1. Medical and Pathogenic Mycology Fungal ABC’s

2. Medical Mycology: Clinical Classification
Yeasts
Systemic disease, pulmonary disease absent or subclinical
Dimorphic fungi
Primary pulmonary disease with dissemination prominent part of disease
Molds
Primary pulmonary disease with dissemination less common

3. Invasive Mold Infections
Immunosuppressed patients only
Pulmonary infection by inhalation of airborne spores with subsequent dissemination
Very aggressive, destructive
Aspergillus most common (>80%)
Aspergillus fumigatus most common species
Others
Rhizopus, Absidia, Mucor (Zygomycetes)
Penicilllium
Pseudallescheria boydii

4. Aspergillus fumigatus
Ubiquitous mold
Found on decaying material
Produces large amount of airborne conidia
On average at 100 to 1000 conidia are inhaled daily

5. A B C D E
Alveolar Infection
Angioinvasion
Dissemination

6. Invasive Aspergillosis
Risk Groups - Risk Factors
Hematologic malignancy
HSCT (especially allogeneic)
Host variables (age, underlying disease)
Transplant factors (source of stem cells)
Late complications (GVHD, corticosteroids, secondary neutropenia)
Solid-organ transplant
Advanced HIV disease
Risk factors for IA:
Host Variables – age at transplantation and underlying disease
Transplant Variables – type of transplant, recipients of cord blood, HPA-mismatched or unrelated donor PBSCs, and T cell-depleted or CD34-selected stem cells all increased the risk
Late complications – acute and chronic GVHD, receipt of corticosteroids, secondary neutropenia, cytomegalovirus disease, and respiratory virus infection.
References
Lin SJ et al. Clin Infect Dis. 2001;32:
Marr KA et al. Blood 2002;100:
SOT = solid organ transplant
Marr KA et al. Blood 2002;100: ; Lin SJ et al. Clin Infect Dis. 2001;32: 6

7. Time to Onset of IFI After HSCT
# of UFU’s
For some time, a bimodal incidence of IFI has been recognized after HSCT, the first peak at 2 weeks and again at 3 months post transplant. The early peak occurs generally prior to engraftment, when the patient is neutropenic and still recovering from the conditioning regimen. Candida are the predominant pathogens in this period. The second wave of fungal infections is primarily due to Aspergillus and is associated with graft-versus-host disease and the use of high-dose corticosteroid therapy.
PG Pappas: Transplant Associated Infection Surveillance Network 7

8. Trends in Mortality Invasive Mycotic Diseases 1980 – 1997
Candidiasis
Other Mycoses
+329%
Rate per 100,000 population
Aspergillosis
+357%
Concomitant with the increase of infection has been an alarming increase in morbidity and mortality due to invasive mycoses over the past 2 decades. Deaths associated with invasive aspergillosis, in particular, have increased a staggering 357% from 1980 to Other moulds, such as Fusarium and Scedosporium, are also associated with high mortality.
Mortality from invasive fungal infections for solid organ transplant patients, in particular, varies from 50% to 80% and for those receiving HSCTs, the overall fatality rate can be as great as 70% to 90%.
Reference
McNeil MM et al. Clin Infect Dis. 2001;33:641-7.
Year
McNeil MM et al. Clin Infect Dis. 2001;33:641-7. 8

9. Invasive Aspergillosis in Canada Emerging Epidemiology:

10. The Diagnostic Challenge – IA
Proven
Histopathology and/or
Growth in culture from tissue biopsy or aspirate from a sterile site
Probable
Presence of 1 host factor criterion, 1 clinical feature and microbiological evidence (includes galactomannan)
Culture from sputum or BAL in immunocompromised patient with clinical evidence of infection
“The problem of uncertainty cannot be disregarded as if it does not exist…”
EORTC International Consensus
Possible
At least 1 host factor criterion
Neutropenia
Persistent fever despite antibiotics in high-risk patients
Signs and symptoms of GVHD
Prolonged corticosteroid use
Diagnostic criteria have been developed to provide consistency in the conduct of clinical trials using criteria based on host factors, clinical features and mycologic evidence. However, clinical application of such definitions at the bed side may be inappropriate. The gold standard for diagnosis remains identification of the organism by histopathology and/or growth in culture from tissue biopsy or aspirate from a sterile site. However, culture of the organism from non-sterile sites (sputum or BAL) from an immunocompromised host who has clinical evidence of infection can be utilized to support a probable diagnosis of invasive aspergillosis. The definitions of “proven”, “probable”, and “possible” were developed based on: host factors, clinical manifestations, and mycological results.
Host Factors: Neutropenia, persistent fever despite broad-spectrum antibiotics in a high-risk patient, signs and symptoms of GVHD (grade ≥2) or chronic GVHD, prolonged (>3 weeks) use of corticosteroids in previous 60 days.
Microbiological factors: Positive culture results for mold from sputum or BAL samples, positive culture or microscopic evaluation for mold from sinus aspirate, sputum or BAL, positive result for Aspergillus antigen in BAL, CSF, or ≥2 blood samples, positive result for cryptococcal antigen in blood sample, positive findings of cytologic or direct microscopic examination for fungal elements in sterile body fluids, 2 positive results of culture of urine samples for yeasts in absence of urinary catheter, Candida casts in urine in absence of catheter, positive result for blood culture.
Clinical factors: Lower respiratory tract infection - Major: new infiltrates on CT imaging - halo sign, air-crescent sign, or cavity within area of consolidation. Minor: symptoms of lower respiratory tract infection (cough, chest pain, hemoptysis, dyspnea), physical finding of pleural rub, pleural effusion.
References
Ascioglu S et al. Clin Infect Dis 2002;34:7-14.
Perlroth J et al. Med Mycol. 2007;45:
Ascioglu S et al. Clin Infect Dis. 2002;34:7-14. 10

11. Autopsy-Proven IFD Confirms Under-Diagnosis of IFD
Two-site autopsy study of 97 allogeneic stem cell recipients
IFI Deaths
Many cases of IFD are missed during screening so the actual incidence is even higher- even when regular galactomannan testing and CT scans are used.
Ante Mortem Screening: (1) Regular galactomannan testing (2) CT scans
Sinko et al. Transpl Infect Dis 2008: 10: 11

12. Diagnostic Methods CT Scan (1,3)-ß-D-glucan assay Galactomannan assay
Nodules or patchy consolidations
Halo sign: attenuated area around a nodule
Specific to IA? - in the setting of immunocompromise
Sensitivity varies with timing relative to diagnosis (high early)
(1,3)-ß-D-glucan assay
Excellent negative predictive value
False positives:
Albumin
Immunoglobulin
Hemodialysis
Galactomannan assay
Sensitivity 0.73, specificity 0.81 (proven IA)
Lowered threshold for test positivity
Bifidobacterium lipoglycan
Concurrent use of ß-lactam antibiotics, particularly piperacillin-tazobactam
PCR detection of fungal DNA
Sensitivity 100% for IA (preceding symptoms by a median of 2 days)
Requires further standardization and validation
Top Left Box - CT Scan - The ‘halo’ sign is often considered specific to IA in the setting of immunocompromise. Horger et al. found the ‘halo’ sign to have a sensitivity of 30.2% but a specificity of 100% for aspergillosis. The ‘halo’ sign is highly sensitive early on, with 80-90% of chest CT scans showing a ‘halo’ sign on the day of diagnosis of invasive aspergillosis. The ‘halo’ sign wanes over time and is eventually replaced by the crescent.
Bottom Left Box - Galactomannan Assay - Galactomannan is a cell wall component released by Aspergillus species during hyphal growth. Galactomannan assay has recently received FDA approval for use in diagnosing IA. A recent meta-analysis found the sensitivity of the test was 0.73 (95% CI, ) and specificity was 0.81 (95% CI, ) for proven aspergillosis. For proven or probable invasive aspergillosis, the sensitivity was 0.69 (95% CI, ) and specificity was 0.89 (95% CI, ), making the test possibly useful at ruling out disease in low pre-test probability populations, but not useful at ruling in the disease. A variety of conditions have been reported to cause false positive assays (e.g., the use of concurrent B-lactam antibiotics - piperacillin-tazobactam).
References
Horger M et al. Br J Radiol 2005;78:
Maertens J et al. Curr Opin Infect Dis. 2006;19:
Perlroth J et al. Med Mycol. 2007;45:
Pfeiffer CD et al. Clin Infect Dis 2006;42:
Perlroth J et al. Med Mycol. 2007;45: 12

13. Galactamannan (GM) Assay
GM is a carbohydrate constituent of the fungal cell wall and is released during hyphal growth
Commercial, FDA approved sandwich EIA for detection of circulating A. fumigatus GM
Can be used on serum or BAL fluid
Cutoff for positive is an index of 0.5 (serum)
May be detected 5-8 days before symptoms

14. Utility and Limitations
Serum
FDA literature - Sensitivity 80.7%, Specificity 89.2%
Meta analysis - Sensitivity 73% and Specificity 81%
Most useful in serial sampling
Highest sensitivity in neutropenic patients
BAL
Cutoff 0.5 – Sensitivity 100%, Specificity 78%
Cutoff 2.0 – Sensitivity 100%, Specificity 93.2%
GM > 2 associated with a 4.68 CHR of death

15. Protocol for MUHC 1. Presumptive diagnosis of IA:
Testing on request of adult inpatients with at least one risk factor for IA and at least one clinical criteria consistent with IA
2. Pre-emptive screening:
Routine screening of all high risk inpatients on hematology wards
Sera will be collected three times per week (Mon-Wed-Fri)
Assays will be run twice weekly (Tues-Thurs).

16. Case 51 year old woman April 2010 AML Induced with FLAG-IDA CR
March 2011
Allo HSCT from brother
Concomitant with the increase of infection has been an alarming increase in morbidity and mortality due to invasive mycoses over the past 2 decades. Deaths associated with invasive aspergillosis, in particular, have increased a staggering 357% from 1980 to Other moulds, such as Fusarium and Scedosporium, are also associated with high mortality.
Mortality from invasive fungal infections for solid organ transplant patients, in particular, varies from 50% to 80% and for those receiving HSCTs, the overall fatality rate can be as great as 70% to 90%.
Reference
McNeil MM et al. Clin Infect Dis. 2001;33:641-7. 16

17. Case Several complications GVHD (Grade III) – liver skin and bowel
CMV positive April 2011 until Dec 2011
Multiple antivirals used including gancyclovir, foscarnet and cidofivir
EBV PCR positive April 2011,
Rituximab given Dec 2011
Concomitant with the increase of infection has been an alarming increase in morbidity and mortality due to invasive mycoses over the past 2 decades. Deaths associated with invasive aspergillosis, in particular, have increased a staggering 357% from 1980 to Other moulds, such as Fusarium and Scedosporium, are also associated with high mortality.
Mortality from invasive fungal infections for solid organ transplant patients, in particular, varies from 50% to 80% and for those receiving HSCTs, the overall fatality rate can be as great as 70% to 90%.
Reference
McNeil MM et al. Clin Infect Dis. 2001;33:641-7. 17

18. Case Admitted Dec 2011 with fevers 7 d after rituximab
S. bovis bacteremia (Rx Ceftriaxone)
RSV + in nasal swab – (Rx Ribivarin)
HHV-6 PCR positive on blood
CMV colitis
Relative stable by Jan and afebrile
Concomitant with the increase of infection has been an alarming increase in morbidity and mortality due to invasive mycoses over the past 2 decades. Deaths associated with invasive aspergillosis, in particular, have increased a staggering 357% from 1980 to Other moulds, such as Fusarium and Scedosporium, are also associated with high mortality.
Mortality from invasive fungal infections for solid organ transplant patients, in particular, varies from 50% to 80% and for those receiving HSCTs, the overall fatality rate can be as great as 70% to 90%.
Reference
McNeil MM et al. Clin Infect Dis. 2001;33:641-7. 18

19. 4
Days

20. Days

21. Voriconazole

22. McGill University: Incidence of IA
AML and Allogeneic Stem Cell Transplant patients
Pre-galactoamman
Incidence of IA

23. McGill University: Incidence of IA
AML and Allogeneic Stem Cell Transplant patients
Post-galactomannan
Incidence of IA

24. Rates of Invasive Aspergillosis
Centre
Population
IA Incidence (%)
Maisonneuve Rosemont Hospital
Allogeneic HSCT 15
Acute Leukemia
8.9
Vancouver General Hospital
18.8
Hotel Dieu Quebec
AML
17.8

25. Invasive Fungal Infection
Management 25

26. Antifungal Agents - Sites of Action
ß-1, 3 glucan polysaccharide
Ampho B
Ergosterol
Cell Membrane
Phospholipid bilayer
Echinocandins
Azoles
The azoles target the membrane of the fungal cell by inhibiting cytochrome P450-dependent ergosterol synthesis in the endoplasmic reticulum. The triazoles are metabolized in the liver by cytochrome P450 enzymes (CYP) (posaconazole is not metabolized in the liver but still interacts with CYP enzymes).
Conventional AMB binds to ergosterol in the fungal cell membrane, inducing conformational change and formation of ionic pores, thereby increasing membrane permeability and allowing the intracellular contents to leak and eventually die.
Echinocandins inhibit synthesis of beta-1,3 glucan by the 1,3-beta-D glucan synthase which contains Fks1p, Fks2p and Rho1p sub-units.
Reference
Metcalf SC, Dockrell DH. J Infect 2007;55:
Adapted from Metcalf SC, Dockrell DH. J Infect. 2007;55: 26

27. Drug Classes and Agents
Polyenes
Amphotericin B (AMB)
Lipid-based formulations
ABLC
ABCD
L-AMB
Expanded-spectrum azoles
Voriconazole
Posaconazole
Ravuconazole*
Azoles
Fluconazole
Itraconazole
Echinocandins
Caspofungin
Micafungin
Anidulafungin
Three classes have been used in prophylaxis and treatment of IFI: the polyenes, azoles, and echinocandins
Polyenes share a broad spectrum of antifungal activity with differing pharmacokinetic properties. Conventional AMB binds to ergosterol in the fungal cell membrane, increasing membrane permeability and allowing the intracellular contents to leak and eventually die. It’s toxicity is well known - renal and infusion-related toxicity. Attempting to limit toxicity by dose reduction can result in inadequate drug levels and subsequent treatment failure. Lipid-based formulations were developed for use in patients refractory or intolerant to AMB. L-AMB is also approved for the treatment of febrile neutropenia and for primary treatment of cryptococcal meningitis in HIV patients.
Azoles - ketoconazole was the first systemic antifungal azole. The triazoles followed - fluconazole, itraconazole, and the second-generation triazole voriconazole. Posaconazole is also a second generation triazole. These antifungals vary in their spectrum of antifungal activity. Fluconazole is primarily active against Candida, Cryptococcus neoformans, and coccidioidomycosis, while Itraconazole is also active against Candida, moulds such as Aspergillus, and the dimorphic fungi, Histoplasma, Coccidioides, and Blastomyces. Voriconazole is active against both yeasts and moulds (except Zygomycetes) and has become the recommended primary therapy for most patients with invasive aspergillosis. Posaconazole has broad antifungal activity, including against Aspergillus, Zygomycetes, Fusarium, C.neoformans, Histoplasma, and Coccidioides.
The azoles target the membrane of the fungal cell by inhibiting the enzymes needed for the biosynthesis of ergosterol, thus disrupting fungal cell membrane structure and function. The triazoles are metabolized in the liver by cytochrome P450 enzymes (CYP) (posaconazole is not metabolized in the liver but still interacts with CYP enzymes). Interaction may be in the form of slowing the metabolism and thus increasing the concentrations of other drugs metabolized by the CYP pathway, drugs that induce CYP pathway can speed the metabolism of the triazoles lowering their plasma concentration, or a combination.
Echinocandins have a limited spectrum of activity and have shown clinical utility against Candida, Aspergillus, and Zygomycetes. They have a mode of action that is different from all other antifungals. Consisting of inhibition of (1,3)-B-D-glucan synthase, which produces an important component of the cell wall of many pathogenic fungi such as Candida spp. and Aspergillus spp. The target of echinocandins does not exist in mammalian cells, so their toxicity is minimal.
References
A Compendium of Pharmaceuticals and Specialties (CPS) Liposomal Amphotericin B approved indications
Metcalf SC, Dockrell DH. J Infect 2007;55: ]
Patterson TF, Wingard JR. Changing the treatment paradigm to improve fungal infection outcomes. CME The Clinician’s Companion #347E7F
Petrikkos G, Skiada A. Internat J Antimicrob Agents 2007;30:
*Not yet approved
ABLC = Amphotericin B lipid complex; ABCD = Amphotericin B colloidal dispersion; L-AMB: Liposomal amphotericin B
Metcalf SC, Dockrell DH. J Infect 2007;55: ; Petrikkos G, Skiada A. Internat J Antimicrob Agents 2007;30: 27

28. IFI Management Prophylactic Preemptive Empirical Therapy
Disease progression No
disease
Markers
Signs & symptoms
Full-blown disease
Sequelae
Prophylactic
Asymptomatic high-risk patient
Asymptomatic + colonization OR novel diagnostic
Preemptive
Empirical
High risk: Antibiotic + fever
Fungal infections can be viewed as a continuum from harmless colonization of an opportunistic organism to disseminated infection. Opportunities to intervene occur along the continuum and can be initiated before infection is obvious and well established. These interventions include prophylaxis (asymptomatic patient at high-risk for IFI); empirical therapy (initiated when an infection is suspected but the cause is not yet determined); treatment (based on definitive evidence of the causative organism).
Prophylaxis: Targets high-risk patients over a defined period of risk, who have no evidence of either infection or clinical disease.
Preemptive therapy: Targets a population of patients with evidence of IFI based on a surrogate marker, but without evidence of clinical disease
Empiric therapy: Persistent neutropenic fever despite broad-spec antibiotics is considered a surrogate market of IFI
Specific treatment: Applies to patients with evidence of infection and clinical disease
References
Bow EJ. Hematol. 2006;1:361-7.
Wingard JR. Best Pract Res Clin Haematol 2007;20:
Evidence of infection
+ clinical disease
Therapy
Wingard JR. Best Pract Res Clin Haematol 2007;20:99-107; Bow EJ. Hematol. 2006;1:361-7. 28

29. Patients Surviving (%)
IA Primary Therapy
Voriconazole vs. Amphotericin B
Survival at 12 weeks
70.8%
Patients Surviving (%)
57.9%
Successful outcome response in favour of voriconazole (52.8% vs 31.6%)
Survival rate in favour of voriconazole (70.8% vs 57.9%)
Fewer drug-related adverse events
Herbrecht et al.’s landmark study compared the efficacy or voriconazole with AMB deoxycholate. 391 patients randomized to receive AMB-d or voriconazole. Most patients had leukemia or other hematologic malignancies, and just under half were neutropenic. Voriconazole was superior to standard antifungal therapy by both the primary endpoint (global response at 12 weeks), and the multiple secondary endpoints, including survival at 12 weeks (70.8 vs. 57.9, P=0.02) In addition fewer side effects were noted in the voriconazole group.
As a result of this study, voriconazole is now considered the drug of choice for invasive aspergillosis.
References
Herbrecht R et al. N Engl J Med 2002;347:
Perlroth J et al. Med Mycol. 2007;45:
P=0.02
Weeks
No. at Risk
Voriconazole
Amphotericin B
Herbrecht R et al. N Engl J Med. 2002;347: 29

30. Cumulative Incidence (%)
Voriconazole
Caveats
No activity against Zygomycetes
Erratic pharmacokinetics
Drug interactions
Hepatotoxicity
Visual toxicity
Cumulative Incidence (%)
Siwek GT et al. reported on 4 cases of Zygomycosis in HSCT recipients, all occurring after Voriconazole began to be used as antifungal prophylactic therapy. The authors also reported that the after the use of voriconazole was instituted, the incidence of zygomycosis increased to 8.9% (and the incidence of aspergillosis decreased). In the preceeding three years before voriconazole was used, there were no cases of zygomycosis.
References
Siwek GT et al. Clin Inffect Dis 2004;39:584-7.
Scott LJ, Simpson D. Drugs 2007;67:
Siwek GT et al. Clin Infect Dis. 2004;39:584-7; Scott LJ, Simpson D. Drugs 2007;67: 30

31. IA Salvage Therapy Caspofungin 83 evaluable patients
refractory to or intolerant of Ampho B, lipid formulations or triazoles
86% refractory, 15% intolerant
48% hematologic malignancy, 25% HSCT
45% favourable response, including
50% with pulmonary aspergillosis
23% with disseminated aspergillosis
Excellent safety profile
Patients failing other antifungal therapy or who had toxicity (usually renal impairment with amphotericin B, n=12) were enrolled in a salvage study, receiving caspofungin monotherapy (70mg loading dose and then 50mg/d). The diagnosis of aspergillosis, reason for enrollment and outcome was reviewed by an external panel.
Patients who survive long enough to receive salvage therapy excludes the most severely ill patient group. However the response rate recorded is indicative of significant activity of caspofungin in invasive aspergillosis.
Reference
Maertens J et al. Clin Infect Dis 2004;39:
Maertens J et al. Clin Infect Dis. 2004;39: 31

32. Early Intervention is Associated with Lower Mortality
Retrospective analysis of the timing of empiric antifungal treatment for 33 cases of invasive aspergillosis between 1987 and 1992
Von Eiff et al. Respiration. 1995;62:

33. Early Therapy  Better Outcomes
Initiation of Therapy
Early Therapy  Better Outcomes
"Clinical trial data indicate rapidity of therapy initiation is an important and independent determinant of outcome."
M. Morrell
An important and independent factor associated with treatment outcome is the rapidity with which therapy is initiated. Unfortunately, the signs and symptoms of IFI are not always identifiable due to compromised host responses and nonspecific manifestations of the infection. Furthermore, current diagnostics are often unable to confirm the pathogen during the early course of infection when treatment has the greatest chance of success.
Reference
Morrell M et al. Antimicrob Agents Chemother 2005;Sept:
Morrell M et al. Antimicrob Agents Chemother. 2005;49: 33

34. IFI Management Prophylactic Preemptive Empirical Therapy
Disease progression No
disease
Markers
Signs & symptoms
Full-blown disease
Sequelae
Prophylactic
Asymptomatic high-risk patient
Asymptomatic + colonization OR novel diagnostic
Preemptive
Empirical
High risk: Antibiotic + fever
During the early 1980s, one quarter to one third of severely neutropenic cancer patients with persistent fever despite broad-spectrum antibiotic therapy developed IFI. Empirical amphotericin B deoxycholate therapy reduced the incidence of IFI and overall mortality by 50%-80% and 23%-45%, respectively. These early experiences (reported in - Pizzo PA et al. Am J Med. 1982;72:101-7 and EORTC International Antimicrobial Therapy Cooperative Group. Am J Med. 1989;86:668-72) have become the rationale for the use of empirical treatment today.
Reference
Bow EJ. Hematology 2006;1:361-7.
Evidence of infection
+ clinical disease
Therapy
Bow EJ. Hematol. 2006;1:361-7. 34

35. Empirical Therapy Pros Cons
Treat all neutropenic patients with persistent fever despite broad-spectrum antibiotics
Pros
High mortality
Difficulties in diagnosis
Treat undetected infection
May reduce systemic mycoses (Pizzo)
May reduce mortality (EORTC)
Cons
Over-treatment
Fever is non-specific
Side-effects and cost
Difficulties in diagnosis
Infected patients: too little treatment
Uninfected patients: too much treatment
The use of empiric therapy (i.e., treat all neutropenic patients with persistent fever despite broad-spectrum antibiotics) is largely based on 2 historical studies (Pizzo 1982 and EORTC 1989). The “Pros” of the empiric approach are that fungal infection have such a high mortality and are difficult to diagnose. Furthermore, Pizzo demonstrated more than 20 years ago that the use of Amphotericin B empirically reduced the incidence of systemic mycoses. The EORTC study also reported that empiric antifungal therapy may reduce mortality.
However, empiric therapy has many shortcomings. Firstly, fever is a poor predictive surrogate. Between 35% to 69% of leukemia patients and 56% to 82% of HSCT receive empirical antifungal therapy, yet proven IFI occurs in only 2% to 15%. Furthermore, a standardized diagnostic work-up at baseline was never consistently applied across empirical trials.
References
Bow EJ. Kematol 2006;1:
EORTC Am J Med 1989;86:
Maertens J et al. Curr Opin Infect Dis 2006;19:
Pizzo PA et al. Am J Med 1982;72:
Wingard JR. Best Pract Res Clin Haematol 2007;20:
Wingard JR. Best Pract Res Clin Haematol 2007;20:99-107; Bow EJ. Hematol 2006;1: ; Pizzo Am J Med. 1982:72;101-11; EORTC Am J Med. 1989;86: 35

36. Early Trials Pizzo Am J Med 1982
First comparative evaluation of empiric antifungal therapy
Enrollment Criteria
Fever for 7d after antimicrobials started, PMN<500
Predominately pediatric population (mean age 16)
Randomized to stopping all abts, no change or 0.5mg/kg/d AmB

37. Pizzo - Outcomes No Δ +AmB D/C Rx # pts 16 18 Candida 4(3) 1 Mold 21
Mold 2
Infectious Complications
7(6) 9
Survival 11 15
Time to defervesce
7-8
3-5d
11-12d
* Minimal renal toxicity

38. EORTC Trial Larger study of empiric AmB use in febrile neutropenics
Enrollment
Adult population
Fever for 4 days after antibacterials started
PMN<1000
Randomized to empiric AmB 0.6mg/kg/d or 1.2mg/kg/2d

39. EORTC - Outcomes No Δ +AmB # pts 64 68 Candida 4 1 Mold 2 Survival 79%
Survival
79%
84%
Response (fever) 53 69

40. Empirical Therapy Voriconazole or Caspofungin vs L-AMB VOR N=415 L-AMB
Point Estimate for Percent Difference (95% CI)
Overall response
no. (%)
108
(26%)
129
(30.6%)
-4.5 (-10.6 to 1.6)
P=NS
Breakthrough
fungal infection 8
(1.9%) 21
(5.0%)
P=0.02
CAS
N=556
L-AMB
N=539
Point Estimate for Percent Difference (95% CI)
Overall response
no. (%)
190
(33.9%)
181
(33.7%)
0.2 (-5.6 to 6.0)
Non-inferiority
Absence of breakthrough
fungal infection 29
(5.2%) 24
(4.5%)
P=0.56
Walsh et al. investigated empiric therapy of voriconazole versus liposomal amphotericin B in febrile neutropenic patients. While the overall success rate was higher in the voriconazole group, voriconazole did not fulfill the protocol-defined criteria for noninferiority to liposomal Amphotericin B with respect to overall response to empirical therapy since the 95% CI limit of -10.6% fell just outside the predefined lower bound of -10 percentage points. However, examination of the individual elements of the composite score for success indicated that the two treatments were similar and that voriconazole was superior in reducing documented breakthrough fungal infections, infusion-related toxicity (not shown) and nephrotoxicity (not shown).
However, voriconazole is not approved for empirical use in febrile neutropenic patients.
Reference
Walsh T et al. N Engl J Med 2002;346:
Walsh T et al. N Engl J Med. 2002;346:225-35; N Engl J Med. 2004;351: 40

41. Empiric therapy - summary
Cons
Original evidence for efficacy is weak
Fever is not specific and not sensitive in hematology population
50% of GM+ patients are afebrile
Institution of highly active mold prophylaxis reduces mortality, pulmonary infiltrates but NOT fever
Overall success in high risk patients is sub-optimal
So what else can we do?

42. IFI Management Prophylactic Preemptive Empirical Therapy
Disease progression No
disease
Markers
Signs & symptoms
Full-blown disease
Sequelae
Prophylactic
Asymptomatic high-risk patient
Asymptomatic + colonization OR novel diagnostic
Preemptive
Empirical
High risk: Antibiotic + fever
Early detection  better outcomes
Preemptive therapy is a variation of empiric treatment - targeted using improved diagnostics. The preemptive strategy rests on:
Better identification of those patients who are at the highest risk for fungal infections so they can be closely monitored
Availability of sensitive techniques that facilitate rapid and early diagnosis of IFI.
References
Bow EJ. Hematol 2006;1:361-7.
Maertens J et al. Clin Infect Dis 2005;41:
Evidence of infection
+ clinical disease
Therapy
Bow EJ. Hematol. 2006;1:361-7. 42

43. Preemptive Therapy Incorporation of Diagnostic Tests
High-risk hematology patients (all received Candida prophylaxis, fluconazole 400 mg/day)
Daily GM monitoring and clinical evaluation
>5 days of unexplained
neutropenic fever refractory to antibiotics or relapsing
New infiltrate on
chest X-ray or
signs/symptoms of
invasive mycosis
OD index
2 x ≥ 0.5
Positive culture
or microscopy (molds)
Thoracic CT scan (± CT sinus)
Thoracic CT
&
BAL
Maertens et al incorporated new diagnostic tests into a clinical trial of 136 neutropenic episodes involving fever refractory to adequate broad-spectrum antibacterial. The intention was to explore the feasibility of initiating antifungal therapy based on diagnostic information as an alternative to the classic empirical approach, in an attempt to reduce the exposure to broad-spectrum antifungal agents.
Note:
All patients received candida prophylaxis with fluconazole 400mg/day.
Reference
Maertens J et al. Clin Infect Dis. 2005;41:
Characteristic of invasive mycosis: ‘halo-sign’
Atypical
lesion
Normal
Bronchoscopy with BAL
Broad-spectrum antifungal therapy + -
Continued monitoring
No antifungal therapy
Maertens J et al. Clin Infect Dis. 2005;41: 43

44. Proven and probable IFI
Empirical vs Preemptive antifungal therapy in high risk neutropenic patients
Overall survival
Proven and probable IFI
p=ns
*p<0.02
Cordonnier et al. CID 2009 44 44

45. Preemptive Therapy Does Not Reduce IA Mortality

46. If earlier is better…
Is prevention best? 46

47. IFI Management Prophylactic Preemptive Empirical Therapy
Disease progression No
disease
Markers
Signs & symptoms
Full-blown disease
Sequelae
Prophylactic
Asymptomatic high-risk patient
Asymptomatic + colonization OR novel diagnostic
Preemptive
Empirical
High risk: Antibiotic + fever
Given the high mortality associated with invasive fungal diseases and the difficulty in recognizing active cases reliably, prophylaxis is seen as a sensible therapeutic approach.
We know from primary treatment studies that earlier treatment decreases mortality. Does this carry forward into prophylaxis?
Patients enrolled in randomized clinical trials generally differ from the population of patients in the real world requiring extrapolation of study results.
References
Bennett JE Med Mycol
Bow EJ. Hematol 2006;1:361-7.
Evidence of infection
+ clinical disease
Therapy
Bow EJ. Hematol. 2006;1:361-7. 47

48. Fluconazole Prophylaxis in HSCT
Evidence for Long-term Survival
Related and Unrelated Donor Transplants
Fluconazole 400 mg/d
Survival Probability
P = .0018
In immunocompromised patients such as hematopoietic stem cell transplant (HSCT) recipients, antifungal therapy improves survival.1,2 Evidence from this trial supports the use of fluconazole as standard prophylaxis in this patient population.3
In this study that followed the survival of HSCT recipients for up to 9 years posttransplantation, prophylaxis therapy with fluconazole was associated with significantly (P = .0018) greater survival compared with placebo treatment.2
In addition, the overall incidence of candidiasis was significantly less in patients who received fluconazole prophylaxis than those who received placebo (P = .0001).2
References
Slavin MA, Osborne B, Adams R, et al. Efficacy and safety of fluconazole prophylaxis for fungal infections after marrow transplantation—a prospective, randomized, double-blind study. J Infect Dis. 1995;171:1545–1552.
Marr KA, Seidel K, Slavin MA, et al. Prolonged fluconazole prophylaxis is associated with persistent protection against candidiasis-related death in allogeneic marrow transplant recipients: long-term follow-up of a randomized, placebo-controlled trial. Blood. 2000;96:2055–2061.
Centers for Disease Control and Prevention. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients: recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. MMWR Recomm Rep. 2000;49:1-125.
Placebo
Years After Transplant
HSCT indicates hematopoietic stem cell transplant.
Marr KA, et al. Blood. 2000;96: 48 48

49. Overall Treatment Success
Micafungin vs. Fluconazole
Proportion of patients with treatment success
P = 0.025, by the log rank test
Treatment success rates for patients in the micafungin arm were significantly higher than for patients in the fluconazole arm (80.0% vs. 73.5%;
p = 0.03). The Kaplan-Meier estimate of treatment success also was greater in the micafungin group than in the fluconazole group (p = 0.025, log rank test).
Reference:
van Burik JA, Ratanatharathorn V, Stepan DE, et al: Micafungin versus fluconazole for prophylaxis against invasive fungal infections during neutropenia in patients undergoing hematopoietic stem cell transplantation. Clin Infect Dis 2004; 39(10):
micafungin (n = 425)
Fluconazole (n = 457)
Time to treatment failure (days since first dose of study drug)
Adapted from van Burik JA, et al: Clin Infect Dis 2004; 39(10): 49 49

50. Voriconazole vs. Fluconazole
p=0.49
p=0.12
After 12 months, there were 25 proven, 30 probable, 15 presumptive, and 74 possible invasive fungal infections identified. The cumulative rates of proven, probable and presumptive IFI were similar in the two arms: 11.2% for FLU and 7.3% for VORI at 6 months (p=0.11) and 13.1% and 11.6% at 12 months (p=0.50), respectively.
Reference:
Wingard JR, Carter SL, Walsh TJ, et al: Results of a randomized, double-blind trial of fluconazole (FLU) vs. voriconazole (VORI) for the prevention of invasive fungal infections (IFI) in 600 allogeneic blood and marrow transplant (BMT) patients [abstract]. Blood (ASH Annual Meeting Abstracts) 2007; 110:163.
Results of a Randomized, Double-Blind Trial of Fluconazole (FLU) vs. Voriconazole (VORI) for the Prevention of Invasive Fungal Infections (IFI) in 600 Allogeneic Blood and Marrow Transplant (BMT) Patients.
John R. Wingard1, Shelly L. Carter1,*, Thomas J. Walsh1,*, Joanne Kurtzberg1, Trudy N. Small1, Iris D. Gersten1,*, Adam M. Mendizabal1,*, Helen Leather1, Dennis L. Confer1, Lindsey R. Baden1,*, Richard T. Maziarz1, Edward A. Stadtmauer1, Javier Bolanos-Meade1, Janice Brown1, John F. DiPersio1, Michael Boeckh1 and Kieren A. Marr1,* 1 The Blood and Marrow Transplant Clinical Trials Network, Bethesda, MD, USA.
Abstract
A multi-center, randomized, double blind trial was performed to determine the impact of FLU (400 mg daily in adults) vs. VORI (200 mg twice daily in adults) on the prevention of IFIs in standard risk allogeneic BMT patients receiving full-intensity conditioning regimens. 600 patients with AML (n=230), ALL (n=122), CML (n=103), MDS (n=98), lymphoma (n=43) and other diseases (n=4) were randomized; 295 to FLU, 305 to VORI between 2003 and 2006 (1 not transplanted). Study drugs were given for 100 days; in those receiving prednisone at a dose of 1 mg/kg/day at day 100 or for recipients of T cell depleted grafts with CD4+ counts <200 at day 100, drugs were administered for 180 days. All patients had serum galactomannan (GM) assayed twice weekly for 60 days, then once to twice weekly until day 100, depending on severity of graft versus host disease (GVHD). Positive GM, radiology or the presence of suspicious symptoms or signs triggered intensive evaluation for IFI. Empirical antifungal therapy was permitted for suspected IFI during diagnostic assessment but was limited to 14 days. The primary endpoint was freedom from IFI or death at 6 months (fungal-free survival) in the intent to treat cohort. Median recipient age was 43 years (range, 3-66) with 92% >18 years; 55% male; 95% with HLA A, B, and DRB1 matched donor; stem cell graft was related donor marrow or PBSC in 56%. There were no significant differences between the two arms in patient, disease type or risk, or transplant characteristics. Rates of engraftment, acute or chronic GVHD, non-fungal infections, expected or unexpected severe adverse events, and rates of premature study drug withdrawal were similar in both arms (p=NS). At a median follow-up of 12 months, overall survival was 80% at 6 months and 67% at 12 months. A blinded data review committee reviewed source documents of all reported fungal infections, deaths, patients with a positive GM and those given empirical antifungal therapy. There were 25 proven, 30 probable, 15 presumptive, and 74 possible IFIs. The cumulative rates of proven, probable and presumptive IFI were similar in the two arms: 10.6% for FLU and 6.6% for VORI at 6 months (p=0.11) and 13.1% and 11.6% at 12 months (p=0.50), respectively. Microbiologically documented IFIs at 6 months in each arm (FLU and VORI) were caused by Aspergillus (16 and 7, p=0.05), Candida (3 and 3), Zygomycetes (3 and 2), and other (1 and 1). Fungal-free survival rates were similar: 76% for FLU and 78% for VORI at 6 months (p=NS) and 65% and 63% at 12 months (p=NS), respectively. Event-free and overall survival rates also were similar in both arms at 6 and 12 months (p=NS). There were no differences in fungal-free survival rates in patients who received prophylactic fluconazole or voriconazole when intensive monitoring and early empirical therapy were employed in standard risk allogeneic BMT recipients.
Subjects: 600 standard-risk allogeneic blood and marrow transplant patients
*Proven + probable + presumptive
Adapted from Wingard JR, et al: Blood epub 2010 50 50

51. Voriconazole vs. Itraconazole: Improvit
489 allogeneic stem cell transplant patients
Allo HSCT patients, 489 patients total. VCZ given as a 4mg/kg load IV bid then 200mg po bid vs ITRA 200 mg po bid with load for 100 to 180 days post transplant. Itra suspension with up to 14d capsules permitted. Composite endpoint required fungal infection free survival to 180d with no discontinuation of the drug. Data strongly suggests differences related to tolerability NOT efficacy
Breakthroughs 6 vs 3
Hepatotoxicity 12 vs 5%

52. Antifungal Prophylaxis: Neutropenia
Posaconazole vs Fluconazole / Itraconazole
Study Design
Posaconazole (n = 304)
Chemotherapy & prophylaxis
Chemotherapy & prophylaxis (if needed)
Day 100 postrandomization
N = 602
Fluconazole or Itraconazole (n = 298)
Treatment phase (on-treatment period): From randomization up to 7 days after last dose (primary end point time period).
100-day period after randomization (fixed time period): 100 days after randomization (secondary end point time period).
Study drug was administered with each cycle of chemotherapy or on the first day of chemotherapy (or 24 hours after the last anthracycline dose, if applicable). Prophylaxis was to continue until recovery from neutropenia, complete remission, occurrence of an invasive fungal infection, or other protocol-specified end points up to a maximum of 12 weeks or 84 calendar days from randomization. Follow-up was 100 days after randomization and 30 days after last dose of study drug.
Reference
Cornely OA et al. N Engl J Med. 2007;356:
Primary end point time period
Secondary end point time period
Cornely OA et al. N Engl J Med 2007;356: 52

53. Posaconazole vs Flu/Itra
Primary Endpoint: Prevention of IFI
Treatment Phase
100 Day Period After Randomization
Fluconazole n=304
Posaconazole n=298
Posaconazole was significantly better than the pooled standard azoles in preventing invasive fungal infections: 7/304 (2%) versus 25/298 (8%); difference of –6.1; 95% confidence interval, –9.7 to –2.5; P < .001). This period of time began at randomization and ended 7 days after the last dose of study drug. Posaconazole maintained superiority over pooled standard azoles in preventing invasive fungal infections during the 100-day period after randomization: 14/304 (5%) versus 33/298 (11%), P = .003.
Posaconazole was also significantly better than pooled standard azoles in preventing invasive aspergillosis during the treatment phase (2 [1%] vs 20 [7%], P < .001) and during the 100-day period after randomization, or fixed time period (4 [1%] vs 26 [9%], P < .001).
Reference
Cornely OA et al. N Engl J Med. 2007;356: †
* P<0.001; † P= 0.003
Cornely OA et al. N Engl J Med 2007;356: 53

54. Antifungal Prophylaxis: Neutropenia
Death From Any Cause
Posaconazole
Fluconazole or Itraconazole
21%
Probability of Death
P = .04*
14%
33% relative reduction in mortality
% observed until d100 or death: ~90%
Reference
Cornely OA. N Engl J Med 2007;356:
Days After Randomization
*Estimated using log-rank statistics. Censoring time is the minimum of the last contact date and day 100.
Cornely OA, et al. N Engl J Med 2007;356: 54

55. Antifungal Prophylaxis: GVHD
Posaconazole vs Fluconazole
Study Design
Posaconazole
(n = 301)
N = 600
First dose
Last dose
Last dose + 7 days
Day 112
Day months
(n = 299)
Fluconazole
Fixed treatment period: study period, 112 days (primary end point time period). Exposure period: time from first study drug dose to 7 days after last dose (secondary end point time period).
This was a phase 3, randomized, multicenter, double-blind, double-dummy, parallel-group, multinational, comparative study in which patients were randomly assigned to prophylaxis with either posaconazole or fluconazole. The primary efficacy end point was the incidence of proven or probable fungal infection during the fixed treatment, or fixed-time period, defined as the time from randomization to day 112, for the intent-to-treat population. The intent-to-treat population consisted of all patients who signed informed consent and were randomly assigned.
The incidence of breakthrough proven or probable invasive fungal infection during the exposure, or on-treatment period, defined as the time from first dose of study drug to 7 days after the last dose, was also assessed. Patients were followed up for 2 months after the 16-week (112 days) study period.
This study differs from the prophylaxis study in neutropenic patients in that in this study, the primary end point time period was the fixed treatment period (from randomization through day 112), which included time while patients were not on prophylaxis. In the neutropenic study, the primary end point time period was the treatment phase, which was the time patients were on prophylaxis.
Reference
Ullmann et al. N Engl J Med. 2007;356:
Secondary end point time period
Primary end point time period
Follow-up
Ullmann AJ et al. New Engl J Med. 2007;356: 55

56. Antifungal Prophylaxis: GVHD
Primary Endpoint: Prevention of IFI
Fixed Treatment Period
Exposure Period
Fluconazole n=304
Posaconazole n=298
Number of IFI (Proven/Probable)
Fixed treatment period: Posaconazole n=301, Fluconazole n=299
Exposure period: Posaconazole n=291, Fluconazole n=288
During the fixed treatment, or time period (primary end point time period, time from randomization to day 112), the difference in the incidence of all proven or probable invasive fungal infection between the posaconazole and fluconazole arms was not significant. Most infections during this fixed treatment period were invasive aspergillosis. There was a statistically significant reduction in aspergillosis in patients treated with posaconazole versus patients treated with fluconazole (P = .006).
During the exposure, or on-treatment period (time from first dose of study drug to 7 days after the last dose), posaconazole significantly reduced the incidence of breakthrough proven or probable invasive fungal infection (P = .004) and invasive aspergillosis (P = .001) versus fluconazole.
Reference
Ullmann et al. N Engl J Med. 2007;356: ‡ †
* P=0.07; † P= 0.006; ‡ P=0.004; § P=0.001
Ullmann AJ et al. New Engl J Med. 2007;356: 56

57. Antifungal Prophylaxis: GVHD
Deaths - By Cause *
Fluconazole (N=301)
Posaconazole (N=299) ** *
Although posaconazole provided no advantage over fluconazole with respect to overall mortality, a difference in mortality due to invasive fungal infections was observed.
Treatment-related adverse events were those that occurred at a frequency of at least 3% in either of the two groups. Treatment-related serious adverse events were those that occurred in at least three patients. Actual totals are also shown. (For further details on treatment-related serious events, see the Supplementary Appendix.) Deaths from all causes were those that occurred during the 24-week observation period. Invasive fungal infections were adjudicated by the data review committee in a blinded fashion. The cause of death was assessed by an investigator as one of the following: an invasive fungal infection, a cause other than an invasive fungal infection but in the presence of an invasive fungal infection, or a cause other than an invasive fungal infection (without evidence on autopsy of invasive fungal infection or with clinical evidence of the resolution of an invasive fungal infection).  
*P = 0.01 by the chi-square test.
** P = by the log-rank test. ､
Reference
Ullmann et al. N Engl J Med. 2007;356:
Ullmann AJ et al. New Engl J Med. 2007;356:

58. Comparative Efficacy in Prophylaxis
Retrospective review: 573 AML inductions over 12 years
Ananda-Rajah et al; Hematologica 2012;97(3)

59. Prophylaxis: What are the trade-offs in the long-term?
Cost and potential resistance
Incidence within an institution (number-needed-to-treat)
Factors to consider when making the decision to use prophylaxis:
incidence of the infection in the patient population versus the potential risks of prophylaxis, and the potential morbidity and mortality resulting from the infection versus whether prophylaxis will prevent these deleterious sequelae.
risk of drug toxicity, potential for drug interactions with concomitant medications
potential for emergence of drug resistance and selection pressure for the growth of other organisms.
The number needed to treat (NNT) may aid the prophylactic decision - a population with a 15% incidence of invasive fungal infections has an NNT of 1:13 (13 patients have to be treated to prevent one invasive fungal infection), whereas a NNT of 1:38 would be found in a population with an incidence of 5%. Another issue with prophylaxis trials is whether a fixed time point is appropriate or during an at-risk time period. Survival due to invasive mycoses is the strongest and most unbiased endpoint but trials are usually not powered to look at survival. Primary endpoint such as infection rate or would a composite endpoint including premature discontinuation rate or severe adverse events be more reliable.
For example de Pauw BE stated that primary prophylaxis is not used in his centre for all patients with GVHD or with prolonged neutropenia. Rather, they rely on an integrated-care plan that involves twice-weekly screening for galactomannan and a low threshold for ordering CT of the chest to detect abnormal pulmonary signs.
Heterogeneity of risk suggest prophylaxis in some patients may be appropriate while unclear in other groups.
References
de Pauw BE. N Engl J Med. 2007;356:
Ullman JA, Cornely OA. Curr Opin Infect Dis 2006;19:
De Pauw BE. N Engl J Med. 2007;356: 59

60. Resistance Intrinsic barrier to resistance for molds
Infections acquired in the community
Not transmitted person to person
No selection pressure on the environmental reservoir
Breakthroughs in 3 years of posaconazole prophylaxis
Intrinsic resistance only
1 case of MDR Fusarium
1 case of Aspergillus calidoustus

61. Costs Costs Prophylactic agent Benefits
Reduced empiric antifungal use or screening protocols
Reduction in associated costs (ICU stay, other drugs/fever workup)
Reduction in mortality
Sensitive to NNT – linked to local epidemiology

62. MUHC Algorithm – Prophylaxis
FUNGAL PROPHYLAXIS
AML/MDS induction
Stem cell transplant GVHD
AML/MDS Induction
(this is the only indication for posaconazole)
POSACONAZOLE
200 mg PO TID
(Check for interactions, optimize absorption**)
YES
**Absorption: Avoid acid suppressants; give with or after high fat meal or with nutritional supplement NO
FLUCONAZOLE
Allo transplant: 400 mg PO/IV QD
Autologous transplant: 200 mg IV/PO QD
GVHD: mg PO/IV QD
(adjust with renal function, check for interactions)

63. MUHC Algorithm – Preemptive
Autologous HSCT, Consolidation, Allo HSCT pre-engraftment