Improved Radiographic Imaging of Invasive Fungal Disease: The Cornerstone to Antifungal Stewardship in the Hematology Units?

Stanzani, Marta; Sassi, Claudia; Battista, Giuseppe; Cavo, Michèle; Lewis, Russell E.

doi:10.1007/s12281-016-0258-1

Cited by 6 publications

(6 citation statements)

References 57 publications

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“…the halo sign), cavitation or an air crescent sign 60 . However, these typical signs are often transient, 60,61 and atypical radiographic findings may be present in patients at varying levels of immunocompromise, in the presence or absence of antifungal prophylaxis, 62 and in children 63 . Atypical appearances include patchy consolidation or ground‐glass change without nodules 62 .…”

Section: Question 3: How Has Thoracic Imaging and Other Types Of Imaging In Ia Improved?mentioning

confidence: 99%

Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021

Douglas

Smibert

Bajel

et al. 2021

Internal Medicine Journal

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Invasive aspergillosis (IA) in haematology/oncology patients presents as primary infection or breakthrough infection, which can become refractory to antifungal treatment and has a high associated mortality. Other emerging patient risk groups include patients in the intensive care setting with severe respiratory viral infections, including COVID‐19. These guidelines present key diagnostic and treatment recommendations in light of advances in knowledge since the previous guidelines in 2014. Culture and histological‐based methods remain central to the diagnosis of IA. There is increasing evidence for the utility of non‐culture methods employing fungal biomarkers in pre‐emptive screening for infection, as well as for IA diagnosis when used in combination. Although azole resistance appears to be uncommon in Australia, susceptibility testing of clinical Aspergillus fumigatus complex isolates is recommended. Voriconazole remains the preferred first‐line antifungal agent for treating primary IA, including for extrapulmonary disease. Recommendations for paediatric treatment broadly follow those for adults. For breakthrough and refractory IA, a change in class of antifungal agent is strongly recommended, and agents under clinical trial may need to be considered. Newer immunological‐based imaging modalities warrant further study, while surveillance for IA and antifungal resistance remain essential to informing the relevance of current treatment recommendations.

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Section: Question 3: How Has Thoracic Imaging and Other Types Of Imaging In Ia Improved?mentioning

confidence: 99%

Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021

Douglas

Smibert

Bajel

et al. 2021

Internal Medicine Journal

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“…Notwithstanding these limitations, CT acts as a prompt for instigating antifungal treatment in numerous hematology units, with HRCT providing opportunities for improved antifungal stewardship ( Stanzani et al, 2016 ). Reductions in the unnecessary use of antifungal drugs have been reported in centers using HRCT to drive treatment strategies in allogeneic transplant patients who have persistent febrile antibiotic-resistant neutropenia ( Dignan et al, 2009 ).…”

Section: Aspergillosis Imaging With Computed Tomography and Magnetic mentioning

confidence: 99%

“…Several studies have indicated that [ 18 F]FDG might be useful for imaging fungal infections ( Sharma et al, 2014 ), for differentiating between non-invasive and invasive aspergillosis ( Kim et al, 2013 ), for identification of extra-pulmonary sites of infection ( Chamilos et al, 2008 ), and for therapy monitoring ( Ho et al, 1998 ; Ozsahin et al, 1998 ; Franzius et al, 2001 ; Stanzani et al, 2016 ). However, a recent study by Rolle et al (2016) , which employed PET and MRI (PET/MRI) to detect lung infections by A. fumigatus in vivo , showed that the increase in [ 18 F]FDG uptake during Aspergillus lung infection could not be distinguished from that seen during sterile inflammation or during bacterial lung infections caused by Streptococcus pneumonia or Yersinia enterocolitica , further demonstrating the lack of specificity of this tracer which has been reported elsewhere ( Petrik et al, 2014 ).…”

Section: Aspergillosis Imaging With [ 18 F]fdg Posmentioning

confidence: 99%

Molecular Imaging of Invasive Pulmonary Aspergillosis Using ImmunoPET/MRI: The Future Looks Bright

Thornton

2018

Front. Microbiol.

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Invasive pulmonary aspergillosis (IPA) is a life-threatening lung disease of immuno-compromised humans caused by the ubiquitous environmental mold Aspergillus. Biomarker tests for the disease lack sensitivity and specificity, and culture of the fungus from invasive lung biopsy is slow, insensitive, and undesirable in critically ill patients. A computed tomogram (CT) of the chest offers a simple non-intrusive diagnostic procedure for rapid decision making, and so is used in many hematology units to drive antifungal treatment. However, radiological indicators that raise the suspicion of IPA are either transient signs in the early stages of the disease or not specific for Aspergillus infection, with other angio-invasive molds or bacterial pathogens producing comparable radiological manifestations in a chest CT. Improvements to the specificity of radiographic imaging of IPA have been attempted by coupling CT and positron emission tomography (PET) with [18F]fluorodeoxyglucose ([18F]FDG), a marker of metabolic activity well suited to cancer imaging, but with limited use in invasive fungal disease diagnostics due to its inability to differentiate between infectious etiologies, cancer, and inflammation. Bioluminescence imaging using single genetically modified strains of Aspergillus fumigatus has enabled in vivo monitoring of IPA in animal models of disease. For in vivo detection of Aspergillus lung infections in humans, radiolabeled Aspergillus-specific monoclonal antibodies, and iron siderophores, hold enormous potential for clinical diagnosis. This review examines the different experimental technologies used to image IPA, and recent advances in state-of-the-art molecular imaging of IPA using antibody-guided PET/magnetic resonance imaging (immunoPET/MRI).

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“…83 Interestingly, Stanzani and colleagues have proposed a radiology-driven diagnostic algorithm as an alternative to non-culture-based biomarkers since the "occluded vessel" sign seen on CT pulmonary angiography (CTPA) in patients with hematologic malignancies and proven or probable IA appears to have similar diagnostic performance (sensitivity 83%, specificity 93%) to serum GM. 84 Patients at their institution first undergo individualized risk assessment using a weighted risk prediction score to discriminate between those at low (<1 % incidence) or high (>5 % incidence) risk for mold infection. 85 While low-risk patients are "screened out" from intensive diagnostic monitoring or mold-directed antifungal prophylaxis, high-risk patients who develop fever undergo chest CT plus/minus pulmonary angiography within 72 hours.…”

Section: Improving Diagnosis Of Invasive Aspergillosismentioning

confidence: 99%

“…As outlined in their protocol, patients with a positive "occluded vessel" sign during CTPA or a "halo" sign when CTPA cannot be performed are initiated on systemic antifungal therapy, whereas those with nonspecific pulmonary infiltrates may receive a short course of empiric antifungal therapy and be considered later for antifungal de-escalation. 84 Data on the effectiveness and generalizability of this approach are certainly needed.…”

Section: Improving Diagnosis Of Invasive Aspergillosismentioning

confidence: 99%

Antifungal stewardship considerations for adults and pediatrics

2016

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Antifungal stewardship refers to coordinated interventions to monitor and direct the appropriate use of antifungal agents in order to achieve the best clinical outcomes and minimize selective pressure and adverse events. Antifungal utilization has steadily risen over time in concert with the increase in number of immunocompromised adults and children at risk for invasive fungal infections (IFI). Challenges in diagnosing IFI often lead to delays in treatment and poorer outcomes. There are also emerging data linking prior antifungal exposure and suboptimal dosing to the emergence of antifungal resistance, particularly for Candida. Antimicrobial stewardship programs can take a multi-pronged bundle approach to ensure suitable prescribing of antifungals via postprescription review and feedback and/or prior authorization. Institutional guidelines can also be developed to guide diagnostic testing in at-risk populations; appropriate choice, dose, and duration of antifungal agent; therapeutic drug monitoring; and opportunities for de-escalation and intravenous-to-oral conversion.

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Improved Radiographic Imaging of Invasive Fungal Disease: The Cornerstone to Antifungal Stewardship in the Hematology Units?

Cited by 6 publications

References 57 publications

Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021

Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021

Molecular Imaging of Invasive Pulmonary Aspergillosis Using ImmunoPET/MRI: The Future Looks Bright

Antifungal stewardship considerations for adults and pediatrics

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