The 1998 Garrod lecture. Current and future antifungal therapy: new targets for antifungal agents. (49/2265)

Invasive fungal infections are a major problem in immunocompromised patients. The recent expansion of antifungal drug research has occurred because there is a critical need for new antifungal agents to treat these life-threatening invasive infections. The overview of the development of antifungal therapy which is provided herein reflects the increased interest in this very special area of infectious diseases. Although we have newer, less toxic, antifungal agents that are available for clinical use, their clinical efficacy in some invasive fungal infections, such as aspergillosis and fusariosis, is not optimal. Thus, intense efforts in antifungal drug discovery are still needed to develop more promising and effective antifungal agents for use in the clinical arena.  (+info)

Out-patient management of acute myeloid leukemia after consolidation chemotherapy. Role of a hematologic emergency unit. (50/2265)

BACKGROUND AND OBJECTIVE: Increasing attention to quality of life and to health care costs has recently induced several cancer centers to change in-patient management into an out-patient setting even during high risk phases of disease. The aim of this prospective study was to evaluate feasibility and safety, as well as clinical characteristics, of out-hospital management of AML patients during their post-consolidation phase. DESIGN AND METHODS: All patients who were treated over a three year period by the three following protocols were included in the study: AML10 EORTC/GIMEMA for patients with AML, except for APL, aged 60 years; AIDA GIMEMA for APL patients. All patients submitted to the AML10 and AML13 protocols and those patients submitted to the AIDA protocol with difficult peripheral vein access had a central venous catheter (CVC) sited. Patients treated as in-patients were discharged at the end of consolidation chemotherapy provided they were in a good clinical condition. They were routinely evaluated on an out-patient basis twice weekly. In the event of any complication they were referred to the Emergency Unit of our Department dedicated to out-patients with hematologic diseases. RESULTS: One hundred and eleven patients with AML were eligible for intensive chemotherapy. After achievement of complete remission they received a total of 133 consolidation courses and in 127 instances they were followed on an out-patient basis during the aplastic phase. There were 69 cases (54%) of rehospitalization, 68 because of fever and only one because of severe anemia. Rehospitalization occurred in 90%,70% and 38% of courses in AML10, AML13 and AIDA protocols, respectively. Only one patient died: the cause of death was a brain hemorrhage. Coagulase negative staphylococci and viridans streptococci were the organisms most frequently isolated from blood. Most coagulase negative staphylococci were isolated in patients submitted to AML10 and AML13 protocols, who had an indwelling CVC. Empiric once-a-day antibacterial therapy with ceftriaxone and amikacin was effective in 75% of the cases and made early discharge possible in 28% of the cases with antibiotic therapy continued in an out-patient setting. Overall, patients were managed out of the hospital for 66% of the period of post-consolidation neutropenia (77%, 48% and 50% of the post-consolidation neutropenia period in patients treated with AIDA, AML10 and AML13 protocols, respectively). INTERPRETATION AND CONCLUSIONS: Thanks to the availability of an emergency unit specifically dedicated to out-patients with hematologic diseases, selected out-hospital management of AML patients during post-consolidation cytopenia is a feasible, well accepted and cost-saving option, and can contribute to lower the risk of developing severe nosocomial infections. The empiric therapy with once-a-day ceftriaxone plus amikacin was effective, with the exception of staphylococcal infections, and made it possible to discharge patients early to continue treatment in an out-patient setting.  (+info)

Experimental pathogenicity of four opportunist Fusarium species in a murine model. (51/2265)

A murine model with immunocompetent animals was used in a comparative study of experimental pathogenicity of 13 isolates belonging to the four most frequent pathogenic species of Fusarium in man (F. solani, F. oxysporum, F. verticillioides and F. proliferatum). Inocula of 5 x 10(6) conidia/mouse of each isolate of Fusarium were injected into a lateral vein of the tail of the mice to produce a systemic infection. F. solani was the most virulent species; the five strains of this species assayed caused the death of all the animals tested in <19 days. The other species of Fusarium were not virulent in this model. The organs mainly affected by F. solani were the kidneys and the heart. These findings correlate with the clinical evidence and demonstrate that there is a high risk associated with infection by F. solani, especially for immunocompromised patients.  (+info)

Identification of Fusarium species involved in human infections by 28S rRNA gene sequencing. (52/2265)

Fusarium spp. have emerged as major opportunistic fungal agents. Since new antifungal agents exhibit variable activity against Fusarium isolates depending on the species, rapid identification at the species level is required. Conventional culture methods are difficult, fastidious, and sometimes inconclusive. In this work, we sequenced a 440-bp fragment encoding the 28S rRNA from 33 Fusarium isolates belonging to six Fusarium species associated with human infections. The data were then analyzed by the neighbor-joining method. By using distance matrix analysis and constructing the phylogram, we could easily distinguish the different species for all but one isolate. The method also allowed differentiation between the closely related genera Acremonium and Cylindrocarpon. In contrast to the case with conventional methods, the results could be obtained within 48 h from a 3-day culture and are independent of mycologist experience, making this method rapid and reliable for identification of Fusarium species isolated from patients.  (+info)

Importance of selective media for recovery of yeasts from clinical specimens. (53/2265)

We compared the recovery of yeasts from clinical specimens cultured on routine bacteriological media to the recovery of yeast from specimens cultured on a selective fungal medium (Sabouraud agar). The use of Sabouraud agar was especially important in cases of mixed cultures, since in such cases yeast was recovered on bacteriological media from only 50% of 44 yeast-positive pus specimens and from 22. 5% of 22 yeast-positive throat specimens. The use of a selective fungal medium is therefore necessary to ensure the detection of yeast in specimens containing a mixture of bacteria and yeasts. As a result, clinicians must request yeast isolation when clinically indicated, and the microbiological laboratory must add a selective fungal medium when clinically significant yeasts are likely to be encountered. It is also important that selective fungal media be used in clinical studies of yeast infections.  (+info)

Fatal case of Trichoderma harzianum infection in a renal transplant recipient. (54/2265)

We describe the second known case of human infection by Trichoderma harzianum. A disseminated fungal infection was detected in the postmortem examination of a renal transplant recipient and confirmed in culture. The only other reported infection by this fungus caused peritonitis in a diabetic patient. The in vitro antifungal susceptibilities of the clinical strain and three other strains of Trichoderma species to six antifungal drugs are provided. This case illustrates the widening spectrum of opportunistic Trichoderma spp. in immunocompromised patients and emphasizes the problems in diagnosing invasive fungal diseases.  (+info)

A case of melanonychia caused by Exophiala dermatitidis. (55/2265)

We report a case of a healthy 61-year-old woman with discoloration of the nail on her right big toe. We first treated her with topical steroid and urea under suspected diagnosis of nail eczema, but the lesion remained. In culture, black, shiny, pasty and yeast-like colonies grew repeatedly. Examination of debris from her nail showed dematiaceous spherical cells and hyphal elements. Microscopically, annelloconidia were produced at the apical ends of anellidic conidiogenous cells. This colony grew at 40C. Mitochondrial DNA restriction fragment length polymorphism was analysed in this strain and its restriction pattern confirmed the isolate to be Exophiala dermatitidis. Based on these findings, we diagnosed this nail deformity as fungal melanonychia due to Exophiala dermatitidis. This is the third reported case of this disease.  (+info)

Specificity and prevalence of natural bovine antimannan antibodies. (56/2265)

Immune responses to the carbohydrate components of microorganisms, mediated both by antibodies and by lectins, are an important part of host defense. In the present experiments, the specificity and presence of natural bovine antibodies against mannan, a common fungal antigen, were examined by enzyme-linked immunosorbent assay (ELISA), using Saccharomyces cerevisiae mannan as an antigen. The results showed that all serum samples from animals of three age groups (newborn, calf, and adult) tested contained antimannan antibodies, and the titer of these antibodies increased significantly in adults. However, titers among individual adult cattle differed widely. Inhibition assays showed that yeast mannan was the strongest inhibitor. D-Mannose exhibited only a minor inhibitory effect at high concentrations. This suggests that most of these antibodies recognize an oligosaccharide-based epitope(s) different from those recognized by lectins. Cattle possess three serum C-type lectins (collectins) capable of recognizing mannan in a calcium-dependent manner. Addition of EDTA to the reaction did not reduce antibody binding, suggesting that the binding of these antibodies to mannan was not affected by the presence of collectin. The antibodies purified from either calf or adult serum by mannan-Sepharose affinity chromatography consisted of mainly immunoglobulin G (IgG) and a smaller amount of IgM. IgG1 was shown to be the dominant antimannan IgG isotype by isotype-specific ELISA. Together, these results demonstrate the production of natural antimannan antibodies in cattle in an age-dependent manner. These antibodies might be involved in defending the host against mannan-containing pathogens as a specific line of defense in conjunction with the innate response by lectins.  (+info)