Appraisal of fungal infections during ECMO therapy

Appraisal of fungal infections during ECMO therapy Mongardon et al. Critical Care (2018) 22:145 https://doi.org/10.1186/s13054-018-2082-1 LETTER Open Access Appraisal of fungal infections during ECMO therapy 1,2,3* 1 4 1,2,5 Nicolas Mongardon , Ophélie Constant , Fabio Silvio Taccone and Eric Levesque See related research by Cavayas et al., https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2023-z We read with great interest the study of Cavayas and cohort in this study. The authors have logically shown colleagues, which retrospectively investigated the oc- how risk factors for Aspergillus (underlying immunodefi- currence and the impact of fungal infections in patients ciency or initial lung injury, i.e., hematological malignan- on extracorporeal membrane oxygenation (ECMO) in- cies, influenza infection, solid organ transplantation) are cluded in the Extracorporeal Life Support Organization significantly different from those for Candida infections registry [1]. Despite the high selection of these patients, (non-specific severity surrogates, i.e., older age, over- the authors concluded that fungal infections were not weight, sepsis, and renal replacement therapy). More- more frequent in patients on ECMO than in other crit- over, recent reports have emphasized the presence of ically ill patients but were independently associated underlying “immunoparalysis” related to critical illness with poor outcome. Because infectious complications and the role of severe lung injury on venous-venous are extremely important in ECMO patients [2], we (VV)-ECMO for the occurrence of IPA [4, 5]; these data would like to discuss some important issues raised by were unfortunately not available in this registry. Also, in- this study. vasive candidiasis is likely to develop because of exposure First, the epidemiology, definitions, and respective to broad-spectrum antibiotics, multiple line cannulation, weights of the different fungal infections should be parenteral nutrition, or multiple surgical procedures; the clearly distinguished. The diagnosis of invasive fungal absence of these variables in the multivariable analysis sig- infection and, particularly, invasive pulmonary aspergil- nificantly limits the interpretation of the main findings in losis (IPA) is problematic in critically ill patients. In the this study. Epidemiological interpretations are further study by Cavayas et al. the lack of data (i.e., host char- hampered by the lack of data on delay of occurrence of acteristics, clinical features, mycological criteria) on these infections. patients with Aspergillus-positive culture precludes a Finally, VV-ECMO and veno-arterial (VA)-ECMO definitive diagnosis in most cases. Similarly, no distinc- were analyzed as a whole. However, VV-ECMO sup- tion is proposed between colonization and proven or ports the most severe forms of respiratory failure; pul- putative IPA, which is possible using the clinical algo- monary damage increases susceptibility to respiratory rithm adapted for critically ill patients who lack the pathogens, like Aspergillus,inthissetting.Onthe usual host factors, such as those with hematological contrary, VA-ECMO supports refractory cardiogenic cancer or on prolonged immunosuppressive therapies shockwithmulti-organfailureand maybeathigher [3]. Consequently, the outcome of patients with IPA and risk for Candida infections. Thus, a separated analysis Aspergillus colonization is extremely different. according to the type of ECMO support might have Second, Aspergillus and Candida diseases are different been more informative on the role of fungal infection fungal infections, whereas the characteristics of patients in ECMO patients. with these two diseases were summarized in one single In light of these supplementary concerns and the retrospective design, the initial conclusions of this study should be interpreted cautiously. These data call for further studies and actions to better understand and * Correspondence: nicolas.mongardon@aphp.fr Service d’Anesthésie-Réanimation Chirurgicale, DHU A-TVB, Hôpitaux recognize secondary infections in patients in whom Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, CHU ECMO is a life-saving support treatment. Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France Faculté de Médecine, Université Paris Est, Créteil, France Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mongardon et al. Critical Care (2018) 22:145 Page 2 of 2 Authors’ contributions NM wrote the manuscript; OC, FST, and EL helped to draft the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate Not applicable. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Service d’Anesthésie-Réanimation Chirurgicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, CHU Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, 2 3 France. Faculté de Médecine, Université Paris Est, Créteil, France. Inserm U955, Equipe 3, Stratégies Pharmacologiques et Thérapeutiques Expérimentales des Insuffisances cardiaques et coronaires, Créteil, France. Department of Intensive Care, Clinique Universitaire de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Bruxelles, Belgique. EA Dynamyc, UPEC ENVA, Créteil, France. Received: 2 May 2018 Accepted: 24 May 2018 References 1. Cavayas YA, Yusuff H, Porter R. Fungal infections in adult patients on extracorporeal life support. Crit Care. 2018;22:98. 2. Biffi S, Di Bella S, Scaravilli V, et al. Infections during extracorporeal membrane oxygenation: epidemiology, risk factors, pathogenesis and prevention. Int J Antimicrob Agents. 2017;50:9–16. 3. Blot SI, Taccone FS, Van den Abeele A-M, et al. A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients. Am J Respir Crit Care Med. 2012;186:56–64. 4. Taccone FS, Van den Abeele A-M, Bulpa P, et al. Epidemiology of invasive aspergillosis in critically ill patients: clinical presentation, underlying conditions, and outcomes. Crit Care. 2015;19:7. 5. Rodriguez-Goncer I, Thomas S, Foden P, et al. Invasive pulmonary aspergillosis is associated with adverse clinical outcomes in critically ill patients receiving veno-venous extracorporeal membrane oxygenation. Eur J Clin Microbiol Infect Dis. 2018. https://doi.org/10.1007/s10096-018-3241-7. Epub ahead of print. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Critical Care Springer Journals

Appraisal of fungal infections during ECMO therapy

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Medicine & Public Health; Intensive / Critical Care Medicine; Emergency Medicine
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Abstract

Mongardon et al. Critical Care (2018) 22:145 https://doi.org/10.1186/s13054-018-2082-1 LETTER Open Access Appraisal of fungal infections during ECMO therapy 1,2,3* 1 4 1,2,5 Nicolas Mongardon , Ophélie Constant , Fabio Silvio Taccone and Eric Levesque See related research by Cavayas et al., https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2023-z We read with great interest the study of Cavayas and cohort in this study. The authors have logically shown colleagues, which retrospectively investigated the oc- how risk factors for Aspergillus (underlying immunodefi- currence and the impact of fungal infections in patients ciency or initial lung injury, i.e., hematological malignan- on extracorporeal membrane oxygenation (ECMO) in- cies, influenza infection, solid organ transplantation) are cluded in the Extracorporeal Life Support Organization significantly different from those for Candida infections registry [1]. Despite the high selection of these patients, (non-specific severity surrogates, i.e., older age, over- the authors concluded that fungal infections were not weight, sepsis, and renal replacement therapy). More- more frequent in patients on ECMO than in other crit- over, recent reports have emphasized the presence of ically ill patients but were independently associated underlying “immunoparalysis” related to critical illness with poor outcome. Because infectious complications and the role of severe lung injury on venous-venous are extremely important in ECMO patients [2], we (VV)-ECMO for the occurrence of IPA [4, 5]; these data would like to discuss some important issues raised by were unfortunately not available in this registry. Also, in- this study. vasive candidiasis is likely to develop because of exposure First, the epidemiology, definitions, and respective to broad-spectrum antibiotics, multiple line cannulation, weights of the different fungal infections should be parenteral nutrition, or multiple surgical procedures; the clearly distinguished. The diagnosis of invasive fungal absence of these variables in the multivariable analysis sig- infection and, particularly, invasive pulmonary aspergil- nificantly limits the interpretation of the main findings in losis (IPA) is problematic in critically ill patients. In the this study. Epidemiological interpretations are further study by Cavayas et al. the lack of data (i.e., host char- hampered by the lack of data on delay of occurrence of acteristics, clinical features, mycological criteria) on these infections. patients with Aspergillus-positive culture precludes a Finally, VV-ECMO and veno-arterial (VA)-ECMO definitive diagnosis in most cases. Similarly, no distinc- were analyzed as a whole. However, VV-ECMO sup- tion is proposed between colonization and proven or ports the most severe forms of respiratory failure; pul- putative IPA, which is possible using the clinical algo- monary damage increases susceptibility to respiratory rithm adapted for critically ill patients who lack the pathogens, like Aspergillus,inthissetting.Onthe usual host factors, such as those with hematological contrary, VA-ECMO supports refractory cardiogenic cancer or on prolonged immunosuppressive therapies shockwithmulti-organfailureand maybeathigher [3]. Consequently, the outcome of patients with IPA and risk for Candida infections. Thus, a separated analysis Aspergillus colonization is extremely different. according to the type of ECMO support might have Second, Aspergillus and Candida diseases are different been more informative on the role of fungal infection fungal infections, whereas the characteristics of patients in ECMO patients. with these two diseases were summarized in one single In light of these supplementary concerns and the retrospective design, the initial conclusions of this study should be interpreted cautiously. These data call for further studies and actions to better understand and * Correspondence: nicolas.mongardon@aphp.fr Service d’Anesthésie-Réanimation Chirurgicale, DHU A-TVB, Hôpitaux recognize secondary infections in patients in whom Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, CHU ECMO is a life-saving support treatment. Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France Faculté de Médecine, Université Paris Est, Créteil, France Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mongardon et al. Critical Care (2018) 22:145 Page 2 of 2 Authors’ contributions NM wrote the manuscript; OC, FST, and EL helped to draft the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate Not applicable. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Service d’Anesthésie-Réanimation Chirurgicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique des Hôpitaux de Paris, CHU Henri Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, 2 3 France. Faculté de Médecine, Université Paris Est, Créteil, France. Inserm U955, Equipe 3, Stratégies Pharmacologiques et Thérapeutiques Expérimentales des Insuffisances cardiaques et coronaires, Créteil, France. Department of Intensive Care, Clinique Universitaire de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Bruxelles, Belgique. EA Dynamyc, UPEC ENVA, Créteil, France. Received: 2 May 2018 Accepted: 24 May 2018 References 1. Cavayas YA, Yusuff H, Porter R. Fungal infections in adult patients on extracorporeal life support. Crit Care. 2018;22:98. 2. Biffi S, Di Bella S, Scaravilli V, et al. Infections during extracorporeal membrane oxygenation: epidemiology, risk factors, pathogenesis and prevention. Int J Antimicrob Agents. 2017;50:9–16. 3. Blot SI, Taccone FS, Van den Abeele A-M, et al. A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients. Am J Respir Crit Care Med. 2012;186:56–64. 4. Taccone FS, Van den Abeele A-M, Bulpa P, et al. Epidemiology of invasive aspergillosis in critically ill patients: clinical presentation, underlying conditions, and outcomes. Crit Care. 2015;19:7. 5. Rodriguez-Goncer I, Thomas S, Foden P, et al. Invasive pulmonary aspergillosis is associated with adverse clinical outcomes in critically ill patients receiving veno-venous extracorporeal membrane oxygenation. Eur J Clin Microbiol Infect Dis. 2018. https://doi.org/10.1007/s10096-018-3241-7. Epub ahead of print.

Journal

Critical CareSpringer Journals

Published: Jun 6, 2018

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