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LIFE Newsletter - Leading International Fungal Education

June 2016

O'Neill final report on antimicrobial resistance has specific recommendations about antifungal resistance.

Lord Jim O’Neill’s global Review on AMR has set out its final recommendations, providing a comprehensive action plan for the world to prevent drug-resistant infections and defeat the rising threat of superbugs, something that could kill 10 million people a year by 2050, the equivalent of 1 person every 3 seconds, and more than cancer kills today. There are 4 recommendations:
1. A global awareness and education campaign.
2. The supply of new antibiotics needs to be improved.
3. We need to use antibiotics more selectively through the use of rapid diagnostics, to reduce unnecessary use, which speeds the incidence and spread of drug resistance.
4. We must reduce the global unnecessary use of antibiotics in agriculture.


With repect to fungal diseases and antifungals, priority areas were identified in the report:

  • Agriculture: Most crops are treated with fungicides, many with triazoles, which are similar to human triazole antifungals. We do not believe you can take away these products en masse to protect food security, but greater research into where trizoles are used and potential bans in their use on luxury items like flowers and wine production make sense.
  • Environment: Like antibiotics, there is a problem with factories dumping active pharmaceutical ingredients or antifungals into the environment, and like antibiotics this needs to stop.
  • Diagnostics: Often fungal infections are mis-diagnosed as TB or other illnesses, meaning that necessary antifungal treatment is not given and unnecessary antibiotic therapy is given. Fungal disease diagnostics have improved greatly. Greater use of rapid diagnostics would play a major role in reducing inappropriate antibiotic and ensuring appropriate antifungal use. Surveillance of resistance also needs to be expanded.
  • New drugs: The early clinical development pipeline has grown substantially in the last three years with eight antifungal compounds in early clinical development. If this healthier pipeline fails to translate into more new drugs, then governments should look at market entry rewards and early-stage funding for research.
    O'Neill Final Report see p64, News item,
    Related news

NEWS

Exposure to fungi in the work place may lead to lung damage

A recent review of occupational hypersensitivity pneumonitis (OHP) has shown that moulds and fungi including Aspergillus, Penicillium, Trichosporon are often implicated in this illness. OHP is an immunologic lung disease which develops as the result of an allergic reaction to a large variety of causal agents, including bacteria, fungi, animal and plant proteins, chemicals and metals. Symptoms are highly variable, and can be separated into two groups: Acute OHP (characterised by recurrent systemic symptoms including chills and body aches) and chronic OHP (characterised by clubbing, hypoxemia and fibrosis on HRCT scan). Data from the German Statutory accident insurance institutions (covering approx. 40 million workers) shows that moulds and fungi were the etiological agents in 45.9% of new OHP cases.

fit

Lung biopsy from a patient with chronic HP showing mild expansion of the alveolar septa (interstitium) by lymphocytes. A multinucleated giant cell, seen within the interstitium to the right of the picture halfway down, is an important clue to the correct diagnosis. By Mutleysmith  https://goo.gl/bdXGE6
 

Establishing a diagnosis of HP is not easy as the variety of clinical and radiologic findings can mimic a wide range of lung diseases. A multidisciplinary approach, from clinicians, radiologists, pathologists and occupational physicians/hygienists is therefore required, both to diagnose HP and importantly, to establish the causal role of the workplace. The authors of the review propose a set of criteria for the diagnosis of both acute and chronic OHP based on previously published criteria and consensus amongst experts (see table 5 of article). Treatment for acute OHP requires early removal from exposure to the agent, in severe acute and chronic cases oxygen with corticosteroids is used.

More information; Article

Intra-abdominal candidiasis is as common as candidaemia and often is lethal

Intra-abdominal candidiasis (IAC) has now been reclassified and from a retrospective study of IAC cases in adults it is highlighted that  source control intervention and prompt antifungal treatment are essential for a good outcome. (Vergidis et al)

Large retrogastric abscess attached to the posterior gastric wall of stomach caused by C glabrata.


Whilst some patients improved without antifungal therapy, the authors did not identify markers for those patients who will recover and those who will deteriorate. Infectious diseases (ID) consultations were obtained in only 48% of patients and this group was significantly more likely to receive antifungal therapy. Antifungal therapy, combined with source control, will be necessary in almost all cases.
This observation parallels the debates about which candidaemic patients should or should not be treated with antifungals – guidelines now recommend that all should be treated. Likewise all isolates should be antifungal- susceptibility tested. Infection specialists must be better engaged with these complex patients.

News Item in full

Burden of fungal diseases in Bangladesh, Japan, Malaysia, Peru, and Congo presented at Advances against Aspergillosis conference & ECCMID

Major country differences in serious fungal diseases were found in the latest 5 countries to have their burden estimated: Japan (population 127M), Bangladesh (population 162M), Malaysia (population 30M) Peru (population 31M) and Congo (population 4.4M). These estimates were presented at the Advances Against Aspergillosis meeting in Manchester (March 3-5) and European Congress on Clinical Microbiology and Infectious Diseases in Amsterdam (April 9-12).

Japan had a remarkably high number of oesophageal candidiasis cases, 280/100,000 per year, primarily in non-HIV patients, many with no underlying disease. This contrasts with low rates of invasive aspergillosis as COPD is relatively uncommon, and low rates of fungal asthma (~60,000 patients). In contrast, Peru and Malaysia have predicted high numbers of fungal asthma at >80,000 and 70,000 patients respectively, with intermediate rates in Bangladesh and Congo (>200,000 and 7,000 respectively). Chronic pulmonary aspergillosis is probably quite common in Congo with >3,350 cases (81/100,000) and Bangladesh at 20,700 affected (48/100,000), but is not rare in Malaysia (25/100,000), Peru (15/100,000) or Japan (6/100,000).
Low rates of cryptococcal meningitis are likely in Bangladesh and Japan (0.01-0.02/100,000), in contrast to Congo and Malaysia with rates of 7 and 2.8/100,000. None of these countries had sufficient data to validate the rate of Candida bloodstream infections, so it was estimated as 5/100,000.
News item in full

Pneumocystis pneumonia guidelines - in Haematology patients

Pneumocystis pneumonia (PCP) remains a rather enigmatic condition without AIDS. Uncommon, acute, non-specific and often fatal, it represents a real challenge to those caring for immunocompromised patients. In a series of 4 articles just published in the Journal of Antimicrobial Chemotherapy, multiple authors from Europe have reviewed the burden, diagnosis, therapy and prevention of PCP in haematology patients, including those undergoing allogeneic stem cell transplantation. It is a generally increasing problem, despite effective prophylaxis.
The presentation of PCP differs substantially between HIV and non-HIV patients. Read more

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Featured LIFE website section: Onychomycosis

Onychomycosis most often affecting toenails is caused by a wide variety of fungi especially Trichophytum rubrum, which causes about 80% of cases in the UK.  Non-dermatophyte moulds that occasionally cause onychomycosis, include: Fusarium spp., Aspergillus spp., Acremonium spp., Alternaria alternataScytalidium dimidiatum, Scytalidium hyalinium (Nattrassia mangiferae), Scopulariopsis brevicaulis and Onychocola canadensisC. albicans and, rarely, Candida parapsilosis can  cause onychomycosis, especially superficial white onychomycosis. Some infections are caused by more than one fungus. A full description of this infection and treatment can be viewed here: LIFE website.


New clinical guidelines section on LIFE website

LIFE has launched a new section bringing together national and international published clinical guidelines for the diagnosis and management of fungal diseases. In the absence of any guidelines for a particular disease, comprehensive reviews are included which contain diagnostic and management recommendations.
The documents have been identified though literature searches, our own comprehensive files and health agency websites. View guidelines
 If you have national or international guidelines to extend this collection please email us.


Top Diagnostic Tip : Radiology of coccidioidomycosis 

Pulmonary coccidioidomycosis is a fungal disease endemic to the desert regions of the southwestern United States, Mexico, Central America, and South America. The incidence of reported disease increased substantially between 1998 and 2011 and the infection is encountered beyond the endemic areas because of a mobile society.
The diagnosis is established by direct visualization of mature spherules by using special stains or cultures from biologic specimens. Serologic testing of anticoccidioidal antibodies is used for diagnosis and treatment monitoring.CT scan with nodules
Radiological features are useful in diagnosis and the lung is the primary site of involvement. On the basis of clinical presentation and imaging abnormalities, pulmonary involvement is categorized into acute, disseminated, and chronic forms, each with a spectrum of imaging findings. In patients with acute disease, the most common findings are lobar or segmental consolidation, multifocal consolidation, and nodules.
Adenopathy and pleural effusions are also seen, usually in association with parenchymal disease. Disseminated disease is rare and occurs in less than 1% of patients. Pulmonary findings are miliary nodules and confluent parenchymal opacities. Acute respiratory distress syndrome is an infrequent complication of disseminated disease. The acute findings resolve in most patients, with chronic changes developing in approximately 5% of patients. Manifestations of chronic disease include residual nodules, chronic cavities, persistent pneumonia with or without adenopathy, pleural effusion, and regressive changes. This article provides good radiological examples for all categories of this disease. Source: Jude et al 2014 Article, Image legend: Axial CT image after 10 months of antifungal therapy show a residual dominant nodule (arrow) with small satellite nodules (arrowheads) in the left upper lobe.

 

Really important reviews: Paediatric Invasive Aspergillosis

"Invasive aspergillosis (IA) is a disease of increasing importance in pediatrics due to growth of the immunocompromised populations at risk and improvements in long-term survival for many of these groups. While general principles of diagnosis and therapy apply similarly across the age spectrum, there are unique considerations for clinicians who care for children and adolescents with IA. This review highlights important differences in the epidemiology, clinical manifestations, diagnosis, and therapy of pediatric IA"
Wattier RL & Ramirez-Avila L J. J Fungi 2016, 2, 19; doi:10.3390/jof2020019 Article

Books

 

Infections in the Immunosuppressed Patient: An Illustrated Case-based Approach: by Pranatharthi H. Chandrasekar, Editor

Infections in the Immunosuppressed Patient offers an illustrated, case-based matrix for treatment of infections across all types of immunosuppressed patients. As the challenges of managing these infections continues to evolve, this collection offers lucid, authoritative guidance to diagnosing and treating these infections effectively.
Comprising 81 cases from leading experts across specialties, this collection offers a guide to both common and uncommon presentations of infections.

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Courses

 

A summer school at Radboud University Medical Centre titled "Azole Resistance in Aspergillus Fumigatus - from Fungicide to Bedside" will be held on 8-12th August 2016 in Nijmegen, The Netherlands. More information

Registration is now open for the next meeting of the ECCM/ISHAM working group on Scedosporium infections, which will be held on the 6-7th October 2016 in Bilbao, Spain. More information

The Advanced Course in Infections in the Immunocompromised Host is being held on the 14-15th October 2016 in Melbourne, VIC. More Information

A scientific workshop of the ISHAM Working Group Dermatophytes to discuss latest achievements will take place at CBS, Utrecht, The Netherlands on 29-30th October 2016. More information
More courses

Help us evaluate the global burden.

Global burden@LIFE copyright

We are looking for volunteers to assist with estimating the burden of fungal infection in the following countries:
Angola, Bolivia, Bulgaria, Bosnia, Burkina Faso, Cambodia, Central African Rep., Chad, DRC, Costa Rica, Gabon, Honduras, Laos, Mali, Myanmar, Nicaragua, Papua New Guinea, Poland.
 Can you help? Contact us

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