IMPORTANCE OF RISK FACTOR IN DIAGNOSIS ......Page 30 Transmission and risk group •Transmission:...
Transcript of IMPORTANCE OF RISK FACTOR IN DIAGNOSIS ......Page 30 Transmission and risk group •Transmission:...
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Outline
Burden of SFI – the magnitude of the problem
Epidemiology – who, where & when
Risk factors & risk groups
Aspergillosis and Candidiasis
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THE BURDEN OF INVASIVE FUNGAL INFECTION
Invasive fungal infections tend to be under-
diagnosed
This is partly because of non-specific signs &
symptoms
Unrecognised/untreated IFI could cause death
A significant number recognised only at autopsy
So, a high index of clinical suspicion is required.
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• Diagnosis of IFI is difficult, with the sensitivity of the
gold standard tests (culture and histopathology) often
<50%.
• Therefore, physicians rely on a constellation of
clinical signs, radiography, culture, histopathology and
adjunctive tests to establish diagnosis
British Journal of Haematology, 139, 519–531
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Treatment of IFI: the earlier the better
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Fungal infection
• Fungal infection may knowed as mysterious and dangerous diseases, even they are often caused by fungi that are common in the environment.
• Fungi can be found in soil, on plants, trees, and other vegetation, and on our skin, mucous membranes, and intestinal tracts.
• Most fungi are not dangerous, and some can even be helpful – for example: penicillin, bread, wine, and beer use ingredients made from fungi.
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Fungal infection
• The symptoms of fungal diseases depend on the type of infection and location within the body.
• Some types of fungal infections can be mild, such as a rash or a mild respiratory illness. However, other fungal infections can be severe, such as fungal pneumonia or bloodstream infection, and can lead to serious complications such as meningitis or death.
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Characteristics fungal infection
• Predisposed in pts with
immunodeficiency
• Reactivated
• More frequent in pts with systemic
infection
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Clinical suspected to invasive
fungal infections
• Persistent fever unresponsive to broad spectrum
antibiotics in high risk patients
• Macronodular cutaneous lession (Candidiasis)
• New pulmonary infiltrate on CXR (Aspergillosis)
• Hallo sign on CT scan or mycotic lession
• Colonization Candida or Aspergillus
• Positive serology test
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Beware of fungal infections
PERSISTENT / RECURRENT FEVER, - Pulmonary infiltrates
- Neutropenia > 7 days
- Adequate AB > 3 d
- Eosinophilia
- Elevated IgE
PREDISPOSING FACTORS
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PREDISPOSING / RISK FACTORS
• Broadspectrum antibiotics
• CVC
• Parenteral nutrition
• Hemodialysis
• Neutropenic pts
• Implantable prosthetic devices
• Immunosuppressive agents and
• Immunomodulators 15
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Normal individual against
infection
• Anatomical barrier
–Skin barrier and mucosal
barrier
• Immune system
–Phagocyte
–Complement
–Cell mediated immunity
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INVASIVE FUNGAL INFECTIONS IN RELATION TO IMMUNE
DEFENSE
compromised defense severely compromised
external fungal population
our body
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Immune Response in Fungal Infections
(Playfair JHL, Immunology at a glance, 1996)
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The others factor could be
influence in fungal infection
• Neonates : weaker
• Invasive procedure ; Catheterization
• Antibiotics
• Environments :
– Cryptococcus spp – bird dropping
– Hospital environments : water supply, hospital
food, toilet, unclean sinks, flower, plant,
parenteral nutrition, room, hospital equipment
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Epidemiolgy
• Assesing incidence and prevalence of IFI
is difficult --- autopsy
• Overall incidence of nosocomial IFI has
increases 2 times in the two last decade
• The incidence of community acquired
infection by cryptococcus neoformans has
increases
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Increases in the prevalence of
systemic Candida infections
Bassetti M, et al. BMC Infect Dis 2006; 6:21
Inci
den
ce o
f ca
nd
idae
mia
(e
pis
od
es/1
0,00
0 p
atie
nt-
day
s/y
ear)
Year
1999
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
2000 2001 2002 2003
Europe Data
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MORTALITY DUE TO INVASIVE
MYCOSES McNeil et al. Clin Infect Dis 2001;33:641-7
0
0,2
0,4
0,6
Rate
per
100,0
00 p
op
ula
tio
n
United States, 1980-1997
Mycoses other than Candida albicans
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1999 2000 2001 2002 2003
0
0,5
1
1,5
2
2,5
3
3,5
Inc
ide
nc
e (
%)
DEVELOPMENT OF FUNGAL INFECTIONS
OVER TIME
other moulds
Aspergillus
Candida
other yeasts
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Increasing rate of
candidiasis in the US
Martin et al, NEJM 2003;348:1546
+300%
+300%
+600%
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nu
mb
er
of
ca
se
s
0
100
200
300
400
Lethality Of The Various Invasive
Fungal Infections
cases casualties
42%
61% 53%
33%
50% 29%
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487 FUNGAL INFECTIONS IN
TRANSPLANT RECIPIENTS
Pappas et al. ICAAC, Chicago 2003; abstr M-1010
Candida
Aspergillus and other moulds
Crypto Endemic Pneumocystis
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BASIC RISK FACTORS FOR FUNGAL INFECTIONS
immuno-
suppression
epidemiologic
exposure
technical / anatomic factors
Adapted from RH Rubin, Boston
OPPORTUNISTS!
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Figure 1: A generalized diagram displaying
infection and disease cycle caused by fungi and
oomycetes.
Mentions: In this review, we summarize common
mechanisms of pathogenesis displayed by
oomycetes and fungi. Pathogenesis by a fungus or
oomycete is a complex process. Briefly, it includes
the following steps: dispersal and arrival of an
infectious particle (usually a spore of some kind) in
the vicinity of the host, adhesion to the host,
recognition of the host (which may occur prior to
adhesion), penetration into the host, invasive
growth within the host, lesion development in the
host, and finally production of additional infectious
particles [5,6] (see Figures 1, 2). In order to
describe the entire process, we formulate a
description of pathogenesis using standardized
terms from the Gene Ontology (GO), including 256
new terms developed by members of the PAMGO
(Plant-Associated Microbe Gene Ontology)
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Transmission and risk group
• Transmission: – Occurs through inhalation of airborne conidia.
– Nosocomial infections : dust exposure
– Occasional outbreaks of cutaneous infection : traced by
contaminated biomedical devices.
• Risk groups: – Severe/prolonged granulocytopenia,
– Hematologic malignancies,
– HIV/AIDS.
– Other risk factors include receipt of hematopoietic stem cell or
solid organ transplants and taking high-dose corticosteroids or
other immunosuppressive therapies.
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PATIENTS RISK GROUP
• Abdominal surgery
• HIV /AIDS
• Auto immun
diseases
• Burn
• Gastroenterology
• Infectious
diseases
• Patients in ICU
• Neonatalogy
• Oncology
• Pulmonology
• Radiotherapy
• Rheumatolgy
• Transplantation
• Prolonged steroid
treatment
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Risk factors fungal
infection
• Surgery : Disruption of normal barrier
• HIV /AIDS : Destroy CD4
• Chronic granulomatous diseases:
Defective neutrophile phagocyte cell
• Immunosuppressive drugs : Steroid,
cyclosporine
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Malignancies patients
o Immunosuppressive drugs :
lymphophenia
o Myelosuppresive chemotherapy
Netropenia
Disease
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Risk (critical illness)
• Prolonged antibiotic use
• CVP
• Prolonged stay in ICU
• Renal failure and hemodialysis
• TPN
• Abdominal surgery
• Immunosuppression
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Catagories
• Opportunistic infections : Cryptococcosis
Aspergillosis
Are becoming increasingly problematic as the number of people
with weakened immune systems rises, this includes cancer
patients, transplant recipients, and people with HIV/AIDS.
• Hospital-associated infections : Especially candidemia are a leading cause of bloodstream
infections.
Advancements and changes in healthcare practices can provide
opportunities can emerge the fungal infection in hospital settings.
• Community-acquired infections: Coccidioidomycosis
Blastomycosis
Histoplasmosis
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Candidiasis
• Candidiasis is a fungal infection caused by yeasts that belong to the
genus Candida.
• There are over 20 species of Candida yeasts that can cause infection
in humans, the most common of which is Candida albicans.
• Candida yeasts normally live on the skin and mucous membranes
without causing infection; however, overgrowth of these organisms
can cause symptoms to develop.
• Symptoms of candidiasis vary depending on the area of the body that
is infected.
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SPECTRUM FUNGAL
INFECTION
• Spectrum fungal infection has changed
• C.Albicans : 1980 (75%)-1995 (60%)
• 1987-1992 :
– C.Albicans : 87-30%
– C.Glabrata : 2-26%
– C.parapsiosis : 9-20%
– C.Tropicalis : 2-24%
j.maertens,european journal of cancer care,2001,10
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Epidemiology of candidemia
Tortorano Trick Diekema Richet Pfaller Marchetti
(n=569) (n=2759) (n=254) (n=377) (n=1134) (n=1137)
J Hosp Infect CID J Clin Microbiol CMI J Clin Microbiol CID
2002 2002 2002 2002 2002 2004
C.alb icans 58,50% 59% 58% 53% 55% 66%
C.glabrata 12,80% 12% 20% 11% 15% 15%
C.parapsilosis 14,60% 11% 7% 16% 15% 1%
C.tropicalis 6,10% 10% 11% 9% 9% 9%
C.krusei 0,90% 1,20% 2% 4% 1% 2%
Miscellaneous 7,10% 7% 2% 6% 1% 7%
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Aspergilosis
• Aspergillus is a common fungus that can be found in
indoor and outdoor environments.
• Most people breathe in Aspergillus spores every day
without being affected.
• Aspergillosis is usually occurs in people with lung
diseases or weakened immune systems.
• The spectrum of illness :
Allergic reactions,
Lung infections,
And infections in other organs
• From the population-based data the infection rate of 1 to
2 cases per 100,000 people per year.
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Clinical features
• Immunosuppressed hosts:
Invasive pulmonary infection, usually with
fever, cough, and chest pain. Infection may
disseminate to other organs, including brain,
skin and bone.
• Immunocompetent hosts: Localized
pulmonary infection in people with underlying
lung disease, allergic bronchopulmonary
disease, and allergic sinusitis.
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Etiologic and
reservoir
• Etiologic Agent: Aspergillus fumigatus,
Aspergillus flavus,
and less commonly A. terreus, A. nidulans, and A.
niger.
• Reservoir: Aspergillus is ubiquitous in the
environment; it can be found in soil, decomposing plant
matter, household dust, building materials, ornamental
plants, food, and water.
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• Early treatment initiation in patients with IFIs has a
profound impact on mortality rates, but reliable diagnostic
measures are lacking.
• Identifying high-risk patients is the first step in reducing IFI-
related mortality.
• Early diagnosis of IFIs is imperative to facilitate treatment
success.