PubMed · 13569356
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Ts ISTAMANOVA. 1958. [Functional hematology].. https://pubmed.ncbi.nlm.nih.gov/13569356/
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Invasive fungal infections are a primary cause of morbidity and mortality in patients with hematological malignancies. Establishing a definite diagnosis of invasive fungal infection in febrile neutropenic patients is particularly challenging and time-consuming, but a delay of antifungal treatment leads to higher mortality. This situation has lead to the strategy of initiation "empirical" antifungal therapy prior to the detection of fungi. Meanwhile, improvements in diagnostic procedures are achieved, especially with imaging techniques and non-culture based methods which include antigen-based assays, metabolite detection and molecular detection of fungal DNA from body fluid samples using conserved or specific genome sequences. The AGIHO presents recommendations for the diagnosis of invasive fungal infections with risk-adapted screening concepts for the neutropenic and febrile episodes of patients with hemato-oncological disorders.
Despite modern technologies, such as immunophenotyping and molecular probing, cytomorphologic examination of stained peripheral blood smears by microscopy remains the mainstay of diagnosis in a large variety of diseases. This holds true especially in underdeveloped or rural areas where profound expertise and equipment are not easily available. Although communication technologies have been dramatically improved, telehematology has not become routine. To date, little information is available on which procedures are critical for successful implementation. Therefore, a study evaluating possible factors that prevented implementation of telehematology was initiated. We found that staining technique, smearing procedure, training skills, number of captured images, and prevalent disease influenced the accuracy of diagnosis by the reference laboratory. Using realtime teleconferencing allowed for overcoming these deficits. Together, when certain rules are observed, telehematology allows for rapid, accurate, standardized, and cheap expert advice. This technology should improve treatment of patients in remote areas where expertise is not available.
The Infectious Diseases Working Party of the German Society of Haematology and Oncology presents their guidelines for the treatment of fungal infections in patients with hematological and oncological malignancies. These guidelines are evidence-based, considering study results, case reports and expert opinions, using the evidence criteria of the Infectious Diseases Society of America (IDSA). The recommendations for major fungal complications in this setting are summarized here. The primary choice of therapy for chronic candidiasis should be fluconazole, reserving caspofungin or amphotericin B (AmB) for use in case of progression of the Candida infection. Patients with candidemia (except C. krusei or C. glabrata) who are in a clinically stable condition without previous azole prophylaxis should receive fluconazole, otherwise AmB or caspofungin. Voriconazole is recommended for the first-line treatment of invasive aspergillosis. The benefit of a combination of AmB and 5-flucytosine has not been demonstrated except in patients with cryptococcal meningitis. Mucormycosis is relatively rare. The drug therapy of choice consists of AmB, desoxycholate or liposomal formulation, in the highest tolerable dosage. Additional surgical intervention has been shown to achieve a lower fatality rate than with antifungal therapy alone. The role of interventional strategies, cytokines/G-CSF, and granulocyte transfusions in invasive fungal infections are further reviewed. These guidelines offer actual standards and discussions on the treatment of oropharyngeal and esophageal candidiasis, invasive candidiasis, cryptococcosis and mould infections.