Journal of Antimicrobial Chemotherapy (2003) 51, 205
© 2003 The British Society for Antimicrobial Chemotherapy
Book Review |
The Effective Prevention and Management of Systemic Fungal Infection in Haematological Malignancy
A. Prentice, T. Rogers and A. Miles, Eds.Aesculapius Medical Press, London, 2001.
ISBN 1-903044-18-9. 157 pp.
This book is one of the UK Key Advances in Clinical Practice series reflecting the contents of a symposium on fungal infection, and is a timely collection of papers on this ever-increasing problem. Although containing much useful background data with plenty of helpful advice, in a rapidly moving field there is much that is already missing. However, the collection is a very useful starting point and comprehensive literature review. The book starts with a useful glossary of terms, which itself could help standardize some of our thinking and description with regard to fungal infection, and if applied formally in clinical trails or routine practice would do much to give consistency in reporting and presentation.
The presentations are split up into three basic groups: the first discussing the epidemiology of fungal infection, the second prophylaxis and treatment, and the third susceptibility testing. The final section is an excellent review by Peter Donnelly on the future prospectives, which alone is worth the book by giving a comprehensive review of current trials and a rational way forward in approaching fungal infection.
The scene is set with the first chapter on incidence, which highlights the importance of fungal infection, the increasing incidence in immunocompromised and neutropenic patients, importance of environmental spread and the involvement of unusual pathogens. A recent survey in North America showed fungal infection to be the seventh most important cause of infectious death, with Aspergillus becoming an increasing problem. The stark difference between diagnosis during life and the incidence at post-mortem is highlighted, and the review by Rogers emphasizes the difficulty in diagnosis when looking at a combination of techniques for prospective surveillance and early detection for effective therapy. The promise of diagnosis by PCR is discussed, with its excellent sensitivity but poor specificity, and disappointingly emphasizes the brief gain in early diagnosis obtained in studies thus far. The importance of early diagnosis has always rested on the premise that once infection is established (and obvious) then mortality increases considerably. Therefore, the concept of pre-emptive therapy has been widely supported, although it still awaits confirmation.
While the idea of early treatment in Candida infection is questioned by some of the data presented by Kibbler, it is clear that in Aspergillus infection, early treatment does equate to better response. To this end prophylactic therapy is reviewed with current available therapies by A. Prentice. All have some drawbacks and not all have been proven effective. Early results with liposomal amphotericin are encouraging but require larger-powered studies. The chapter by O’Gorman and Chopra emphasizes that high-risk patients need to be identified. In these patients prophylactic approaches need to be explored, and the importance of early empirical/pre-emptive therapy is clear. In those at low risk, confirmation can be awaited without significant impact on mortality. This presentation highlights the potential size of the problem, differentiating those neutropenic patients who become pyrexial from those who potentially require an anti-fungal approach. In the UK in particular, if not in the USA, the main high-risk area is treatment of Aspergillus infection, where many new and novel approaches have been attempted. These are reviewed by H. G. Prentice and Hann, including some of the newer therapies (although in all of these the results are premature), the value of selective surgery and the potentially exciting synergic effect of growth factors in combination with amphotericin formulations.
One of the significant conundrums in fungal infection is that of susceptibility testing. Although anti-fungal susceptibility has reached the same level of standardization and reliability as testing with anti-bacterial agents, the results cannot be relied on as a definitive predictor of treatment. Further refinement is awaited. The data are excellently summarized by Odds.
In summary, this selection of reviews is an excellent and easy read, and a comprehensive background to the problem of fungal infection in haematological malignancy; in a rapidly moving field, it misses much on the newer anti-fungal agents that are available and the newer work on diagnostic techniques. However, this does not detract from the comprehensive review of the state of the anti-fungal art up to one year ago, and leaves us in anticipation of the next volume in the series that will update us to the present day.
Professor A. C. Newland
Department of Haematology, Barts and the London Hospital, Turner Street, London E1 1BB, UK
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