Pulmonary Infection in the Immunocompromised Patient: Strategies for Management

448 Pages·2009·12.386 MB·English

P
ULMONARY INFECTION IN
THE IMMUNOCOMPROMISED
PATIENT
Pulmonary Infection in the Immunocompromised Patient: Strategies for Managemen Edited by Carlos Agustí and Antoni Torres
© 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-31957-4
P
ULMONARY INFECTION IN
THE IMMUNOCOMPROMISED
PATIENT
STRATEGIES FOR MANAGEMENT
Editors
Carlos Agustı´ and Antoni Torres
CapdeServeidePneumologiaiAlle`rgiaRespirato`riaHospitalCl´ınicdeBarcelona,
Barcelona,Spain
Thiseditionfirstpublished2009
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LibraryofCongressCataloguing-in-PublicationData
Pulmonaryinfectionintheimmuno-compromisedpatient:strategiesformanagement/editedbyCarlos
AgustiandAntoniTorres.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN978-0-470-31957-4(cloth)
1. Respiratoryinfections.2. Lungs–Infections.3. Immunosuppression–Complications. I.Agusti,Carlos.
II.TorresMarti,A.(Antoni)
[DNLM:1. LungDiseases–complications.2. OpportunisticInfections–complications.3. ImmunocompromisedHost.
4. LungDiseases–therapy.5. OpportunisticInfections–therapy.WF600P9834952009]
RC740.P832009
616.204–dc22 2008036179
ISBN978-0-470-31957-4
AcataloguerecordforthisbookisavailablefromtheBritishLibrary.
Setin10.5/12.5ptTimesbyThomsonDigital,Noida,India
PrintedinSingaporebyMarkonoPrintMediaPte.Ltd.
Firstprinting–2009
Contents
Preface ix
List of Contributors xi
1 Lung Immune Defences in the Immunosuppressed Patient 1
Naimish Patel and Henry Koziel
1.1 Introduction 1
1.2 Hostdefencefunctioninhealth 1
1.3 Hostdefencefunctioninselectimmunocompromised
patients 7
1.4 Summaryandfuturedirectionsforthisfield 17
2 Microbiological Diagnosis of Respiratory Infections
in the Immunocompromised 29
Margareta Ieven
2.1 Introduction 29
2.2 HIVinfectionandMycobacteriumtuberculosis 30
2.3 HIVinfectionandnontuberculousmycobacteria(NTM) 33
2.4 HIVandPneumocystisjirovecii 34
2.5 Infectionsintransplant patientsorotherimmunodeficiencies 35
2.6 Concluding remarks 45
3 Diagnosis of Pneumonia in Immunocompromised Patient 53
Robert P. Baughman and Elyse E. Lower
3.1 Introduction 53
3.2 Clinicalassessment 55
3.3 Bloodcultures 60
3.4 Sputum 60
3.5 Endotrachealaspirate 61
3.6 Nonbronchoscopicbronchoalveolarlavage 63
3.7 Protectedbrushsample(PBS) 64
3.8 Bronchoalveolarlavage(BAL) 65
3.9 Transbronchialbiopsy(TBB) 71
3.10 Surgicallungbiopsy(SLB) 73
3.11 Sampleprocessing 74
3.12 Clinicalapproachtopulmonaryinfiltrates
inimmunosuppressedpatient 76
3.13 Conclusion 80
vi CONTENTS
4 Pulmonary Imaging in Immunocompromised Patients 95
(cid:1)
Tomas Franquet
4.1 Pulmonaryinfectionsinimmunocompromisedpatient 95
4.2 Respiratory infections 100
4.3 Interventionalproceduresinpatientswithpneumonia 111
4.4 Summary 113
5 Pulmonary Infections in HIV Patients in the Highly Active
Antiretroviral Therapy Era 117
Natividad Benito and Asuncio´n Moreno-Camacho
5.1 Introduction 117
5.2 Epidemologyandetiology 118
5.3 Diagnosis 128
5.4 Prognosis 131
5.5 Conclusions 132
6 Neutropenia 143
Maria J. Ru¨ping, Jo¨rg J. Vehreschild, Santiago Ewig
and Oliver A. Cornely
6.1 Introduction 143
6.2 Managementoftheneutropenicpatient 149
6.3 Specificinfectiousdiseases 160
7 General Management of Suspected Pneumonia
in the Solid Organ Transplant Patient 197
Andrew F. Shorr
7.1 Introduction 197
7.2 Epidemiology 197
7.3 Differentialdiagnosisandnon-infectiouscomplications 199
7.4 Diagnosticapproach 201
7.5 Conclusion 210
8 Respiratory Infections Following Haematopoietic Stem Cell
Transplantation 213
Ayman O. Soubani
8.1 ImmunesystemrecoveryafterHSCT 215
8.2 Bacterialpneumonia 217
8.3 Invasivepulmonaryaspergillosis 222
8.4 Cytomegalovirus 232
8.5 Communityrespiratoryviruses 235
8.6 Non-infectiouspulmonarycomplications 239
8.7 Conclusion 241
CONTENTS vii
9 Chronic Non-infectious Pulmonary Complications
in Haematopoietic Stem Cell Transplantation 257
Bekele Afessa and Steve G. Peters
9.1 Introduction 257
9.2 BronchiolitisObliterans(BO) 260
9.3 BronchiolitisObliteransorganizing
pneumonia(BOOP) 263
9.4 Idiopathicpneumoniasyndrome(IPS) 265
9.5 Diffusealveolarhaemorrhage(DAH) 267
9.6 Peri-engraftment respiratorydistress
syndrome(PERDS) 269
9.7 Delayedpulmonarytoxicitysyndrome(DPTS) 270
9.8 Pulmonarycytolyticthrombi(PCT) 271
9.9 Othernon-infectiouspulmonarycomplications 272
9.10 Summary 274
10 Pulmonary Infections in Patients on Chronic
Glucocorticoid Treatment 283
Ana Ran˜o´ and Carlos Agust´ı
10.1 Introduction 283
10.2 Associated inflammatoryresponseinpneumonia 283
10.3 Glucocorticoids: Mechanismsofaction 284
10.4 Glucocorticoidtherapy inclinicalpractice 286
10.5 Diagnosticapproach 296
10.6 Empiricaltreatmentofsuspectedpneumoniainpatients
receivingchronicGCtherapy 298
10.7 Prognosis 298
10.8 Conclusions 299
11 Intensive Care Management in the Immunocompromised
Patient with Pulmonary Infiltrates 305
Gilles Hilbert, Didier Gruson and Frederic Vargas
11.1 Introduction 305
11.2 Invasiveventilation 306
11.3 RationaleforNIV 307
11.4 Mechanisms ofimprovementwithNIV
inimmunocompromisedpatients withacute
respiratoryfailure 308
11.5 Clinicalstudies 309
11.6 Equipment andtechniques:particularities
inimmunocompromisedpatients 316
11.7 Predictive factorsofNIVoutcome 319
11.8 Conclusions 320
viii CONTENTS
12 Current Strategies and Future Directions
in Antibacterial Treatment 325
Jan Jelrik Oosterheert and Andy I.M. Hoepelman
12.1 Introduction 325
12.2 Farmacokineticsandfarmacodynamics 325
12.3 Antibacterialtreatmentoptions 331
12.4 Resistance 336
12.5 HIVrelatedbacterialpulmonaryinfections 339
12.6 Lengthoftreatment 342
12.7 Conclusions 343
13 Current Strategies in the Treatment of Fungal Infections
in the Intensive Care Unit Setting 349
Mitchell Goldman and George A. Sarosi
13.1 Introduction 349
13.2 Antifungaltherapies 350
13.3 Theendemicfungiinthecriticalcareunit 351
13.4 Otheryeastinfectionsinthecriticalcareunit 358
13.5 Invasivemouldinfectionsinthecriticalcareunit 363
13.6 Summary 375
14 Current Strategies and Future Directions
in Cytomegalovirus (CMV) Pneumonitis 383
(cid:1)
Julio C. Medina Presentado and Jose M. Aguado
14.1 EffectsofCMVinfectioninimmunocompromisedpatients 383
14.2 PathophysiologyofCMVpneumonitis 384
14.3 RiskfactorsforCMVpneumonitis 385
14.4 PulmonarymanifestationsofCMVinfection 386
14.5 IndirectrespiratoryeffectsofCMVinfection 387
14.6 Diagnosis ofCMV pneumonitis 387
14.7 AntiviralagentsagainstCMV 388
14.8 TreatmentofCMVpneumonia 390
14.9 PreventionofCMVpneumonia 393
15 Antiviral Agents against Respiratory Viruses 401
Michael G. Ison
15.1 M2inhibitors 402
15.2 Neuraminidaseinhibitors 407
15.3 Cidofovir 412
15.4 Ribavirin 414
15.5 Investigationalagents 417
Index 429
Preface
The number of immunocompromised patients has increased over the last decade.
Improvementsinsolid-organandhaematopoieticstemcelltransplantationtechniques,
the expanded use of chemotherapic treatments and glucocorticoids use, and the
appearance of new immunomodulatory therapies are some of the reasons that justify
thisincrease.Thesuccessofthedifferenttransplanttechniqueshasgeneratedagreat
dealofinterestinthemanagementofimmunocompromisedpatientsamongclinicians
andbasicscientists.Therecognitionandmanagementofpulmonarycomplicationsthat
resultfromimmunosuppressionisachallengingtask.Thelungsmaybeinjureddirectly
throughaninfectiousortoxicinsult.Conversely,lungdiseasemayresultasasecondary
event.Pulmonarycomplicationsinthesepatientsrequireamultidisciplinaryapproach
thatofteninvolvesdifferentspecialists.Thisincludesanappreciationoftheepidemi-
ologyofpost-transplantpulmonarycomplications,thedifferentialdiagnosesforthese
processes, the appropriate diagnostic explorations, and the specific treatments and
potential interactions.
Our goals in this book are to provide an integrated discussion of progress in a
comprehensivefashion.Thegeneralaspectsofthelungimmunedefencesarereviewed
by Drs Patel and Koziel. Microbiological diagnosis and respiratory sampling in this
population are a very important issues, related to the adequacy of treatment and
mortality. Dr Ieven and Dr Baughman have reviewed both chapters in depth. The
radiological approach to the diagnosis of respiratory complications is of particular
importanceandDrFranquetpresentsthedifferenttoolsthatwecurrentlyhaveinour
hands.
The remaining chapters of the book are dedicated to the review of respiratory
infections regarding different types of immunosuppression: HIV infected patients,
neutropenia, haematopoietic stem cell transplantation and chronic steroid treatment.
Finally, intensive care management, antibacterial, antifungal and antiviral treatments
are updated by experts in these subjects.
Asinanymulti-authorbook,thesuccessoftheendeavourrelatestothecommitment
andcreativityofthecollaboratingauthors;weareextremelythankfulforthehardand
carefulworkofeachofourcontributors.Wewouldalsoliketothankourcolleaguesat
John Wiley & Sons, Ltd who provided outstanding support for this project.
Carlos Agust´ı
Antoni Torres
Contributors
Bekele Afessa Santiago Ewig
DivisionofPulmonaryandCriticalCare ThoraxzentrumRuhrgebiet,Klinikenfu€r
Medicine,MayoClinicCollegeofMedicine, PneumologieundInfektiologie,
200FirstST,Rochester, Evangelisches KrankenhausHerneund
MN55905,USA Augusta-Kranken-Anstalt, Bergstrasse26,
Email:[email protected] 44791Bochum,Germany
Email:[email protected]
Jose´ M. Aguado
UnitofInfectiousDiseases,University Toma´s Franquet
Hospital12deOctubre,Av. deAndaluc´ıa
ChiefofThoracicImagingSection,
Km.5,400.28041Madrid,Spain
DepartmentofRadiology,HospitaldeSant
Email:[email protected]
Pau,St.AntoniMariaClaret,167,08025,
Barcelona,Spain;andDepartmentof
Carlos Agust´ı Radiology,UniversitatAuto´nomaof
InstitutClinic dePneumologiaICPCT, Barcelona,Barcelona,Spain
HospitalClinic,C/Villarroel,170,08036 Email:[email protected]
Barcelona,Spain
Email:[email protected]
Mitchell Goldman
DivisionofInfectiousDiseases,Indiana
Robert P. Baughman
University SchoolofMedicine,Wishard
UniversityofCincinnatiMedicalCenter,
MemorialHospital(RoomOPW430),
1001Holmes,EdenAvenue,Cincinnati,
1001W.10thStreet,IN46202,USA
OH45267-0565, USA
Email:[email protected]
Email:[email protected]
Didier Gruson
Natividad Benito
DivisionofMedicalIntensiveCare,
InfectiousDiseasesUnit,SantPauHospital,
University HospitalBordeaux,Hoˆpital
SantAntoniMariaClaret167,08025
Pellegrin,PlaceAmelieRaba-L(cid:1)eon,
Barcelona.Spain
F-33076BordeauxCedex,France
Email:[email protected]
Oliver A. Cornely Gilles Hilbert
UniklinikKo€ln,KlinikIfu€rInnereMedizin, DivisionofMedicalIntensiveCare,
KlinischesStudienzentrum, Schwerpunkt University HospitalBordeaux,Hoˆpital
InfektiologieII,BachemerStrasse86, Pellegrin,PlaceAmelieRaba-L(cid:1)eon,F 33076
50931Ko€ln,Germany Bordeaux Cedex,France
Email:[email protected] Email:[email protected]
xii CONTRIBUTORS
Andy I.M. Hoepelman Jan Jelrik Oosterheert
UniversityMedicalCenterUtrecht, UniversityMedicalCenterUtrecht,
DivisionofMedicine,Department DivisionofMedicine,Department
ofInternalMedicineandInfectious ofInternalMedicineandInfectious
Diseases,POBox85500, Diseases,POBox85500,3508
3508GA Utrecht,TheNetherlands GAUtrecht,TheNetherlands
Email:[email protected] Email:[email protected]
Margareta Ieven
Naimish Patel
DepartmentofMedicalMicrobiology,
DivisionofPulmonary,CriticalCare
FacultyofMedicine,UniversityofAntwerp,
andSleepMedicine,KirsteinHall,Room
Universiteitsplein1S3,
E/KSB-23,BethIsraelDeaconessMedical
B-2610,Wilrijk,Belgium
CenterandHarvardMedical
Email:[email protected]
School,330BrooklineAvenue,
Boston,MA02215,USA
Michael G. Ison
NorthwesternUniversityFeinbergSchool
ofMedicine,DivisionsofInfectiousDiseases Steve G. Peters
&OrganTransplantation,Transplant DivisionofPulmonaryandCriticalCare
&ImmunocompromisedHostInfectious Medicine,MayoClinicCollegeofMedicine,
DiseasesService,676N. StreetClair 200FirstSt,Rochester,
StreetSuite200,Chicago,IL60611,USA MN55905,USA
Email:[email protected] Email:[email protected]
Henry Koziel
DivisionofPulmonary,CriticalCareand Julio C. Medina Presentado
SleepMedicine,KirsteinHall, RoomE/KSB- C(cid:1)atedradeEnfermedadesInfecciosas,
23,BethIsraelDeaconessMedicalCenter UniversidaddelaRepu´blica,
andHarvardMedicalSchool,330Brookline Uruguay
Avenue,Boston,
MA02215,USA
Email:[email protected] Ana Ran˜o´
InstitutClinicdePneumologiaICPCT,
Elyse E. Lower HospitalClinic,C/Villarroel,170,
UniversityofCincinnatiMedicalCenter, 08036Barcelona,Spain
1001Holmes,EdenAvenue,Cincinnati,OH
45267-0565,USA
Maria J. Ru¨ping
Asuncio´n Moreno-Camacho UniklinikKo€ln,KlinikIfu€rInnereMedizin,
InfectiousDiseasesService, KlinischesStudienzentrum, Schwerpunkt
HospitalClinic,Villarroel170, InfektiologieII,BachemerStrasse86,
08036-Barcelona,Spain 50931Ko€ln,Germany
Email:[email protected] Email:[email protected]