Improvement in the outcome of invasive fusariosis in the last decade

Abstract

Invasive fusariosis (IF) has been associated with a poor prognosis. Although recent series have reported improved outcomes, the definition of optimal treatments remains controversial. The objective of this study was to evaluate changes in the outcome of IF. We retrospectively analysed 233 cases of IF from 11 countries, comparing demographics, clinical findings, treatment and outcome in two periods: 1985-2000 (period 1) and 2001-2011 (period 2). Most patients (92%) had haematological disease. Primary treatment with deoxycholate amphotericin B was more frequent in period 1 (63% vs. 30%, p <0.001), whereas voriconazole (32% vs. 2%, p <0.001) and combination therapies (18% vs. 1%, p <0.001) were more frequent in period 2. The 90-day probabilities of survival in periods 1 and 2 were 22% and 43%, respectively (p <0.001). In period 2, the 90-day probabilities of survival were 60% with voriconazole, 53% with a lipid formulation of amphotericin B, and 28% with deoxycholate amphotericin B (p 0.04). Variables associated with poor prognosis (death 90 days after the diagnosis of fusariosis) by multivariable analysis were: receipt of corticosteroids (hazard ratio (HR) 2.11, 95% CI 1.18-3.76, p 0.01), neutropenia at end of treatment (HR 2.70, 95% CI 1.57-4.65, p <0.001), and receipt of deoxycholate amphotericin B (HR 1.83, 95% CI 1.06-3.16, p 0.03). Treatment practices have changed over the last decade, with an increased use of voriconazole and combination therapies. There has been a 21% increase in survival rate in the last decade.

Role of Antifungal Susceptibility Testing in Non-Aspergillus Invasive Mold Infections

“…Unexpectedly, we found the MIC value of the first-line antifungal drug to be the most important factor in predicting response to therapy, an association that was not demonstrated previously (9)(10)(11)(12). It should be emphasized that prior studies assessing predictors of NAIMI focused on overall mortality as an outcome, whereas we specifically assessed response to therapy based on clinical and radiological signs according to EORTC-MSG definitions (8).…”

“…Most experts have highlighted the lack of correlation between MICs and outcomes for Fusarium spp. and recommended voriconazole as first-line therapy regardless of the MIC values (10,15,16). However, in our series, most cases of fusariosis were treated with voriconazole, for which MICs were consistently very high (Ն16 g/ml), and outcomes were very poor.…”

Emergence of fusarioses in a university hospital in Turkey during a 20-year period

“…Disseminated infections seem predominantly related to hematological disorders [12], sometimes with a link to a pre-existing nail or cutaneous infection [13,14]. The observed number of fusarioses has been reported to increase over the past several decades: this may be partly due to the growing number of immunocompromised patients and their prolonged average survival time, partly due to prophylactic therapeutic approaches against opportunistic fungal infections which have little impact on Fusarium, and partly to our improved ability to identify the infective agents [14,15].…”

Antimold Prophylaxis May Reduce the Risk of Invasive Fusariosis in Hematologic Patients with Superficial Skin Lesions with Positive Culture for Fusarium

“…Cases without a baseline skin lesion in the extremities were considered to have been acquired by inhalation of conidia present in the air (airway portal of entry) or from a central venous catheter in patients with fever and/or rigors after catheter manipulation and positive cultures from blood taken from the catheter. Neutropenia was defined as an absolute neutrophil count (ANC) of Ͻ500 cells/mm 3 . We collected data regarding demographics, underlying disease, type of treatment (chemotherapy for acute leukemia or MDS, conditioning regimen for HCT, immunosuppression for AA), duration of neutropenia, presence of graft-versus-host disease (GVHD), receipt of corticosteroids, presence and type of skin lesions at baseline, isolation of Fusarium spp.…”

“…The typical clinical picture is that of a disseminated disease with frequent lung involvement, positive blood cultures, and metastatic skin lesions (2). The prognosis is usually poor, with mortality rates exceeding 50%, although an improvement in the outcome has been documented in the last decade (3). Most cases of invasive fusariosis are acquired by inhaling conidia, with subsequent hematogenous spread (1).…”