The times.. they are a changing

Dr. Hamdi AkanAnkara University Medical School

Dept. of Hematology

0

0,2

0,4

0,6

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

Rate

per

10

0,0

00

pop

ula

tion

United States, 1980-1997

Mortality duıe to invasive mycosisMcNeil MM, et al. Clin Infect Dis 2001;33:641-7

Mortality duıe to invasive mycosisMcNeil MM, et al. Clin Infect Dis 2001;33:641-7

Candida Aspergillus Other Mycoses

From De Bauw

Epidemiology of Invasive Candidiasis: a Persistent Public Health Problem

Pfaller and Diekema Clin. Microbiol. Rev..2007; 20: 133-163

Epidemiology of Invasive Candidiasis: a Persistent Public Health Problem

Pfaller and Diekema Clin. Microbiol. Rev..2007; 20: 133-163

0

10

20

30

40

50

60

70

1996 1997 1998 1999 2000 2001 2002 2003

IAIC

Results of autopsy after fluconazole prophylaxis for hematological malignancies

Kami et al. Brit J Haematol 2002; 117:40-6

Results of autopsy after fluconazole prophylaxis for hematological malignancies

Kami et al. Brit J Haematol 2002; 117:40-6

720 patients

252InvasiveFungal

infections

positive blood cultures 8/37 (22%) C. albicans 11/24 (46%) non-albicans

CandidaAspergillusZygomycetesTrichosporonFusariumCryptococcusunknown

949191

34

80’s:14%

90’s:10%

From Ben De Pauw

Epidemiology of Invasive Candidiasis: a Persistent Public Health Problem

Pfaller and Diekema Clin. Microbiol. Rev..2007; 20: 133-163

Comparison of invasive fungal infection after nonmyeloablative and myeloablative HCT

(1993-1998)

Fukuda, T. et al. Blood 2003;102:827-833

N=1673

ns

N=163All IFI Aspergillosis

Risk factors, timing, and mortality of aspergillosis after RIC vs conventional SCT

Daly 2003, Fukuda 2004, Kojima 2004

1. Aspergillosis occurs LATER after RIC (d120 vs d90)

2. Case FATALITY rates are comparable

3. Aspergillosis is the first cause of infectious mortality

NEW DRUGS!

Opportunistic infections in 547 organ transplant recipients receiving alemtuzumab, a humanized

monoclonal CD-52 antibody.Peleg AY, et al,. Clin Infect Dis. 2007 Jan 15;44(2):204-12.

CONCLUSIONS: Patients who received alemtuzumab for the

treatment of allograft rejection were significantly more likely to

develop an opportunistic infection, compared with patients who

received alemtuzumab for induction therapy only. Such data

have implications for new antimicrobial prophylactic strategies.

Infliximab use in patients with severe graft-versus-host disease and other emerging risk factors of non-Candida invasive fungal infections in allogeneic hematopoietic stem cell transplant

recipients: a cohort study. Francisco MM et al. Blood, 15 October 2003, Vol. 102, No. 8, pp. 2768-2776

We conclude that infliximab administration is associated

with a significantly increased risk of non-Candida IFI

in HSCT recipients with severe GVHD disease. Pre-

emptive systemic antifungal therapy against molds

should be considered in patients who develop severe

GVHD after HSCT if infliximab is used.

NO GOOD NEWS?

Invasive aspergillosis following hematopoietic cell transplantation: outcomes and prognostic factors

associated with mortality.Upton A, Kirby KA, Carpenter P, Boeckh M, Marr KA

Clin Infect Dis. 2007 Feb 15;44(4):531-40.

• CONCLUSIONS: There has been a significant decrease in

mortality in patients with a diagnosis of IA following HCT in

recent years, coinciding with multiple changes in transplantation

practices, including use of nonmyeloablative conditioning

regimens, receipt of peripheral blood stem cells, more prompt

diagnosis of IA, and use of voriconazole.

Yüksek riskli hastalar

GM 2 kez >0.5PA. AC. grafide

infiltrat veya İFİ ile uyumlu bulgu, belirti

Pozitif kültür, mikroskopi

5 günden fazla nötropenik ateş

Toraks CT ve/veya Sinus CTToraks CT ve BAL

Halo belirtisi

Atipik infiltrat

Bronkoskopi ve BAL

Normal

+ -

Geniş spektrumlu antifungal tedavi Antifungal tedavi verme, izlemeye devam et

Galactomannan and Computed Tomography–Based Preemptive Antifungal Therapy in Neutropenic Patients at High Risk for Invasive

Fungal Infection: A Prospective Feasibility Study. Maertens J, et al. CID 2005; 41:1242–50

In the febrile neutropenic group, antifungal treatment was needed in 35% of the patients treated empirically, this is only 7.7% in patients in the preemptively treated group.

Most of the patients who died had an underlying diease not in remision (76.9% vs. 30% three mo.).

Time to listen to an expert!

Dr. J. Maertens