From guesswork to guidelines: advancing diagnostic stewardship in immunocompromised hosts.

Introduction: Diagnostic stewardship, the optimization of diagnostic testing to improve patient outcomes, is a rapidly evolving field; however, data relating to immunocompromised hosts are scarce.

Areas Covered: This review examines recent advances in diagnostic stewardship and explores best practice principles for key clinical scenarios in immunocompromised patients, including febrile neutropenia, central nervous system infections, invasive fungal infections, cytomegalovirus, and infection.

Expert Opinion: Key challenges remain, including optimizing test utilization without compromising patient safety, interpreting advanced diagnostics in the context of immunosuppression, and demonstrating cost-effectiveness.

Outcomes of Invasive Aspergillosis in Liver Transplant Recipients From an Institution Using Targeted Antifungal Prophylaxis and an Antifungal Stewardship Program.

Background: Recent evidence suggests liver transplant recipients (LiTRs) with invasive aspergillosis (IA) have lower rates of dissemination and mortality compared to historical data. However, contemporary data from other centers remain scarce. We aimed to evaluate modern IA outcomes at our institution, where targeted perioperative echinocandin prophylaxis and an active antifungal stewardship program (AFSP) have been implemented.

Perioperative Penicillin and Cephalosporin Antibiotic Allergy Assessment and Testing: The PREPARE Pilot Randomized Clinical Trial.

Importance: Antibiotic allergy labels (AALs) impact patient health and perioperative outcomes. Antibiotic allergy delabeling could improve antibiotic prescribing and infection-related outcomes perioperatively.

Objective: To assess the feasibility and safety of antibiotic allergy assessment and delabeling in anesthesiologist-led preoperative assessment clinics and expand delabeling efforts outside of specialist allergy clinics.

Evaluating diagnostic tools, outcome measures and antibiotic approach in diabetic foot osteomyelitis: a scoping review and narrative synthesis.

Introduction: Diabetic foot osteomyelitis (DFO) is a significant complication of diabetic foot disease; however, diagnosis remains challenging and treatment success is difficult to ascertain. Literature in this space that has utilized varying diagnostic criteria and ideal outcome measures for success is unclear.

Areas Covered: This scoping review assesses methods of diagnosis of DFO and definitions of treatment outcomes in the literature assessing antibiotic therapy for treatment of DFO.

Low-risk penicillin allergy delabeling: a scoping review of direct oral challenge practice, implementation, and multi-disciplinary approaches.

Introduction: Penicillin allergy is common, and there is increased clinician interest in direct oral challenge (DOC) as a testing strategy for low-risk penicillin allergy. To aid wider implementation of DOC, consensus definitions of low-risk penicillin allergy phenotypes, and standardized approaches to assessment, DOC procedures, and evaluation, are required.

Areas Covered: This review systematically reviews studies that have utilized penicillin DOC in healthcare settings to identify heterogeneity in implementation approaches and synthesize low-risk definitions, procedures, and evaluation.

Infections in haematology patients treated with CAR-T therapies: A systematic review and meta-analysis.

A registered (PROSPERO - CRD42022346462) systematic review and meta-analysis was conducted of all-grade infections amongst adult patients receiving CAR-T therapy for haematological malignancy. Meta-analysis of pooled incidence, using random effects model, was conducted. Cochran's Q test examined heterogeneity.

Invasive fungal infection following venetoclax and posaconazole co-administration.

The co-administration of venetoclax, a BCL-2 inhibitor, with a mould-active azole, such a posaconazole, has potential to both prevent invasive fungal infection (IFI) and reduce the required treatment dose, and cost, of venetoclax. Posaconazole drug-level monitoring is critical to ensuring adequate mould prophylaxis. A retrospective audit of 99 patients at a tertiary cancer centre, with myeloid malignancies co-prescribed venetoclax and posaconazole between January 2018 and April 2022, was undertaken to evaluate the adequacy of posaconazole prescribing and the rate of breakthrough IFI.

Recommendations on prevention of infections in patients with T-cell lymphomas: a narrative review and synthesis.

T/Natural killer (NK) cell lymphomas (TCL) represent a heterogenous subgroup of non-Hodgkin lymphoma, associated with poorer prognosis and higher treatment toxicity. A cohesive synthesis of infection outcomes among TCL patients is lacking. International guidelines offer no specific recommendations regarding prophylaxis or supportive infection care for TCL patients.

Vaccine schedule recommendations and updates for patients with hematologic malignancy post-hematopoietic cell transplant or CAR T-cell therapy.

Revaccination after receipt of a hematopoietic cell transplant (HCT) or cellular therapies is a pillar of patient supportive care, with the potential to reduce morbidity and mortality linked to vaccine-preventable infections. This review synthesizes national, international, and expert consensus vaccination schedules post-HCT and presents evidence regarding the efficacy of newer vaccine formulations for pneumococcus, recombinant zoster vaccine, and coronavirus disease 2019 in patients with hematological malignancy. Revaccination post-cellular therapies are less well defined.

Infections following bispecific antibodies in myeloma: a systematic review and meta-analysis.

Bispecific antibodies, a novel immunotherapy with promising efficacy against multiple myeloma, form immune synapses between T-cell surface marker CD3 and malignant cell markers, including B-cell maturation antigen (BCMA), FcRH5, and G protein-coupled receptor GPRC5D. These bispecific antibodies so effectively deplete plasma cells (and to some extent T-cells) that patients are at increased risk of developing infections. A systematic review and meta-analysis of infections in published studies of patients with myeloma treated with bispecific antibodies was conducted to better characterize the infection risks.

COVID-19 infection among patients with cancer in Australia from 2020 to 2022: a national multicentre cohort study.

Background: The global COVID-19 pandemic disproportionately affected certain populations and its management differed between countries. This national study describes characteristics and outcomes of COVID-19 in patients with cancer in Australia.

Methods: We performed a multicentre cohort study of patients with cancer and COVID-19 from March 2020 to April 2022.

Predicting infections in patients with haematological malignancies treated with chimeric antigen receptor T-cell therapies: A systematic scoping review and narrative synthesis.

Background: Chimeric antigen receptor T cells (CAR-T cells) are increasingly used to treat haematological malignancies. Strategies for preventing infections in CAR-T-treated patients rely on expert opinions and consensus guidelines.

Objectives: This scoping review aimed to identify risk factors for infections in CAR-T-treated patients with haematological malignancies.

Disseminated Invasive Mucormycosis Infection Following Autologous Stem Cell Transplantation for Diffuse Large B-Cell Lymphoma.

Invasive fungal infections (IFI) are challenging to predict, diagnose and treat, and are associated with a particularly high mortality among patients with hematological malignancies. They are relatively uncommon in patients with lymphoma, compared with those with acute leukemia or undergoing allogeneic transplantation. We present a patient, autografted for recurrent lymphoma, with fever and refractory diarrhea persisting post engraftment, eventually attributable to disseminated mucor infection.