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Progress in Definition, Prevention and Treatment of Fungal Infections in Cystic Fibrosis

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Progress in Definition, Prevention and Treatment of Fungal Infections in Cystic Fibrosis Mycopathologia (2018) 183:21–32 https://doi.org/10.1007/s11046-017-0182-0 Progress in Definition, Prevention and Treatment of Fungal Infections in Cystic Fibrosis Carsten Schwarz . Dominik Hartl . Olaf Eickmeier . Andreas Hector . Christian Benden . Isabelle Durieu . Amparo Sole . Silvia Gartner . Carlos E. Milla . Peter James Barry Received: 28 May 2017 / Accepted: 19 July 2017 / Published online: 31 July 2017 Ó Springer Science+Business Media B.V. 2017 Abstract Cystic fibrosis (CF) is a chronic lethal cause severe pneumonia requiring appropriate tar- multi-system condition; however, most of the mor- geted treatment. The most common fungi in respira- bidity and mortality is dependent on the status of the tory samples of patients with CF are Aspergillus respiratory system. Progressive respiratory decline is fumigatus, Aspergillus terreus and Scedosporium mediated by chronic infection and inflammation, species for filamentous fungi, and yeasts such as punctuated by important acute events known as Candida albicans and Candida glabrata. Therapeutic pulmonary exacerbations which can lead to acceler- strategies depend on the detected fungus and the ated decline. The main bacterial species causing underlying clinical status of the patient. The antifungal infections include Pseudomonas aeruginosa, Staphy- therapy can range from a simple monotherapy up to a lococcus aureus, Haemophilus influenzae and Achro- combination of three different drugs. Treatment mobacter xylosoxidans. In addition to bacteria, fungi course may be indicated in some patients for two are detected in a significant number of patients. The weeks and in others for up to six months, and in rare impact of fungal colonization of the airways is still not cases even longer. New antifungal drugs have been completely elucidated, but an increasing body of developed and are being tested in clinical studies evidence suggests an important role for moulds and offering the hope of therapeutic alternatives to existing yeasts. Although fungal infections are rare, fungi can C. Schwarz (&) I. Durieu Charite´ – Universita¨tsmedizin Berlin, Corporate Member Lyon University Hospital, Lyon, France of Freie Universita¨t Berlin, Humboldt-Universita¨tzu Berlin, and Berlin Institute of Health, Berlin, Germany A. Sole e-mail: [email protected] University Hospital la FE, Universitat de Valencia, Valencia, Spain D. Hartl Á A. Hector Universita¨tsklinik fu¨r Kinder-und Jugendmedizin S. Gartner (Abteilung I), Tu¨bingen, Germany Hospital Universitari Vall d’Hebron, Barcelona, Spain O. Eickmeier C. E. Milla Goethe University Children’s Hospital, Frankfurt/Main, Lucile Salter Packard Children’s Hospital, Stanford Germany University, Stanford, CA, USA C. Benden P. J. Barry Klinik fu¨r Pneumologie, Universita¨tsspital Zu¨rich, Zurich, University Hospital of South Manchester, Manchester, Switzerland UK 123 22 Mycopathologia (2018) 183:21–32 drugs. Identifying relevant risk factors and diagnostic 1. Increased sputum production. criteria for fungal colonization and infection is crucial 2. Multiple isolation of the same fungal species from to enabling an adequate prevention, diagnosis and sputum or bronchoalveolar lavage (BAL) (at least treatment. two culture-positive samples in 6 months). 3. Pulmonary infiltrate(s) on chest CT scan or X-ray. Keywords Yeasts Á Filamentous fungi Á Azoles Á 4. Treatment failure with antibiotic therapy (two and Polyenes Á Echinocandins Á Allylamines more antibiotic treatments, duration two or more weeks). 5. Unexplained lung function decline (exclusion of Introduction new CF-related diseases, e.g. diabetes mellitus). 6. Exclusion of new/other bacteria (e.g. non-tubercu- Patients with cystic fibrosis (CF) suffer from chronic lous mycobacteria or Pseudomonas aeruginosa). infections of the lung and multiple recurrent bron- 7. Exclusion of allergic bronchopulmonary chopulmonary disease exacerbations. Besides bacteria aspergillosis. such as Pseudomonas aeruginosa, some filamentous fungi such as Aspergillus spp., Scedosporium spp. and Exophiala spp. are gaining increasing importance as Antifungal Treatment Strategies cause of CF bronchopulmonary exacerbations. The prevalence of these pathogenic fungi ranges from 1.9 Aspergillus spp. to 56.7% [1, 2], and their pathogenicity may differ from that of bacteria as fungi may differ in their ability Aspergillus spp. are the most frequent colonizing to colonize the airways. Therefore, their pathogenicity fungal pathogens in patients with CF. In a recent study may be dependent on certain immunological pathways examining 25,975 sputum samples from patients with modifying patients’ susceptibility. Predisposing fac- CF, Aspergillus spp. were detected in 35% of samples tors such as defective muco-ciliary clearance, pro- (29% with A. fumigatus)[2]. The inhalation of longed antibiotic treatments, local inflammation, and Aspergillus conidia can chiefly result in two clinical the use of inhaled and systemic corticosteroids may scenarios, either Aspergillus colonization of the facilitate fungal growth in the CF lungs. airways or allergic bronchopulmonary aspergillosis The fungal biota is dominated by filamentous fungi (ABPA), but sensitization, aspergilloma and pul- such as Aspergillus fumigatus, Aspergillus terreus, monary infections may also occur. Aspergillus infec- Scedosporium apiospermum, and yeasts such as tions are treated with antifungal drugs. In contrast, the Candida albicans and Candida glabrata [1, 2]. How- mainstay of treatment of acute exacerbations of ABPA ever, rare fungi such as Exophiala dermatitidis, is corticosteroids, which may be augmented chroni- Trichosporon mycotoxinivorans and Rasamsonia cally with antifungal agents. The use of the anti-IgE argillacea can colonize the airways of CF patients, monoclonal antibody omalizumab has been reported causing significant clinical infections. Therapy can be in small case series [3–5], often with an antifungal challenging as some of the moulds are multi-drug therapy to reduce fungal burden and prevent exacer- resistant, for example Lomentospora prolificans. bations. The relatively small number of antifungal Others like A. fumigatus usually tend to be easily agents limits treatment options currently available. treatable. Nevertheless, an increasing number of One of the major concerns in patients with CF is that azole-resistant Aspergillus species have been they do not achieve adequate therapeutic levels with described in the recent years (for a review, see the usual doses and require higher doses, up to Hamprecht et al. in this special issue). In this context, 30–50% of recommended dose [6–9]. In addition, this review will address therapeutic strategies and there is a lack of prospective intervention studies. In a prevention of fungal infections in patients with CF. recently published Cochrane review, no randomized Since criteria for invasive fungal infections (pneu- controlled trials that evaluate the use of antifungal monia) in CF patients have not been defined yet, the therapies for the treatment of ABPA in CF patients following criteria for ‘‘highly probable’’ invasive pul- were found [10]. monary fungal infection were considered by the authors: 123 Mycopathologia (2018) 183:21–32 23 For Aspergillus infections, especially in invasive recommended for azole-resistant aspergillosis. Resis- infections, voriconazole is the recommended treat- tance to azoles might emerge as a new therapeutic ment according to almost all guidelines based on a challenge in several countries. Although de novo azole significant survival benefit, which is maintained in resistance occurs occasionally in patients during azole multiple real-life retrospective studies [11–13]. Until therapy, the main threat is the acquisition of resistance now, no consensus recommendations for treatment of through the environment. In this setting, the evolution Aspergillus infections specifically in the CF context of resistance is attributed to the widespread use of have been reached. Therefore, when treating Asper- azole-based fungicides [15], increasing the risk of gillus infections in CF, most clinicians will refer to the failure of antifungal treatment in patients with CF. aforementioned guidelines with voriconazole as first- In a study from Burgel et al. [16], A. fumigatus was line therapy. In addition to voriconazole, posacona- isolated from the sputum of 131/249 (52.6%) adult zole can also be recommended for Aspergillus infec- patients with CF. In this cohort, 47/131 (35.9%) tions and its use has been evaluated in severely ill patients had received previous treatment with itra- patients. In 67 non-CF patients receiving posacona- conazole. Interestingly, reduced susceptibility of A. zole therapy for at least 6 months, a response was seen fumigatus isolates to itraconazole (minimum inhibi- in 41 patients; 6 patients died, 9 had an adverse event, tory concentration or MIC [ 2 mg/L) was confirmed and 11 showed clinical and/or radiological deteriora- in 6/131 (4.6%) subjects. A further important issue tion. Therefore, at 6 months, posaconazole treatment regarding the risk of aspergillosis arises following was successful for 41 (61%) of 67 patients and failed lung transplantation. As CF is one of the most common for 26 (39%) of 67. Overall improvement at 6 months indications for lung transplantation, identifying risk was observed in 9 patients (13%). There were 41 factors for worse outcome after transplantation is evaluable patients at 12 months, of whom 2 had crucial [17, 18]. Pre-transplantation Aspergillus colo- primary posaconazole
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