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LIFE Newsletter - Leading International Fungal Education

April 2017

The World Health Organisation places itraconazole, voriconazole and natamycin (ophthalmic preparation) on the Essential Medicines List (EML).

GAFFI (Global Action Fund for Fungal Infections) has campaigned for these three antifungals to be on the EML in conjunction with colleagues from the Instituto de Salud Carlos III, International Foundation for Dermatology, London School of Hygiene of Tropical Medicine and The University of Manchester. The WHO ruling puts itraconazole (capsules and oral suspension), voriconazole (capsules and intravenous solution) and natamycin 5% ophthalmic solution on the Essential Medicine List (EML).
The antifungal medicines itraconazole and voriconazole are critical to reduce deaths and illness, and natamycin to reduce blindness. They are very inexpensive in most countries.
Prof Denning form GAFFI said "This endorsement by the WHO of their essentiality is a key step in reducing mortality from fungal diseases. We are delighted that our campaign has WHO recognition.  Our challenge now will be to make sure these drugs get to the people who desperately need them.”

itraconazoleThe proposed indications for itraconazole capsules are chronic cavitary pulmonary aspergillosis, invasive aspergillosis, histoplasmosis (therapy, primary and secondary prophylaxis), sporotrichosis, paracoccidioidomycosis, infections caused by Talaromyces marneffei (penicilliosis) (therapy, primary and secondary prophylaxis) and chromoblastomycosis. These are all conditions for which fluconazole is ineffective. Itraconazole oral solution is preferred in late stage AIDS patients, leukaemia patients and children.

The proposed indications for voriconazole are invasive and chronic pulmonary aspergillosis, with intravenous therapy preferred initially, in invasive disease.

The important indication for topical natamycin 5% in the eye is fungal (mycotic) keratitis - 3 randomised studies have shown it to be more efficacious than other topical medicines, given alone.

More information


Prevalence, clinical and economic burden of mucormycosis related admissions in the USA

There were 555 cases of mucormycosis in hospitals among 47 million inpatient episodes, a prevalence  of 0.16 per 10,000 discharges. The median length of stay was ~17 days and mean cost was $112,419.

Mucormycosis is an uncommon, opportunistic fungal infection primarily caused by Mucorales, a filamentous fungus of the Mucormycetes class. This fungal infection particularly affects patients with diabetes mellitus (especially following ketoacidosis) or those with hematologic malignancies on chemotherapy (especially with neutropenia), stem cell and solid organ transplants.
The study used the Premier’s Perspective™ Comparative Database, a large, U.S hospital based database covering more than 560 participating hospitals across the U.S and 104 million patients. Data was collected from January 2005 to June 2014. Mucormycosis related-hospitalisations were identified with an ICD-9 code of 17.7 or a positive laboratory microbiology result for Mucorales. 
Fluconazole, voriconazole and echinocandins are not effective antifungal therapy against mucormycosis. Amphotericin B , liposomal amphotericin B, posaconazole and isavuconazole are effective treatments. The projection of the total costs associated with mucormycosis in the USA is $48 million.

More information. Article


Delivering on antimicrobial resistance not possible without improving diagnostic capabilities

Ignorance of fungal disease and lack of fungal diagnostics is causing doctors to unknowingly overprescribe antibiotics - a new report warns.

In a paper published today in the cutting edge US Journal Emerging Infectious Diseases (click here), several leading authors from GAFFI warn of the gross misuse of antibacterial antibiotics, because doctors treat patients without knowing what is wrong with them. The authors focus on common scenarios, where the lack of the best diagnostic tests, prevents the correct antimicrobial being given.
Examples include mis-diagnosis of TB where the patient actually has chronic pulmonary aspergillosis- which is diagnosable with a simple antibody test and chest imaging. Also many asthma and patients with emphysema (COPD) get exacerbations, which are treated with antibacterials and steroids. Some have fungal asthma or are admitted to hospital with COPD. There are over 200 million asthmatics and an estimated 6-15 million have fungal asthma, which is diagnosable with skin prick testing or IgE blood tests, and which responds to antifungal agents, minimizing antibacterial use.

David Denning president of GAFFI, said on the lack of fungal diagnostics:" Solving AMR is not possible without accurate and timely diagnosis. Fungal disease diagnostics are critical in the AMR fight, and will improve survival from fungal disease across the world. The close link between fungal diagnostics and antibacterial prescribing needs a great deal more attention".
More information. Article


Invasive Fungal Infections in the Middle East: High mortality and new underlying diseases

A retrospective study of 102 hospitalised patients with invasive candidiasis or aspergillosis in Saudi Arabia and Lebanon (Alothman et al, 2017) identifies several non-traditional common co-morbidities including coronary artery disease (24%), congestive heart failure (15%), moderate-to-severe renal disease (16%), and diabetes (41%). In selected and diagnosed patients, some immunocompromising factors were also present, notably corticosteroids prior to admission (20%) and chemotherapy in the prior 3 months (26%). The authors caution their peers: “Earlier consideration .. of IFI in medically comorbid patients may reduce the time to antifungal treatment and improve outcomes.”
This study highlights a high mortality of 42%, mean hospitalisation period of 32 days, the low use of Aspergillus galactomannan testing (11%), and the delay before a diagnosis of invasive fungal infection was made. They note that the median time from admission to diagnosis was 6 days (range 0 to 92 days), and it took another day for antifungal therapy to be started. A median of 2.5 days (range −3 to 80 days) elapsed between culture collection and treatment given. Fluconazole was the favoured antifungal, but over 50% of the infections were resistant to it.
Read more; Article
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LIFE would also appreciate your help to tell us if you have antifungal eyedrops in your country. GAFFI is seeking to map the availability of eyedrops globally.
Do you have these eyedrops for fungal keratitis in your country: - natamycin, voriconazole, econazole or chlorhexidine? Mail your reply here. Thank you we really need your help!


Featured LIFE website section: Talaromyces marneffei infections (formerly penicilliosis)

 All cases originate from southeast Asia, notably Thailand, Vietnam, Hong Kong, southern China, Taiwan, India, Indonesia, Cambodia and Laos, unless laboratory acquired. 10% of AIDS patients in Hong Kong and ~30% of patients in N.Thailand present with a Talaromyces marneffei  infections. Patient with AIDS and penicilliosis present all over the world.
Most patients have fever, weight loss and malaise. Subcutaneous abscesses and papule-like ulcers are common. Sometimes the skin lesions are very small, like molluscum contagiosum. Anaemia, hepatosplenomegaly, lymphadenopathy and diarrhoea are also relatively common. As patients usually have very low CD+ counts, other concurrent opportunistic infections are common. Cough is common, but pneumonia is rare, despite this being the portal of entry of the organism.

The mortality of untreated T. marneffei infection is 100%. Treatment of choice is amphotericin B (0.6mg/kg) for 2 weeks followed by oral itraconazole 400mg per day for 10 weeks. Itraconazole treatment alone is effective but a higher relapse rate. Simultaneous initiation of anti-retroviral treatment with amphotericin B or at the start of itraconazole therapy, if appropriate.
View LIFE section.

Top Diagnostic Tip: Fine needle aspiration cytology in the adrenal gland - for identification of fungi and non-neoplastic pathology

Fine needle aspiration biopsy was performed under ultrasound or CT guidance and staining performed when required. The technique is shown to be an easy, reliable, rapid and minimally invasive method to diagnose and categorize the various benign non-neoplastic diseases of adrenal glands In a sample of 15 cases - 5 had TB, 5 had histoplasmosis (PAS stain positive), 2 had acute inflammation, 2 were granulomatous and 1 with myelolipoma.



Really Important Review: Tinea Capitis: Current status

Tinea capitis is still a common infection with prevalence rates exceeding 40 %. Yet knowledge of the underlying pathogenetic mechanisms and the development of effective immunity have shown striking advances, and new methods of diagnosis ranging from dermoscopy to molecular laboratory tests have been developed even though they have not been assimilated into routine practice.

This review deals with all aspects including the epidemiology, pathology and immunological response, clinical varieties of infection, diagnosis, complications and management.

R.J Hay, Mycopathologia (2017) 182:87–93
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/)


This resource is available in an eBook format for anyone aiming to develop their skills in medical mycology.The transition from a standard textbook on medical mycology to real-life clinical situations is a challenge.
In the recently published iBook ’Illustrative cases in Medical Mycology’ (Cara Holmes et al) the authors have assembled a series of cases that span the full spectrum of fungal disease that have been developed for the University of Manchester Masters in Medical Mycology This book is available free of charge for anyone with an iPhone, iPad, or Apple computer: (https://itunes.apple.com/us/book/id1179377033)

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A specialisation course in medical mycology will be held in Leuven, Belgium between 11th and 21st September 2017.  For more information and registration, contact Katrien Lagrou

A web-based course 'Invasive Mold Infections: Emerging Approaches' is running between the 31st December 2016 and 30th December 2017  More information

E-learning course in direct microscopy for identifying fungal infections
Experts in Manchester have recently launched the first e-learning course in direct microscopy for identifying fungal infection, also teaching histological staining methods and interpretation of fungal elements. The course is accredited by the University of Manchester & will teach not only how to rapidly and accurately diagnose life-threatening fungal infections, but also how to set up direct microscopy in a diagnostic laboratory. It is available at www.microfungi.net. The first 50 students to complete this course will be offered free ESCMID membership for one year.

A web-based course 'Invasive Mycoses: Emerging Paradigms & Practical Applications' is running between 25th September 2016 and 24th September 2017. More information

Global burden@LIFE copyright

We are looking for volunteers to assist with estimating the burden of fungal infection in the following countries:
Bhutan, Bolivia, Burkina Faso, Chad, DRC, Gabon, Guinea and Guinea Bissau, Papua New Guinea, Rwanda and Sierra Leone.
Can you help? Contact us