TECHNICAL NOTE
Prophylaxis of fungal infections in transplant patients
Edson AbdalaI, Sílvia Figueiredo CostaII, Tania Mara Varejão StrabelliIII, Lígia Camera PierrottiIV, Marlova Luzzi CaramoriV, Luis Sérgio Fonseca de AzevedoVI, Karim Y IbrahimIV, Frederico Luiz DulleyVII, Glaucia Fernanda VarkuljaVIII, Gilberto de Castro JuniorIX, Gisele Madeira Duboc de AlmeidaX, Heloisa Helena de Souza MarquesXI, Maria Aparecida Shikanai-YasudaII,
, Comissão de Infecção em Imunodeprimidos, Hospital das Clínicas da Faculdade de Medicina da USP
Corresponding author
I Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Liver Transplant Service, São Paulo/SP, Brazil
II Faculdade de Medicina da Universidade de São Paulo (FMUSP), Department of Infectious and Parasitic Diseases, São Paulo/SP, Brazil
III Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (INCOR-HCFMUSP), Heart Transplant Area, São Paulo/SP, Brazil
IV Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Clinical Division of Infectious Diseases, São Paulo/SP, Brazil
V Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (INCOR- HCFMUSP), Lung Transplant Unit, São Paulo/SP, Brazil
VI Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Kidney Transplant Unit, Urology Division, São Paulo/SP, Brazil
VII Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Hematologia, Serviço de Transplante de Medula Óssea, São Paulo/SP, Brazil
VIII Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICHC-HCFMUSP), Infection Control Committee of the Instituto Central, São Paulo/SP, Brazil
IX Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo/SP, Brazil
X Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Division of Central Laboratory, (HCFMUSP), São Paulo/SP, Brazil
XI Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr-HCFMUSP), Instituto da Criança, São Paulo/SP, Brazil
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Transplant Service, São Paulo/SP, Brazil" "etiqueta" => "I" "identificador" => "af1" ] 1 => array:3 [ "entidad" => "Faculdade de Medicina da Universidade de São Paulo (FMUSP), Department of Infectious and Parasitic Diseases, São Paulo/SP, Brazil" "etiqueta" => "II" "identificador" => "af2" ] 2 => array:3 [ "entidad" => "Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (INCOR-HCFMUSP), Heart Transplant Area, São Paulo/SP, Brazil" "etiqueta" => "III" "identificador" => "af3" ] 3 => array:3 [ "entidad" => "Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Clinical Division of Infectious Diseases, São Paulo/SP, Brazil" "etiqueta" => "IV" "identificador" => "af4" ] 4 => array:3 [ "entidad" => "Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (INCOR- HCFMUSP), Lung Transplant Unit, São Paulo/SP, Brazil" "etiqueta" => "V" "identificador" => "af5" ] 5 => array:3 [ "entidad" => "Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Kidney Transplant Unit, Urology Division, São Paulo/SP, Brazil" "etiqueta" => "VI" "identificador" => "af6" ] 6 => array:3 [ "entidad" => "Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Hematologia, Serviço de Transplante de Medula Óssea, São Paulo/SP, Brazil" "etiqueta" => "VII" "identificador" => "af7" ] 7 => array:3 [ "entidad" => "Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICHC-HCFMUSP), Infection Control Committee of the Instituto Central, São Paulo/SP, Brazil" "etiqueta" => "VIII" "identificador" => "af8" ] 8 => array:3 [ "entidad" => "Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo/SP, Brazil" "etiqueta" => "IX" "identificador" => "af9" ] 9 => array:3 [ "entidad" => "Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Division of Central Laboratory, (HCFMUSP), São Paulo/SP, Brazil" "etiqueta" => "X" "identificador" => "af10" ] 10 => array:3 [ "entidad" => "Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr-HCFMUSP), Instituto da Criança, São Paulo/SP, Brazil" "etiqueta" => "XI" "identificador" => "af11" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "c1" "etiqueta" => "*" "correspondencia" => "Tel.: 55 11 3061 7048" ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="para10" class="elsevierStylePara elsevierViewall">Fungi are an important cause of infection in patients undergoing solid organ transplantation and bone marrow or hematopoietic stem cell transplantation (BMT/HSCT). The incidence and mortality of fungal infections differ according to the organ and the time since transplantation. In the first 30 days after transplantation, yeast (primarily <span class="elsevierStyleItalic">Candida spp.</span>) predominate. After the first month, filamentous fungi, such as <span class="elsevierStyleItalic">Aspergillus spp.</span>, are the most frequent agents of infection (<a class="elsevierStyleCrossRefs" href="#bib1">1–6</a>).</p><p id="para20" class="elsevierStylePara elsevierViewall">In BMT/HSCT patients, however, invasive aspergillosis has two peaks of incidence: one at one month post-transplantation and another approximately 90 days after the transplant if the patient develops chronic graft versus host disease (<a class="elsevierStyleCrossRef" href="#bib7">7</a>,<a class="elsevierStyleCrossRef" href="#bib8">8</a>).</p><p id="para30" class="elsevierStylePara elsevierViewall">Among solid organ transplantation, liver and lung transplant have the highest risk for fungal infection due to underlying diseases, surgical techniques and the graft itself (<a class="elsevierStyleCrossRef" href="#bib4">4</a>,<a class="elsevierStyleCrossRef" href="#bib9">9</a>).</p><p id="para40" class="elsevierStylePara elsevierViewall">Antifungal prophylaxis use is well established following some transplant types, such as BMT/HSCT and liver (<a class="elsevierStyleCrossRef" href="#bib10">10</a>,<a class="elsevierStyleCrossRef" href="#bib11">11</a>). However, few studies have evaluated heart and pancreas transplants. One of the major challenges is the prevention of filamentous fungal infections, especially by <span class="elsevierStyleItalic">Aspergillus spp</span>., in high-risk patients, such as those who have undergone an allogeneic BMT and developed chronic graft versus host disease or undergone a lung transplantation (<a class="elsevierStyleCrossRef" href="#bib12">12</a>,<a class="elsevierStyleCrossRef" href="#bib13">13</a>).</p><p id="para50" class="elsevierStylePara elsevierViewall">To standardize the use of primary prophylaxis in transplant patients, we analyzed the literature related to the following transplants: liver, kidney, heart, lung, and HSCT. The IDSA (Infectious Diseases Society of America) system was used to determine the levels of evidence.</p><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">Recommendations</span><p id="para60" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="celist10"><li class="elsevierStyleListItem" id="celistitem10"><span class="elsevierStyleLabel">1.</span><p id="para70" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Liver transplantation</span> (<a class="elsevierStyleCrossRefs" href="#bib11">11,14–20</a>)</p><p id="para80" class="elsevierStylePara elsevierViewall">Universal prophylaxis: no (CII)</p><p id="para90" class="elsevierStylePara elsevierViewall">Targeted prophylaxis: yes (AI)</p><p id="para100" class="elsevierStylePara elsevierViewall">- Fluconazole 400 mg/day for 21 days<ul class="elsevierStyleList" id="celist20"><li class="elsevierStyleListItem" id="celistitem20"><span class="elsevierStyleLabel">•</span><p id="para110" class="elsevierStylePara elsevierViewall">Criterion 1 – at least one of the following risk factors: fulminant hepatitis, re-transplant requirement, post-tx hemodialysis, or the use of antibodies for rejection treatment.</p></li><li class="elsevierStyleListItem" id="celistitem30"><span class="elsevierStyleLabel">•</span><p id="para120" class="elsevierStylePara elsevierViewall">Criterion 2 – at least two of the following risk factors: antibiotic prophylaxis for spontaneous bacterial peritonitis (SBP) pre-tx, reoperation, ICU admission in the 30 days before the tx, or antibiotic use in the 30 days before the tx.</p></li></ul></p></li><li class="elsevierStyleListItem" id="celistitem40"><span class="elsevierStyleLabel">2.</span><p id="para130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Kidney transplantation</span></p><p id="para140" class="elsevierStylePara elsevierViewall">There are no studies on prophylaxis.</p><p id="para150" class="elsevierStylePara elsevierViewall">Prophylaxis is not recommended (DII).</p></li><li class="elsevierStyleListItem" id="celistitem50"><span class="elsevierStyleLabel">3.</span><p id="para160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Lung transplantation</span> (<a class="elsevierStyleCrossRef" href="#bib12">12</a>,<a class="elsevierStyleCrossRefs" href="#bib21">21–24</a>)</p><p id="para170" class="elsevierStylePara elsevierViewall">Universal prophylaxis: yes (AI)</p><p id="para180" class="elsevierStylePara elsevierViewall">- Inhaled amphotericin B deoxycholate for 3 months (50 mg + 50 ml of distilled water; 10 ml inhalation twice a day)</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para190" class="elsevierStylePara elsevierViewall">Targeted prophylaxis: yes, if the recipient or donor has airway colonization by <span class="elsevierStyleItalic">Aspergillus spp.</span> pre-tx or post-tx (associated with amphotericin B inhalation).</p><p id="para200" class="elsevierStylePara elsevierViewall">First choice*: 400 mg itraconazole orally for 3 months (BIII)</p><p id="para210" class="elsevierStylePara elsevierViewall">Second choice: IV voriconazole (6 mg/kg/day) or oral voriconazole (400 mg/day) for 3 months (CIII)</p><p id="para220" class="elsevierStylePara elsevierViewall">* Advised serum concentration.</p></li><li class="elsevierStyleListItem" id="celistitem60"><span class="elsevierStyleLabel">4.</span><p id="para230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Heart transplantation</span> (<a class="elsevierStyleCrossRef" href="#bib22">22</a>)</p><p id="para240" class="elsevierStylePara elsevierViewall">Prophylaxis not indicated (DII).</p></li><li class="elsevierStyleListItem" id="celistitem70"><span class="elsevierStyleLabel">5.</span><p id="para250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Hematopoietic stem cell transplant</span> (HSCT)(<a class="elsevierStyleCrossRef" href="#bib10">10</a>,<a class="elsevierStyleCrossRefs" href="#bib25">25–28</a>)</p><p id="para260" class="elsevierStylePara elsevierViewall">Universal prophylaxis: yes (AI)</p><p id="para270" class="elsevierStylePara elsevierViewall">Fluconazole 400 mg/day IV or oral for 100 days</p><p id="para280" class="elsevierStylePara elsevierViewall">Targeted prophylaxis: yes, for patients under treatment for GVHD</p><p id="para290" class="elsevierStylePara elsevierViewall">First option: amphotericin B deoxycholate 1 mg/kg/day (or equivalent doses of a lipidic formulation) for 100 days (CIII)</p><p id="para300" class="elsevierStylePara elsevierViewall">Second option: itraconazole* 400 mg/day, oral for 100 days (CIII)</p><p id="para310" class="elsevierStylePara elsevierViewall">Third option: EV voriconazole (6 mg/kg/day) or oral voriconazole (400 mg/day) for 100 days (CIII)</p><p id="para320" class="elsevierStylePara elsevierViewall">** Advised serum concentration.</p><p id="para330" class="elsevierStylePara elsevierViewall">Controlled and randomized studies have been registered with other azoles, but they were not standardized in the institution or perhaps they are not available in Brazil.</p></li><li class="elsevierStyleListItem" id="celistitem80"><span class="elsevierStyleLabel">6.</span><p id="para340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pancreas transplant</span> (<a class="elsevierStyleCrossRef" href="#bib29">29</a>)</p><p id="para350" class="elsevierStylePara elsevierViewall">Universal prophylaxis: yes (CII)</p><p id="para360" class="elsevierStylePara elsevierViewall">Fluconazole 400 mg/day IV or VO for 7 days (surgical prophylaxis)</p><p id="para370" class="elsevierStylePara elsevierViewall">Targeted prophylaxis: no (DII)</p></li></ul></p><p id="para380" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Conflicts of interest:</span> Edson Abdala - speaker for Bago, performs clinical research with Bristol. Sílvia Figueiredo Costa - speaker for Pfizer. Tania Mara Varejão Strabelli - speaker for Novartis, works with Novartis, performs clinical research with Merck.</p></span></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">AUTHOR CONTRIBUTIONS</span><p id="para390" class="elsevierStylePara elsevierViewall">Abdala E wrote the manuscript (Portuguese), participated of the discussion of the final recommendations and of the revision of the manuscript. Costa SF presented the recommendation for bone marrow transplantation, helped to write the manuscript, wrote part of English version and revised the literature and the final text. Strabelli TMV presented the recommendation for heart transplantantion, wrote part of English version and revised the final text. Caramori ML presented the recommendation for lung transplantation and discussed the final recommendation. Pierrotti LC, Azevedo LSF, Ibrahim KY, Dulley FL, Varkulja GF, Castro Jr C, Almeida GMD, Souza Marques HH participated of the discussion of the text and of the final recommendations. Shikanai-Yasuda MA coordinated the presentations and discussion of the recommendations, helped to revise the final recommendations and to prepare the manuscript for submission.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "cesec10" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "cesec20" "titulo" => "Recommendations" ] ] ] 1 => array:2 [ "identificador" => "cesec30" "titulo" => "AUTHOR CONTRIBUTIONS" ] 2 => array:2 [ "identificador" => "xack639405" "titulo" => "ACKNOWLEDGMENTS" ] 3 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">No potential conflict of interest was reported.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:5 [ "apendice" => "<p id="para410" class="elsevierStylePara elsevierViewall">Os fungos são uma importante causa de infecção nos pacientes submetidos a transplante de órgão sólido e medula óssea ou transplante de células tronco hematopoiéticas (TMO/TCTH). A incidência e a letalidade das infecções fúngicas variam, entretanto, de acordo com o tipo de transplante e do período após o transplante. Nos primeiros 30 dias ocorre o predomínio das leveduras particurlamente <span class="elsevierStyleItalic">Candida</span> spp. Após o primeiro mês predominam os fungos filamentosos como <span class="elsevierStyleItalic">Aspergillus</span> spp (1-6). Nos pacientes submetidos a TMO/TCTH, entretanto, a Aspergilose invasiva apresenta dois picos de incidência um no final do primeiro mês e outro aproximadamente 90 dias depois do transplante caso o paciente desenvolva doença do enxerto versus o hospedeiro (7-8). Dentre os transplantes de órgão sólidos os que apresentam maior risco para o desenvolvimento de infecções fúngicas são o transplante de fígado e de pulmão, por questões ligadas às próprias doenças de base, técnica cirúrgica e enxerto (4,9).<elsevierMultimedia ident="tbl2"></elsevierMultimedia></p> <p id="para420" class="elsevierStylePara elsevierViewall">O uso de profilaxia antifúngica já esta bem consolidada para alguns grupos de transplantes como TMO/TCTH e transplantes hepáticos (10,11). Contudo, ainda há uma escassez de estudo em transplante de coração e pâncreas. O grande dilema, entretanto, é a prevenção de infecções por fungos filamentosos em especial <span class="elsevierStyleItalic">Aspergillus</span> spp nos pacientes de alto risco como transplante de medula óssea alogênico com doença do enxerto contra o hospedeiro (DECH) e transplantados de pulmão (12,13).</p> <p id="para430" class="elsevierStylePara elsevierViewall">Com intuito de padronizar o uso de profilaxia primária em pacientes transplantados, foi analisada a literatura referente aos seguintes transplantes: fígado, rim, coração, pulmão e TCTH. Para a determinação dos níveis de evidência foi utilizado o sistema da IDSA (Infectious Diseases Society of America).</p>" "etiqueta" => "APPENDIX" "titulo" => "PROFILAXIA DAS INFECçõES FúNGICAS EM PACIENTES TRANSPLANTADOS" "identificador" => "cesec40" "apendiceSeccion" => array:1 [ 0 => array:3 [ "apendice" => "<p id="para440" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="celist30"><li class="elsevierStyleListItem" id="celistitem90"><span class="elsevierStyleLabel">1.</span><p id="para450" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Transplante de Fígado</span> (<a class="elsevierStyleCrossRef" href="#bib11">11</a>,<a class="elsevierStyleCrossRefs" href="#bib14">14–20</a>)</p><p id="para460" class="elsevierStylePara elsevierViewall">Profilaxia universal: não (CII)</p><p id="para470" class="elsevierStylePara elsevierViewall">Profilaxia dirigida: sim (AI)</p><p id="para480" class="elsevierStylePara elsevierViewall">- Fluconazol 400 mg/dia por 21 dias<ul class="elsevierStyleList" id="celist40"><li class="elsevierStyleListItem" id="celistitem100"><span class="elsevierStyleLabel">•</span><p id="para490" class="elsevierStylePara elsevierViewall">Critério 1 – pelo menos um dos seguintes fatores de risco: hepatite fulminante, re-transplante, hemodiálise pós-transplante, uso de anticorpos para tratamento de rejeição.</p></li><li class="elsevierStyleListItem" id="celistitem110"><span class="elsevierStyleLabel">•</span><p id="para500" class="elsevierStylePara elsevierViewall">Critério 2 – pelo menos dois dos seguintes fatores de risco: uso de antibiótico profilático para peritonite bacteriana espontânea pré-transplante, reoperação, admissão em unidade de terapia intensiva nos últimos 30 dias antes do transplante, antibióticos nos últimos 30 dias antes do transplante.</p></li></ul></p></li><li class="elsevierStyleListItem" id="celistitem120"><span class="elsevierStyleLabel">2.</span><p id="para510" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Transplante de Rim</span></p><p id="para520" class="elsevierStylePara elsevierViewall">Não há estudos sobre profilaxia</p><p id="para530" class="elsevierStylePara elsevierViewall">Profilaxia não indicada (DII)</p></li><li class="elsevierStyleListItem" id="celistitem130"><span class="elsevierStyleLabel">3.</span><p id="para540" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Transplante de Pulmão</span> (<a class="elsevierStyleCrossRef" href="#bib12">12</a>,<a class="elsevierStyleCrossRefs" href="#bib21">21–24</a>)</p><p id="para550" class="elsevierStylePara elsevierViewall">Profilaxia universal: sim (AI)</p><p id="para560" class="elsevierStylePara elsevierViewall">Anfotericina B deoxicolato via inalatória, por 3 meses (50 mg + 50 ml de água destilada – inalação com 10 ml, 2 vezes por dia)</p><p id="para570" class="elsevierStylePara elsevierViewall">Profilaxia dirigida: sim, se receptor ou doador com colonização das vias aéreas por <span class="elsevierStyleItalic">Aspergillus</span> spp pré-tx ou pós-tx (associada à anfotericina B inalatória)</p><p id="para580" class="elsevierStylePara elsevierViewall">Primeira opção: Itraconazol* 400 mg oral por 3 meses (BIII)</p><p id="para590" class="elsevierStylePara elsevierViewall">Segunda opção: Voriconazol EV (6 mg/kg/dia)/Oral (400 mg/dia) por 3 meses (CIII)</p><p id="para600" class="elsevierStylePara elsevierViewall">*Aconselhável dosagem sérica.</p></li><li class="elsevierStyleListItem" id="celistitem140"><span class="elsevierStyleLabel">4.</span><p id="para610" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Transplante de Coração</span> (<a class="elsevierStyleCrossRef" href="#bib22">22</a>)</p><p id="para620" class="elsevierStylePara elsevierViewall">Profilaxia não indicada (DII)</p></li><li class="elsevierStyleListItem" id="celistitem150"><span class="elsevierStyleLabel">5.</span><p id="para630" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Transplante de Células Tronco Hematopoéticas</span> (<a class="elsevierStyleCrossRef" href="#bib10">10</a>,<a class="elsevierStyleCrossRefs" href="#bib25">25-28</a>)</p><p id="para640" class="elsevierStylePara elsevierViewall">Profilaxia universal: sim (AI)</p><p id="para650" class="elsevierStylePara elsevierViewall">Fluconazol 400 mg/dia EV/Oral por 100 dias</p><p id="para660" class="elsevierStylePara elsevierViewall">Profilaxia dirigida: sim, para pacientes sob tratamento para DECH.</p><p id="para670" class="elsevierStylePara elsevierViewall">Primeira opção: Anfotericina B deoxicolato 1 mg/kg/dia (ou doses equivalentes de formulações lipídicas) por 100 dias (CIII)</p><p id="para680" class="elsevierStylePara elsevierViewall">Segunda opção: Itraconazol* oral 400 mg/dia por 100 dias (CIII)</p><p id="para690" class="elsevierStylePara elsevierViewall">Terceira opção Voriconazol: EV (6 mg/kg/dia)/Oral (400 mg/dia) por 100 dias (CIII)</p><p id="para700" class="elsevierStylePara elsevierViewall">*Aconselhável dosagem sérica</p><p id="para710" class="elsevierStylePara elsevierViewall">Obs. Há estudos controlados e randomizados com outros azólicos, porém não são medicamentos padronizados na instituição ou talvez não disponíveis no Brasil.</p></li><li class="elsevierStyleListItem" id="celistitem160"><span class="elsevierStyleLabel">6.</span><p id="para720" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Transplante de Pâncreas</span> (<a class="elsevierStyleCrossRef" href="#bib29">29</a>)</p><p id="para730" class="elsevierStylePara elsevierViewall">Profilaxia universal: sim (CII)</p><p id="para740" class="elsevierStylePara elsevierViewall">Fluconazol 400 mg/dia EV/VO por 7 dias (profilaxia cirúrgica)</p><p id="para750" class="elsevierStylePara elsevierViewall">Profilaxia dirigida: não (DII)</p></li></ul></p>" "titulo" => "Recomendações:" "identificador" => "cesec50" ] ] ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">NR: not reported.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Transplant \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Incidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">Liver \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">8-15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">50-60% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">Lung \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">15-35% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">30-75% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">Kidney \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">3.5-6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">Pancreas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">NR \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">Heart \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">2.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">30% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">HSCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">3.9% (AI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">50% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">The incidence and mortality of fungal infections in patients who received a solid organ transplantation or BMT/HSCT (<a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRef" href="#bib4">4</a>).</p>" ] ] 1 => array:7 [ "identificador" => "tbl2" "etiqueta" => "Tabela 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:2 [ "leyenda" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">NR: não relatado.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="justify" valign="top" scope="col" style="border-bottom: 2px solid black">Transplante \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Incidência \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mortalidade \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="justify" valign="top"><span class="elsevierStyleBold">Fígado</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">8-15%</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">50-60%</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="justify" valign="top"><span class="elsevierStyleBold">Pulmão</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">15-35%</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">30-75%</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="justify" valign="top"><span class="elsevierStyleBold">Rim</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">3,5-6%</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">NR</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="justify" valign="top"><span class="elsevierStyleBold">Pâncreas</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">9%</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">NR</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="justify" valign="top"><span class="elsevierStyleBold">Coração</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">2,2%</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">30%</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="justify" valign="top"><span class="elsevierStyleBold">TCTH</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">3,9% (AI)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top"><span class="elsevierStyleBold">50%</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Incidência e mortalidade das Infecções Fúngicas na população de pacientes submetidos a transplante de órgãos sólidos e TMO/TCTH [1,4].</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aspergillus infections in transplant recipients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ N Singh \n \t\t\t\t\t\t\t\t """ 1 => """ DL Paterson \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/CMR.18.1.44-69.2005" "Revista" => array:7 [ "tituloSerie" => "Clin Microbiol Rev" "fecha" => "2005" "volumen" => "18" "numero" => "1" "paginaInicial" => "44" "paginaFinal" => "69" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15653818" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 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"https://static.elsevier.es/multimedia/18075932/0000006700000006/v1_202212011548/S1807593222018087/v1_202212011548/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222018087?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
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