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Egger M, Bellmann R, Krause R, Boyer J, Jakšić D, Hoenigl M. Salvage Treatment for Invasive Aspergillosis and Mucormycosis: Challenges, Recommendations and Future Considerations. Infect Drug Resist 2023; 16:2167-2178. [PMID: 37077251 PMCID: PMC10106327 DOI: 10.2147/idr.s372546] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023] Open
Abstract
Invasive mold diseases are devastating systemic infections which demand meticulous care in selection, dosing, and therapy monitoring of antifungal drugs. Various circumstances regarding PK/PD properties of the applied drug, resistance/tolerance of the causative pathogen or host intolerability can lead to failure of the initial antifungal therapy. This necessitates treatment adaption in the sense of switching antifungal drug class or potentially adding another drug for a combination therapy approach. In the current state of drastically limited options of antifungal drug classes adaption of therapy remains challenging. Current guidelines provide restricted recommendations only and emphasize individual approaches. However, novel antifungals, incorporating innovative mechanisms of action, show promising results in late stage clinical development. These will expand options for salvage therapy in the future potentially as monotherapy or in combination with conventional or other novel antifungals. We outline current recommendations for salvage therapy including PK/PD considerations as well as elucidate possible future treatment options for invasive aspergillosis and mucormycosis.
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Affiliation(s)
- Matthias Egger
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Biotechmed-Graz, Graz, Austria
| | - Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Biotechmed-Graz, Graz, Austria
| | - Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Daniela Jakšić
- Department of Microbiology, Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Biotechmed-Graz, Graz, Austria
- Clinical and Translational Fungal-Working Group, University of California San Diego, San Diego, CA, USA
- Translational Medical Mycology Research Unit, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
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Abstract
Concentrations of anidulafungin and micafungin were determined in eight different tissues obtained during autopsy of four deceased individuals who had been treated with anidulafungin and of seven who had received micafungin. The largest amounts were recovered from liver, with anidulafungin concentrations of 11.01 to 66.50 μg/g and micafungin levels of 0.36 to 5.53 μg/g (0.65 μg/g 30 days after the last administration). The lowest anidulafungin levels were measured in skeletal muscle, and the lowest micafungin concentrations were in kidneys.
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Renzi DF, de Almeida Campos L, Miranda EH, Mainardes RM, Abraham WR, Grigoletto DF, Khalil NM. Nanoparticles as a Tool for Broadening Antifungal Activities. Curr Med Chem 2021; 28:1841-1873. [PMID: 32223729 DOI: 10.2174/0929867327666200330143338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/28/2020] [Accepted: 03/09/2020] [Indexed: 11/22/2022]
Abstract
Fungal infections are diseases that are considered neglected although their infection rates have increased worldwide in the last decades. Thus, since the antifungal arsenal is restricted and many strains have shown resistance, new therapeutic alternatives are necessary. Nanoparticles are considered important alternatives to promote drug delivery. In this sense, the objective of the present study was to evaluate the contributions of newly developed nanoparticles to the treatment of fungal infections. Studies have shown that nanoparticles generally improve the biopharmaceutical and pharmacokinetic characteristics of antifungals, which is reflected in a greater pharmacodynamic potential and lower toxicity, as well as the possibility of prolonged action. It also offers the proposition of new routes of administration. Nanotechnology is known to contribute to a new drug delivery system, not only for the control of infectious diseases but for various other diseases as well. In recent years, several studies have emphasized its application in infectious diseases, presenting better alternatives for the treatment of fungal infections.
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Affiliation(s)
- Daniele Fernanda Renzi
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Laís de Almeida Campos
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Eduardo Hösel Miranda
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Rubiana Mara Mainardes
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Wolf-Rainer Abraham
- Helmholtz Center for Infection Research, Chemical Microbiology, Inhoffenstraße 7, 38124 Braunschweig, Germany
| | - Diana Fortkamp Grigoletto
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
| | - Najeh Maissar Khalil
- Pharmaceutical Nanotechnology Laboratory, Universidade Estadual do Centro-Oeste, Alameda Élio Antonio Dalla Vecchia, 838 - CEP 85040-167, Guarapuava-PR, Brazil
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Wirth F, Ishida K. Antifungal drugs: An updated review of central nervous system pharmacokinetics. Mycoses 2020; 63:1047-1059. [PMID: 32772402 DOI: 10.1111/myc.13157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 01/06/2023]
Abstract
Invasive fungal infections (IFIs) in the central nervous system (CNS) are particularly hard to treat and are associated with high morbidity and mortality rates. Four chemical classes of systemic antifungal agents are used for the treatment of IFIs (eg meningitis), including polyenes, triazoles, pyrimidine analogues and echinocandins. This review will address all of these classes and discuss their penetration and accumulation in the CNS. Treatment of fungal meningitis is based on the antifungal that shows good penetration and accumulation in the CNS. Pharmacokinetic data concerning the entry of antifungal agents into the intracranial compartments are faulty. This review will provide an overview of the ability of systemic antifungals to penetrate the CNS, based on previously published drug physicochemical properties and pharmacokinetic data, for evaluation of the most promising antifungal drugs for the treatment of fungal CNS infections. The studies selected and discussed in this review are from 1990 to 2019.
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Affiliation(s)
- Fernanda Wirth
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Kelly Ishida
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
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Abstract
Neonates and immunosuppressed/immunocompromised pediatric patients are at high risk of invasive fungal diseases. Appropriate antifungal selection and optimized dosing are imperative to the successful prevention and treatment of these life-threatening infections. Conventional amphotericin B was the mainstay of antifungal therapy for many decades, but dose-limiting nephrotoxicity and infusion-related adverse events impeded its use. Despite the development of several new antifungal classes and agents in the past 20 years, and their now routine use in at-risk pediatric populations, data to guide the optimal dosing of antifungals in children are limited. This paper reviews the spectra of activity for approved antifungal agents and summarizes the current literature specific to pediatric patients regarding pharmacokinetic/pharmacodynamic data, dosing, and therapeutic drug monitoring.
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Affiliation(s)
- Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 2716 South Street, Suite 10360, Philadelphia, PA, 19146, USA.
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Brian T Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 2716 South Street, Suite 10360, Philadelphia, PA, 19146, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Chikley A, Ben-Ami R, Kontoyiannis DP. Mucormycosis of the Central Nervous System. J Fungi (Basel) 2019; 5:jof5030059. [PMID: 31288475 PMCID: PMC6787740 DOI: 10.3390/jof5030059] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022] Open
Abstract
Mucormycosis involves the central nervous system by direct extension from infected paranasal sinuses or hematogenous dissemination from the lungs. Incidence rates of this rare disease seem to be rising, with a shift from the rhino-orbital-cerebral syndrome typical of patients with diabetes mellitus and ketoacidosis, to disseminated disease in patients with hematological malignancies. We present our current understanding of the pathobiology, clinical features, and diagnostic and treatment strategies of cerebral mucormycosis. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability. Emerging molecular diagnostics, advances in experimental systems and the establishment of large patient registries are key components of ongoing efforts to provide a timely diagnosis and effective treatment to patients with cerebral mucormycosis.
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Affiliation(s)
- Amanda Chikley
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel.
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, The University of Texas, M.D. Anderson Cancer Center, Houston 77030, TexasTX 77030, USA.
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Bodilsen J, Brouwer MC, Nielsen H, Van De Beek D. Anti-infective treatment of brain abscess. Expert Rev Anti Infect Ther 2018; 16:565-578. [PMID: 29909695 DOI: 10.1080/14787210.2018.1489722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Brain abscess is an uncommon and potentially life-threatening infection of the CNS that can be caused by a range of different pathogens including bacteria, fungi, and parasites. A multidisciplinary approach is important and anti-infective treatment remains crucial. Here, we review anti-infective treatment of brain abscess. Areas covered: We used the terms '(Brain abscess[ti] AND (antibiotic* OR treatment)) NOT case report'), to conduct a search in the PubMed. Additional papers were identified by cross-reference checking and by browsing textbooks of infectious diseases and neurology. COMMENTARY Empiric treatment of bacterial brain abscess consists of cefotaxime and metronidazole with the addition of vancomycin if meticilline-resistant Staphylococcus aureus is suspected. For severely immuno-suppressed patients, for example transplant recipients, voriconazole and trimethoprim-sulfamethoxazole or sulfadiazine should be added. Increased knowledge of the pharmacokinetic profile of anti-infective treatments may help to improve the treatment of brain abscess. Future studies should address efficacy and safety of continuous abscess drainage, mode of anti-infective administration (continuous vs. bolus), and anti-infective treatments in immuno-suppressed patients.
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Affiliation(s)
- Jacob Bodilsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Matthijs C Brouwer
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Henrik Nielsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Diederik Van De Beek
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
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Bellmann R, Smuszkiewicz P. Pharmacokinetics of antifungal drugs: practical implications for optimized treatment of patients. Infection 2017; 45:737-779. [PMID: 28702763 PMCID: PMC5696449 DOI: 10.1007/s15010-017-1042-z] [Citation(s) in RCA: 209] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/25/2017] [Indexed: 02/08/2023]
Abstract
Introduction Because of the high mortality of invasive fungal infections (IFIs), appropriate exposure to antifungals appears to be crucial for therapeutic efficacy and safety. Materials and methods This review summarises published pharmacokinetic data on systemically administered antifungals focusing on co-morbidities, target-site penetration, and combination antifungal therapy. Conclusions and discussion Amphotericin B is eliminated unchanged via urine and faeces. Flucytosine and fluconazole display low protein binding and are eliminated by the kidney. Itraconazole, voriconazole, posaconazole and isavuconazole are metabolised in the liver. Azoles are substrates and inhibitors of cytochrome P450 (CYP) isoenzymes and are therefore involved in numerous drug–drug interactions. Anidulafungin is spontaneously degraded in the plasma. Caspofungin and micafungin undergo enzymatic metabolism in the liver, which is independent of CYP. Although several drug–drug interactions occur during caspofungin and micafungin treatment, echinocandins display a lower potential for drug–drug interactions. Flucytosine and azoles penetrate into most of relevant tissues. Amphotericin B accumulates in the liver and in the spleen. Its concentrations in lung and kidney are intermediate and relatively low myocardium and brain. Tissue distribution of echinocandins is similar to that of amphotericin. Combination antifungal therapy is established for cryptococcosis but controversial in other IFIs such as invasive aspergillosis and mucormycosis.
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Affiliation(s)
- Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Treatment, University Hospital, Poznań, Poland
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Perez-Jorge C, Gomez-Barrena E, Horcajada JP, Puig-Verdie L, Esteban J. Drug treatments for prosthetic joint infections in the era of multidrug resistance. Expert Opin Pharmacother 2016; 17:1233-46. [PMID: 27054293 DOI: 10.1080/14656566.2016.1176142] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Despite many advances, the management of prosthetic joint infection is still a complex issue. Moreover, in recent years the problem of antimicrobial resistance has emerged as an important challenge. AREAS COVERED We analysed recent advances in different aspects of prosthetic joint infections. The importance of biofilms needs to be considered for antibiotic selection because, when embedded in these structures, bacteria acquire resistant behaviour. Moreover, the presence of resistance mechanisms in some species of organisms increases the difficulty of management. In this sense, the growing importance of methicillin-resistant staphylococci, multidrug-resistant Enterobacteriaceae or Pseudomonas aeruginosa is of increasing concern. Together with these organisms, others with constitutive resistance against most antibiotics (like Enterococcus sp., mycobacteria or fungi) represent a similar problem for selection of therapy. Research into new materials that can be used as drug carriers opens a new field for management of these infections and will likely come to the front line in the coming years. EXPERT OPINION Individualised therapies should carefully consider the aetiology, pathogenesis and antimicrobial susceptibility. Satisfactory clinical outcome could be further fostered by enhancing the multidisciplinary approach, with better collaboration in the antibiotic selection and the surgical management.
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Affiliation(s)
- Concepcion Perez-Jorge
- a Bone and Joint Infection Unit, Department of Clinical Microbiology , IIS-Fundacion Jimenez Diaz, UAM , Madrid , Spain
| | - Enrique Gomez-Barrena
- b Department of Orthopaedic Surgery , IdiPaz-Hospital La Paz Institute for Health Research, UAM , Madrid , Spain
| | - Juan-Pablo Horcajada
- c Service of Infectious Diseases, Hospital del Mar, CEXS Universitat Pompeu Fabra , Institut Hospital del Mar d'Investigacions Mèdiques , Barcelona , Spain
| | - Lluis Puig-Verdie
- d Department of Orthopaedic Surgery , Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques , Barcelona , Spain
| | - Jaime Esteban
- a Bone and Joint Infection Unit, Department of Clinical Microbiology , IIS-Fundacion Jimenez Diaz, UAM , Madrid , Spain
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Cars O, Craig WA. Pharmacodynamics of Antibiotics-Consequences for Dosing: Proceedings of a Symposium Held in Stockholm, June 7–9, 1990. ACTA ACUST UNITED AC 2015. [DOI: 10.3109/inf.1990.22.suppl-74.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Understanding the tissue penetration of systemically administered antifungal agents is critical for a proper appreciation of their antifungal efficacy in animals and humans. Both the time course of an antifungal drug and its absolute concentrations within tissues may differ significantly from those observed in the bloodstream. In addition, tissue concentrations must also be interpreted within the context of the pathogenesis of the various invasive fungal infections, which differ significantly. There are major technical obstacles to the estimation of concentrations of antifungal agents in various tissue subcompartments, yet these agents, even those within the same class, may exhibit markedly different tissue distributions. This review explores these issues and provides a summary of tissue concentrations of 11 currently licensed systemic antifungal agents. It also explores the therapeutic implications of their distribution at various sites of infection.
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Susceptibility breakpoints for amphotericin B and Aspergillus species in an in vitro pharmacokinetic-pharmacodynamic model simulating free-drug concentrations in human serum. Antimicrob Agents Chemother 2014; 58:2356-62. [PMID: 24514094 DOI: 10.1128/aac.02661-13] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although conventional amphotericin B was for many years the drug of choice and remains an important agent against invasive aspergillosis, reliable susceptibility breakpoints are lacking. Three clinical Aspergillus isolates (Aspergillus fumigatus, Aspergillus flavus, and Aspergillus terreus) were tested in an in vitro pharmacokinetic-pharmacodynamic model simulating the biphasic 24-h time-concentration profile of free amphotericin B concentrations in human serum with free peak concentrations (fCmax) of 0.1, 0.3, 0.6, 1.2, and 2.4 mg/liter administered once daily. Drug concentrations were measured with a bioassay, and fungal growth was monitored for 72 h with galactomannan production. The fCmax/MIC corresponding to half-maximal activity (P50) was determined for each species, and the percentage of target attainment was calculated for different MICs for the standard (1 mg/kg of body weight) and a lower (0.6-mg/kg) dose of amphotericin B with Monte Carlo simulation analysis. The fCmax/MICs (95% confidence intervals) corresponding to P50 were 0.145 (0.133 to 0.158), 0.371 (0.283 to 0.486), and 0.41 (0.292 to 0.522) for A. fumigatus, A. flavus, and A. terreus, respectively. The median percentages of P50 attainment were ≥88%, 47%, and 0% for A. fumigatus isolates with MICs of ≤0.5, 1, and ≥2 mg/liter, respectively, and ≥81%, 24%, and 0% and ≥75%, 15%, and 0% for A. flavus and A. terreus isolates with MICs of ≤0.25, 0.5, and ≥1 mg/liter, respectively. The lower dose of 0.6 mg/kg would retain efficacy for A. fumigatus, A. flavus, and A. terreus isolates with MICs of ≤0.25, ≤0.125, and ≤0.125 mg/liter, respectively. The susceptibility, intermediate susceptibility, and resistance breakpoints of ≤0.5, 1, and ≥2 mg/liter for A. fumigatus and ≤0.25, 0.5, and ≥1 mg/liter for A. flavus and A. terreus were determined for conventional amphotericin B with a pharmacokinetic-pharmacodynamic model simulating free-drug serum concentrations.
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Falagas ME, Karageorgopoulos DE, Tansarli GS. continuous versus conventional infusion of amphotericin B deoxycholate: a meta-analysis. PLoS One 2013; 8:e77075. [PMID: 24204739 PMCID: PMC3804519 DOI: 10.1371/journal.pone.0077075] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 09/06/2013] [Indexed: 12/04/2022] Open
Abstract
Background Treatment with Amphotericin B (AmB) deoxycholate, which is still used widely, particularly in low-resource countries, has been challenged due to nephrotoxicity. We sought to study whether continuous infusion of AmB deoxycholate reduces nephrotoxicity retaining, however, the effectiveness of the drug. Methods PubMed and Scopus databases were systematically searched to identify studies comparing the outcomes of patients receiving 24-h infusion of AmB (“continuous group”) and those receiving 2–6-h infusion of AmB (“conventional group”). Nephrotoxicity and all-cause mortality were the primary outcomes of the review, while treatment failure was the secondary outcome. Results Five studies met the inclusion criteria; one randomized controlled trial, two prospective cohort studies, and two retrospective cohort studies. The majority of patients were neutropenic with an underlying hematologic malignancy. All 5 studies (392 patients) provided data regarding the development of nephrotoxicity. A non-significant trend towards lower nephrotoxicity was observed for patients receiving continuous infusion of AmB compared with those receiving conventional infusion [RR = 0.61 (95% CI 0.36, 1.02)]. Four studies (365 patients) provided data regarding mortality; no relevant difference was detected between patients receiving continuous and those receiving conventional infusion of AmB [RR = 0.81 (95% CI 0.36, 1.83)]. Data on treatment failure of the two methods of administration was insufficient for meaningful conclusions. Conclusion The available evidence from mainly non-randomized studies suggests that continuous infusion of AmB deoxycholate might offer an advantage over the conventional infusion regarding the development of nephrotoxicity, without compromising patient survival. Further randomized studies are needed to investigate this issue.
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Affiliation(s)
- Matthew E. Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece
- Department of Internal Medicine - Infectious Diseases, Mitera Hospital, Hygeia Group, Athens, Greece
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- * E-mail:
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Schwartz S. [Diagnostic imaging methods and therapy options for cerebral aspergillosis]. Mycoses 2013; 55 Suppl 2:10-6. [PMID: 22519627 DOI: 10.1111/j.1439-0507.2012.02178.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Stefan Schwartz
- Medizinische Klinik III, Charité Campus Benjamin Franklin, Berlin, Deutschland.
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Lewis RE, Viale P. Update on Amphotericin B Pharmacology and Dosing for Common Systemic Mycoses. CURRENT FUNGAL INFECTION REPORTS 2012. [DOI: 10.1007/s12281-012-0107-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Importance of pharmacokinetic considerations for selecting therapy in the treatment of invasive fungal infections. Am J Ther 2012; 19:51-63. [PMID: 21248618 DOI: 10.1097/mjt.0b013e3181ff7e10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Invasive fungal infections continue to be a significant cause of morbidity and mortality among at-risk patients. Over the last decade, the epidemiology of invasive mycoses has been defined by increasing rates of infection caused by azole-resistant yeast (Candida glabrata, Candida krusei), Aspergillus, and in some centers, non-Aspergillus moulds, such as Fusarium species, Scedosporium species, and Mucorales. Early and appropriate antifungal therapy is crucial for a favorable clinical outcome. When selecting antifungal therapy--especially during the initial acute phases of treatment--spectrum of activity and pharmacokinetic characteristics are key treatment considerations. Important pharmacokinetic considerations for selecting antifungal therapy in the treatment of invasive fungal infections include drug-drug interactions and variability in adsorption that may limit efficacy during the early phase of treatment, poor oral availability, and variable tissue distribution. A patient's underlying condition and pharmacogenetics also may affect the pharmacokinetics of antifungal drugs, resulting in interpatient pharmacokinetic differences.
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Kweon C, McLaren AC, Leon C, McLemore R. Amphotericin B delivery from bone cement increases with porosity but strength decreases. Clin Orthop Relat Res 2011; 469:3002-7. [PMID: 21638100 PMCID: PMC3183199 DOI: 10.1007/s11999-011-1928-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Amphotericin B is a highly hydrophobic antifungal used for orthopaedic infections. There is disagreement about whether amphotericin B is released when it is loaded in polymethylmethacrylate (PMMA). It is unknown how much a poragen will increase amphotericin B release or decrease the compressive strength of the PMMA. QUESTIONS/PURPOSES We therefore measured amphotericin B release and the compressive strength of amphotericin B loaded bone cement with and without adding high-dose poragen. METHODS Antifungal-loaded bone cement was formulated with Simplex P cement and 200 mg amphotericin B with and without 10 g cefazolin (poragen) per batch. Twenty standardized test cylinders were eluted in deionized water for each formulation. Cumulative amphotericin B mass and compressive strength were measured. Data were analyzed using repeated-measures analysis of variance. RESULTS Antifungal-loaded bone cement (ALBC) with 10 g poragen delivered more amphotericin B than ALBC containing amphotericin B alone by Day 15, 12.76 μg/cylinder (0.5%) versus 1.74 μg/cylinder (0.04%), respectively. With amphotericin B alone, compressive strength was unchanged and compressive strength did not decrease during elution. Adding 10 g poragen to ALBC with 200 mg amphotericin B decreased the compressive strength and compressive strength decreased further during elution, 80, 61, and 46 MPa at 0, 1, and 30 days, respectively. CONCLUSIONS Amphotericin B is released in very small amounts from antifungal-loaded bone cement. Release can be increased by adding high-dose poragen, but compressive strength decreases sufficiently to limit its use for implant fixation.
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Affiliation(s)
- Chris Kweon
- Banner Orthopaedic Residency, 901 E Wiletta, Phoenix, AZ 85006 USA
| | - Alex C. McLaren
- Banner Orthopaedic Residency, 901 E Wiletta, Phoenix, AZ 85006 USA
- Center for Interventional Biomaterials, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ USA
| | - Christine Leon
- Center for Interventional Biomaterials, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ USA
| | - Ryan McLemore
- Banner Orthopaedic Residency, 901 E Wiletta, Phoenix, AZ 85006 USA
- Center for Interventional Biomaterials, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ USA
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Harmsen S, McLaren AC, Pauken C, McLemore R. Amphotericin B is cytotoxic at locally delivered concentrations. Clin Orthop Relat Res 2011; 469:3016-21. [PMID: 21484472 PMCID: PMC3183219 DOI: 10.1007/s11999-011-1890-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Orthopaedic fungal infections are commonly treated with systemic amphotericin, which has a narrow therapeutic index and is associated with systemic toxicities. Local delivery of amphotericin has been described yet is poorly understood. As with bacterial infections, fungal infections are associated with biofilm. However, it is unclear whether experience with local delivery of antibacterials can be applied to local antifungal delivery. QUESTIONS/PURPOSES We asked whether (1) 100 to 1000 μg amphotericin/mL caused osteoblast cell death; (2) 1 to 10 μg amphotericin/mL caused sublethal toxicity to osteoblasts and fibroblasts; and (3) sublethal amphotericin toxicity could be reversed. METHODS Mouse osteoblasts and fibroblasts were exposed in vitro to amphotericin concentrations of 0, 1, 10, 100, and 1000 μg/mL for 5 hours or 0, 1, 5, and 10 μg/mL for 7 days and then 3 days with no amphotericin. Cell morphology on light microscopy and proliferation assays (alamarBlue(®) and MTT) were used as measures of toxicity. RESULTS Amphotericin concentrations of 100 μg/mL and above caused cell death; 5 to 10 μg/mL caused abnormal cell morphology and decreased proliferation. Cells regained normal morphology and resumed cell proliferation within 3 days after removal of amphotericin. CONCLUSIONS In this in vitro study, amphotericin was cytotoxic to osteoblasts and fibroblasts at concentrations achievable by local delivery. CLINICAL RELEVANCE If local concentrations of 100 to 1000 times the minimum inhibitory concentration are necessary to treat biofilm-associated fungal infections as they are for bacterial infection, cell toxicity at the local depot site should be considered.
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Affiliation(s)
- Samuel Harmsen
- Banner Orthopaedic Residency, Banner Good Samaritan Medical Center, 1300 N 12th Street, Suite 620, Phoenix, AZ 85006 USA
| | - Alex C. McLaren
- Banner Orthopaedic Residency, Banner Good Samaritan Medical Center, 1300 N 12th Street, Suite 620, Phoenix, AZ 85006 USA ,Center for Interventional Biomaterials, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ USA
| | - Christine Pauken
- Center for Interventional Biomaterials, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ USA
| | - Ryan McLemore
- Banner Orthopaedic Residency, Banner Good Samaritan Medical Center, 1300 N 12th Street, Suite 620, Phoenix, AZ 85006 USA ,Center for Interventional Biomaterials, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ USA
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Pros and Cons of Extrapolating Animal Data on Antifungal Pharmacodynamics to Humans. CURRENT FUNGAL INFECTION REPORTS 2011; 5:59-66. [DOI: 10.1007/s12281-011-0051-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lemke A, Kiderlen AF, Petri B, Kayser O. Delivery of amphotericin B nanosuspensions to the brain and determination of activity against Balamuthia mandrillaris amebas. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2010; 6:597-603. [PMID: 20060497 DOI: 10.1016/j.nano.2009.12.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 12/14/2009] [Accepted: 12/18/2009] [Indexed: 10/20/2022]
Abstract
Amphotericin B was formulated as nanosuspensions to develop a nanoparticulate brain delivery system. Nanosuspensions were produced with different surfactant solutions by high-pressure homogenization and then characterized by laser diffractometry and photon correlation spectroscopy. Before in vitro and in vivo testing all nanosuspensions were investigated for protein adsorption by two-dimensional polyacrylamide gel electrophoresis to predict brain-targeting capacities. Selected nanosuspensions were tested for amebicidal activity against Balamuthia mandrillaris, an agent of lethal encephalitis. Our results indicate that nanosuspensions coated with polysorbate 80 and sodium cholate markedly increased drug brain delivery and inhibited the parasite in vitro, though less in vivo. From the clinical editor: The antifungal Amphotericin B was formulated as nanosuspensions to develop a nanoparticulate brain delivery system. The results indicate that nanosuspensions coated with polysorbate 80 and sodium cholate markedly increased drug brain delivery and inhibited the parasite in vitro, though less in vivo.
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Affiliation(s)
- Andreas Lemke
- Rijksuniversiteit Groningen, GUIDE, Farmaceutische Biologie, Groningen, The Netherlands
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Watanabe A, Matsumoto K, Igari H, Uesato M, Yoshida S, Nakamura Y, Morita K, Shibuya K, Matsubara H, Yoshino I, Kamei K. Comparison between concentrations of amphotericin B in infected lung lesion and in uninfected lung tissue in a patient treated with liposomal amphotericin B (AmBisome). Int J Infect Dis 2009; 14 Suppl 3:e220-3. [PMID: 19959388 DOI: 10.1016/j.ijid.2009.07.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 07/13/2009] [Accepted: 07/21/2009] [Indexed: 10/20/2022] Open
Abstract
Generally, the primary lesion of a mold infection is in the airway, an extravascular site. Therefore, the antifungal drug concentration at the actual tissue lesion of a mold infection is as important as in the blood compartment. Although our antifungal armamentarium has expanded recently, polyenes are still often needed in clinical practice because of their potent fungicidal activity and the rarity of resistance. Nevertheless, the distribution of amphotericin B (AmB) in infected lung tissue has not yet been evaluated. Using high-performance liquid chromatography analysis, we determined the concentrations of AmB in plasma and infected and uninfected tissues of resected lung simultaneously, in a patient with pulmonary aspergillosis treated with liposomal amphotericin B (L-AmB). The AmB concentration in the infected lesion of the lung was approximately 5.2 times higher than that in plasma and 3.7 times higher than in uninfected lung tissue. L-AmB accumulated in the infected lesion of the lung at a higher concentration. Although our data are from only one patient, they may be useful in helping to develop better strategies for the use of L-AmB against pulmonary fungal infections.
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Affiliation(s)
- Akira Watanabe
- Division of Control and Treatment of Infectious Diseases, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, Japan
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Tolman JA, Nelson NA, Son YJ, Bosselmann S, Wiederhold NP, Peters JI, McConville JT, Williams RO. Characterization and pharmacokinetic analysis of aerosolized aqueous voriconazole solution. Eur J Pharm Biopharm 2009; 72:199-205. [DOI: 10.1016/j.ejpb.2008.12.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Cerebral aspergillosis is increasingly recognized in severely immunocompromised patients and, until recently, this type of fungal infection was associated with a mortality approaching 100%. The central nervous system is a protected environment and penetration of drugs across the blood-brain barrier is mainly limited by their molecular size and physicochemical properties, as well as drug interaction with transporter systems (e.g., P-glycoprotein) at the blood-brain barrier. Most antifungal agents are large molecules (>700 Da), which makes sufficient penetration into the central nervous system unlikely. In fact, the available data indicate low levels of most antifungal agents in cerebrospinal fluid and brain tissue, except for fluconazole and voriconazole. Concentrations of voriconazole exceeding inhibitory concentrations for Aspergillus species were found repeatedly in cerebrospinal fluid and brain tissue, including brain abscess material. A recent retrospective study confirmed that voriconazole treatment resulted in improved response and survival rates in patients with cerebral aspergillosis. Data from animal models, which explored escalated doses or combinations of antifungal agents in experimental neuroaspergillosis, suggest that selected combination or dose-escalated therapies might further improve the still unsatisfactory prognosis in this particular type of Aspergillus infection.
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Affiliation(s)
- S Schwartz
- Medizinische Klinik III, Charite Campus Benjamin Franklin, Berlin, Germany.
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Ellis M. New dosing strategies for liposomal amphotericin B in high-risk patients. Clin Microbiol Infect 2008; 14 Suppl 4:55-64. [DOI: 10.1111/j.1469-0691.2008.01982.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Early diagnosis of CNS aspergillosis requires a high degree of clinical suspicion, because there are no typical clinical symptoms or CSF findings. Clinical features are usually dramatic and tend to progress rapidly. Changes in mental status, hemiparesis and seizures are most common, but other nonspecific neurological features may occur and should always be an indication for neuroradiological examination in high-risk patients, in order to allow early initiation of antifungal therapy. Low density lesions with little or no mass effect and minimal or no contrast enhancement on CT scans that are usually more numerous on MRI and show intermediate signal intensity within high-signal areas on T2-weighted images, may suggest CNS aspergillosis. Cerebral lesions in CNS aspergillosis are often located not only in the cerebral hemispheres but also in the basal ganglia, thalami, corpus callosum and perforator artery territories. There is frequently a lack of contrast enhancement or perifocal oedema, due to the immunosuppressed status of the patient. A definite diagnosis requires brain tissue for histopathological analysis. However, neurosurgery is often not feasible, so that any of the neuroradiological findings mentioned above should raise the suspicion of CNS aspergillosis in immunocompromised patients and lead to early initiation of antifungal therapy. In the past, amphotericin B-based therapy was the treatment of choice for CNS aspergillosis, but this treatment produced negligible effects. Recently, voriconazole has been reported to be more effective than amphotericin B in the treatment of invasive aspergillosis. Response rates of about 35% have been achieved with voriconazole in patients with CNS aspergillosis. Combination therapy with antifungal agents, such as voriconazole plus caspofungin or liposomal amphotericin B, is being investigated in vitro and in animal models, and optimistic results have been observed. A combined medical and neurosurgical treatment should be considered in all patients with this disease.
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Affiliation(s)
- Markus Ruhnke
- Department of Internal Medicine, Charité Campus Mitte, Berlin, Germany.
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Schwartz S, Ruhnke M, Ribaud P, Reed E, Troke P, Thiel E. Poor efficacy of amphotericin B-based therapy in CNS aspergillosis. Mycoses 2007; 50:196-200. [PMID: 17472616 DOI: 10.1111/j.1439-0507.2007.01345.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recently, improved response and survival rates in patients treated with voriconazole and neurosurgery for central nervous system (CNS) aspergillosis have been reported. We assessed retrospectively the outcome in 17 patients with definite or probable CNS aspergillosis treated with amphotericin B alone (n = 15) or in combination with 5-fluorocytosine (n = 3) or itraconazole (n = 2). Four patients underwent neurosurgery. The mortality rate was 100% with a median survival of only 10 days (range: 3-60) after onset of first symptoms or first radiological evidence of CNS aspergillosis. In conclusion, treatment with amphotericin B and itraconazole has negligible efficacy in CNS aspergillosis.
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Affiliation(s)
- Stefan Schwartz
- Medizinische Klinik III, Charité Campus Benjamin Franklin, Freie Universität, Berlin, Germany.
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Elter T, Sieniawski M, Gossmann A, Wickenhauser C, Schröder U, Seifert H, Kuchta J, Burhenne J, Riedel KD, Fätkenheuer G, Cornely OA. Voriconazole brain tissue levels in rhinocerebral aspergillosis in a successfully treated young woman. Int J Antimicrob Agents 2006; 28:262-5. [PMID: 16908120 DOI: 10.1016/j.ijantimicag.2006.04.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 04/04/2006] [Accepted: 04/07/2006] [Indexed: 11/28/2022]
Abstract
Invasive aspergillosis of the central nervous system has a mortality rate exceeding 90%. We describe a 29-year-old woman with a medical history of chronic polyarthritis who developed a proven rhinocerebral Aspergillus fumigatus infection refractory to first-line treatment with liposomal amphotericin B. The patient responded successfully to salvage combination treatment with voriconazole and caspofungin. Furthermore, for the first time, voriconazole levels in an intracerebral abscess were measured in this patient undergoing voriconazole oral therapy.
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Affiliation(s)
- Thomas Elter
- 1st Department of Internal Medicine, University of Cologne, 50924 Cologne, Germany
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Wiederhold NP, Tam VH, Chi J, Prince RA, Kontoyiannis DP, Lewis RE. Pharmacodynamic activity of amphotericin B deoxycholate is associated with peak plasma concentrations in a neutropenic murine model of invasive pulmonary aspergillosis. Antimicrob Agents Chemother 2006; 50:469-73. [PMID: 16436698 PMCID: PMC1366892 DOI: 10.1128/aac.50.2.469-473.2006] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We conducted a dose fractionation study of neutropenic, corticosteroid-immunosuppressed mice to characterize the pharmacodynamic/pharmacokinetic (PK/PD) parameter most closely associated with amphotericin B (AMB) efficacy in the treatment of invasive pulmonary aspergillosis. Pharmacokinetic parameter estimates were determined by a nonparametric population pharmacokinetic analysis of plasma drug concentrations following single intraperitoneal doses (0.25, 1.0, and 3.0 mg/kg of body weight) of amphotericin B deoxycholate. Three dosage groups (0.5, 0.75, and 1.0 mg/kg) fractionated into three dosing intervals (every 8 h [q8h], q24h, or q72h) were tested to discriminate between the PK/PD parameters (the ratio of maximum concentration of drug in serum [Cmax]/MIC, the ratio of area under the concentration-time curve/MIC, and percentage of time above MIC) most closely associated with AMB efficacy over a range of clinically achievable exposures in humans. The efficacy of each regimen was determined by quantitative PCR and survival. Reductions in pulmonary fungal burden and improvements in survival were maximized at the highest peak plasma concentrations in each of the dosage groups. Reductions in pulmonary fungal burden and increased survival were most closely associated with Cmax/MIC, with maximal activity occurring as the Cmax/MIC approached 2.4. In our model, Cmax/MIC is the PK/PD parameter most closely associated with efficacy in the treatment of invasive pulmonary aspergillosis. These data predict that less frequently administered, higher dosages of AMB would optimize efficacy.
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Demartini G, Lequaglie C, Brega Massone PP, Scaglione F, Fraschini F. Penetration of amphotericin B in human lung tissue after single liposomal amphotericin B (AmBisome) infusion. J Chemother 2005; 17:82-5. [PMID: 15828449 DOI: 10.1179/joc.2005.17.1.82] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The distribution of amphotericin B in lung tissue was studied in 18 patients with primary or secondary lung cancer who underwent thoracotomy and pulmonary resection. At different times before surgery the patients were treated with liposomal amphotericin B 1.5 mg/kg by i.v. infusion over 1h. Blood and lung tissue samples were collected during surgery (one subject for each collecting time) and assayed for amphotericin B levels by HPLC. Due to surgical requirements, it was possible to obtain data from the 10th to the 25th h after the end of infusion. Plasma amphotericin B concentrations progressively decreased from 3.4 microg/ml at the 10th h to 1 microg/ml at the 25th h after the end of intravenous infusion. In lung tissue samples the lowest amphotericin B concentration (about 1 microg/g) was observed at the 10th h, then a progressive increase was observed with the highest value (2.5 microg/g) determined at the 25th h.
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Affiliation(s)
- G Demartini
- Dept of Pharmacology, University of Milan, Italy
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Abstract
Fungal infections are common in the newborn period, especially among premature neonates, and are responsible for considerable morbidity and mortality. Currently, three classes of antifungals are commonly used in the treatment of systemic fungal infections in neonates: the polyene macrolides (e.g. amphotericin B [deoxycholate and lipid preparations]); the azoles (e.g. fluconazole); and the fluorinated pyrimidines (e.g. flucytosine). The echinocandins (e.g. caspofungin and micafungin) are a newer class of antifungals which shows promise in this population.The available kinetic data on amphotericin B deoxycholate in neonates are derived from very small studies and exhibit considerable variability. There are no kinetic data available for the use of lipid preparations in this population and, again, much has been inferred from adult studies. The information available for flucytosine is also limited but appears similar to what is observed in adults. Fluconazole has the most neonatal pharmacokinetic data, which show slightly less variability than the other antifungals. Genomic factors which affect the metabolism of amphotericin B and fluconazole may explain some of the observed variability. Most of the data for the efficacy of antifungal drugs in neonates are derived from retrospective studies and case reports. The data for amphotericin B deoxycholate and flucytosine are limited. There are more data for the liposomal and lipid complex preparations of amphotericin B and for fluconazole in this population. These support the use of these drugs in neonates, but because of their largely noncomparative nature they can not define the optimal dosage or duration of therapy. Amphotericin B deoxycholate is primarily nephrotoxic. It also induces electrolyte abnormalities and is to a lesser degree cardiotoxic. This toxicity in neonates appears similar to published data in older children and adults. While the lipid preparations of amphotericin B owe their existence to a presumed decrease in toxicity, the observed toxicity in neonates appears to be equal to that seen with the deoxycholate, although it should be noted that the lipid preparations are usually given at much higher dosages. Fluconazole toxicity appears to be milder and less frequent in this population than is seen with amphotericin B. In the final analysis, we do not have sufficient data to define the pharmacokinetic profiles, optimal dose or duration of therapy, or toxicity for any of these compounds in neonates. Further studies are necessary if the optimisation of antifungal therapy in this population is to continue.
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Affiliation(s)
- Daniel A C Frattarelli
- Division of Clinical Pharmacology, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien, Detroit, MI 48201, USA.
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Kontoyiannis DP, Lewis RE. Combination chemotherapy for invasive fungal infections: what laboratory and clinical studies tell us so far. Drug Resist Updat 2003; 6:257-69. [PMID: 14643296 DOI: 10.1016/j.drup.2003.08.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Despite potential benefits, few objective clinical data (with the exception of cryptococcocal meningitis) are available supporting the routine use of combination antifungal regimens in patients with invasive mycoses, importantly aspergillosis or candidiasis. There is considerable debate on what constitutes synergy or antagonism in vitro and whether these laboratory findings are translated to beneficial interactions in patients. Given the lack of rigorous clinical data, a better understanding of the important concepts for the justification of the clinical and pharmacoeconomic threshold of antifungal therapy is needed. Such concepts include standardized methods for screening antifungal combinations in culture or in animals and collaborative efforts to collect clinical data on the efficacy and safety of combination regimens.
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Affiliation(s)
- Dimitrios P Kontoyiannis
- Departments of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Box 402, 1515 Holcombe Blvd, Houston TX, USA.
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Lewis RE, Wiederhold NP. The solubility ceiling: a rationale for continuous infusion amphotericin B therapy? Clin Infect Dis 2003; 37:871-2. [PMID: 12955666 DOI: 10.1086/377279] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Jantunen E, Volin L, Salonen O, Piilonen A, Parkkali T, Anttila VJ, Paetau A, Ruutu T. Central nervous system aspergillosis in allogeneic stem cell transplant recipients. Bone Marrow Transplant 2003; 31:191-6. [PMID: 12621480 DOI: 10.1038/sj.bmt.1703812] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Invasive aspergillosis (IA) is relatively common in allogeneic stem cell transplant (SCT) recipients. Although lungs are the most common site, central nervous system (CNS) involvement is also observed in this setting. We have retrospectively studied 14 cases of CNS aspergillosis found in a cohort of 455 allogeneic SCT recipients (incidence 3%). All patients, except one, had experienced acute graft-versus-host disease treated with high-dose methylprednisolone, and eight patients (57%) had also received ATG. The median time to the diagnosis of CNS aspergillosis was 124 days (range 49-347 days) from SCT. Pulmonary aspergillosis had been diagnosed earlier in four patients (29%). The most common initial symptoms of CNS aspergillosis were convulsions, hemiparesis, and mental alteration. Neuroradiological studies revealed single (two patients) or multiple (seven patients) focal lesions of 0.2-9 cm in diameter. Despite clinical suspicion in many patients, a confirmed diagnosis of CNS aspergillosis was made during life in only one patient. A total of 12 patients (86%) received amphotericin B. Despite therapy, all patients died 0-27 days (median seven days) after the initial CNS symptoms. CNS aspergillosis is not uncommon in allogeneic SCT recipients. Clinical manifestations are usually dramatic and progress quickly. Earlier and more effective treatment of IA is needed to prevent dissemination of infection into the CNS.
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Affiliation(s)
- E Jantunen
- Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland
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Lewis RE. Pharmacotherapy of Candida bloodstream infections: new treatment options, new era. Expert Opin Pharmacother 2002; 3:1039-57. [PMID: 12150684 DOI: 10.1517/14656566.3.8.1039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Evolving medical practices and the widespread use of fluconazole have clearly affected the spectrum of invasive mycoses now encountered by clinicians. The proportion of infections due to azole-resistant Candida species and invasive moulds has increased steadily over the last decade, creating a need for broad-spectrum antifungal agents with safety profiles similar to fluconazole. Efforts to address this need have lead to the reformulation of older, broad-spectrum antifungals and the development of new agents with enhanced activity against non-C. albicans and Aspergillus species. This review highlights pharmacodynamic, pharmacokinetic, safety and cost considerations for current and emerging antifungal therapies to be used in the treatment of bloodstream candidiasis.
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Affiliation(s)
- Russell E Lewis
- University of Houston College of Pharmacy, Texas Medical Center, Houston, TX 77030, USA.
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Vitale RG, Mouton JW, Afeltra J, Meis JFGM, Verweij PE. Method for measuring postantifungal effect in Aspergillus species. Antimicrob Agents Chemother 2002; 46:1960-5. [PMID: 12019115 PMCID: PMC127200 DOI: 10.1128/aac.46.6.1960-1965.2002] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
An in vitro method for determination of postantifungal effect (PAFE) in molds was developed by using three isolates each of Aspergillus fumigatus, A. flavus, A. terreus, A. nidulans, and A. ustus. MICs of amphotericin B and itraconazole were determined by using National Committee for Clinical Laboratory Standards guidelines (M38-P). The inoculum was prepared in RPMI 1640 broth buffered with MOPS (morpholinepropanesulfonic acid) at pH 7.0, and conidia were exposed to amphotericin B and itraconazole at concentrations of 4, 1, and 0.25 times the MIC, each for 4, 2, and 1 h at 37 degrees C. The same procedure was followed for controls with drug-free medium. Following exposure, the conidia were washed three times in saline and the numbers of CFU per milliliter were determined. Exposed and control conidia were then inoculated into microtitration plates and incubated at 37 degrees C for 48 h in a spectrophotometer reader. The optical density (OD) was measured automatically at 10-min intervals, resulting in growth curves. PAFE was quantified by comparing three arbitrary points in the control growth curve, the first increase of OD and the points when 20 and 50% of the maximal growth were reached, with the growth curve of drug-exposed conidia. Amphotericin B induced PAFE in A. fumigatus at four times the MIC after 2 and 4 h of exposure ranging from 1.83 to 6.00 h and 9.33 to 10.80 h, respectively. Significantly shorter PAFEs or lack of PAFE was observed for A. terreus, A. ustus, and A. nidulans. Itraconazole did not induce measurable PAFE in the Aspergillus isolates at any concentration or exposure time tested. Further studies are warranted to investigate the implications of PAFE in relation to clinical efficacy and dosing frequency.
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Affiliation(s)
- Roxana G Vitale
- Department of Medical Microbiology, University Medical Center Nijmegen, The Netherlands
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Bekersky I, Fielding RM, Dressler DE, Lee JW, Buell DN, Walsh TJ. Pharmacokinetics, excretion, and mass balance of liposomal amphotericin B (AmBisome) and amphotericin B deoxycholate in humans. Antimicrob Agents Chemother 2002; 46:828-33. [PMID: 11850268 PMCID: PMC127462 DOI: 10.1128/aac.46.3.828-833.2002] [Citation(s) in RCA: 216] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The pharmacokinetics, excretion, and mass balance of liposomal amphotericin B (AmBisome) (liposomal AMB) and the conventional formulation, AMB deoxycholate (AMB-DOC), were compared in a phase IV, open-label, parallel study in healthy volunteers. After a single 2-h infusion of 2 mg of liposomal AMB/kg of body weight or 0.6 mg of AMB-DOC/kg, plasma, urine, and feces were collected for 168 h. The concentrations of AMB were determined by liquid chromatography tandem mass spectrometry (plasma, urine, feces) or high-performance liquid chromatography (HPLC) (plasma). Infusion-related side effects similar to those reported in patients, including nausea and back pain, were observed in both groups. Both formulations had triphasic plasma profiles with long terminal half-lives (liposomal AMB, 152 +/- 116 h; AMB-DOC, 127 +/- 30 h), but plasma concentrations were higher (P < 0.01) after administration of liposomal AMB (maximum concentration of drug in serum [C(max)], 22.9 +/- 10 microg/ml) than those of AMB-DOC (Cmax, 1.4 +/- 0.2 microg/ml). Liposomal AMB had a central compartment volume close to that of plasma (50 +/- 19 ml/kg) and a volume of distribution at steady state (Vss) (774 +/- 550 ml/kg) smaller than the Vss of AMB-DOC (1,807 +/- 239 ml/kg) (P < 0.01). Total clearances were similar (approximately 10 ml hr(-1) kg(-1)), but renal and fecal clearances of liposomal AMB were 10-fold lower than those of AMB-DOC (P < 0.01). Two-thirds of the AMB-DOC was excreted unchanged in the urine (20.6%) and feces (42.5%) with >90% accounted for in mass balance calculations at 1 week, suggesting that metabolism plays at most a minor role in AMB elimination. In contrast, <10% of the liposomal AMB was excreted unchanged. No metabolites were observed by HPLC or mass spectrometry. In comparison to AMB-DOC, liposomal AMB produced higher plasma exposures and lower volumes of distribution and markedly decreased the excretion of unchanged drug in urine and feces. Thus, liposomal AMB significantly alters the excretion and mass balance of AMB. The ability of liposomes to sequester drugs in circulating liposomes and within deep tissue compartments may account for these differences.
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Affiliation(s)
- Ihor Bekersky
- Fujisawa Healthcare, Inc., Deerfield, Illinois 60015-2548, USA.
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Duflo F, Allaouchiche B, Chassard D. Biliary excretion of amphotericin B deoxycholate and amphotericin B lipid complex. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2001; 32:581. [PMID: 11055677 DOI: 10.1080/003655400459009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Varlam DE, Siddiq MM, Parton LA, Rüssmann H. Apoptosis contributes to amphotericin B-induced nephrotoxicity. Antimicrob Agents Chemother 2001; 45:679-85. [PMID: 11181342 PMCID: PMC90355 DOI: 10.1128/aac.45.3.679-685.2001] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to investigate whether apoptosis contributes to nephrotoxicity caused by amphotericin B (AmB). By detecting apoptosis-specific DNA fragmentation, it is demonstrated that proximal tubular cells (LLC-PK(1)) and medullary interstitial cells (RMIC) respond with programmed cell death when treated with therapeutic doses of AmB. Concomitant application of AmB and recombinant human insulin-like growth factor-1 (rhIGF-1), a known antiapoptotic agent, abrogated apoptosis in vitro. To validate that the observed apoptotic effects on renal tissue culture cells are applicable to an in vivo setting, an animal model was used for verification. Therefore, Sprague-Dawley rats were treated with AmB. The drug caused hypokalemia, decreased weight gain, loss of renal concentrating ability, and dehydration in a dose-dependent fashion. Microscopic examination of renal tissue sections revealed apoptotic alterations predominantly in proximal and distal tubular epithelial cells. To verify that the observed clinical side effects were linked to apoptosis, rhIGF-1 was applied concomitantly with AmB. In all animals, rhIGF-1 prevented the above-mentioned clinical side effects. Moreover, significantly reduced apoptosis was observed in renal tissue sections of these animals, indicating the relevance of apoptosis in nephrotoxicity. This is the first report to demonstrate that AmB induces apoptosis in the rat kidney in a dose-dependent fashion. The incidence of apoptosis correlates with renal toxicity and can be abrogated by concomitant treatment with rhIGF-1.
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Affiliation(s)
- D E Varlam
- Department of Pediatrics, SUNY at Stony Brook, Stony Brook, New York 11794-8111, USA
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41
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Santangelo R, Paderu P, Delmas G, Chen ZW, Mannino R, Zarif L, Perlin DS. Efficacy of oral cochleate-amphotericin B in a mouse model of systemic candidiasis. Antimicrob Agents Chemother 2000; 44:2356-60. [PMID: 10952579 PMCID: PMC90069 DOI: 10.1128/aac.44.9.2356-2360.2000] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Amphotericin B (AMB) remains the principal therapeutic choice for deep mycoses. However, its application is limited by toxicity and a route of administration requiring slow intravenous injection. An oral formulation of this drug is desirable to treat acute infections and provide prophylactic therapy for high-risk patients. Cochleates are a novel lipid-based delivery system that have the potential for oral administration of hydrophobic drugs. They are stable phospholipid-cation crystalline structures consisting of a spiral lipid bilayer sheet with no internal aqueous space. Cochleates containing AMB (CAMB) inhibit the growth of Candida albicans, and the in vivo therapeutic efficacy of CAMB administered orally was evaluated in a mouse model of systemic candidiasis. The results indicate that 100% of the mice treated at all CAMB doses, including a low dosage of 0.5 mg/kg of body weight/day, survived the experimental period (16 days). In contrast, 100% mortality was observed with untreated mice by day 12. The fungal tissue burden in kidneys and lungs was assessed in parallel, and a dose-dependent reduction in C. albicans from the kidneys was observed, with a maximum 3.5-log reduction in total cell counts at 2.5 mg/kg/day. However, complete clearance of the organism from the lungs, resulting in more than a 4-log reduction, was observed at the same dose. These results were comparable to a deoxycholate AMB formulation administered intraperitoneally at 2 mg/kg/day (P < 0.05). Overall, these data demonstrate that cochleates are an effective oral delivery system for AMB in a model of systemic candidiasis.
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Affiliation(s)
- R Santangelo
- Public Health Research Institute, New York, NY 10016, USA
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42
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Extraction and liquid-chromatographic determination of amphotericin B in oil-water lecithin-based microemulsions. Chromatographia 1998. [DOI: 10.1007/bf02467651] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Vazquez JA, Arganoza MT, Boikov D, Yoon S, Sobel JD, Akins RA. Stable phenotypic resistance of Candida species to amphotericin B conferred by preexposure to subinhibitory levels of azoles. J Clin Microbiol 1998; 36:2690-5. [PMID: 9705415 PMCID: PMC105185 DOI: 10.1128/jcm.36.9.2690-2695.1998] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The fungicidal activity of amphotericin B (AmB) was quantitated for several Candida species. Candida albicans and C. tropicalis were consistently susceptible to AmB, with less than 1% survivors after 6 h of exposure to AmB. C. parapsilosis and variants of C. lusitaniae and C. guilliermondii were the most resistant, demonstrating 50 to 90% survivors in this time period and as high as 1% survival after a 24-h exposure time. All Candida species were killed (<1% survivors) after 24 h of exposure to AmB. In contrast, overnight exposure to either fluconazole or itraconazole resulted in pronounced increases in resistance to subsequent exposures to AmB. Most dramatically, C. albicans was able to grow in AmB cultures after azole preexposure. Several other Candida species did not grow in AmB but showed little or no reduction in viability after up to 24 h in AmB. Depending on the growth conditions, Candida cells preexposed to azoles may retain AmB resistance for days after the azoles have been removed. If this in vitro antagonism applies to the clinical setting, treatment of patients with certain antifungal combinations may not be beneficial. The ability of some Candida isolates to survive transient exposures to AmB was not reflected in the in vitro susceptibility changes as measured by standard MIC assays. This finding should be considered in studies attempting to correlate patient outcome with in vitro susceptibilities of clinical fungal isolates. Patients who fail to respond to AmB may be infected with isolates that are classified as susceptible by standard in vitro assays but that may be resistant to transient antifungal exposures which may be more relevant in the clinical setting.
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Affiliation(s)
- J A Vazquez
- Veterans Administration Medical Center, Detroit, Michigan 48201, USA.
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Koizumi T, Kubo K, Kaneki T, Hanaoka M, Hayano T, Miyahara T, Okada K, Fujimoto K, Yamamoto H, Kobayashi T, Sekiguchi M. Pharmacokinetic evaluation of amphotericin B in lung tissue: lung lymph distribution after intravenous injection and airspace distribution after aerosolization and inhalation of amphotericin B. Antimicrob Agents Chemother 1998; 42:1597-600. [PMID: 9660990 PMCID: PMC105652 DOI: 10.1128/aac.42.7.1597] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
We have studied the pharmacokinetics of amphotericin B (AmB) in lung lymph circulation and bronchial-wash fluid after intravenous infusion and inhalation, respectively. For two experiments with awake sheep, we used lung lymph fistulas and tracheotomy. In experiment 1, AmB concentrations in plasma and lung lymph after intravenous infusion of AmB (1 mg/kg of body weight) over 1.5 h were measured. The mean peak in plasma level was 756.0 +/- 188.8 ng/ml at 3 h after the start of infusion, and the level then decreased gradually to 194.8 +/- 28.9 ng/ml at 24 h. The stable and maximal levels in lung lymph last 5 to 9 h after the start of AmB infusion. The concentrations in lung lymph after 9 h were slightly higher than those in plasma. Thus, the lung lymph-to-plasma ratio of AmB concentrations increased gradually during infusion, and the ratio was more than 1.0 after the end of infusion, suggesting that AmB could be easily moved from plasma to pulmonary interstitium and/or lung lymph circulation. In another experiment, 5 or 30 mg of aerosol AmB was inhaled, and the concentration of AmB in the bronchial-wash fluid was determined by bronchoalveolar lavage. The peak AmB concentration in the fluid was observed at 0.5 h. After that, AmB was slowly eliminated over 24 h. The area under the concentration-time curve for 30 mg of inhaled AmB was higher than that for 5 mg, but maximum concentrations of AmB in serum for 5 and 30 mg were almost similar. These observations identify the pharmacokinetic characteristics of AmB in the lung and may provide a new insight into the strategy for clinical treatment of fungal pneumonia.
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Affiliation(s)
- T Koizumi
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
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Adedoyin A, Bernardo JF, Swenson CE, Bolsack LE, Horwith G, DeWit S, Kelly E, Klasterksy J, Sculier JP, DeValeriola D, Anaissie E, Lopez-Berestein G, Llanos-Cuentas A, Boyle A, Branch RA. Pharmacokinetic profile of ABELCET (amphotericin B lipid complex injection): combined experience from phase I and phase II studies. Antimicrob Agents Chemother 1997; 41:2201-8. [PMID: 9333048 PMCID: PMC164093 DOI: 10.1128/aac.41.10.2201] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Amphotericin B (AmB) has been the most effective systemic antifungal agent, but its use is limited by the dose-limiting toxicity of the conventional micellar dispersion formulation (Fungizone). New formulations with better and improved safety profiles are being developed and include ABELCET (formerly ABLC), but their dispositions have not been well characterized; hence, the reason for their improved profiles remains unclear. This report details the pharmacokinetics of ABELCET examined in various pharmacokinetic and efficacy studies by using whole-blood measurements of AmB concentration performed by high-pressure liquid chromatography. The data indicated that the disposition of AmB after administration of ABELCET is different from that after administration of Fungizone, with a faster clearance and a larger volume of distribution. It exhibits complex and nonlinear pharmacokinetics with wide interindividual variability, extensive distribution, and low clearance. The pharmacokinetics were unusual. Clearance and volume of distribution were increased with dose, peak and trough concentrations after multiple dosings increased less than proportionately with dose, steady state appeared to have been attained in 2 to 3 days, despite an estimated half-life of up to 5 days, and there was no evidence of significant accumulation in the blood. The data are internally consistent, even though they were gathered under different conditions and circumstances. The pharmacokinetics of ABELCET suggest that lower concentrations in blood due to higher clearance and greater distribution may be responsible for its improved toxicity profile compared to those of conventional formulations.
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Affiliation(s)
- A Adedoyin
- Center for Clinical Pharmacology, University of Pittsburgh Medical Center, Pennsylvania 15213-2582, USA
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Abstract
OBJECTIVE To evaluate the published data on the effectiveness and safety of amphotericin B lipid complex (ABLC) for the treatment of invasive mycosis and to evaluate data describing the pharmacologic properties and pharmacokinetic behavior of ABLC in both animals and humans. DATA SOURCE A MEDLINE search was conducted to identify literature published from 1965 to January 1997 for amphotericin B deoxycholate (DCAB) and ABLC. In addition, preliminary data published as abstracts and presented at national conferences on infectious disease and hematology within the last 6 years were also included in this review. STUDY SELECTION Both human and animal studies were reviewed. Animal and in vitro studies were selected to evaluate the pharmacologic and toxicologic properties of ABLC. For the evaluation of the efficacy, safety, and pharmacokinetic behavior of ABLC, large, well-controlled studies were reviewed. In addition, data from open-label and emergency use protocols were also included in the review. DATA EXTRACTION The study and analytical methods, results, and conclusions of the selected studies were evaluated. Pharmacokinetic data for both ABLC and DCAB that were derived from human subjects were also evaluated. DATA SYNTHESIS DCAB has been the cornerstone for the treatment of invasive mycosis, even though it has a narrow therapeutic index. Infusion-related toxicities (e.g., fever, chills, rigors) are likely due to DCAB stimulation of cytokine and prostaglandin synthesis. Conversely, nephrotoxicity, the primary non-infusion-related toxicity, likely results from the nonselective cytotoxic interaction between DCAB and cholesterol-containing mammalian cells. ABLC represents a new approach to improving the therapeutic index of DCAB. Mammalian cytotoxicity is attenuated by complexing amphotericin B to a mixture of phospholipids. This alters the affinity of amphotericin B and decreases its selective transfer from the complex to cholesterol-containing mammalian cells. Fungi also possess lipase, which improves the selective transfer from the complex to ergosterol-containing cell membranes. In humans, the lipid formulation increases the volume of distribution of amphotericin B. Thus, compared with DCAB, larger doses of ABLC can be administered for a longer duration with less nephrotoxicity. However, the prevalence of infusion-related toxicities associated with ABLC is similar to that of DCAB. Whether the alteration in distribution improves efficacy by improving tissue concentrations of amphotericin B has not been determined. The cost of this agent will limit its use. CONCLUSIONS ABLC has been shown to be at least as effective as DCAB, and it has been well tolerated in the clinical studies to date. Despite large dosages and extended courses of administration, there is little nephrotoxicity associated with its use. However, the cost of this agent will limit its use to the treatment of refractory mycosis or to cases where DCAB is contraindicated due to significant renal insufficiency.
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Affiliation(s)
- R P Rapp
- College of Pharmacy, University of Kentucky Medical Center, Lexington, USA
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Chavanet P, Clement C, Duong M, Buisson M, D'Athis P, Dumas M, Bonnin A, Portier H. Toxicity and efficacy of conventional amphotericin B deoxycholate versus escalating doses of amphotericin B deoxycholate---fat emulsion in HIV-infected patients with oral candidosis. Clin Microbiol Infect 1997; 3:455-461. [PMID: 11864156 DOI: 10.1111/j.1469-0691.1997.tb00282.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND: Amphotericin B deoxycholate remains the treatment of choice for most systemic fungal infections; however, its clinical use can be limited by infusion-related side effects and nephrotoxicity. New formulations of amphotericin in lipid compounds have been shown to decrease toxicity. We previously showed that a lipid emulsion preparation of amphotericin B deoxycholate was better tolerated than the conventional preparation in dextrose. Therefore, we have now studied the clinical tolerance, renal toxicity and efficacy of higher doses of amphotericin B deoxycholate prepared and infused in a fat emulsion (Intralipid 20%). Thus, this report adds information to the previous publication. METHODS: Forty-two patients infected with HIV and suffering oral candidosis entered the study. The patients received either amphotericin B deoxycholate---glucose 1 mg/kg/day or amphotericin B deoxycholate---lipid emulsion 1 mg/kg/day for 4 days (randomized phase), or amphotericin B deoxycholate---lipid emulsion 2 mg/kg/day or 3 mg/kg/day (escalating-dose phase) for 5 days. Clinical (immediate) side effects and renal (creatinine) tolerance were assessed daily; efficacy against oral candidosis was measured by using a simple clinical score. Serum levels of amphotericin B were also measured. RESULTS: None of the patients receiving amphotericin B deoxycholate---lipid emulsion had treatment interrupted, as compared to four (36%) in the amphotericin B deoxycholate---glucose group (pless-than-or-equal0.01); chills during or after the infusions were significantly less frequent in the amphotericin B deoxycholate---lipid emulsion groups than in the amphotericin B deoxycholate-glucose group (p=0.03). The increase of creatininemia during treatment was significantly higher for patients receiving amphotericin B deoxycholate---glucose than for those receiving amphotericin B deoxycholate---lipid emulsion (p=0.001). The number of patients who had a creatininemia greater-than-or-equal18 mg/L during treatment was significantly higher in both the amphotericin B deoxycholate---glucose group (36%) and in the group receiving the highest dose of amphotericin B deoxycholate---lipid emulsion than in other groups (pless-than-or-equal0.06). The serum concentrations of amphotericin B were lower for the amphotericin B deoxycholate---lipid emulsion regimen than for the amphotericin B deoxycholate---glucose regimen at the same dose of 1 mg/kg/day, but increased with the dose. The change of the oral candidosis score was similar for the same dose of 1 mg/kg/day of amphotericin B deoxycholate infused in either glucose or lipid emulsion; higher doses of amphotericin B deoxycholate---lipid emulsion were more efficacious (p=0.009) and this efficacy seemed to increase with the dose (p=0.06). CONCLUSIONS: The clinical and renal tolerance of amphotericin B deoxycholate are improved when the drug is directly prepared and infused in lipid emulsion (Intrapid) and this preparation allows for greater dosage, up to 3 mg/kg/day, with resultant greater efficacy. This preparation is simple and cost-effective (approximately 7 US $ per 50 mg of amphotercin B) and could be clinically compared to other formulations of amphotericin B.
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Affiliation(s)
- Pascal Chavanet
- Infectious Diseases Department, Hopital du Bocage, Dijon, France
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Heinemann V, Bosse D, Jehn U, Kähny B, Wachholz K, Debus A, Scholz P, Kolb HJ, Wilmanns W. Pharmacokinetics of liposomal amphotericin B (Ambisome) in critically ill patients. Antimicrob Agents Chemother 1997; 41:1275-80. [PMID: 9174183 PMCID: PMC163899 DOI: 10.1128/aac.41.6.1275] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The liposomal formulation of amphotericin B (AmBisome) greatly reduces the acute and chronic side effects of the parent drug. The present study describes the pharmacokinetic characteristics of AmBisome applied to 10 patients at a dose of 2.8 to 3.0 mg/kg of body weight and compares them to the pharmacokinetics observed in 6 patients treated with amphotericin B deoxycholate at the standard dose of 1.0 mg/kg. Interpatient variabilities of amphotericin B peak concentrations (Cmax) and areas under concentration-time curves (AUC) were 8- to 10-fold greater for patients treated with AmBisome than for patients treated with amphotericin B deoxycholate. At the threefold greater dose of AmBisome, median Cmaxs were 8.4-fold higher (14.4 versus 1.7 microg/ml) and median AUCs exceeded those observed with amphotericin B deoxycholate by 9-fold. This was in part explained by a 5.7-fold lower volume of distribution (0.42 liters/kg) in AmBisome-treated patients. The elimination of amphotericin B from serum was biphasic for both formulations. However, the apparent half-life of elimination was twofold shorter for AmBisome (P = 0.03). Neither hemodialysis nor hemofiltration had a significant impact on AmBisome pharmacokinetics as analyzed in one patient. In conclusion, the liposomal formulation of amphotericin B significantly (P = 0.001) reduces the volume of drug distribution, thereby allowing for greater drug concentrations in serum. The low toxicity of AmBisome therefore cannot readily be explained by its serum pharmacokinetics.
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Affiliation(s)
- V Heinemann
- Klinikum Grosshadern, III Medical Clinic, University of Munich, Germany
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49
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Abstract
Amphotericin B (AmB), the drug of choice for the treatment of most systemic fungal infections, is marketed under the trademark Fungizone, as an AmB-deoxycholate complex suitable for intravenous administration. The association between AmB and deoxycholate is relatively weak; therefore, dissociation occurs in the blood. The drug itself interacts with both mammalian and fungal cell membranes to damage cells, but the greater susceptibility of fungal cells to its effects forms the basis for its clinical usefulness. The ability of the drug to form stable complexes with lipids has allowed the development of new formulations of AmB based on this property. Several lipid-based formulations of the drug which are more selective in damaging fungal or parasitic cells than mammalian cells and some of which also have a better therapeutic index than Fungizone have been developed. In vitro investigations have led to the conclusion that the increase in selectivity observed is due to the selective transfer of AmB from lipid complexes to fungal cells or to the higher thermodynamic stability of lipid formulations. Association with lipids modulates AmB binding to lipoproteins in vivo, thus influencing tissue distribution and toxicity. For example, lipid complexes of AmB can be internalized by macrophages, and the macrophages then serve as a reservoir for the drug. Furthermore, stable AmB-lipid complexes are much less toxic to the host than Fungizone and can therefore be administered in higher doses. Experimentally, the efficacy of AmB-lipid formulations compared with Fungizone depends on the animal model used. Improved therapeutic indices for AmB-lipid formations have been demonstrated in clinical trials, but the definitive trials leading to the selection of an optimal formulation and therapeutic regimen have not been done.
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Affiliation(s)
- J Brajtburg
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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50
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Nagata MP, Gentry CA, Hampton EM. Is there a therapeutic or pharmacokinetic rationale for amphotericin B dosing in systemic Candida infections? Ann Pharmacother 1996; 30:811-8. [PMID: 8826566 DOI: 10.1177/106002809603000720] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To review the literature regarding the dosage of amphotericin B in Candida infections. The correlation or rationale of current dosing practices is assessed in light of the literature. DATA SOURCES A MEDLINE search encompassing the years 1968-1995 was used to identify pertinent literature. Additional references were obtained from the articles retrieved from MEDLINE. STUDY SELECTION Studies that directly assessed amphotericin B dosage and/or duration, pharmacokinetic literature dealing with plasma concentrations and amphotericin B disposition, and literature dealing with dose and/or concentration as well as clinical outcome were selected for inclusion. Additional relevant citations were used in the introductory material and discussion. DATA EXTRACTION Although there was a large number of articles related to amphotericin B, surprisingly few large studies were designed to address the issues in question. The description of the methods and results of these heterogeneous articles are the basis of this review. Although additional controlled studies with more subjects need to be performed, the results to date provide a foundation from which to make some inferences regarding optimal use of this therapeutic modality until more definitive data become available. DATA SYNTHESIS Despite numerous articles addressing the pharmacokinetics of amphotericin B, little is known about its tissue distribution, the rate of transfer of the drug from vascular to peripheral sites, or its terminal disposition. Less information is available regarding the relevance of pharmacokinetic parameters or serum concentrations to clinical outcome. Most of the articles mentioning dosing provide little or no justification for the doses employed. The variety of the dosages used and the heterogeneity of the populations studied make determination of dose-outcome relationships difficult. CONCLUSIONS From the available clinical data, it appears that early initiation of amphotericin B therapy is crucial to a favorable outcome. Daily dosing initially followed by every-other-day administration of twice the daily dose is better tolerated by the patient than daily dosing and produces a similar therapeutic outcome. The drug should be continued until therapeutic endpoints have been achieved, rather than until a specific total dosage has been administered. The nephrotoxicity that occurs with amphotericin B administration is apparently reversible and should not be used as an endpoint for therapy if total dosages do not exceed 4 g. Additional well-designed, controlled trials evaluating standardized dosing methods of amphotericin B with predetermined dosing regimens and/or definitive therapeutic endpoints are needed to determine the optimal dosing approach for this agent.
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Affiliation(s)
- M P Nagata
- Veterans Affairs Medical Center, Oklahoma City, OK, USA
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