Dimitrios P. Kontoyiannis, MD, ScD
Grant Support: This research is supported in part by the MD Anderson Cancer Center (grant CA016672). Dr. Kontoyiannis is the recipient of the Frances King Black Endowed Professorship for Cancer Research.
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2735.
Requests for Single Reprints: Dimitrios P. Kontoyiannis, MD, ScD, Department of Infectious Diseases, Infection Control and Employee Health, Unit 402, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030; e-mail, firstname.lastname@example.org.
Author Contributions: Conception and design: D. Kontoyiannis.
Analysis and interpretation of the data: D. Kontoyiannis.
Drafting of the article: D. Kontoyiannis.
Critical revision of the article for important intellectual content: D. Kontoyiannis.
Final approval of the article: D. Kontoyiannis.
Kontoyiannis DP. Preventing Fungal Disease in Chronically Immunosuppressed Outpatients: Time for Action?. Ann Intern Med. 2013;158:555-556. doi: 10.7326/0003-4819-158-7-201304020-00007
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Published: Ann Intern Med. 2013;158(7):555-556.
The issues of infection control and avoiding exposure to environmental fungi in outpatients with chronic immunosuppression are unique and timely, especially for transplant recipients or those with hematologic cancer. The increasing use of chemotherapy and stem cell transplantation in the outpatient setting and the increased mobility of these patients, including long-distance travel, create complex and variable scenarios of exposure to various fungi and late infectious complications (1). Typically, these patients have a lower net state of immunosuppression than acutely hospitalized patients and have differing patterns and degrees of immune reconstitution. The safety of patients' residences is not regulated, because the hospital setting is where policies and procedures are in place about air quality, water, fomites, food, and infection control measures. At home, there may be a greater likelihood of exposure to high levels of fungal inocula. Furthermore, outpatients with chronic immunosuppression typically are prescribed prolonged antifungal prophylaxis (2), often with oral broad-spectrum triazoles. Physicians should not have a false sense of security that broad-spectrum oral azoles can eliminate fungal risk in chronically immunosuppressed outpatients. Once at home, patients may take medications erratically or have diminished blood levels owing to drug–drug interactions. They may have severe invasive fungal infections (IFIs) with delayed or unusual clinical presentations. Therefore, a low threshold is required for drug monitoring to maintain an optimal target of serum levels of new triazoles, especially if adherence and pharmacokinetic problems are suspected.
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Hematology/Oncology, Infectious Disease, Prevention/Screening.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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