Comparison of national clinical practice guidelines and recommendations on vaccination of adult patients with autoimmune rheumatic diseases

Abstract: The aim of the study is to identify and compare national recommendations on vaccination of adult patients with autoimmune rheumatic diseases (ARDs) in Europe, North America, and Australia. We conducted a search for recommended immunizations in adult patients with ARDs in the Medline database and the Web sites of National Rheumatologic Societies, Ministries of Health, National Advisory Committees on Immunization, and other relevant National Scientific Societies. We compared national guidelines and identified points of agreement and differences. Guidelines on vaccination of adult patients with ARDs were identified in 21 countries. Points of agreement include administering influenza and pneumococcal vaccines in addition to inactivated age-appropriate or travel-related vaccines, and avoiding the use of live vaccines in immunocompromised patients with ARDs. The most important differences concern the steroid dose that induces immunosuppression, the time interval between live vaccines and the initiation of immunosuppressive treatment, herpes zoster vaccination, and the preferred pneumococcal vaccine in patients with ARDs. We observed significant differences among national recommendations on immunizations in patients with ARDs, reflecting the lack of evidence-based data. © 2013 Springer-Verlag Berlin Heidelberg

Invasive fungal infections in patients with cancer in the Intensive Care Unit

Invasive fungal infections (IFIs) have emerged as a major cause of morbidity and mortality amongst critically ill patients. Cancer patients admitted to the Intensive Care Unit (ICU) have multiple risk factors for IFIs. The vast majority of IFIs in the ICU are due to Candida spp. The incidence of invasive candidiasis (IC) has increased over recent decades, especially in the ICU. A shift in the distribution of Candida spp. from Candida albicans to non-albicans Candida spp. has been observed both in ICUs and oncology units in the last two decades. Timely diagnosis of IC remains a challenge despite the introduction of new microbiology techniques. Delayed initiation of antifungal therapy is associated with increased mortality. Therefore, prediction rules have been developed and validated prospectively in order to identify those ICU patients at high risk for IC and likely to benefit from early treatment. These rules, however, have not been validated in cancer patients. Similarly, major clinical studies on the efficacy of newer antifungals typically do not include cancer patients. Despite the introduction of more potent and less toxic antifungals, mortality from IFIs amongst cancer patients remains high. In recent years, aspergillosis and mucormycosis have also emerged as significant causes of morbidity and mortality amongst ICU patients with haematological cancer. © 2012 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved

Micafungin in haematology

Invasive fungal infections have emerged as a major cause of increased morbidity and mortality among severely immunosuppressed patients with haematological malignancy. Micafungin, a new member of the echinocandin class, is a valuable addition to the antifungal armamentarium of the 21 st century as it is active against Candida species, Aspergillus species, and other unusual mycoses that frequently affect these high risk patients. Available data on the safety and efficacy of micafungin as prophylaxis, preemptive/empirical treatment, or treatment of documented invasive fungal infection in patients with haematological malignancies are summarized in this review. © 2012 Blackwell Verlag GmbH

Is Sjögren's syndrome a retroviral disease?

Circumstantial evidence suggests that retroviruses play a role in the pathogenesis of Sjögren's syndrome. Such evidence, derived from studies of patients with Sjögren's syndrome, includes the following: the presence of serum antibodies cross-reactive with retroviral Gag proteins; the occurrence of reverse transcriptase activity in salivary glands; the detection of retroviral antigens, retrovirus-like particles, or novel retroviral sequences in salivary glands; the occurrence of Sjögren's syndrome-like illnesses in patients having confirmed systematic infections with retroviruses such as human immunodeficiency virus-1 (HIV-1) and human T lymphotropic virus type 1; and the beneficial effect of anti-retroviral treatment on the occurrence of HIV-1-associated sicca syndrome. Additional evidence is provided by animal models. © 2011 BioMed Central Ltd

Subclinical tumor lysis-like syndrome during treatment of visceral leishmaniasis with low-dose intermittent liposomal amphotericin B

We retrospectively evaluated the rate of renal dysfunction during treatment with liposomal amphotericin B (L-AmB) (3-4 mg/kg, for 7-10 days) in nine consecutive patients with visceral leishmaniasis (VL). During the frst week of treatment, 5 patients (56%) experienced transient deterioration of renal function, with a rise in serum creatinine to 1.27-2.44 times the baseline level, and a parallel elevation of uric acid levels without other metabolic or electrolyte disturbances. Serum renal function parameters were restored to normal levels after the completion of therapy, on day 21. These 5 patients had presented with prolonged fever and/or signifcant spleen enlargement, refecting high parasite load. This observation suggests that treatment of VL with intermittent L-AmB causes a subclinical tumor lysis-like syndrome, especially in patients with high parasite load. © Versita Sp. z o.o

Invasive fungal infections in patients with hematological malignancies: Emergence of resistant pathogens and new antifungal therapies [Hematolojik kanserleri olan invaziv mantar enfeksiyonlu hastalar: Dirençli patojenlerin ortaya çıkışı ve yeni antifungal tedaviler]

Invasive fungal infections caused by drug-resistant organisms are an emerging threat to heavily immunosuppressed patients with hematological malignancies. Modern early antifungal treatment strategies, such as prophylaxis and empirical and preemptive therapy, result in long-term exposure to antifungal agents, which is a major driving force for the development of resistance. The extended use of central venous catheters, the nonlinear pharmacokinetics of certain antifungal agents, neutropenia, other forms of intense immunosuppression, and drug toxicities are other contributing factors. The widespread use of agricultural and industrial fungicides with similar chemical structures and mechanisms of action has resulted in the development of environmental reservoirs for some drug-resistant fungi, especially azole-resistant Aspergillus species, which have been reported from four continents. The majority of resistant strains have the mutation TR34/L98H, a finding suggesting that the source of resistance is the environment. The global emergence of new fungal pathogens with inherent resistance, such as Candida auris, is a new public health threat. The most common mechanism of antifungal drug resistance is the induction of efflux pumps, which decrease intracellular drug concentrations. Overexpression, depletion, and alteration of the drug target are other mechanisms of resistance. Mutations in the ERG11 gene alter the protein structure of C-demethylase, reducing the efficacy of antifungal triazoles. Candida species become echinocandin-resistant by mutations in FKS genes. A shift in the epidemiology of Candida towards resistant non-albicans Candida spp. has emerged among patients with hematological malignancies. There is no definite association between antifungal resistance, as defined by elevated minimum inhibitory concentrations, and clinical outcomes in this population. Detection of genes or mutations conferring resistance with the use of molecular methods may offer better predictive values in certain cases. Treatment options for resistant fungal infections are limited and new drugs with novel mechanisms of actions are needed. Prevention of resistance through antifungal stewardship programs is of paramount importance. © 2018 by Turkish Society of Hematology