1. The times.. they are a changing Dr. Hamdi Akan Ankara University Medical School Dept. of Hematology

2. 0 0,2 0,4 0,6 198019811982198319841985 1986 198719881989199019911992199319941995 1996 1997 Rate per 100,000 population United States, 1980-1997 Mortality duıe to invasive mycosis M cNeil MM, et al. Clin Infect Dis 2001;33:641-7 CandidaAspergillusOther Mycoses From De Bauw

3. Epidemiology of Invasive Candidiasis: a Persistent Public Health Problem Pfaller and Diekema Clin. Microbiol. Rev..2007; 20: 133-163

4. Epidemiology of Invasive Candidiasis: a Persistent Public Health Problem Pfaller and Diekema Clin. Microbiol. Rev..2007; 20: 133-163

5. Results of autopsy after fluconazole prophylaxis for hematological malignancies Kami et al. Brit J Haematol 2002; 117:40-6 720 patients 252 Invasive Fungal infections positive blood cultures 8/37 (22%) C. albicans 11/24 (46%) non-albicans Candida Aspergillus Zygomycetes Trichosporon Fusarium Cryptococcus unknown 94 91 34 80’s: 14% 90’s: 10% From Ben De Pauw

6. Epidemiology of Invasive Candidiasis: a Persistent Public Health Problem Pfaller and Diekema Clin. Microbiol. Rev..2007; 20: 133-163

7. Comparison of invasive fungal infection after nonmyeloablative and myeloablative HCT (1993-1998) Fukuda, T. et al. Blood 2003;102:827-833 N=1673 ns N=163 All IFI Aspergillosis

8. Risk factors, timing, and mortality of aspergillosis after RIC vs conventional SCT Daly 2003, Fukuda 2004, Kojima 2004 1. Aspergillosis occurs LATER after RIC (d120 vs d90) 2. Case FATALITY rates are comparable 3. Aspergillosis is the first cause of infectious mortality

9. NEW DRUGS!

11. Opportunistic infections in 547 organ transplant recipients receiving alemtuzumab, a humanized monoclonal CD-52 antibody. Peleg AY, et al,. Clin Infect Dis. 2007 Jan 15;44(2):204-12. CONCLUSIONS: Patients who received alemtuzumab for the treatment of allograft rejection were significantly more likely to develop an opportunistic infection, compared with patients who received alemtuzumab for induction therapy only. Such data have implications for new antimicrobial prophylactic strategies.

12. Infliximab use in patients with severe graft-versus-host disease and other emerging risk factors of non-Candida invasive fungal infections in allogeneic hematopoietic stem cell transplant recipients: a cohort study. Francisco MM et al. Blood, 15 October 2003, Vol. 102, No. 8, pp. 2768-2776 We conclude that infliximab administration is associated with a significantly increased risk of non-Candida IFI in HSCT recipients with severe GVHD disease. Pre- emptive systemic antifungal therapy against molds should be considered in patients who develop severe GVHD after HSCT if infliximab is used.

13. NO GOOD NEWS?

14. Invasive aspergillosis following hematopoietic cell transplantation: outcomes and prognostic factors associated with mortality. Upton A, Kirby KA, Carpenter P, Boeckh M, Marr KA Clin Infect Dis. 2007 Feb 15;44(4):531-40. CONCLUSIONS: There has been a significant decrease in mortality in patients with a diagnosis of IA following HCT in recent years, coinciding with multiple changes in transplantation practices, including use of nonmyeloablative conditioning regimens, receipt of peripheral blood stem cells, more prompt diagnosis of IA, and use of voriconazole.

15. Yüksek riskli hastalar GM 2 kez >0.5 PA. AC. grafide infiltrat veya İFİ ile uyumlu bulgu, belirti Pozitif kültür, mikroskopi 5 günden fazla nötropenik ateş Toraks CT ve/veya Sinus CT Toraks CT ve BAL Halo belirtisi Atipik infiltrat Bronkoskopi ve BAL Normal +- Geniş spektrumlu antifungal tedaviAntifungal tedavi verme, izlemeye devam et Galactomannan and Computed Tomography–Based Preemptive Antifungal Therapy in Neutropenic Patients at High Risk for Invasive Fungal Infection: A Prospective Feasibility Study. Maertens J, et al. CID 2005; 41:1242–50

16. In the febrile neutropenic group, antifungal treatment was needed in 35% of the patients treated empirically, this is only 7.7 % in patients in the preemptively treated group. Most of the patients who died had an underlying diease not in remision (76.9% vs. 30% three mo.).

17. Time to listen to an expert! Dr. J. Maertens