1. News in Diagnosis and Treatment of Fungal Infections Theoklis Zaoutis, MD, MSCE Professor of Pediatrics and Epidemiology Perelman School of Medicine at the University of Pennsylvania Associate Chief, Division of Infectious Diseases The Children’s Hospital of Philadelphia Pediatric Infectious Diseases Seminar, Thessaloniki 2014

2. Overview Changes in epidemiology – Do they change or treatment decisions? Challenges in diagnosis What’s new in treatment New considerations in neonatal candidiasis

3. Fridkin, S. K. et al. Pediatrics 2006;117:1680-1687 Neonatal Candidiasis: Incidence over Time

4. Fisher, et al CID 2013

5. Vital Signs: Central Line-Associated Bloodstream Infections-US, 2001 to 2008-2009 Hospital ICUs: 58% reduction (2001 vs 2009) – 25,000 fewer CLABSIs – 3-6K lives saved (2009) – $414M saved (2009) – $1.8B cumulative savings, 27K lives (2001-2009) Candida spp. (46% reduction; RR = 0.54; CI = 0.487-- 0.606) MMWR, March 4, 2011

6. YearC. albicansC. parapsilosisC. glabrata 1992-200049-6319-450-7 1996-2001 (Italy)66176 1998-2008(GER)451714 2001-2004 (AUS)42384 2000-2006 (USA)264513 2004-2009 (DEN)73133 2000-2009 (USA)44247 1997-2009 (USA)49244 2005-2009 (GRE)45235 2000-2009 (UK)55224 2000-2010 (USA)47289 2007-2010 (PFN)562211 2009-2011 (ESP)37474 Pfaller MA, Diekema DJ. Clin Microbiol Rev. 2007;20:133-163. Manno G. Int J Antimicrob Agents. 2004; Tragiannidis A et al. Clin Microbiol Infect. 2012;18:e27- e30. Blyth CC et al. Pediatrics. 2009;123:1360-1368. Neu N et al. Pediatr Infect Dis J. 2009,28:806-809. Arendrup MC et al. J Clin Microbiol. 2011;49:3300-3308. Dutta A, Palazzi DL. Pediatr Infect Dis J. 2011;30:664-668. Dotis J et al. Pediatr Infect Dis J. 2012;31:557-560. Oeser C et al. Pediatr Infect Dis J. 2013;32:23-26. Steinbach WJ et al. Pediatr Infect Dis J. 2012;31:1252-1257. Klatte JM et al, ICHE 2013 Species Distribution in Children

7. Species Specific Risk Factors Independent risk factors for C. parapsilosis –99 cases compared to 307 other Candida spp. –Urinary catheter within 1 week, OR 0.37 (95% CI: 0.19, 0.72) –Mech ventilation 48 hrs prior, OR 2.44 (95% CI: 1.44, 4.14) –No difference in outcomes 112 cases C. albicans vs 141 non-albicans Candida –No difference in risk factors or outcomes Independent risk factors for C. glabrata –26 C. glabrata/C. krusei compared to 380 other Candida spp. –Fluconazole exposure in week prior, OR 2.96 (95% CI: 1.18, 7.42) –Age > 2 years, OR 3.52 (95% CI: 1.28, 9.66) Dotis J et al. Pediatr Infect Dis J. 2012;31:557-560. Dutta A et al. Pediatr Infect Dis J. 2011;30:664-668. Prasad P et al. J Pediatr Infect Dis Soc. 2013;2:263-266.

8. Frequency of Antifungal Resistance in Sentry 2008-2009 (% Resistant) C. albicansC. glabrataC. parapsilosisC. tropicalisC. kruzei Fluconazole07.75.83.30 Voriconazole06.402.20 Posaconazole05.1000 Caspofungin0.55.1008.7 Micafungin0.253.2000 Anidulafungin0.253.8000 Resistance defined as: >0.5 for cas, anid, mica for cab, ctrop, ckz and > 4 for Cpar; Cglab >.12 for mica, >.5 for anid and cas; flu > 4 for cab, ctrop, cpara and > 32 for pos and vori for all species Pfaller, et al AAC 2011

9. Diagnosis

10. Diagnostic Considerations in Children Standard diagnostic procedures generally not different between children and adults –Blood cultures for yeasts and molds –Cultures, microscopy Different from adults (?) –Chest CT imaging –Usefulness of antigen markers –PCR

11. Day 3 Day 7 Day 14 “halo sign” 68% 22% 19% “air crescent sign” 8% 28% 63% Computerized tomography in adults with invasive aspergillosis Caillot et al. JCO, 2001;19:253

12. CT Scan Characteristics: Less Specific in Children Prospective study of 139 cases of proven or probable IA in children – Nodules (35%), infiltrates (21%), cavity (14%) – Halo sign (11%) and air crescent sign (2%) uncommon Retrospective study proven/probable IA (14 cases) – Nodules, pleural effusion, segmental pneumonia – Halo sign in 2/14(14%) and air crescent sign in 3/14 (21%) Retrospective study of children with IA (8 cases with CT scans) – Multiple small nodules, no halo or air crescent sign – Bibasilar and segmental infiltrate Burgos A et al. Pediatrics. 2008;121:e1286-e1294. Thomas KE et al. Pediatr Radiol. 2003;33:453-460. Allan BT et al. Pediatr Radiol. 1988;18:118-122.

13. Author YearTotal # patients/ episodes in study Testing Indication IA Definition a Proven or probable IA SensSpecTPFPTNFNFalse positive rate b Rohrlich 199637NeutropeniaGuiot 1994 Criteria 10100%92.6%1022507.4% Sulaihan 2011347NeutropeniaLocally defined 9100%89.9%934304010.1% Steinbach 200764Neutropenia/ acute GVHD EORTC/MSG 2002 10%87%0855112.7% d Hovi 2007117NeutropeniaEORTC/MSG 2002 1100%93%11110509.5% Armenian 200978Neutropenia +/- fever/GVHD EORTC/MSG 2008 3e3e 100%98.7%3434 17401.3% Fisher 2012195NeutropeniaEORTC/MSG 2002 10%95%01018415.2% Prospective Studies Evaluating Galactomannan in Children Table adapted with permission from Fisher BT et al. J Pediatr Infect Dis Soc. 2012;1:103-111.

14. Diagnosis of IFD Recommendations  Prospective monitoring of GM in serum every three to four days in children at high risk for IFD is reasonable for early diagnosis of invasive aspergillosis (AII)*  Although the optimal cut-off value of GM in the serum of children is not well defined, published data support the use of a threshold of an optical density index 0.5. (serum specimens) (BIII) ** uncertainty whether implementation of this strategy improves clinical outcome; unclear whether this strategy is cost effective (modified)

15. Diagnosis of IFD Recommendations  The very limited published data support the value of GM in the diagnosis of pulmonary aspergillosis (GM in BAL; cut-off 1) and central nervous system aspergillosis (GM in CSF; cut-off 0.5) in children (BIII)  Systemic mold-active prophylaxis may decrease the performance of the test (BIII).

16. β- D -Glucan (BG) Very limited data in children: –Elevated levels of BG were reported in 4 children with IFD (3 patients with candidemia, 1 patient with probable aspergillosis) –Mean BG levels are higher in immunocompetent uninfected children than adults: optimal cut-off children Cohort study of 130 pediatric patients –Malignancy (89 hematologic, 11 other) –Critically ill at high risk (30) –Twice-week sampling using GKT-5M assay –Sensitivity 82% and specificity 82% Karageorgopoulos DE et al. Clin Infect Dis. 2011;52:750-770. Mularoni A et al. Clin Vaccine Immunol. 2010,17:882-883. Smith PB et al. Clin Vaccine Immunol. 2007;14:924-926. Zhao L et al. J Clin Pediatr. 2010;28:1-10.

17. Diagnosis of IFD Recommendations  Although BG testing has been shown to be useful in diagnosing IFD in adult patients, data are too limited to make any recommendations on BG testing in children

18. Polymerase Chain Reaction-Based Assays for the Detection of Candida Species in Blood Samples From Patients With Invasive Candidiasis Reference (Date) DesignPopulation Characteristics No. of Centers PCR Amplification and Identification Method Type of Blood Sample Maximum Sens of Assay (cfu/mL) Volume of Blood Used (mL) Gene(s)Sens/Spec/ PPV/NPV Wellinghausen et al (2009) P, DAdults and children: 329 adults and 55 children with HM and immuno- deficiency and/or ICU stay 3Real-time PCRWB35 (adults), 2.5 or 1.4 (children) 18S88/93/ 21.8/99.7 Khlif et al (2009) P, DAdults and children: 110 at risk for invasive fungal infection 1Real-time PCRWB1000.218S, ITS1, ITS2 81/96/ 90.6/91 Tirodker et al (2003) P, DChildren: 70 in neonatal ICU or pediatric ICU with suspicion of sepsis 1PCRSe2000.2-0.518S100/88/ 45.5/100 Dendis et al (2003) P, DChildren: 24 with cancer and FN 1PCR followed by APLP/RFLP and sequencing WB30.5ITS2100/75/ 44.5/100 True-positive findings are defined as blood cultures positive for Candida species, whereas true-negative findings are defined as the absence of European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria for invasive candidiasis. Abbreviations: APLP, amplification product length polymorphism; D, diagnostic; ED, emergency department; FN, febrile neutropenia; HM, hematological malignancy; ICU, intensive care unit; ITS, internal transcribed spacer, NPV, negative predictive value; P, prospective; PCR, polymerase chain reaction; PPV, positive predictive value; RFLP, restriction fragment length polymorphism; S, Svedberg; Scr, screening; Se, serum; Sens, sensitivity; Spec, specificity; WB, whole blood.

19. ECIL 4 Recommendations: 1 st line Therapy of Invasive Aspergillosis Antifungal therapy: * ABLCB II 1 Liposomal AmBB I 1 Voriconazole i.v. +TDMA I 1 Combination therapyC III 1 voriconazole should be preferred in CNS infection. 2 oral voriconazole should be used in presence of renal failure because of potential for accumulation of the cyclodextrin excipient * in alphabetical order

20. Initial Treatment Algorithm in Pediatric Patients Voriconazole susceptible strain likely Liposomal Amphotericin Modification guided by species, response and tolerance yes Voriconazole no VCZ exposed PCZ exposed high incidence of zygomycosis or no TDM available age < 2 years contraindications references in Groll AH, EHD 2011

21. © The Author 2011. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.comjournals.permissions@oup.com Soler-Palacín P et al. J. Antimicrob. Chemother. 2012;67:700-706 Voriconazole doses in patients <5 years old and ≥5 years old achieving trough therapeutic plasma levels of voriconazole (1–5.5 mg/L).

22. © The Author 2011. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.comjournals.permissions@oup.com Soler-Palacín P et al. J. Antimicrob. Chemother. 2012;67:700-706 Relationship between voriconazole trough therapeutic plasma levels until week 4 (yeasts)/week 6 (moulds) and Outcome 1.

23. Voriconazole: Current Dosage Recommendation Children 2 to 11 years and adolescents 12-14 years and <50 kg - 2x8 mg/kg IV (day 1: 2x9 mg/kg) - 2x9 mg/kg PO (max: 2x350mg) Adolescents ≥12 to 14 years and > 50 kg and those 15 years and beyond: - 2x4 mg/kg IV (2x6 mg day 1) - 2x200 mg PO (2x400 mg day 1) (adult dose)

24. New considerations for neonatal candidiasis

25. Outcomes Following Candiduria in Extremely Low Birth Weight Infants Characteristic No Proven Infection (n = 744) Candiduria (n = 34) a Candidemia (n = 69) b Adjusted OR c (95% CI) e Death by discharge c 85/744 (11%)9/34 (26%)19/69 (28%)2.69 (1.18 – 6.13) Death by 18 months c 94/725 (13%)10/33 (30%)22/61 (36%)2.77 (1.25 – 6.14) NDI by 18 months d 130/159 (22%)6/22 (27%)15/39 (38%)1.62 (.57 – 4.59) Death or NDI by 18 months d 224/693 (32%)16/32 (50%)37/61 (61%)2.49 (1.16 – 5.33) Reasons NDI could be missing: child died, child was not present at the 18-month follow-up, or not enough information was available to determine NDI. Number of children with complete NDI data: no infection (Bayley II [n = 290], Bayley III [n = 309]), candiduria (Bayley II [n = 9], Bayley III [n = 13]), candidemia (Bayley II [n = 26], Bayley III [n = 13]). Abbreviations: CI, confidence interval; CSF, cerebrospinal fluid; NDI, neurodevelopmental impairment; OR, odds ratio. a At least 1 urine culture positive during hospitalization. Infants who had multiple episodes of infection from the same organism are included. Infants who also had Candida in blood/CSF/other sterile source at any time during hospitalization are excluded. b At least 1 blood culture positive during hospitalization. Infants who had multiple episodes of infection from the same organism are included. Infants who also had Candida in urine/CSF/other sterile source at any time during hospitalization are excluded. c Analysis of death by discharge and death by 18 months are adjusted for clustering of children within center. d Analysis of NDI by 18 months or death/NDI by 18 month are adjusted to clustering of children within center and Bayley cohort. e OR (95% CI) is for no proven infection versus candiduria.

26. Guidelines for the Treatment of Neonatal Candidiasis IDSA – AmB deoxycholate 1 mg/kg (A-II) – Test dose not required; may contribute to delayed clearance – Tolerated well with limited effect on creatinine – Lipid formulations at 3- 5 mg/kg (B-II) if urinary tract involvement is excluded Fluconazole 12/mg/kg (B-II) Echinocandins should be used with caution ESCMID – fluconazole, AmB, Lipid Ampho B, micafungin (B-II) – Caspofungin, ABLC (C-2) Pappas P, CID 2009; Wade KC, et al. Antimicrob Agents Chemother. 2008; Linder N, et al. J.Antimicrob.Chemother. 2003; Saez- Llorens AAC 2008. 5. Heresi G PIDJ 2006; Hope WW, et al Clin Micro Infect 2012

27. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Antifungal Therapy and Outcomes in Infants With Invasive Candida Infections. Ascher, Simon; Smith, P; Brian MD, MPH; Watt, Kevin; Benjamin, Daniel; Cohen-Wolkowiez, Michael; Clark, Reese; Benjamin, Daniel; MD, PhD; Moran, Cassandra Pediatric Infectious Disease Journal. 31(5):439-443, May 2012. DOI: 10.1097/INF.0b013e3182467a72 FIGURE 1. Kaplan-Meier curve for mortality by antifungal therapy. HRs from Cox regression controlling for: gestational age groups (33 weeks), day of life at onset of infection groups (0-7, 8-30, >30 days), delay in therapy (days), and site of infection groups (any blood, any urine, and any CSF positive cultures).

28. Fisher et al. CID 2013

29. Summary Incidence of candidemia is decreasing in United Species distribution relatively stable Resistance does not seem to big problem at this time More evidence being accumulated on improved diagnostics and treatments Mortality maybe decreasing?