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Changing Epidemiology: The Importance of Broad Spectrum Therapeutics

Changing Epidemiology: The Importance of Broad Spectrum Therapeutics . Cornelia Lass-Flörl Innsbruck Medical University. Candidiasis. Aspergillosis. Incidence of Fatal Invasive Mycoses in USA. Mc Neil et al 2001 Clin Infect Dis 33;641. Incidence of Invasive Mycoses .

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Changing Epidemiology: The Importance of Broad Spectrum Therapeutics

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  1. Changing Epidemiology: The Importance of Broad Spectrum Therapeutics Cornelia Lass-Flörl Innsbruck Medical University

  2. Candidiasis Aspergillosis Incidence of Fatal Invasive Mycoses in USA Mc Neil et al 2001 Clin Infect Dis 33;641

  3. Incidence of Invasive Mycoses Incidence per 100.000 population Pfaller, ICAAC M 1805, 2006

  4. The medically most important opportunistic mycoses in Europe are caused by Aspergillus spp. and Candida spp. Aspergillus spp.A.fumigatus is the most common etiologic agent (80-90%), other species are A.flavus (10-15%), A.terreus (2-5%), A.niger (1-2%). Candida spp.C. albicans, with an increasing incidence of C. glabrata , C. tropicalis and C. krusei. Kullberg et al. Epidemiology of opportunistic invasive mycosis. Europ. J Med. Research, 2002

  5. Candida Species

  6. Nosocomial Bloodstream Infections in US Hospitals: 1995-2002 BSI=blood stream infection. Surveillance and Control of Pathogens of Epidemiologic Importance (SCOPE) study. Wisplinghoff H, et al. Clin Infect Dis. 2004;39:309-317.

  7. Incidence & Distribution of Candidemia (1999-2003) in San Martino Hospital ICU Number of isolates (% of species) Bassetti M et al. BMC Infectious Diseases 2006:1-6.

  8. Sub-optimal fluconazole dosing Pan-azole resistance Over 10 years, the frequency of C. glabrata increased in Canada, 13-24% Europe, 11-13% USA, 14-28% Least common in Latin America (7.5%) Candida glabrata Pfaller 2006, Bhatti 2006, Pfaller 2007

  9. 2nd most common species in blood, related to catheters and glucose solutions Causes biofilms which usually require removal of catheters etc, as antifungal drugs are ineffective in eradicating biofilms Biofilms and Candida parapsilosis Pfaller 2006, Pfaller 2007

  10. C. albicans C. glabrata C. tropicalis C. parapsilosis C. krusei Other species Evolution of Isolation of Candida Species in Relation to Fluconazole Consumption Sendid B et al. BMC Infectious Diseases 2006:61-9.

  11. “Aspergillus and the Others…”

  12. Invasive Aspergillosis in Transplant Recipients Singh & Paterson. Clin Microbiol Rev. 2005 18:44-69.

  13. Aspergillus – 38 species have Caused Disease

  14. Asp.spp A.terreus zygomycosis Invasive Proven Mould Infections, LKI Lass-Flörl, 2005, additional unpublished data added

  15. 27% of proven infections are due to zygomycetes Lass-Flörl et al,submitted, 2007

  16. Vulnerable populations Malignancy Bone marrow transplantation Solid organ transplantation Corticosteroid exposure GvHD CMV reactivity neutropenia Diabetes mellitus Initial presentation with sinusitis Occurrence as breakthrough prior VRC prophylaxis 56% mortality Zygomycosis others… Fusarium sp. Penicillium sp. Trichosporon sp. Marr, CID 2002 Steinbach, J Infect 2004 Roden, et al. Clin Inf Dis 2005;41:634-53. Kontoyiannis et al. JID, 2005; 191:1350-60. Siwek et al. CID 2004; 39:584-87.

  17. Antifungal MICs (µg/ml) againstClinical Isolates of Zygomycetes Sun QN et al. AAC 2002; 46: 1581–1582.

  18. Environment as a Risk FactorFungus at Home • Hospital construction is known to increase cases of IA • HEPA filtration is known to decrease cases of IA • Aspergillus may be found in patient showers… genetically identical to the one from the patient! • Highest concentration of Aspergillus fumigatus is at home • Protective environment for pts with allo-BMT now included in the new draft CDC guidelines for isolation Williamson, Thorax 1997;52:229. Taskinen, Acta Paediatr 1999; 88:1373. Oren, Am J Hematol 2001; Anaissie, CID 2002.

  19. Variables that Account for the Current Trends in the Epidemiology • Increasing number of susceptible hosts: transplant type • Center to center differences, patient selection • Greater laboratory expertise in detection & identification of fungi • Use of new transplant modalities for hematopietic stem cell transplantation • Changing surgical techniques: evolution in organ transplant practices • Use of corticosteroid-sparing regimens and overall conservative approach to immunosuppression • Use of novel immunosuppressive agents • Antimicrobial prophylactic practices • Underlying Diseases • Poor diagnostic tools Singh 2001; Denning 2005, Kontoyiannis 2005, Lass-Flörl 2005

  20. …turning risk factors and local epidemiology into useful information! Thank you for your attention!

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