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,
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.
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.
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.
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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