funghi filamentosi) è chiaremente elevata (29%). Se questi dati clinici fossero confermati da altri studi
sarà necessario valutare e considerare l’impatto sulla morbilità e mortalità dei pazienti e il conseguente
incremento dei costi. Nel passato altri studi avevano dimostrato che frequentemente pazienti con
aspergillosi polmonare invasiva presentavano coinfezioni (49%) prevalentemente con altri patogeni
respiratori (batteri, virus) e meno con Aspergillus spp. o altre specie fungine (Georgiadou S.P. et al.
Concurrent lung infections in patients with hematological malignances and invasive pulmonary aspergillosis:
how firm is the Aspergillus diagnosis ? Journal of Infection 2012;65:262-268).
33
P1090 - Paper Poster Session V
improving fungal diagnostics
performance of Aspergillus pCr, multifungal DnA microarray, galactomannan, 1,3-beta-D-glucan and
Aspergillus azole resistance pCr for diagnosis of invasive fungal infections in haematological patients
T. Boch, B. Spiess, O.A. Cornely, J.J. Vehreschild, P. Rath, J. Steinmann, W.J. Heinz, J. Hahn, S.W. Krause, M.
Kiehl, G. Egerer, M. Koldehoff, M. Klein, F. Nolte, S. Will, N. Merker, W. Hofmann, D. Buchheidt, M. Reinwald
Objectives: The high mortality rates of invasive fungal infections (IFI), especially invasive aspergillosis (IA) in
immunocompromised haemato-oncological patients (pts) and current diagnostic limitations require improvement of
detection and characterization of fungal pathogens by defining the optimal use of biomarkers.
Methods: Clinical samples (bronchoalveolar lavage (BAL) and blood) of 75 immunocompromised patients with
suspected IFI and haematooncological diseases were investigated within a multicentre prospective study
(ClinicalTrials.gov Identifier: NCT01695512). Results of a nested Aspergillus-PCR assay, a multifungal DNA
microarray (DNA Chip) detecting 15 clinically relevant fungal species, a galactomannan EIA (GM) and a 1,3-beta-Dglucan assay (BDG) were analysed. Complete data from 37 patients was available for this preliminary evaluation.
Additionally, 11 Aspergillus DNA-positive samples were further analysed for the four most common triazole
resistance mutations in Aspergillus fumigatus by PCR assays and consecutive DNA sequence analysis.
Results: According to EORTC/MSG criteria, patients were classified as proven (n=2), probable (n=14), possible
(n=10), and no IFI (n=11). The table shows the diagnostic performance of different test combinations for detection of
IFI or IA (GM, PCR) in proven/ probable vs. no IFI pts.
Table. Diagnostic performance of test combinations (PPV = positive predictive value; NPV = negative predictive value; DOR = diagnostic
odds ratio): Aspergillus specific PCR assay, fungal DNA chip, galactomannan (GM) and 1,3-beta-D-glucan (BDG).
Specimen
Blood
Blood
BAL
BAL
BAL
Blood/BAL
Blood/BAL
Test combination
PCR AND Chip AND GM AND BDG
PCR OR Chip OR GM OR BDG
PCR OR Chip OR GM OR BDG
PCR AND Chip AND GM AND BDG
PCR OR GM
GM (blood) OR PCR (BAL)
BDG (blood) OR GM (BAL)
Sensitivity [%]
0
88
88
19
64
75
83
Specificity [%]
100
73
36
100
100
100
100
PPV [%]
0
82
67
100
100
100
100
NPV [%]
55
80
67
46
67
79
85
DOR
0
19
4
>200
>200
>200
>200
Analysis of the Aspergillus DNA-positive samples revealed no triazole resistance mutations.
Conclusions: Evaluation of preliminary data of this prospective multicentre diagnostic study reveals that combining
biomarkers is superior to their sole use in diagnosing IFI.
Performance of biomarkers in blood alone is inferior to BAL, but integrating blood and BAL into the diagnostic
algorithm is an advantageous approach which merits further investigation. In addition, auxiliary DNA-microarray
analysis broadens the spectrum of detectable fungal pathogens beyond Aspergillus spp.
This study was supported by a scientific grant from Gilead Sciences, Germany.
34
Key points
Elevati tassi di mortalità prodotti dalle infezioni fungine invasive (IFI), specialmente le aspergillosi invasive
(A.I.), sono ancora oggi osservati nei pazienti oncoematologici. Le attuali limitazioni diagnostiche
dovrebbero essere superate attraverso un miglioramento nella identificazione e caratterizzazione delle
infezioni fungine.
In uno studio prospettico e multicentrico, condotto in 75 pazienti affetti da malattie oncoematologiche e
con IFI sospetta, sono stati esaminati campioni di BAL e sangue.
I campioni sono stati analizzati tramite: nested aspergillus-PCRassay, multifungal DNA microarray (capace
di identificare 15 specie fungine clinicamente rilevanti), test del galattomannano e test del Beta glucano.
Undici campioni positivi per DNA di Aspergillus spp. sono stati ulteriormente analizzati mediante metodi
molecolari per la ricerca di mutazioni associate alla resistenza agli azoli.
Per questa valutazione preliminare sono disponibili i dati completi di 37 pazienti.
La performance dei test ha mostrato che l’uso combinato dei biomarcatori è superiore all’uso di un singolo
test per la diagnosi di IFI. Lo scopo è stato quello di confrontare la performance dei biomarcatori nei
pazienti con IFI o A.I. (proven/probable) versus pazienti senza IFI.
L’efficienza dei biomarcatori per la diagnosi di IFI, utilizzando sangue, è inferiore al BAL ma l’integrazione
dell’uso di biomarcatori, utilizzando sangue e BAL sembra essere un approccio vantaggioso. In aggiunta
l’uso del metodo DNA microarray potrebbe allargare lo spettro di patogeni fungini identificabili oltre che
Aspergillus spp.
Commento
Questo studio prospettico e multicentrico condotto in pazienti con malattie oncoematologiche è stato
disegnato con lo scopo di valutare l’efficienza dei biomarcatori per la diagnosi di infezione fungina
invasiva (IFI). L’uso combinato dei biomarcatori si è rivelato superiore all’uso di un singolo test,
soprattutto utilizzando il liquido di broncolavaggio. Al momento della presentazione dello studio al
congresso erano stati valutati in modo preliminare i dati clinici completi di 37 su un totale di 75 pazienti
arruolati nello studio. Più recentemente, lo stesso gruppo di ricerca ha esteso i suoi risultati a un gruppo
di 101 pazienti, confermando che l’analisi combinata di biomarcatori è superiore all’uso di un singolo
marcatore per la diagnosi di IFI. Soprattutto, si è confermato che l’analisi combinata del sangue e del BAL
è più vantaggiosa dello studio in un singolo compartimento biologico e che l’analisi del DNA mediante
microarray estende lo spettro di patogeni fungini identificabili oltre che Aspergillus (Boch T, et al:
Combination of Aspergillus PCR, multifungal DNA microarray, galactomannan, 1,3-Beta-D-Glucan and
azole resistance PCRs in blood and BAL samples for diagnosis of invasive fungal infections in
haematological patients. ICAAC September 2015,M-360). È auspicabile che i dati conclusivi di questo
studio siano pubblicati in modo esteso quanto prima.
35
P1222 - Paper Poster Session VI
invasive fungal infections in immunocompromised patients
breakthrough of fungal infections in allogeneic stem cell transplanted patients in antifungal
prophylaxis
G. Maffongelli, V. Malagnino, G. De Angelis, R. Cerretti, A. Picardi, L. Cudillo, M.G. Cefalo, G. Elisa,
M. Benedetta, A. William, A. Massimo, S. Loredana
Objectives: Invasive Fungal Diseases (IFD) remain one of the causes of morbidity and mortality in patients
undergoing allogeneic hematopoietic stem cell transplantation (HSCT). We report an epidemiological analysis about
the occurrence of breakthrough of IFD in a population of 181 HSCT patients underwent primary antifungal
prophylaxis.
Methods: We retrospectively evaluated a population of 233 adult patients who received an allogeneic HSCT
between 2008 and 2013 in Stem Cell Transplant Unit of Tor Vergata University of Rome and who received primary or
secondary antifungal prophylaxis. The follow-up has been extended, in each case, up to one year after HSCT.
Patients received primary antifungal prophylaxis with fluconazole or posaconazole if assessed as low or high risk of
post-transplant fungal infection. In the analysis, we excluded 52 patients who had been given a secondary
prophylaxis for a previous fungal infection.
Results: Among the 181 patients considered, 89 (49%) were male. The median age was 48 years (interquartile range
[IQR]: 18-74). 99 patients (55%) underwent transplantation from HLA-identical sibling, 55 (30%) from haploidentical
family donor and 20 (11%) from matched unrelated donor, while 7 patients (4%) receiveid unrelated cord blood cells.
In the first year post-transplant, a proven/probable IFD was documented in 13% (24/181) transplanted patients.
Eleven out of 24 (46%) were defined as proven and 13/24 (54%) as probable IFD. In the 11 proven IFD, the isolates
were: 2 Aspergillus fumigatus, 1 Aspergillus niger, 2 Fusarium solanii, 1 Rhodotorula glutinis, 1 Saccharomyces
cerevisiae, 1 Candida tropicalis, 1 Scopularopsios brevicularis, 1 Candida kruseii, 1 Criptococcus spp.
Of 24 Proven/Probable IFD, 12 (50%) occured during the first 30 days after transplant and 18 (75%) during the first
100 days. No difference was observed in the incidence of IFD by comparing patients transplanted from an HLA
unrelated donor with those grafted from an HLA identical Sibling (13,5% vs 13%, p=0,58).
A Proven/Probable IFD was documented in 10 out of 34 patients (29%) with acute Graft versus Host Disease (aGVHD), while 6 out of 60 patients (10%) with chronic GVHD experienced an IFD (p=0,15).
The presence of an IFD resulted in a higher risk of mortality within one year after transplantation (OR 5.4762, CI 95%
2.1838 - 13.7322, p=0.002).
Conclusion: Fungal infections remain a major cause of mortality in patients receiving HSCT and in our population
the IFD incidence is higher in the first 100 days post transplant. No difference in the percentage of subjects with
fungal infection were observed between patients receiving transplant from related or unrelated donor.
36
Key points
Le infezioni fungine invasive (IFI) rappresentano, ancora oggi, una delle principali cause infettive di morbilità
e mortalità per i pazienti riceventi trapianto allogenico di cellule staminali.
Obiettivo dello studio: descrivere gli aspetti epidemiologici e clinici di IFI documentate in una popolazione
di 181 pazienti riceventi trapianto allogenico di cellule staminali e profilassi antifungina primaria.
Lo studio retrospettivo, condotto tra il 2008 e il 2013, ha valutato originariamente una popolazione di 223
individui adulti riceventi trapianto allogenico di cellule staminali. I pazienti hanno ricevuto profilassi
antifungina primaria o secondaria. Fluconazolo è stato usato come profilassi antifungina primaria per
pazienti considerati a basso rischio, mentre posaconazolo è stato usato come profilassi antifungina
primaria per pazienti considerati ad alto rischio. Ogni paziente è stato sottoposto a follow-up durato
almeno un anno. Sono stati esclusi dall’analisi 52 pazienti poiché avevano ricevuto profilassi secondaria per
precedenti infezioni fungine.
99 pazienti (55%) hanno ricevuto trapianto da donatore HLA-identico, 55 pazienti (30%) da donatore
familiare aploidentico, 20 pazienti (11%) da donatori matched non correlati e 7 (4%) hanno ricevuto cellule
da cordone non correlato.
Nel primo anno dopo trapianto, una diagnosi di IFI “proven/probable” è stata documentata nel 13% (24/181)
dei pazienti trapiantati. Il 46% delle IFI diagnosticate è stato di tipo “proven” e il 54% di tipo “probable”.
Delle 24 IFI osservate, il 50% è stato diagnosticato durante i primi 30 giorni dopo il trapianto. L’incidenza di
IFI nei pazienti riceventi trapianto da donatore HLA non correlato non è stata statisticamente diversa dai
pazienti riceventi trapianto HLA identico (13,5% vs 13%, p=0,58).
IFI è stata documentata nel 29% dei pazienti con Graft versus Host Disease (GVHD) acuta, mentre nei
pazienti con GVHD cronica IFI è stata documentata nel 10% dei pazienti (p=0,15).
La presenza di IFI era significativamente associata a tassi di mortalità più elevata nel primo anno dopo il
trapianto.
Conclusioni. Le IFI sono una causa frequente di morte nei pazienti riceventi trapianto allogenico di cellule staminali.
In questo studio l’incidenza di IFI è stata più elevata nei primi 100 giorni dopo il trapianto. Non è stata osservata
alcuna differenza nell’incidenza di IFI tra pazienti riceventi trapianto da donatore correlato o non correlato.
Commento
Questo studio retrospettivo condotto in una popolazione di 223 individui adulti riceventi trapianto allogenico
di cellule staminali ha valutato gli aspetti epidemiologici e clinici di infezioni fungine invasive (IFI) durante la
profilassi antifungina primaria. Nel 13% dei pazienti analizzati, nonostante la profilassi primaria, è stata
diagnosticata una IFI entro il primo anno dopo il trapianto ed è di rilievo sottolineare che il 46% delle IFI
diagnosticate è stato di tipo proven. Nello studio non è riportato quante e quali siano state le infezioni
fungine osservate nei pazienti a basso rischio profilassati con fluconazolo e quelle osservate nei pazienti ad
alto rischio profillasati con posaconazolo. Inoltre, più del 50% delle IFI era provocato da patogeni diversi da
Aspergillus e da Candida. La diagnosi di IFI era associata ad una elevata mortalità dei pazienti.
Complessivamente, questo studio, in linea con la letteratura più recente (Corso-Leon D.E. et al.
Epidemiology and outcomes of invasive fungal infections in allogeneic haematopoietic stem cell transplant
recipients in the era of antifungal prophylaxis: a single-centre study with focus on emerging pathogens.
Mycoses 2015;58:325-336) evidenzia i limiti della profilassi antifungina e l’attuale rilevanza delle IFI nei
pazienti riceventi trapianto allogenico di cellule staminali.
37
P1256 - Paper Poster Session VI
invasive candidiasis
A decade of nation-wide fungaemia surveillance in Denmark: current status and major trends
M.C. Arendrup, R.H. Jensen, H.K. Johansen, J.D. Knudsen, L.E. Lemming, B.L. Røder, F.S. Rosenvinge,
L. Kristensen, L. Nielsen, B. Olesen, E. Dzajic, P. Kjældgård, H.C. Schønheyder
Objectives: Single or multicentre studies of fungaemia can be informative but population-based studies are more
reliable concerning general trends and overall disease burden. We report data from an ongoing nationwide
fungaemia surveillance programme in Denmark with emphasis on the two recent years 2012-13 and major trends
and patient characteristics during the last decade.
Methods: The programme is based on voluntary referral of blood culture isolates from departments of clinical
microbiology to the national referral centre, Statens Serum Institut, Copenhagen. Repeat isolated were included if
>21 days had passed. Species identification was performed using classical techniques supplemented by ID32C
assimilation tests and MALDI-TOF. Susceptibility testing was done according to EUCAST EDEF 7.2 except for
amphotericin B where Etest was used.
Results: In 2012-13 961 patients were diagnosed with 998 unique episodes of fungaemia involving 1026 isolates
(8.92/100,000 inhabitants). The overall episode rate was 19.4% higher in 2013 than 10 years earlier but remained
stable compared to 2010-11. Men older than 80 years were an exception (59-69/100,000) (Fig). C. albicans
accounted for 48.8% of yeast, but had declined from 52.1% in 2010-11 and 63.2% in 2004-5 (statistically
significant, P<0.0001). C. glabrata was second with 31.9%, up from 28.0% in 2010-11 and 18.3% in 2004-5. C.
krusei, C. parapsilosis and C. tropicalis remained sparsely represented (4%). The species distribution was agedependent with an increase of C. glabrata at the expense of C. albicans and C. parapsilosis. Above 50 years of age
gender had a notable impact on the occurrence of C. glabrata (3#7.7% in women vs. 29.9% in men, P=0.02).
Acquired echinocandin resistance was detected in 14 isolates including 10 C. glabrata (3.1%), two C. krusei (5.3%)
and two C. tropicalis (4.7%) isolates and was molecularly confirmed in 12 isolates compared to three isolates in
2010-11. In contrast, no echinocandin resistant isolates were detected in 2004-7, and five such isolates were found
in each of the two following periods 2008-9 and 2010-11 (Chi sqare for trend P<0.0001). Amphotericin B
susceptibility remained high (98.1%) whereas fluconazole susceptibility declined (60.4% compared to 66.7% in
2010-11). Nationwide antifungal use increased by 7%, 22%, 24% and 267% compared to 5 years earlier for
echinocandins, fluconazole, voriconazole and posaconazole, respectively.
Conclusion: In Denmark, the incidence of fungaemia remains high with a further increase for C. glabrata. More
echinocandin resistant isolates were detected which is concerning although numbers are small because only initial
blood isolates are included the surveillance programme.
Attempts to reduce the overall antifungal selection pressure and in particular longer-term echinocandin use should
be explored.
Figure. Gender and age specific national incidence rates of fungaemia in 2012-13 in Denmark compared to 2010-11 and 2004-09.
Cases/100,000 inhabitants
70
60
50
40
Male 2012-13
Male 2010-11
Male 2004-09
Female 2012-13
Female 2010-11
Female 2004-09
30
20
10
0
<1
1-9
10-19
20-29
30-39
40-49
50-59
Age group (years)
38
60-69
70-79
80-89
90-99
Key points
Gli studi basati sull’analisi di grandi popolazioni sono più adeguati di altre tipologie di analisi per valutare
l’impatto complessivo di una infezione su una data popolazione in esame. Si riporta uno studio, ancora in
corso, su un programma nazionale di sorveglianza delle fungemie diagnosticate in Danimarca, con
particolare enfasi agli anni 2012-2013 e alle relative caratteristiche cliniche dei pazienti degli ultimi 10 anni.
Nel periodo 2012-2013 sono stati diagnosticati 998 episodi di fungemia osservati in 961 pazienti analizzati
(8.92/100.000 abitanti). Complessivamente la frequenza di fungemia era il 19,4% più elevata nel 2013
rispetto a 10 anni prima, ma rimaneva stabile se confrontata alla frequenza delle infezioni documentate nel
periodo 2010/2011.
Candida albicans rappresentava il 48,8% dei lieviti isolati.
Candida glabrata era isolata nel 31,9% dei casi.
Candida krusei, C. parapsilosis e C. tropicalis rappresentavano il 4% delle fungemie.
La resistenza acquisita alle echinocandine è stata osservata nel 3,1% dei casi di fungemia da Candida
glabrata, nel 5,3% di fungemia da C. krusei e nel 4,7% di C. tropicalis ed era confermata con metodi
molecolari in 12 ceppi in confronto a 13 ceppi isolati nel 2010/2011. Al contrario, nel periodo 2004 -2007
non sono stati identificati ceppi resistenti ad echinocandine, mentre, nei periodi 2008-2009 e 2010-2011,
sono stati identificati solo 5 ceppi per ogni periodo di tempo esaminato.
La sensibilità ad amfotericina B dei ceppi isolati rimaneva elevata (98,1%) mentre la sensibilità a
fluconazolo declinava nel tempo (60,4%).
L’uso dei farmaci antifungini era incrementata, in Danimarca, del 7%, 22%, 24%, e 267% in confronto a 5
anni prima, rispettivamente per echinocandine, fluconazolo, voriconazolo e posaconazolo.
In Danimarca l’incidenza di fungemia è elevata con particolare incremento per C. glabrata e sono stati
osservati ceppi echinocandino-resistenti.
Commento
In accordo con la letteratura più recente (Guinea J. Global trends in the distribution of Candida species
causing candidemia. Clinical Microbiology Infection 2014;20(suppl 6):5-10), lo studio di Arendrup MC,
et al., basato su un programma nazionale, ancora in corso, di sorveglianza delle fungemie in
Danimarca, conferma l’elevata incidenza di candidemia in questo paese. In particolare, si nota un
incremento di circa il 20% di candidemia, osservato nel 2013 rispetto a 10 anni prima e questo
probabilmente spiega anche l’incremento di uso di farmaci antifungini documentato dallo studio.
Complessivamente, solo cinque specie di Candida (C. albicans, C. glabrata, C. krusei, C. parapsilosis e
C. tropicalis) sono state causa dell’84,7% dei casi di candidemia, confermando l’aumento, dell’ordine
del 3%-5%, di ceppi con caratteristiche di echinocandino-resistenza acquisita, mentre la sensibilità ad
amfotericina B di tali ceppi rimaneva elevata. I dati sottolineano l’importanza della conoscenza della
resistenza acquisita di Candida spp., aspetto poco valutato nell’ambito degli studi epidemiologici finora
pubblicati.
39
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INDICAZIONI TERAPEUTICHE di AmBisome: *Trattamento empirico della neutropenia febbrile. La dose giornaliera raccomandata è 3 mg/kg. Trattamento
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