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Global guideline for the diagnosis and management of rare mould infections: an initiative of the European Confederation of Medical Mycology in cooperation with the International Society for Human and Animal Mycology and the American Society for Microbiology

https://doi.org/10.1016/S1473-3099(20)30784-2Get rights and content

Summary

With increasing numbers of patients needing intensive care or who are immunosuppressed, infections caused by moulds other than Aspergillus spp or Mucorales are increasing. Although antifungal prophylaxis has shown effectiveness in preventing many invasive fungal infections, selective pressure has caused an increase of breakthrough infections caused by Fusarium, Lomentospora, and Scedosporium species, as well as by dematiaceous moulds, Rasamsonia, Schizophyllum, Scopulariopsis, Paecilomyces, Penicillium, Talaromyces and Purpureocillium species. Guidance on the complex multidisciplinary management of infections caused by these pathogens has the potential to improve prognosis. Management routes depend on the availability of diagnostic and therapeutic options. The present recommendations are part of the One World—One Guideline initiative to incorporate regional differences in the epidemiology and management of rare mould infections. Experts from 24 countries contributed their knowledge and analysed published evidence on the diagnosis and treatment of rare mould infections. This consensus document intends to provide practical guidance in clinical decision making by engaging physicians and scientists involved in various aspects of clinical management. Moreover, we identify areas of uncertainty and constraints in optimising this management.

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Background

Although invasive aspergillosis and mucormycosis have been the most commonly documented invasive mould infections,1 mycoses caused by rare moulds are increasing.2 These pathogens include dematiaceous moulds that cause phaeohyphomycosis, Fusarium, Lomentospora, Scedosporium, Rasamsonia, Scopulariopsis, Penicillium, Talaromyces species other than T marneffei, Paecilomyces, Purpureocillium and Schizophyllum species, and other basidiomycetes.3, 4, 5, 6 Maximising survival to these infections

Epidemiology of fusariosis

Fusarium spp are the most clinically prevalent rare moulds causing superficial infections, such as keratitis, in immunocompetent hosts, and severe disseminated infections (frequently presenting as fungaemia) in immunocompromised individuals. These fungi are ubiquitous in nature and are found in soil and air.13 Of particular importance are the species complexes Fusarium solani (causing more than 50% of severe cases) and Fusarium oxysporum (causing 20% of severe cases).13, 14 The main routes of

Epidemiology of lomentosporiosis

Lomentospora prolificans (formerly Scedosporium prolificans) is morphologically and clinically distinct from Scedosporium spp, although before phylogenetic profiling both genera were classed together.34 L prolificans is ubiquitously found as a soil saprophyte, predominantly in the arid climates of Australia, southwestern USA, and Spain, which is reflected by the proportionally high number of reported cases in these regions.35, 36, 37 Prevalence and incidence data for lomentosporiosis are

Epidemiology of scedosporiosis

Scedosporium spp are ubiquitous saprophytes mostly found in temperate areas, with regional differences in species distribution.55 In the clinical setting, the most commonly isolated species worldwide are Scedosporium boydii and Scedosporium apiospermum.

Scedosporium spp initiate two distinct diseases: mycetoma and scedosporiosis. In immunocompetent patients, Scedosporium spp are an important cause of eumycotic mycetoma and the most common cause of this infection in the USA.56 Solid organ

Other rare mould infections

This guideline also covers dematiaceous moulds causing phaeohyphomycosis, Rasamsonia spp, Schizophyllum spp and other basidiomycetes, Scopulariopsis, Paecilomyces, Penicillium, Talaromyces, and Purpureocillium spp.6 A summary of antifungal treatment recommendations for these agents is displayed in figure 6.

Details on epidemiology, as well as evidence and recommendations for the diagnosis (including photoplates and pathways) and treatment are outlined in the appendix pp 67–161.

Constraints in optimising management

The identification of rare moulds is complicated by the constant change in the nomenclature, which in turn compromises targeted treatment.65 Advocates for nomenclatural stability of medically important fungi have maintained that new names for fungal species should not be adapted for clinical use until confirmed by independent laboratories.66 Most microbiologists are not familiar with some of the rarest fungal species because they are either rarely encountered or are mistaken for contaminants.

References (75)

  • L Sedlacek et al.

    Prevalence of Scedosporium species and Lomentospora prolificans in patients with cystic fibrosis in a multicenter trial by use of a selective medium

    J Cyst Fibros

    (2015)
  • W Wangchinda et al.

    Lomentospora prolificans vertebral osteomyelitis with spinal epidural abscess in an immunocompetent woman: case report and literature review

    Med Mycol Case Rep

    (2018)
  • JD Jenks et al.

    Voriconazole plus terbinafine combination antifungal therapy for invasive Lomentospora prolificans infections: analysis of 41 patients from the FungiScope registry 2008–2019

    Clin Microbiol Infect

    (2020)
  • C Schwarz et al.

    Combined antifungal therapy is superior to monotherapy in pulmonary scedosporiosis in cystic fibrosis

    J Cyst Fibros

    (2019)
  • SC Signore et al.

    Scedosporium apiospermum brain abscesses in a patient after near-drowning—a case report with 10-year follow-up and a review of the literature

    Med Mycol Case Rep

    (2017)
  • TC Chen et al.

    Disseminated Scedosporium apiospermum infection in a near-drowning patient

    J Formos Med Assoc

    (2016)
  • Y Nakamura et al.

    Scedosporium aurantiacum brain abscess after near-drowning in a survivor of a tsunami in Japan

    Respir Investig

    (2013)
  • C Poignon et al.

    Invasive pulmonary fusariosis in an immunocompetent critically ill patient with severe COVID-19

    Clin Microbiol Infect

    (2020)
  • DP Kontoyiannis et al.

    Prospective surveillance for invasive fungal infections in hematopoietic stem cell transplant recipients, 2001–2006: overview of the Transplant-Associated Infection Surveillance Network (TRANSNET) database

    Clin Infect Dis

    (2010)
  • BJ Park et al.

    Invasive non-Aspergillus mold infections in transplant recipients, United States, 2001–2006

    Emerg Infect Dis

    (2011)
  • F Lamoth et al.

    Changing epidemiology of invasive mold infections in patients receiving azole prophylaxis

    Clin Infect Dis

    (2017)
  • J Stemler et al.

    Risk factors and mortality in invasive Rasamsonia spp infection: analysis of cases in the FungiScope registry and from the literature

    Mycoses

    (2020)
  • CC Blyth et al.

    Consensus guidelines for the treatment of invasive mould infections in haematological malignancy and haemopoietic stem cell transplantation, 2014

    Intern Med J

    (2014)
  • OA Cornely et al.

    Improving outcome of fungal diseases—guiding experts and patients towards excellence

    Mycoses

    (2017)
  • M Hoenigl et al.

    Global guidelines and initiatives from the European Confederation of Medical Mycology to improve patient care and research worldwide: new leadership is about working together

    Mycoses

    (2018)
  • M Muhammed et al.

    Fusarium infection: report of 26 cases and review of 97 cases from the literature

    Medicine (Baltimore)

    (2013)
  • J Guarro

    Fusariosis, a complex infection caused by a high diversity of fungal species refractory to treatment

    Eur J Clin Microbiol Infect Dis

    (2013)
  • M Nucci et al.

    Fusarium infections in immunocompromised patients

    Clin Microbiol Rev

    (2007)
  • M Nucci et al.

    Fusarium infection in hematopoietic stem cell transplant recipients

    Clin Infect Dis

    (2004)
  • SE Nielsen et al.

    Incidence and clinical characteristics of fungal keratitis in a Danish population from 2000 to 2013

    Acta Ophthalmol

    (2015)
  • M Nucci et al.

    Earlier diagnosis of invasive fusariosis with Aspergillus serum galactomannan testing

    PLoS One

    (2014)
  • C Hennequin et al.

    Comparison of aerobic standard medium with specific fungal medium for detecting Fusarium spp in blood cultures

    Eur J Clin Microbiol Infect Dis

    (2002)
  • K Liu et al.

    Morphologic criteria for the preliminary identification of Fusarium, Paecilomyces, and Acremonium species by histopathology

    Am J Clin Pathol

    (1998)
  • GS De Hoog et al.

    Atlas of clinical fungi

    (2019)
  • RV Fleming et al.

    Comparison of amphotericin B lipid complex (ABLC) vs ambisome in the treatment of suspected or documented fungal infections in patients with leukemia

    Leuk Lymphoma

    (2001)
  • O Lortholary et al.

    International retrospective analysis of 73 cases of invasive fusariosis treated with voriconazole

    Antimicrob Agents Chemother

    (2010)
  • JR Perfect et al.

    Voriconazole treatment for less-common, emerging, or refractory fungal infections

    Clin Infect Dis

    (2003)
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