Invasive Aspergillosis in Critically Ill Patients A New 21th Century Problem - PowerPoint PPT Presentation

Loading...

PPT – Invasive Aspergillosis in Critically Ill Patients A New 21th Century Problem PowerPoint presentation | free to download - id: 26e47-YmFhM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Invasive Aspergillosis in Critically Ill Patients A New 21th Century Problem

Description:

Vall s J. A 7 year Study of Severe Hospital Acquired Pneumonia requiring ICU Admission. ... secretions and presence of pneumonia ... – PowerPoint PPT presentation

Number of Views:221
Avg rating:3.0/5.0
Slides: 31
Provided by: koenraadv
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Invasive Aspergillosis in Critically Ill Patients A New 21th Century Problem


1
Invasive Aspergillosis in Critically Ill
PatientsA New 21th Century Problem?
  • Koenraad Vandewoude, MD
  • Intensive Care Dpt. Solid Organ Transplant
    Centre
  • Ghent University Hospital
  • Ghent, Belgium

2
Invasive Aspergillosis
  • Extensive data available in distinct high-risk
    patient populations
  • Hemato-oncological patients
  • Allogeneic SCT, graft-vs.-host disease
  • Persistant neutropenia
  • Solid organ transplant patients, lung
  • Immunosuppressive therapy
  • Chronic granulomatous disease
  • Severe combined immunodeficiency
  • HIV

3
Aspergillus spp. Underestimated Pathogen in the
ICU?
  • Epidemiological data on incidence and outcome of
    Invasive Aspergillosis in Critically Ill patients
    are scarce
  • Low index of suspicion
  • Positive cultures often discarded as colonization
    or contamination
  • Absence of feasible diagnostic reference standard

4
Invasive Pulmonary Aspergillosis in Critically
Ill patients
  • Differentiate between
  • Pts referred to the ICU with IPA
  • e.g. pt. from Bone Marrow Transplant Unit with
    proven/probable IPA and respiratory failure
  • 100 mortality? 1
  • Pts. with IPA diagnosed in the ICU
  • community acquired
  • nosocomial
  • ICU acquired
  • grim prognosis 2
  • Janssen JJ. Outcome of ICU treatment in Invasive
    Aspergillosis. Intens Care Med 1996 22 1291-93
  • Vallés J. A 7 year Study of Severe Hospital
    Acquired Pneumonia requiring ICU Admission.
    Intens Care Med 2003 29 1981-88

5
Pulmonary Aspergillosis A Spectrum of Clinical
Entities
  • Depending on patient immune status
  • With tissue invasion 1,2
  • Acute invasive aspergillosis
  • Subacute invasive aspergillosis
  • Chronic cavitary and fibrosing pleuropulmonary
    aspergillosis
  • Acute Tracheobronchitis with tissue invasion
  • Without tissue invasion
  • Tracheobronchial colonization
  • Tracheobronchitis
  • Pulmonary Aspergilloma

Clinical entity may change due immune defence
alteration
1 Denning DW. Chronic cavitary and fibrosing
pulmonary and pleural aspergillosis. Clin Infect
Dis 2003 2 Paterson DL. New clinical
presentations of invasive pulmonary aspergillosis
in non-conventional hosts. Clin Microbiol Infect
2004
6
IPA diagnosis in ICU patients
  • EORTC/MSG Case Definitions 1
  • Difficult to apply outside high risk populations
  • Not useful to guide therapy

1 Ascioglu S. Defining opportunistic invasive
fungal infections in immunocompromised patients
with cancer and hematopoietic stem cell
transplants. Clin Infect Dis 2002
7
Consensus Definitions
  • Proven IPA
  • Histopathology culture
  • Probable IPA
  • 1 host 1 microbiological 1 clinical
  • Host neutropenia, fever, immunosuppressive
    therapy, steroids, GVHD
  • Microbiological
  • positive culture sputum, BAL
  • Non-invasive test galactomannan, ?-D-glucan
  • CT halo, air-crescent, cavity within area of
    consolidation
  • Possible IPA
  • 1 host 1 microbiological OR 1 clinical
  • More specific signs / symptoms
  • CT halo, air-crescent, cavity
  • New infiltrate specific pulmonary pleural rub
    pleural pain hemoptysis

8
Particular Issues in ICU patients
  • Interpretation of Host Factors
  • not always clearly detectable
  • (combination of) underlying disease and/or
    critical illness induced immunosuppression with
    low or intermediate probability of invasive
    disease 1, 2
  • Impaired phagocytic function
  • Organ dysfunctions, metabolic derangements
  • Corticosteroids 3, 4
  • difficult assessment of treshold dose/duration of
    exposure

1 Hartemink KJ. Immunoparalysis as a cause for
invasive aspergillosis? Intensive Care Med 2003 2
Engelich G. Acquired disorders of phagocyte
function complicating medical and surgical
illnesses. Clin Infect Dis 2001 3 Lionakis M.
Glucocorticoids and Invasive Fungal Infections.
Lancet 2003 362 1828-38 4 Palmer LB.
Corticosteroid Treatment as a Risk Factor for
Invasive Aspergillosis in Patients with Lung
Disease. Thorax 1991 46 15-20
9
Particular Issues in ICU patients
  • Signs and symptoms difficult to appreciate
  • cough, chest pain, pleural rub, hemoptysis,
    dyspnea
  • non specific
  • evaluation difficult or impossible
  • fever?
  • clinical examination hampered by mechanical
    ventilation

10
Particular Issues in ICU patients
  • Medical Imaging
  • Concurrent pulmonary injury hampers
    interpretation
  • residual infiltrates, atelectasis, ARDS,
  • CT scan feasible in case of high-grade
    ventilatory and inotropic dependency?
  • Typical lesions Halo, Air-crescent
  • low incidence in non-neutropenic patients

Greene RA. Radiologic findings in acute invasive
pulmonary aspergillosis utility of the halo and
air-crescent sign for diagnosis and treatment of
invasive pulmonary aspergillosis in high-risk
patients. 13th ECCMID, 2002, Glasgow
11
  • Microbiological sampling
  • lower respiratory tract samples
  • BAL not always feasible
  • Direct microscopy is mandatory!
  • Serology
  • Aspergillus galactomannan?
  • validation in neutropenic pts
  • sensitive/significant in other patients
  • ß-glucan ?
  • Biopsy procedures
  • transbronchial biopsy not possible
  • thoracoscopic procedure preferred
  • caveats
  • ventilator and pressor dependency
  • coagulation disorders

Uffredi ML. Significance of aspergillus
fumigatus isolation from respiratory specimens in
non-granulocytopenic patients. Eur J Clin
Microbiol Infect Dis 2003 Maertens J.
Screening for circulating galactomannan as a
non-invasive diagnostic tool for invasive
aspergillosis in prolonged neutropenic patients
and stem cell transplantation recipients. Blood
2001 97 1604-10 Ostrosky-Zeichner L.
Multicenter clinical evaluation of the (1-3)
beta-D-glucan assay as an aid in diagnosis of
fungal infections in humans. Clin Infect Dis
2005 41 654-9
12
Invasive Aspergillosis in ICU PatientsFact or
Fiction?
  • Isolation of Aspergillus spp. in immunocompetent
    host is often/always interpreted as colonization
    .
  • Assessment of clinical signifance most difficult
    in patient groups with intermediate risk of
    invasive disease
  • Literature data
  • Variable diagnostic criteria

13
Perfect J. Impact of culture isolation of
Aspergillus species a hospital-based survey of
Aspergillosis. Clin Infect Diseases 2001
14
(No Transcript)
15
  • Invasive pulmonary aspergillosis in
    non-immunocompromised, non-neutropenic hosts
  • Review of 32 cases
  • Underlying diseases lung fibrosis, COPD,
    Influenza A, diabetes mellitus, alcoholism,
    short course of steroids,
  • IPA should be considered when Aspergillus spp.
    is isolated in resp. secretions and presence of
    pneumonia .

Karam G. Invasive pulmonary aspergillosis in
non-immunocompromised, non-neutropenic hosts.
Reviews of infectious diseases 1986 8 357-63
16
  • COPD patients with IPA benefits of ICU?
  • 23 pts, 16 proven, 7 probable (repeated
    isolation)
  • recent steroid treatment, or intensification of
    steroid treatment
  • severe bronchospasm (12/23)
  • all required mechanical ventilation
  • Mortality 100

Bulpa P. COPD patients with invasive pulmonary
aspergillosis benefits of intensive care? Intens
Care Med 2001 27 59-67
17
  • Invasive pulmonary aspergillosis in COPD
    patients an emerging fungal pathogen
  • 13 cases of IPA in COPD pts admitted to ICU
  • bronchospasm
  • steroid treatment often continued in spite of
    isolation of Aspergillus spp.
  • Mortality 100 - proven IPA by autopsy

Ader F. Invasive pulmonary aspergillosis in
COPD patients an emerging fungal pathogen. Clin
Microbiol Infec 2005 Jun11427-9.
18
  • Retrospective cohort study based on prospectively
    gathered microbiology and autopsy data UZ
    KULeuven 127/1850 ptn

Meersseman W. Invasive Aspergillosis in
Critically Ill patients without Malignancy Am J
Respir Crit Care Med 2004
19
(No Transcript)
20
  • Clinical relevance of Aspergillus isolation from
    respiratory tract samples in critically ill
    patients. Critical Care 2006
  • Retrospective study
  • 1997-2003
  • Sole entry criterion positive lower respiratory
    tract specimen
  • Adapted criteria to discriminate colonization vs.
    clinical relevant infection (i.e. relevant to
    start antifungal treatment)
  • Incidence 3.3/1000 admission

21
Adapted Diagnostic Criteria
  • Definite IPA
  • positive histology (culture) of lung tissue
  • positive culture from normally sterile site
  • Probable IPA
  • Lower resp tract sample pos for Aspergillus
  • Compatible signs and symptoms
  • Abnormal medical imaging of chest
  • Either
  • host risk factors neutropenia, hemato-oncologic
    malignancy treated with cytostatics, steroid
    treatment 20 mg/day, immunodeficiency
  • BAL
  • semiquantitative positive culture /
  • and
  • cytologic exam positive (branching hyhae)

Vandewoude K. Clinical relevance of Aspergillus
isolation from respiratory tract samples in
critically ill patients. Critical Care 2006
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
Survival curves for ICU patients with IPA vs
Aspergillus spp. colonization
26
  • Does Invasive Aspergillosis has an impact on ICU
    patient outcome?
  • i.e. is there an attributable mortality?
  • Case-control study
  • 12 matching
  • Matching criteria
  • APACHE II (admission)
  • Diagnostic category
  • Age
  • Two cohorts of pts with same expected mortality

Vandewoude K. Invasive aspergillosis in
critically ill patients attributable mortality
and excesses in length of stay and ventilator
dependence. J Hosp Infection 2004
27
Vandewoude K. Invasive aspergillosis in
critically ill patients attributable mortality
and excesses in length of stay and ventilator
dependence. J Hosp Infection 2004
28
Conclusion
  • Invasive Aspergillosis in ICU patient is a Fact
  • Incidence
  • 0.33 5.8
  • Depending on patient mix MICU SICU
  • Limited patient groups, precluding firm
    conclusions
  • Underestimated?
  • Delayed diagnosis
  • Diagnosis post mortem
  • Grim prognosis
  • Mortality exceeding 77
  • Observed mortality predicted mortality
  • Attributable mortality ?

29
Conclusion
  • Do not discard an Aspergillus spp. positive
    respiratory tract specimen in critically ill
    patients consider the clinical significance
    even in the absence of EORTC/MSG host risk
    factors

30
?
  • Epidemiology prospective multicenter
    observational studies needed to estimate
    incidence
  • Biopsy if possible?
  • Protocol based autopsy policy
  • Validation of clinical diagnostic algorithm,
  • Useful to guide (pre-emptive) therapy
  • Development of criteria for pre-emptive treatment
  • Consideration of additional host risk factors
  • COPD, steroid treatment, MOF, .
  • Explore and measure immunoparalytic state
  • Evaluation of non-invasive serologic markers in
    ICU pts
  • galactomannan
  • Beta-D-glucan
  • PCR
About PowerShow.com