Sepsis in oncologic and hematologic patients fileAcute Hypoxemic Respiratory Failure in...
Transcript of Sepsis in oncologic and hematologic patients fileAcute Hypoxemic Respiratory Failure in...
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Peter Pickkers
Department of Intensive Care Medicine
Fellow-onderwijs, 2017
Sepsis in oncologic and hematologic patients
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….
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….
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1992
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Bone marrow transplants
Cancer
2009
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2014
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2015
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Also in the Netherlands?
Radboudumc Nijmegen, the Netherlands
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To explore trends over time in admission prevalence and (risk-adjusted) mortality of critically ill haematological patients and compare these trends to those of several subgroups of patients admitted to the medical intensive care unit (medical ICU patients).
A total of 1,741 haematological and 60,954 non-haematological patients admitted to the medical ICU were analysed.
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Fraction of hematological patients compared to
total number of medical ICU-patients
Leuko’s ≥ 1.0
Leuko’s < 1.0
Increase p=0.007
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Compared to
medical admission patients
Risk-adjusted hospital mortality rate significantly decreased in both the haematological and non-haematological group with an OR of 0.93 (95 % CI 0.92–0.95) per year.
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Compared to
severely ill medical admission patients
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Compared to
severely ill medical admission patients
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Compared to
severely ill medical admission patients
No effect of leukopenia
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142 patients 431 patients 401 patients
149 patients
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Hospital survival 1-year survival ICU survival
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Major challenges critical care specialists will face with cancer patients in the next 10 years • Increasing numbers both of patients diagnosed with cancer and of cancer survivors
• Increasing need for ICU management of cancer patients due to intensive therapeutic regimens and highly
toxic targeted therapies
• Increasing number of cancer survivors remaining severely immunocompromised, with advanced age and
comorbidities
• Urgent need to improve medical skills of ICU specialists, develop remote patient management, and set up
expert networks
• Achieving a consensus on the standard of care to be offered for critically ill cancer patients in industrialized
countries
• Establishing universal criteria for the timing of ICU admission for cancer patients
• Establishing, validating, and spreading standard procedures and protocols to optimize patient management
and outcomes
• Improving our understanding of organ dysfunction with the hope of improving organ recovery and
increasing the proportion of patients fit for intensive curative treatments
• Gathering multicenter data on outcomes associated with time-limited trials, with a special focus on the
balance between avoiding both premature end-of-life decisions and giving nonbeneficial care
• Introducing early palliative care for critically ill cancer patients
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Acute Hypoxemic Respiratory Failure in Immunocompromised Patients: The Efraim Multinational Prospective Cohort Study Elie Azoulay, Peter Pickkers, Marcio Soares, Anders Perner, Jordi Rello, Philippe Bauer, Andry van de Louw, Pleun Hemelaar, Virginie Lemiale, Fabio Silvio Taccone, Ignacio Martin Loeches, Tine Sylvest Meyhoff, Jorge Salluh, Peter Schellongowski, Katerina Rusinova, Nicolas Terzi, Sangeeta Mehta, Massimo Antonelli, Achille Kouatchet, Andreas Barratt-Due, Miia Valkonen, Precious Pearl Landburg, Fabrice Bruneel, Ramin Brandt Bukan, Frédéric Pène, Victoria Metaxa, Anne Sophie Moreau, Virginie Souppart, Gaston Burghi, Christophe Girault, Ulysses V.A. Silva, Luca Montini, Francois Barbier, Lene B Nielsen, Benjamin Gaborit, Djamel Mokart, Sylvie Chevret. For the Efraim investigators and the Nine-I study group.
665
183
119 112 106
72 7155 46 42 36 31 31 30 21
50
100
200
300
400
500
600
700
no
mb
re d
'in
clu
sio
ns
Pays
France
Netherland
Brazil
Denmark
Spain
USA
Belgium
Austria
Czech Rep
Italy
Canada
Norway
Finland
Ireland
England
Uruguay
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1611 immunocompromized patients admitted to 68 ICUs in 16 countries for acute hypoxemic
respiratory failure
596 (37.0%) received first line intubation
and mechanical ventilation (IMV)
ICU mortality: 44.4% Hospital
mortality: 52.5%
920 (57.1%) were not intubated at ICU admission and received standard O2, noninvasive ventilation (NIV) or high flow oxygen
through nasal cannula (HFNC)
496 (53.9%) received
Standard O2 only
190 (38.3%) needed IMV
ICU mortality: 51% Hospital
mortality: 59%
187 (20.3%) received HFNC
only
77 (41.2%) needed IMV
ICU mortality: 60% Hospital
mortality: 65%
158 (17.2%) received NIV
only
58 (36.7%) needed IMV
ICU mortality: 50% Hospital
mortality: 55%
79 (8.6%) received HFNC
and NIV
32 (40.5%) needed IMV
ICU mortality: 41% Hospital
mortality: 44%
95 (5.9%) missing data on initial
oxygenation strategy
54 (56.8%) needed IMV
ICU mortality: 24% Hospital
mortality: 33%
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Pro
bab
ilit
y o
f In
tub
atio
n a
nd
Me
chan
ical
Ve
nti
lati
on
Time (days) since ICU admission
P (Log Rank test) = 0.9422
Standard Oxygen
High Flow Oxygen through nasal cannula (HFNC)
Noninvasive ventilation (NIV) with standard oxygen within NIV sessions
Noninvasive ventilation with HFNC within NIV sessions
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Age (per year) 0.92 (0.86-0.99)
High Flow Oxygen (HFNC) 0.77 (0.59-1.01)
Noninvasive ventilation (NIV) 0.94 (0.69-1.28)
NIV + HFNC 0.74 (0.51-1.09)
Chronic Respiratory Insufficiency 0.76 (0.54-1.08)
SOFA score at ICU admission 1.09 (1.06-1.13)
Acute Respiratory Distress Syndrome 1.47 (1.05-2.07)
Pneumocystis jirovecii Pneumonia 2.11 (1.42-3.14)
Invasive Pulmonary Aspergillosis 1.85 (1.21-2.85)
Undetermined ARF etiology 1.46 (1.09-1.98)
Age (per year) 0.92 (0.86-0.99)
High Flow Oxygen (HFNC) 0.77 (0.59-1.01)
Noninvasive ventilation (NIV) 0.94 (0.69-1.28)
NIV + HFNC 0.74 (0.51-1.09)
Chronic Respiratory Insufficiency 0.76 (0.54-1.08)
SOFA score at ICU admission 1.09 (1.06-1.13)
Acute Respiratory Distress Syndrome 1.47 (1.05-2.07)
Pneumocystis jirovecii Pneumonia 2.11 (1.42-3.14)
Invasive Pulmonary Aspergillosis 1.85 (1.21-2.85)
Undetermined ARF etiology 1.46 (1.09-1.98)
Age (per year) 0.92 (0.86-0.99)
High Flow Oxygen (HFNC) 0.77 (0.59-1.01)
Noninvasive ventilation (NIV) 0.94 (0.69-1.28)
NIV + HFNC 0.74 (0.51-1.09)
Chronic Respiratory Insufficiency 0.76 (0.54-1.08)
SOFA score at ICU admission 1.09 (1.06-1.13)
Acute Respiratory Distress Syndrome 1.47 (1.05-2.07)
Pneumocystis jirovecii Pneumonia 2.11 (1.42-3.14)
Invasive Pulmonary Aspergillosis 1.85 (1.21-2.85)
Undetermined ARF etiology 1.46 (1.09-1.98)
Initial ventilation strategy (with standard Oxygen as reference)
Etiology of the Acute Respiratory Failure (ARF)
Increased risk of intubation and mechanical ventilation
Hazard Ratios (95% Confidence Intervals)
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ARDS (according to the Berlin definition, with PaO2/FiO2>300 as the reference)
Age (per year) 1.18 (1.09-1.27)
Intercept 0.06 (0.03-0.11)
Direct admission to the ICU 0.69 (0.54-0.87)
Odd Ratios (95% Confidence Intervals)
Day 1 SOFA score withoutrespiratory items
1.12 (1.08-1.16)
Severe ARDS 1.60 (1.03-2.48)
Moderate ARDS 1.46 (0.98-2.18)
Mild ARDS 1.30 (0.83-2.05)
Need for intubation and mechanical ventilation (IMV, with no intubation as the reference)
Undetermined ARF etiology 1.43 (1.04-1.97)
First line IMV 2.55 (1.94-3.29)
IMV after failure of NIV+HFNC 2.31 (1.09-4.91)
IMV after standard oxygen failure 4.16 (2.91-5.93)
IMV after high flow oxygen (HFNC) failure 5.54 (3.27-9.38)
IMV after noninvasive ventilation (NIV) failure 3.65 (2.05-6.53)
Increased risk of hospital mortality
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Recent changes to previously held beliefs pertaining to the management of critically ill cancer patients
• It is wrong to state that cancer-related characteristics (e.g., type of cancer, neutropenia, cancer-related
complications) are the main prognostic factors among the pre-acute illness conditions
• It is wrong to state that de-escalation of antibiotics is unsafe in neutropenic patients with septic shock
• It is wrong to state that FOB-BAL is mandatory in the diagnostic workup of patients with ARF and
pulmonary infiltrates
• It is wrong to state that noninvasive ventilatory support strategies should be the rule in patients with ARF,
as they improve survival and reduce intubation rates
• It is wrong to state that our ability to identify patients likely to benefit from ICU admission or not is optimal
• It is wrong to state that prognostic scores can assist in ICU admission triage decisions
• It is wrong to state that intensivists and oncohematologists should plan care separately to avoid conflicts
• It is wrong to state that outcomes in high-volume centers are the same as in general hospitals
• It is wrong to state that one should wait for resolution of organ failure before starting chemotherapy
• It is wrong to state that the ICU is not the place for palliative care and should be restricted to cancer
patients with full-code status
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Conclusions
• “The times they are a changin’”
• Mortality is twice as high compared to the medical ICU patient, but similar
to the cirrhosis, the heart failure patient
• Neutropenia is no issue at all
• Long-term outcome/QoL of survivors is similar to others
“ “
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Gastheer: De IC patiënt
P. Pickkers
Intensive Care
Invasieve Candida infecties
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Candidemie:
Nummer 4 oorzaak van ‘bloodstream infections’ in
de Verenigde Staten.
M.n. relevant bij IC patienten en onafhankelijk
geassocieerd met morbiditeit en mortaliteit.
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Het probleem
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Candidemie en mortaliteit
Garey KW et al, CID 2006
Time to fluconazole therapy in 230 patients with candidemia
Independent determinants of mortality:
APACHE II score
Time to start fluconazole (AOR, 1.42; p = 0.0009)
0
5
10
15
20
25
30
35
culture Day 1 Day 2 Day ≥3
Days to start of fluconazole
Ho
spit
al M
ort
alit
y (%
)
40
Morrell M, et al. AAC 2005
157 patients – 2001-2004
Independent determinants of hospital mortality:
APACHE II score (one-point increments) (p <0.001)
Administration of antifungal therapy >12 hours after the first positive blood culture (AOR, 2.09; p = 0.018)
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Timely initiation of therapy
Kollef, CID 2012
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Source control
Kollef, CID 2012
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Timely initiation of therapy
• Tijdig starten vermindert mortaliteit • Maar tijd tot identificatie duurt vaak lang… • Sensitiviteit bloedkweken 70%
• Vroege diagnose en snelle identificatie van organisme is essentieel!
• Redenen om over profylactische behandeling na te denken.
Morrell, AAC 2005;48; Kollef CID 2012; Azoulay CCM 2012
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Maar er zijn ook nadelen…
• Kosten
• Resistentievorming
• Wat is er bekend en • welke afwegingen moeten wij maken?
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Treatment strategies in ICU
Timing is everything!
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Strategies in ICU: background
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Treatment strategies in ICU
Leon, CCM 2009; Bassetti Crit Care 2010
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Treatment strategies in ICU
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Treatment strategies in ICU
• Profylactic / Preventative
• Empirical • Pre-emptive • Targeted
Schuster; Annals of Int Med 20008
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Playford, J Antimicrob. Chemother. 2006
Strategies in ICU: prophylaxis
NNT 94
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Strategies in ICU: prophylaxis
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Discussie en Conclusies • Candida infectie ontstaat door endogene
kolonisatie • Fluconazol profylaxe geeft risico voor candidemie • de incidentie van kolonisatie en invasieve
candidiasis • Geen shift richting resistente Candida species • Generalisering van de resultaten niet mogelijk
(wellicht alleen gebruik bij gekoloniseerde patiënten)
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Treatment strategies in ICU
• Profylactic / Preventative
• Empirical • Pre-emptive • Targeted
Schuster; Annals of Int Med 20008
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Een prospectieve studie naar empirische therapie in niet-neutropene IC-patienten • Fluconazol vs placebo
• bij 270 volwassen ICU patienten • > 96 uur opgenomen , APACHE II >16 koorts > 4 dagen zonder ander focus
op de IC + empirisch breedspectrum antibiotica voor mi 4 van de
voorafgaande 6 dagen en tenminste 24 uur CVC catheter in situ
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Schuster; Annals of Int Med 2008
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Treatment strategies in ICU
Schuster; Annals of Int Med 2008
Invasieve schimmelinfecties: 5 vs 9% (NS), mortaliteit 24 vs 22% (NS)
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Identificeren van hoog-risicopatienten
Leon, CCM 2009; Bassetti Crit Care 2010
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Blumberg et al: the National Epidemiology of Mycoses Survey
(NEMIS) Data prospectief verzameld op 6 Chirurgische ICUs in de VS
42 BSIs in 4276 patients were identified during a 2-year period (0.9 %)
Blumberg et al. Risk Factors for Candidal Bloodstream Infections in Surgical
Intensive Care Unit Patients: The NEMIS Prospective Multicenter Study.
Clin Inf Dis 2001;33:177-86
Voorspellen van hoog-risicopatienten
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Candida infection
+ - pos a b
Risk factor PPV: a/a+b neg c d
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The positief voorspellende waarde was < 5%
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PPV: < 3%
< 3%
< 3%
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The positive predictive value of colonization was <3%
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Ostrosky-Zeichner: New approaches to the risk of Candida in the intensive care unit.
Curr Opin Infect Dis 2003;16:533-537
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Ostrosky-Zeichner: New approaches to the risk of Candia in the intensive
care unit. Curr Opin Infect Dis 2003;16:533-537
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Ostrosky-rule:
* > 4 dagen ICU * én tenminste: AB en/of CVL
* én tenminste 2 van: TPN, dialyse, major surgery, pancreatitis,
steroiden andere immuunsupressie
>>>> kans op 9,9 % op candidemie
(ICAAC M505, 2003)
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Pre-emptive therapy of Candidemia and Invasive Candidiasis
Currently three options:
• Candida score
• Colonisation index • 1,3 Beta Di Glucan
Antonelli, CCM 2011; Leon CCM 2006 and 2009; Ostrovsky 2009; poster ECCMID 2012; Eggiman, Annals of Intensive Care 2011; Bassetti, Crit Care 2010
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Strategies in ICU: Candida score
Leon, CCM 2006
1
1
1
2
1600 IC patienten >7 dgn opgenomen
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Strategies in ICU: Candida score
Leon, CCM 2006
Candida score ≥ 3 Sensitivity 81% Specificity 75% PPV 18% NPV 98%
Achtergrondprevalentie: 5-6%
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Pre-emptive therapy of Candidemia
• Candida scores
• CS ≥ 3 iedere IC patient behandelen?, afkappunt op > 4 leggen??
Leon CCM 2006 and 2009
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Pre-emptive therapy of Candidemia
• Colonisation Index (CI) en Corrected Colonisation Index (CCI)
Pittet 2004;
Kwantificering wordt toegepast van het aantal kolonies: het aantal kwantitatief sterk gekoloniseerde lokaties
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Pre-emptive therapy of Candidemia
Pittet 2004;
PPV 60%
PPV 100%
NB: Op basis van retrospectieve data
C.I. wordt berekend als het aantal positieve Candida lokalisaties op het totaal aantal gemeten lokaties. CCI idem maar betekent dat een kwantificering is toegepast van het aantal kolonies
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Pre-emptive therapy of Candidemia and Invasive Candidiasis
Posteraro, Crit Care 2011
Candida score (CS) ≥ 3
Colonisation index ≥ 0.5
95 high-risk patienten, Prevalentie 17% (!) BG PPV 72% NPV 99%
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In deze studie
• 95 high risk IC patienten naast en CI en CS een BDG bepaald
• NPV van BDG erg hoog, bijna 100%: de test kan dus gebruikt worden om IFI uit te
sluiten, minder om het aan te tonen
• Prevalentie in deze studie groep was 16,9% (in Nederlandse IC’s gemiddeld 1%) dus
high risk populatie.Vraag is hoe de PPV zal uitvallen in een populatie waarin de
prevalentie lager is
• De NPV in deze populatie bleek 99%. Evengoed geldt echter dat in een populatie
met een zeer hoge voorafkans op invasieve candida infectie (25-50%) de NPV zal
dalen…
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Hoe zit het met de kosten?
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Het effect van de a priori kans
Incidentie 40% 2%
Effect profylaxe 50% reductie 50% reductie Absolute risicoreductie 20% 1% NNT 5 100
Kosten van fluconazol, 50 Euro x 5 dagen = 250 Euro per patiënt
Totale kosten 1250,- Euro 25.000,- Euro per invasieve candidiasis die wordt voorkomen
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Wa kos da?
Geschatte kosten verlengde opname door invasieve candidiasis:
20.000,- Euro Incidentie 40% 2%
Winst: 18750,- Euro Verlies 5000,- Euro
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Dus profylactisch gebruik van fluconazol op een IC waar candida geen groot probleem is kost geld en geeft mogelijk het risico op resistentie.
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Practische leidraad?
1 van: A.b.-gebruik/CVL
+ 2 van: TPN, RRT, major surgery, pancreatitis, steroiden
Zou bij ons meer dan de helft van de patiënten betekenen...
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Praktische leidraad Bij sepsispatienten
>7 dgn op de IC Koorts ondanks a.b. Geen ander focus
2 risicofactoren (>1 a.b.>3dgn, GI surgery, abd process, steroids, imm suppr, DM, RRT)
Kolonisatie
Kweek bloed, urine, sputum Antifungale therapie
Re-evaluatie op dag 3.
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Pre-emptive therapy of Candidemia
Ergosterol
-(1,6)-Glucan
Mannoproteins
-(1,3)-Glucan
GS
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Fungal cell wall and antifungal targets
Ergosterol
-(1,6)-Glucan
Mannoproteins
-(1,3)-Glucan
-(1,3)-Glucan synthesis
GS
Polyenes – bind to ergosterol: Amphotericin B, lipid formulations of Amphotericin B, nystatin
Azoles – inhibit CYP450 enzyme responsible for ergosterol synthesis: Fluconazole,
voriconazole, itraconazole, posaconazole
Echinocandins – inhibit enzyme: Anidulafungin, caspofungin, micafungin
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Forest plot of the pooled sensitivity and specificity of measuring serum or plasma (1→3)-β-D-glucan levels for the diagnosis of proven or probable invasive fungal infections.
Karageorgopoulos D E et al. Clin Infect Dis.2011
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Pre-emptive therapy of Candidemia
• Beta Di Glucan: CII evidence volgens de 2012 ESCMID richtlijn
• Dure test • Waarde van de test sterk afhankelijk van studie populatie
Antonelli, CCM; Leon CCM 2006 and 2009; Ostrovsky 2009; poster ECCMID 2012; Eggiman, Annals of Intensive Care 2011 Bassetti, Crit Care 2010
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Clinical approach for the patient with proven candidaemia
• The ICU patient with a blood culture positive for yeasts
• Species and susceptibility as yet unknown
• Which initial therapy to start?
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Compound Recommendation References Comment
Anidulafungin 200→100 mg A I Reboli NEJM 2007 Kett Int J Antimicrob Agents 2008
Caspofungin 70→50 mg A I Mora-Duarte NEJM 2002 Pappas Clin Infect Dis 2007
Micafungin 100 mg A I Kuse Lancet 2007 Pappas Clin Infect Dis 2007
L-Amphotericin B 3 mg/kg B I Kuse Lancet 2007 Dupont Crit Care 2009
Voriconazole 6→3 mg/kg bid B I
Kullberg Lancet 2005 Ostrosky-Zeichner Eur J Clin Microbiol Infect Dis 2003 Perfect Clin Infect Dis 2003
Fluconazole 800→400 mg B–C I
Anaissie Clin Infect Dis 1996 Rex NEJM 1994 Rex Clin Infect Dis 2003 Philips Eur J Clin Microbiol Infect Dis 1995 Reboli NEJM 2007
AmB lipid complex 5 mg/kg C II Anaissie ICAAC 1995 Ito Clin Infect Dis 2005
AmB deoxycholate 0.7–1 mg/kg
D I
Bates Clin Infect Dis 2001 Anaissie Clin Infect Dis 1996 Rex NEJM 1994 Philips Eur J Clin Microbiol Infect Dis 1995 Mora-Duarte NEJM 2002
Therapy of candidaemia
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Echinocandin success rates in ICU patients
Re
spo
nse
rat
e (
%)
68
56 63
66
46
67
Mic
afu
ngi
n
L-A
mp
ho
teri
cin
B
Cas
po
fun
gin
Am
ph
ote
rici
n B
Flu
con
azo
le
An
idu
lafu
ngi
n
N=97 N=230 N=63
DiNubile et al. J Crit Care 2007;22:237–244; Dupont et al. Crit Care 2009;13:R159; Kett & Cubillos. Int J Antimicrob Agents 2008;32:S99–S102
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Echinocandin mortality rates in ICU patients
45
40 38
35
22
17 Mo
rtal
ity
rate
(%
)
Mic
afu
ngi
n
L-A
mp
ho
teri
cin
B
Cas
po
fun
gin
Am
ph
ote
rici
n B
Flu
con
- az
ole
An
idu
la-
fun
gin
N=97 N=230 N=63
DiNubile et al. J Crit Care 2007;22:237–244; Dupont et al. Crit Care 2009;13:R159; Kett & Cubillos. Int J Antimicrob Agents 2008;32:S99–S102
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Reboli et al. N Engl J Med 2007;356:2472–2482
Anidulafungin candidaemia study
success at EOIVT by pathogen
(N=61) (N=74)
C. albicans
(N=45) (N=45)
Non-albicans
*Patients with a single baseline pathogen
Anidulafungin
Fluconazole
Difference driven by C. albicans infections!
81.1
62.3
71.1
60.0
n=60 n=38 n=32 n=27
75.6
60.2
∆15.4% p=0.009
∆18.8% p=0.015
∆11.1% p=0.26
All patients
80
100
40
60
0
20
Su
ccess (
%)
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Agent Recommendation References Comment
Anidulafungin 200→100 mg
A I Reboli NEJM 2007 Kett Int J Antimicrob Agents 2008
• Broad spectrum • Resistance rare • Fungicidal • Less active against • C. parapsilosis • Safety profile • Few drug–drug interactions
Caspofungin 70→50 mg
A I Mora-Duarte NEJM 2002 Pappas Clin Inf Dis 2007
• As above
Micafungin 100 mg
A I Kuse Lancet 2007 Pappas Clin Inf Dis 2007
• As above
Liposomal AmB 3 mg/kg
B I Kuse Lancet 2007 Dupont Crit Care 2009
• Similar efficacy as micafungin • Greater toxicity
Therapy of candidaemia
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Compound Recommendation References Comment
Voriconazole 6→3 mg/kg bid
B I
Kullberg Lancet 2005 Ostrosky-Zeichner Eur J Clin Microbiol Infect Dis 2003 Perfect Clin Inf Dis 2003
• Limited spectrum compared
with echinocandins
• Drug–drug interactions
Fluconazole 800→400 mg
B-C I
Anaissie Clin Inf Dis 1996
Rex NEJM 1994 Rex Clin Inf Dis 2003
Philips Eur J Clin Microbiol Infect Dis 1995
Reboli NEJM 2007
• Limited spectrum
• Inferior to anidulafungin
• Preferred for C. parapsilosis
AmB lipid complex 5 mg/kg
C II Anaissie ICAAC 1995
Ito CID 2005
AmB deoxycholate 0.7–1 mg/kg
D I
Ullmann Clin Inf Dis 2006
Bates Clin Inf Dis 2001
Anaissie Clin Inf Dis 1996
Rex NEJM 1994 Philips Eur J Clin Microbiol Infect Dis 1995
Mora-Duarte NEJM 2002
• Greater toxicity
Therapy of candidaemia
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Echinocandins chemical structure
Boucher et al, Drugs 2004;64:1997–2020
Caspofungin Glarea lozoyensis
Micafungin Coleophoma empetri
Anidulafungin Aspergillus nidulans
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Pharmacology: metabolism, elimination, bioavailability and protein binding
Anidulafungin Caspofungin Micafungin
Metabolism Non-hepatic chemical degradation
Hepatic metabolism by hydrolysis and
N-acetylation
Spontaneous non-hepatic chemical degeneration
Hepatic metabolism by arylsulfatase and
catechol-O-methyltransferase
Volume of distribution V1 = 10 L V2 = 23 L
V1 = 8 L V2 = 4 L
V1 = 9 L V2 = 8 L
Half-life Around 24 hours 9–11 hours (beta phase) 45 hours (gamma phase)
10–17 hours
Elimination/excretion Urine <1%; Faeces 30% (of which 10%
parent compound)
Urine 41% (of which 1% parent compound)
Faeces 34%
Urine 12% Faeces 71%
Protein binding >99% 93–97% >99%
Oral bioavailability <5% <5% <5%
Loading dose Yes Yes No
Damle et al, Antimicrob Agents Chemother 2009;53:1149–1156; Dodds Ashley et al, Clin Infect Dis 2006;43:S28–S39; Anidulafungin EMA SPC, Caspofungin EMA SPC; Micafungin EMA SPC; Dowell et al, J Clin Pharmacol 2004;44:590–598; Wurtwein et al, Antimicrob Agents Chemother 2012;56:536–543; Ikawa et al, Antimicrob Agents Chemother 2009;64:840–844
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Interacting drug
Anidulafungin Caspofungin Micafungin
Effect on interacting drug
Effect on anidulafungin
Effect on interacting drug
Effect on caspofungin
Effect on interacting drug
Effect on micafungin
Ciclosporin – Increased AUC by 21% – Increased AUC by 35% – –
Itraconazole Not determined Not determined – – Increased AUC
by 22% –
Mycophenolate mofetil
Not determined Not determined – – – –
Nifedipin Not determined Not determined Not determined Not determined Increased AUC
by 18% –
Posaconazole Not determined Not determined – – – –
Prednisolone Not determined Not determined Not determined Not determined – –
Rifampicin (enzymatic inducers)
– – Not determined 60% increased on day 1;
30% decreased on day 14 –
Sirolimus Not determined Not determined Not determined Not determined Increased AUC
by 21% –
Tacrolimus – – Reduced Cmin
by 26% – – –
Voriconazole – – Not determined Not determined – –
Drug interactions for echinocandins
Anidulafungin EMA SPC, Caspofungin EMA SPC; Micafungin EMA SPC; Dowell et al, J Clin Pharmacol 2005;45:227–233; Dowell et al, J Clin Pharmacol 2005;45:1373–1382; Keirns et al, Antimicrob Agents Chemother 2007;51:787–790; Krishna et al, J Clin Pharmacol 2011;51:84–92; Stone et al, Antimicrob Agents Chemother November 2004;48:4306–4314; Scientific discussion section Cancidas, Mycamine and Ecalta http://www.ema.europe.eu
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No dose adjustment of echinocandins in renal failure
Dowell et al, J Clin Pharmacol 2007;47:461–70; Hebert et al, J Clin Pharmacol 2005;45:1145–1152; Caspofungin data available at scientific discussion section Cancidas http://www.ema.europe.eu
Caspofungin similar to anidulafungin and micafungin. Caspofungin does not require dose-adaptation in renal failure. An increase in AUC of 31, 49 and 30 % was observed, respectively, in moderate, severe and end stage renal disease (n=36 with 70 mg single dose).
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Influence of hepatic dysfunction
Dowell et al, J Clin Pharmacol 2007;47:461–470; Hebert et al, J Clin Pharmacol 2005;45:1145–1152; Mistry et al. Clin Pharmacol 007;47:951–961
** For the calculation of micafungin clearance, a body weight of 70 kg was used
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Clinical approach for the patient with proven candidaemia
• The ICU patient with a blood culture positive for yeasts
• Should CVC be removed?
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Intravascular catheters and candidaemia
The debate goes on …
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Does removal decrease mortality?
Australia (n=266)
Removal of central
venous catheter within
5 days decreased
mortality (p < 0.01)
0 10 20 30
1.00
0.75
0.50
0.25
0.00
Analysis time (days)
Catheter removed after diagnosis Catheter not removed after diagnosis
Survivor function for removal of catheter
No, mortality not reduced:
• Rodriguez Clin Microbiol Infect 2007
• 172 patients (any antifungal, 2002–2003)
No, mortality not reduced:
• Vos & Oude Lashof (unpublished)
• 370 patients on voriconazole vs AmB→Flu
Slavin et al. J Antimicrob Chemother 2010
Pro
bab
ility
of
surv
ival
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Recent large dataset: remove CVC or not?
Nucci et al.
• Data from pivotal micafungin trials
• Micafungin 100 mg versus liposomal amphotericin B
• Micafungin 100 mg versus micafungin 150 mg versus caspofungin
• Total dataset: n=842
Multivariate analysis: outcome and mortality not affected by CVC removal
• CVC became irrelevant
• OR for cure: 1.20 (95% CI 0.89–1.69)
• OR for survival: 1.25 (95% CI 0.88–1.75)
• Outcomes and mortality driven by APACHE II score, age and persistence of
neutropenia
Hypothesis: Echinocandins sterilise the catheter as they are active in biofilms
Nucci et al. Clin Infect Dis 2010;51:295–303
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Catheter management
• 1915 patients, individual patient-level pooled analysis
• Overall mortality, CVC retention 41% versus CVC removal 28% (p <0.0001)
APACHE II Quartile
Survivor function for removal of catheter
Mo
rtal
ity
(%)
100
80
60
40
20
0
1 2 3 4
Retained Removed
*
*
*
Andes, Kullberg, et al. Clin Infect Dis 2012
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Population Intervention Recommendation References
Non-neutropenic patients with candidaemia
Remove intravascular catheters
B II Andes CID 2012 Nucci CID 2010 Liu J Infect 2009 Weinberger J Hosp Inf 2005 Leroy Crit Care Med 2009 Rex CID 1995 Almirante J Clin Microbiol 2005 Rodriguez Clin Microbiol Infect 2007 Kucharikova Antimicrob Agents Chemother 2010 Kuhn Antimicrob Agents Chemother 2002 Mukherjee Int J Antimicrob Agents 2009
Catheter management
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Samenvattend
• Recommendations for prophylaxis, empirical therapy, or the use of β-
glucan or other biomarkers do not significantly differ from previous guidelines
• Echinocandins as the first choice for treatment of candidaemia/invasive candidiasis in most patients
• CVC removal is recommended independently of antifungal choice
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Dank voor jullie aandacht!