43 research outputs found
Cliniciansâ challenges in managing patients with invasive fungal diseases in seven Asian countries: An Asia Fungal Working Group(AFWG) Survey
Background: Invasive fungal diseases (IFD) are a serious threat, but physicians in Asia lack access to many
advanced diagnostics in mycology. It is likely that they face other impediments in the management of IFD.
A gap analysis was performed to understand the challenges Asian physicians faced in medical mycology.
Methods: The Asia Fungal Working Group (AFWG) conducted a web-based survey on management
practices for IFD among clinicians in China, India, Indonesia, Philippines, Singapore, Taiwan and Thailand.
Findings: Among 292 respondents, 51.7% were infectious disease (ID) specialists. Only 37% of respondents
had received formal training in medical mycology. They handled only around 2â4 proven cases of each
fungal infection monthly, with invasive candidiasis the most common. For laboratory support, the
majority had access to direct microscopy (96%) and histopathology (87%), but galactomannan and azole
levels were available to 60% and 25% of respondents, respectively. The majority (84%) used clinical
parameters for treatment response monitoring, and 77% followed the Infectious Diseases Society of
America guidelines. The majority (84%) did not use the services of an ID physician. Where febrile
neutropenia was concerned, 74% of respondents used the empirical approach. Only 30% had an antifungal
stewardship program in their hospital. Eighty percent could not use preferred antifungals because of cost.
Interpretation: The survey identified inadequacies in medical mycology training, non-culture diagnostics,
access to antifungal drugs, and local guidelines as the major gaps in the management of IFDs in Asian
countries. These gaps are targets for improvement
Survey of laboratory practices for diagnosis of fungal infection in seven Asian countries: An Asia Fungal Working Group (AFWG) initiative
An online survey of mycology laboratories in seven Asian countries was conducted to
assess the status, competence, and services available. Country representatives from the
Asia Fungal Working Group (AFWG) contacted as many laboratories performing mycology
diagnosis as possible in their respective countries, requesting that the laboratory
heads complete the online survey. In total, 241 laboratories responded, including 71 in
China, 104 in India, 11 in Indonesia, 26 in the Philippines, four in Singapore, 18 in Taiwan,
and seven in Thailand. Overall, 129/241 (53.5%) surveyed mycology laboratories operate
as separate designated mycology laboratories, 75/241 (31.1%) conduct regular formal
staff training, 103/241 (42.7%) are accredited, and 88/157 (56.1%) participate in external
quality assurance scheme (EQAS) programs. Microscopy and culture methods are available
in nearly all laboratories, although few perform DNA sequencing (37/219; 16.9%)
or use matrix-assisted laser desorption/ionization time-of-flight mass spectroscopy (MALDI-TOF MS) (27/219; 12.3%) for isolate identification. Antifungal susceptibility testing
is performed in 142/241 (58.9%) laboratories, mainly for yeasts. The most commonly
performed nonculture diagnostic is cryptococcal antigen testing (66 laboratories), followed
by galactomannan testing (55), polymerase chain reaction (PCR) diagnosis (37),
and beta-D-glucan testing (24). Therapeutic drug monitoring is conducted in 21 laboratories.
There is almost no access to advanced diagnostic tests, like galactomannan,
Îē-D-glucan, and PCR, in the surveyed laboratories in Indonesia, the Philippines, and
Thailand. These results highlight the need for development of quality laboratories, accreditation
and training of manpower in existing laboratories, and access to advanced
nonâculture-based diagnostic tests to facilitate the diagnosis of fungal infections in Asia
Baseline Chest Computed Tomography as Standard of Care in High-Risk Hematology Patients
Baseline chest computed tomography (BCT) in high-risk hematology patients allows for the early diagnosis of invasive pulmonary aspergillosis (IPA). The distribution of BCT implementation in hematology departments and impact on outcome is unknown. A web-based questionnaire was designed. International scientific bodies were invited. The estimated numbers of annually treated hematology patients, chest imaging timepoints and techniques, IPA rates, and follow-up imaging were assessed. In total, 142 physicians from 43 countries participated. The specialties included infectious diseases (n = 69; 49%), hematology (n = 68; 48%), and others (n = 41; 29%). BCT was performed in 57% (n = 54) of 92 hospitals. Upon the diagnosis of malignancy or admission, 48% and 24% performed BCT, respectively, and X-ray was performed in 48% and 69%, respectively. BCT was more often used in hematopoietic cell transplantation and in relapsed acute leukemia. European centers performed BCT in 59% and non-European centers in 53%. Median estimated IPA rate was 8% and did not differ between BCT (9%; IQR 5-15%) and non-BCT centers (7%; IQR 5-10%) (p = 0.69). Follow-up computed tomography (CT) for IPA was performed in 98% (n = 90) of centers. In high-risk hematology patients, baseline CT is becoming a standard-of-care. Chest X-ray, while inferior, is still widely used. Randomized, controlled trials are needed to investigate the impact of BCT on patient outcome
Understanding the potential impact of different drug properties on SARS-CoV-2 transmission and disease burden : a modelling analysis
Q1Q1Background
The unprecedented public health impact of the COVID-19 pandemic has motivated a rapid
search for potential therapeutics, with some key successes. However, the potential impact of
different treatments, and consequently research and procurement priorities, have not been clear.
Methods and Findings
develop a mathematical model of SARS-CoV-2 transmission, COVID-19 disease and
clinical care to explore the potential public-health impact of a range of different potential
therapeutics, under a range of different scenarios varying: i) healthcare capacity, ii) epidemic
trajectories; and iii) drug efficacy in the absence of supportive care. In each case, the outcome
of interest was the number of COVID-19 deaths averted in scenarios with the therapeutic
compared to scenarios without. We find the impact of drugs like dexamethasone (which are
delivered to the most critically-ill in hospital and whose therapeutic benefit is expected to
depend on the availability of supportive care such as oxygen and mechanical ventilation) is
likely to be limited in settings where healthcare capacity is lowest or where uncontrolled
epidemics result in hospitals being overwhelmed. As such, it may avert 22% of deaths in highincome countries but only 8% in low-income countries (assuming R=1.35). Therapeutics for
different patient populations (those not in hospital, early in the course of infection) and types
of benefit (reducing disease severity or infectiousness, preventing hospitalisation) could have
much greater benefits, particularly in resource-poor settings facing large epidemics.
Conclusions
There is a global asymmetry in who is likely to benefit from advances in the treatment of
COVID-19 to date, which have been focussed on hospitalised-patients and predicated on an
assumption of adequate access to supportive care. Therapeutics that can feasibly be delivered
to those earlier in the course of infection that reduce the need for healthcare or reduce
infectiousness could have significant impact, and research into their efficacy and means of
delivery should be a priorityRevista Internacional - Indexad
Chronic Pulmonary Aspergillosis Following Nontuberculous Mycobacterial Infections: An Emerging Disease
Chronic pulmonary aspergillosis (CPA) following nontuberculous mycobacterial (NTM) lung disease is being increasingly recognized, especially in countries where tuberculosis is not endemic, with an incidence rate of 3.9–16.7%. NTM lung disease has been identified as a predictor of mortality in CPA patients. The major risk factors for NTM-associated CPA include fibrocavitary NTM lung disease, the presence of pulmonary emphysema, and high-dose corticosteroid use. The onset of CPA is 1.5–7 years following the diagnosis of NTM lung disease. The diagnosis can be made using standard criteria; however, serological diagnosis using Aspergillus precipitin has demonstrated a higher sensitivity and specificity when compared with fungal culture from respiratory specimens. Treatment is challenging since rifampicin and oral triazoles should not be used concomitantly. The prognosis is poor, and the factors associated with worse prognosis are corticosteroid use and high C-reactive protein level
Risk Factors, Clinical Characteristics, Management, and Outcomes of Musculoskeletal Fungal Infection at Thailand’s Largest National Tertiary Referral Center
To investigate the risk factors, clinical characteristics, management, and outcomes of musculoskeletal fungal infection in Thai patients, patients aged ≥18 years definitively diagnosed with musculoskeletal fungal infection by culture and/or histopathology at Siriraj Hospital (Bangkok, Thailand) during 2002–2020 were retrospectively enrolled. Twenty-eight patients (median age: 58.5 years [range: 22–81], 57.1% male) with fungal osteomyelitis (n = 22), septic arthritis (n = 1), or fungal osteomyelitis with septic arthritis (n = 5) were included. Immunocompromised status was common (82%). Most patients had de novo infection from hematogenous spreading that usually presented at a single, non-contiguous site. The median symptom duration prior to diagnosis was 2 months. The tibia and knee were the most common site of osteomyelitis (30%) and septic arthritis (72%), respectively. The most common pathogens were Talaromyces marneffei and Cryptococcus neoformans. Organism identification from tissues at the affected sites was required in all cases. Most patients (82%) required combination surgery and systemic antifungal therapy. Among those with complete follow-up (23/28), 61% and 39% had complete and partial responses, respectively. Musculoskeletal fungal infection is an uncommon disease with insidious onset and non-specific manifestations that requires pathogen identification via tissue cultures and histopathologic studies. Combination surgery and systemic antifungal therapy yielded generally favorable outcomes
Clinical Features of Cryptococcal Meningoencephalitis in HIV-Positive and -Negative Patients in a Resource-Limited Setting
Cryptococcal meningoencephalitis is a systemic fungal infection in immunocompromised and immunocompetent individuals. This study investigated the clinical characteristics and factors associated with mortality in HIV-associated and non-HIV-associated cryptococcal meningoencephalitis in a resource-limited setting. This was a retrospective cohort study of patients with cryptococcal meningoencephalitis between January 2009 and December 2019 at a tertiary teaching hospital in Thailand. Overall, 1019 patients with cryptococcal meningoencephalitis were enrolled, and 923 (90.6%) were HIV-positive. The patients with HIV-associated cryptococcal meningoencephalitis were younger than the HIV-negative patients (37 versus 56 years, p p p p p 3; p p p p p = 0.53). The HIV-positive patients with comorbidities, fever, an altered mental status at presentation, a CSF white blood cell count below 20 cell/mm3, fungemia, and positive CSF India ink were independently associated with 30-day mortality. In comparison, an altered mental status at presentation and fungemia were associated with 30-day mortality in HIV-negative patients. In conclusion, HIV-negative patients with cryptococcal meningoencephalitis had more extensive central nervous system inflammation, although the two groupsâ mortality rates were similar. Unfavorable prognostic factors included comorbidities, fever, an altered mental status at presentation, a low CSF white blood cell count, fungemia, and positive CSF India ink
Impact of the Disk Diffusion Test on Fluconazole De-Escalation in Patients with Candidemia
Disk diffusion (DD) is a simple antifungal susceptibility method for Candida. This study examined the impact of fluconazole DD testing on antifungal de-escalation. We enrolled patients with candidemia whose Candida isolates were tested for fluconazole susceptibility using DD between January 2019 and January 2020. The historical controls were patients with candidemia who underwent fluconazole susceptibility testing using the broth microdilution (BMD) method. Clinical data including antifungal therapy were analyzed. In total, 108 patients were enrolled. Most baseline characteristics were comparable between the groups. C. tropicalis was the predominant isolate (54.6%), followed by C. albicans (17.6%). The rates of antifungal de-escalation within 72 h were 25.9 and 9.3% in the DD and BMD groups, respectively (p = 0.023). The median time to de-escalation was 3 days in the DD group, versus 6 days in the BMD group (p = 0.037). The 14-day mortality rate and antifungal cost tended to be lower in the DD group. There were no differences in the length of hospital stay and treatment-related complications between the two groups. The agreement between the DD and BMD results was 90%. DD testing can be substituted for BMD to enhance antifungal de-escalation and antifungal stewardship
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