Declaring War on Aspergillus

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http://www.medscape.com/viewarticle/419290

41st Interscience Conference on Antimicrobial Agents and Chemotherapy |

Fungal Infections

Declaring War on Aspergillus

Ostrosky-Zeichner, MD H. Rex, MD Disclosures

Invasive pulmonary aspergillosis and disseminated aspergillosis are

life-threatening infections that affect immunocompromised hosts. Particular

patients at risk include those with hematological malignancies (on and off

of chemotherapy as well as those with and without bone marrow transplant),

solid tumors, AIDS, and organ transplant recipients.[1] The incidence of

this dreaded complication has steadily risen in the past few decades to a

point of nearly doubling. This phenomenon is believed to be in direct

relation to the number of vulnerable patients surviving longer and to the

use of more powerful immunosuppressive agents and technologies.[2,3]

Attributable mortality from invasive aspergillosis has been reported as high

as 85% and gross mortality as high as 95%, even with optimal therapy.[4,5]

All these factors have caused the biomedical community to take a closer look

at this disease.[6]

The state-of the-art until a few years ago was to start amphotericin B at

the highest tolerated dose as soon as the infection was suspected or

detected, provide aggressive supportive care, and hope for the best.

Guidelines have been written on the subject and are available online.[7]

Fortunately, as the problem of invasive aspergillosis has been recognized,

intensive research has focused on it, making it a completely different

disease to treat in 2002. War has now been declared on this infection. This

review will focus on key advances in the field, with an emphasis on those

presented at the 41st ICAAC.

One recent finding is that not all aspergilli are created equal. The ability

to correctly characterize and identify the different Aspergillus species has

become useful, since we now know that some species respond better to

amphotericin B and the other agents, and some do not. Such is the case of

Aspergillus terrreus, which responds poorly to amphotericin B; as soon as it

is identified, therapy should be switched to other agents.[8]

Another important advance has been the ability to " fingerprint " Aspergillus

isolates and study their epidemiology. This has allowed researchers and

clinicians to pinpoint the sources of Aspergillus as well as study possible

transmission mechanisms and outbreaks. Recent theories state that

Aspergillus may be transmitted by water, both inside and outside the

hospital, although strains from patients and environmental samples often do

not match.[9,10]

Along this line, we must mention an international cooperation effort, the

Aspergillus genome project. This large-scale project should shed light on

the pathogenic mechanisms of Aspergillus and provide several new therapeutic

targets.

Advances in Diagnosis

Development of Clinical and Radiologic Diagnostic Criteria

Perhaps one of the most important advances in the field in recent years is

the development of radiologic and clinical diagnostic criteria.

Microbiologic diagnosis has been unrewarding, since the blood cultures are

generally negative in disseminated infection and one gets confusing results

when culturing nonsterile sites.[11,12] Traditionally, diagnosis has been

done by biopsy, but this often causes a delay or simply it cannot be done

due to the conditions of the patients or coagulation problems.

High-resolution computed tomography of the chest offers the possibility to

detect distinct lesions or signs that are typical of the infection and

appear relatively early in the course of the disease. These lesions are

small nodules, small pleural-based lesions with straight edges and

surrounding attenuation (the " halo sign " ), and the cavitation of those

lesions, which in turn gives a characteristic " air-crescent "

appearance.[13,14] Magnetic resonance imaging is also an important tool in

diagnosing central nervous system disease.[15]

Recently, the Mycoses Study Group (MSG) of the United States and the

European Organization for Research and Treatment of Cancer (EORTC) reached a

consensus of diagnostic criteria that classifies the disease as possible,

probable, or proven. The classification is dynamic, since it relies on host

factors (or risk factors), culture results, histopathology (when available),

and clinical findings. The group recently published their consensus

statement in Clinical Infectious Diseases.[16] Although not meant for

clinical diagnostic use, these criteria will be useful for clinical studies.

These criteria also capture much of the thinking about ways to support the

diagnosis of aspergillosis. Nevertheless, as explained above, it is always

useful to obtain a tissue sample and to culture it in order to differentiate

or confirm the organism. This is particularly important with the

availability of new antifungal agents of narrower spectrum than amphotericin

B, whose utility outside of aspergillosis is nonexistent or has not been

adequately explored, such as the case of echinocandins or the new azoles.

Serodiagnostics

Serodiagnostics is an exciting new way to diagnose aspergillosis. With

newer, reliable, and easier assays, the focus has turned to surveillance,

early detection, and preemptive treatment. This approach to intervention is

not much different from, and can be as successful as, cytomegalovirus

antigenemia surveillance in the same population.

Early attempts for serodiagnostic exams for aspergillosis were plagued by

the lack of sensitivity and specificity, as well as a paucity of reliable,

standardized antigens, antibodies, and methods to detect them.[17,18] The

past few years have seen the rise of a useful tool in this area: the

galactomannan assay.

Galactomannan is a polysaccharide component of the fungal cell wall that,

while not specific to Aspergillus, seems to be highly conserved. An

enzyme-linked immunosorbent assay-based assay has been developed to

quantitatively and reliably detect galactommanan in serum and other body

fluids (eg, pleural fluid, urine, and cerebrospinal fluid) in about 4

hours.[19-22] A kit is commercially available in Europe and is in process

for Food and Drug Administration (FDA) licensure in the United States. A

test result above 1.5 is considered to be positive, while results between

1.0 and 1.5 are intermediate. Sensitivity and specificity are > 90% at this

cut-off. An alternative cut-off of 0.7 was proposed in a study presented by

V. Letscher-Bru and colleagues for non-bone marrow transplant

recipients.[23]

Causes for false positives with the galactomannan test include infections by

Paelomyces and Penicillium, environmental contamination of kit materials,

presence of mold in the patients' food and drinks, and more important, the

use of mold-derived antibiotics, such as penicillin.[24-26] Although the

test is not very sensitive, serial determinations that show an increasing

trend or repeated positive samples are the key to successful use of this

test. Other antigen detection assays, such as beta-glucan (another component

of the fungal cell wall), have not yet proven to be useful for this disease

but are under intense investigation.[27]

PCR

Polymerase chain reaction (PCR) to amplify fragments of the Aspergillus

genome is an attractive strategy for a quick and accurate diagnosis. It can

be performed on sputum and several body fluids. Despite its technical

difficulties and technological requirements, it has proven to be a very

sensitive and specific technique. The problem with this strategy, as with

any highly sensitive test, is the high rate of false positives. Many studies

and publications in the past years have concentrated on exploring which

primer works best for diagnosis.[28-31]

PCR is also an important research tool. Researchers from Merck Research

Laboratories presented an animal model in which products of genetic

amplification -- named " conidial equivalents " -- correlated much better with

disease severity than the traditional colony unit organ counts in an organ

clearance model of disseminated disease. This model uses TaqMan technology

and should prove to be a valuable research technique, since colony-forming

unit counts for this disease are highly unreliable and do not correlate with

survival.[32] The next generation of research assays, destined to evaluate

new antifungals in ways not previously available, is now here.

Advances in Therapy

Lipid Formulations of Amphotericin B

While the current standard of care for invasive or disseminated

aspergillosis has been amphotericin B deoxycholate, experience has

accumulated in recent years favoring the use of lipid-based formulations of

amphotericin B, since they are at least as effective, and considerably less

toxic.[33-35] They offer the ability to administer and deliver higher doses

of amphotericin B before toxicities are seen. Although they have much less

nephrotoxicity than amphotericin B deoxycholate, they do have some renal

toxicity as well as other side effects, and they should be used with

care.[36,37] Physicians express economic concerns about their widespread

use, but recent studies have indeed shown that the cost (both economical and

in morbidity) of the nephrotoxicity seen with amphotericin B deoxycholate

favors the use of the lipid formulations.[37-39]

Intravenous Itraconazole

The introduction of intravenous itraconazole has also given us a new

therapeutic choice, with response rates of about 50%, which aren't much

different from those seen with other current agents.[40,41] The main problem

with itraconazole is its drug interactions at the cytochrome P-450 level, as

well as limited pharmacokinetic knowledge of its carrier molecule:

cyclodextrin. However, important advances in the field of prophylaxis have

been made with this drug, since it reliably provides the blood levels that

are required to adequately prevent fungal infections in populations at high

risk. A meta-analysis presented at the meeting by Glasmacher and colleagues

proved its utility for that purpose.[42]

Echinocandins

Perhaps one of the biggest news stories in the field of medical mycology

this past year was the FDA licensure of caspofungin for the treatment of

refractory or intolerant invasive aspergillosis. This was based on a small

clinical trial, in which patients experienced a salvage response rate of

about 40%. Caspofungin and the other echinocandins (micafungin and

anidulafungin) seem to be active against this organism in vitro and in

animal models, and clinical experience is rapidly accumulating. Toxicities

are minimal (mostly infusion-related reactions), and the drug requires dose

adjustment only for severe cirrhosis but not for any level of renal

impairment.[43-45]

Voriconazole and the New Azoles

Voriconazole, a congener of fluconazole, has also been a big newsmaker. This

new agent has excellent in vitro activity against Aspergillus and Candida

species, and clinical experience with it has also been encouraging. R.

Herbrecht, on behalf of the EORTC and Pfizer, presented results from a

randomized, open-label, clinical trial comparing voriconazole with

amphotericin B followed by other antifungals for the primary treatment of

invasive aspergillosis.[46] Immunocompromised patients older than 12 years

with a diagnosis of proven or probable invasive aspergillosis (probable as

defined by the MSG/EORTC criteria) were randomly assigned to receive either

voriconazole 4 mg/kg twice a day (with a loading dose of 6 mg/kg on day 1)

or amphotericin B 1.0-1.5 mg/kg per day. Patients on voriconazole could

switch to the oral form, and both groups could switch to other licensed

antifungal agents if investigators judged there was insufficient response or

toxicity. The main end point was to show noninferiority, and the trial was

powered accordingly. A total of 391 patients were enrolled, of whom 144 were

analyzed for voriconazole and 133 for amphotericin B in a modified

intention-to-treat analysis. Baseline characteristics of the groups were

similar, and 45% of the patients were neutropenic. The median duration of

treatment for patients on voriconazole was 77 days, and for amphotericin B

was 10 days. Switch to other licensed antifungals occurred in 37% of

patients on voriconazole and 80% of patients on amphotericin B.

Response rates at 12 weeks were 53% for the voriconazole group and 32% for

the other group. At the end of therapy, response rates were 53% for the

voriconazole group and 22% for the other group. This proved clear

superiority of voriconazole when compared with the current standard of care.

Survival at 12 weeks was 71% for voriconazole patients and 58% for the other

patients. Adverse events were mainly renal toxicity in the amphotericin

group and mild visual disturbances or hallucinations, which occurred in 44%

of patients receiving voriconazole. This side effect is known to happen in

about one third of patients receiving voriconazole, has been extensively

studied, and appears to be transient and mild. There were no differences in

liver toxicities among the groups. This landmark trial may cause a deep

paradigm shift to voriconazole as the standard of care for this infection,

since it not only proved its " noninferiority, " but also showed a clear

advantage. A future trial of interest would be to compare the lipid-based

preparations of amphotericin B with voriconazole for this indication.

Other new azoles, such as posaconazole and ravuconazole, have also shown

encouraging in vitro data and limited clinical experience against

Aspergillus and other molds.[47,48]

Combination Antifungal Therapy

A recurrent motif in the past paragraphs has been a relatively low success

rate, even for the most active new agents. This naturally leads to the

question of whether a combination of agents would be superior to

monotherapy.[49] In vitro data have shown possible synergism between the

echinocandins and amphotericin B,[50,51] and there are also data and

theoretical concerns for antagonism between older azoles and amphotericin

B.[52-54]

Although many physicians advocate for these combinations and even

empirically use them, there is no hard evidence for or against them. This is

one of the most important areas of research, both for academia and the

pharmaceutical industry. Combinations of particular interest are lipid-based

amphotericin B with echinocandins, lipid-based amphotericin B with the new

azoles, and echinocandins with the new azoles.

Helping the Host

Having briefly reviewed all the advances in diagnostics, early/preemptive

therapy, and all the new available agents, we reach an unavoidable point:

All these interventions perform poorly at their best. Not one of them comes

nearly close to the efficacy of a fully functional immune system. Simply

expressed: People with normal immune systems usually do not die of invasive

or disseminated aspergillosis. The single most important factor widely

identified to provide a good outcome for patients with this disease is

recovery from neutropenia.[55] Therefore, some researchers have focused on

ways to stimulate, restore, or rebuild the immune system of these patients.

A sometimes desperate intervention, granulocyte transfusion, has a history

of anecdotal successes, but it is often impractical due to the limited

half-life of donor granulocytes and the large numbers of donors required for

transient improvements.[56-58] Other research has concentrated in

hematopoietic growth factors (such as granulocyte colony-stimulating factor

and granulocyte-monocyte colony-stimulating factor), but again,

evidence-based clinical experience is limited, and their use in patients

with hematologic malignancies is sometimes discouraged. They are sometimes

also used in granulocyte donors, which greatly boosts the numbers of donated

cells.[59] Current research instead focuses on stem cell content of grafts,

lymphoid progenitor transfusions, and the use of cytokines, such as

interferon-gamma, and other Th-1 effectors.[60-62]

Visions of the Future

Predicting the future is indeed a risky endeavor, because the probability of

being wrong is high. But all these advances make us optimistic about the

future of patients with invasive or disseminated aspergillosis. We can

foresee a day not too far away when the Aspergillus genome project will be

completed and will supply scientists with new pathogenic mechanisms, a

deeper understanding of the biology of the organism, and a new generation of

therapeutic targets. There will be a day when patients will undergo serial

testing by a highly sensitive and specific serodiagnostic method or PCR,

diagnosing infection before full blown disease, and preemptively treating it

with combinations of powerful and safe agents. Perhaps more important,

immunosuppressive agents will be tailored to cause more specific and shorter

immunosuppression, and hosts will also benefit from well-characterized

immune-reconstitution measures. We hope for a day when mortality is inverted

and becomes only 5% to 15%.

The path has been laid by those before us, and the war on Aspergillus has

been declared in earnest!

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