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Sharma D, Bisht GS. Recent Updates on Antifungal Peptides. Mini Rev Med Chem 2020; 20:260-268. [PMID: 31556857 DOI: 10.2174/1389557519666190926112423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/17/2018] [Accepted: 09/06/2019] [Indexed: 12/11/2022]
Abstract
The current trend of increment in the frequency of antifungal resistance has brought research into an era where new antifungal compounds with novel mechanisms of action are required. Natural antimicrobial peptides, which are ubiquitous components of innate immunity, represent their candidature for novel antifungal peptides. Various antifungal peptides have been isolated from different species ranging from small marine organisms to insects and from various other living species. Based on these peptides, various mimetics of antifungal peptides have also been synthesized using non-natural amino acids. Utilization of these antifungal peptides is somehow limited due to their toxic and unstable nature. This review discusses recent updates and future directions of antifungal peptides, for taking them to the shelf from the bench.
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Affiliation(s)
- Deepika Sharma
- Department of Pharmacy, Jaypee University of Information Technology, Waknaghat, Solan, Himachal Pradesh, 173234, India
| | - Gopal Singh Bisht
- Department of Biotechnology and Bioinformatics, Jaypee University of Information Technology, Waknaghat, Solan, Himachal Pradesh, 173234, India
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Mullins C, Beaulac K, Sylvia L. Drug-Induced Liver Injury (DILI) With Micafungin: The Importance of Causality Assessment. Ann Pharmacother 2019; 54:526-532. [PMID: 31786964 DOI: 10.1177/1060028019892587] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Micafungin is increasingly used in the treatment and prevention of candidiasis in hospitalized patients. Limited data are available from which to assess the risk of drug-induced liver injury (DILI) with micafungin. No studies, to date, have applied a standardized causality assessment method to the study of micafungin-associated DILI. Objective: This study aimed to identify the frequency and clinical pattern of DILI in micafungin-treated patients as determined using 2 standardized causality assessment algorithms. Methods: A retrospective analysis was conducted of micafungin-treated patients at a single center between May 15, 2017, and May 15, 2018. DILI was defined on the basis of liver test elevations and the presence of associated signs and symptoms. The Roussel UClaf Causality Assessment Method (RUCAM) and the Naranjo algorithm were applied to each case. Results: A total of 99 patients were assessed; 52 were excluded, with a final sample of 47 evaluable patients. The definition of DILI was met in 9 (19%) patients, with a clinical pattern consistent with cholestatic injury in 7 of 9 (78%) patients. No cases were associated with jaundice. Agreement between the 2 causality assessment methods occurred in 4 of 9 (44%) cases. Application of the RUCAM algorithm led to the exclusion of 4 cases, resulting in a final reported prevalence of micafungin-associated DILI of 10.6%. Conclusion and Relevance: Asymptomatic DILI was identified in 10.6% of micafungin-treated patients. The choice of a causality assessment nomogram substantially influenced the determination of DILI prevalence. Compared with the Naranjo algorithm, the RUCAM algorithm is recommended as a more precise tool of assessing the relationship between drug exposure and DILI.
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Micafungin prophylaxis for acute leukemia patients undergoing induction chemotherapy. BMC Cancer 2019; 19:358. [PMID: 30991992 PMCID: PMC6469030 DOI: 10.1186/s12885-019-5557-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/31/2019] [Indexed: 01/17/2023] Open
Abstract
Background Micafungin is a well-tolerated and effective prophylactic antifungal agent used in hematologic diseases. In this prospective trial, we evaluated the efficacy and safety of prophylactic micafungin during first induction chemotherapy in patients with acute leukemia. We also compared outcomes of prophylactic micafungin with those of prophylactic posaconazole in acute myeloid leukemia (AML). Methods Medically fit patients with newly diagnosed acute leukemia received 50 mg micafungin intravenously once daily from the initiation of first induction chemotherapy to recovery of neutrophil count, suspected fungal infection, or unacceptable drug-related toxicity (Clinicaltrials.gov number, NCT02440178). The primary end point was incidence of invasive fungal infection, and the secondary end points were adverse events of prophylactic micafungin and mortality during induction therapy. Results The 65 patients (median age = 51 years, male:female = 34:31) enrolled in this study had diagnoses of AML (33, 50.8%), acute lymphoblastic leukemia (31, 47.7%), and acute biphenotypic leukemia (1, 1.5%). Median duration of micafungin treatment was 24 days (range 1–68), with proven invasive fungal disease in one patient (1.5%) and possible fungal infection in two patients (3.1%). Three of the patients (4.6%) experienced the following adverse events, but all events were tolerable: liver function abnormality (Grade 2, n = 1; Grade 3, n = 1) and allergic reaction (Grade 2, n = 1). Three patients died during induction therapy, and invasive aspergillosis pneumonia was the cause of death for one of those patients. Overall, 19 patients (29.2%) discontinued prophylactic micafungin, and 18 (27.7%) patients switched to another antifungal agent. We observed no fungal infections caused by amphotericin B-resistant organisms. In AML patients, outcomes of prophylactic micafungin during induction chemotherapy did not differ significantly with those of prophylactic posaconazole with regard to incidence of fungal infections, rate of discontinuation, or safety. Conclusions Our study demonstrates that prophylactic micafungin is safe and effective in patients with acute leukemia undergoing induction chemotherapy. Outcomes in patients with AML were similar to those of prophylactic posaconazole, indicating the usefulness of micafungin as a prophylactic antifungal agent during induction chemotherapy for AML. Trial registration Clinicaltrials.gov NCT02440178, registered May 12th 2015.
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Enoch DA, Murphy ME, Micallef C, Yang H, Brown NM, Aliyu SH. Micafungin use in a UK tertiary referral hospital. J Glob Antimicrob Resist 2018; 15:82-87. [DOI: 10.1016/j.jgar.2018.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 05/22/2018] [Accepted: 06/15/2018] [Indexed: 01/05/2023] Open
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Kardos T, Kovács R, Kardos G, Varga I, Bozó A, Tóth Z, Nagy F, Majoros L. Poor in vivo efficacy of caspofungin, micafungin and amphotericin B against wild-type Candida krusei clinical isolates does not correlate with in vitro susceptibility results. J Chemother 2018; 30:233-239. [PMID: 30025501 DOI: 10.1080/1120009x.2018.1487150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We determined micafungin, caspofungin and amphotericin B (AMB) minimum inhibitory concentration (MICs) and killing rates in RPMI-1640 and in RPMI-1640 with 50% serum against three Candida krusei bloodstream isolates. MIC ranges in RPMI-1640 were 0.125-0.25, 0.25 and 0.125-0.5 mg/L, in RPMI-1640 with 50% serum, MICs were 64-128-, 8- and 4-16-fold higher, respectively. In RPMI-1640 micafungin and caspofungin at 1, 4, 16 and 32 mg/L as well as AMB at 2 mg/L were fungicidal against all isolates in ≤3.96, ≤4.42 and 14.96 h, respectively. In RPMI-1640 with 50% serum, caspofungin was fungicidal for all isolates only at 32 mg/L, micafungin and AMB were fungistatic. In neutropenic mice, 5 mg/kg caspofungin and 1 mg/kg AMB were ineffective against two of the three isolates. Thus, in vivo efficacy of echinocandins and AMB is weak or absent against C. krusei. Prescribers treating C. krusei infections with echinocandins should watch out for clinical resistance and therapeutic failure.
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Affiliation(s)
- Tamás Kardos
- a Faculty of Medicine, Department of Pulmonology , University of Debrecen , Debrecen , Hungary.,b Faculty of Medicine, Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - Renátó Kovács
- b Faculty of Medicine, Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary.,c Faculty of Pharmacy , University of Debrecen , Debrecen , Hungary
| | - Gábor Kardos
- b Faculty of Medicine, Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - Istvan Varga
- d Faculty of Dentistry , University of Debrecen , Debrecen , Hungary
| | - Aliz Bozó
- b Faculty of Medicine, Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - Zoltán Tóth
- b Faculty of Medicine, Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - Fruzsina Nagy
- b Faculty of Medicine, Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - László Majoros
- b Faculty of Medicine, Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
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Maseda E, Grau S, Luque S, Castillo-Mafla MP, Suárez-de-la-Rica A, Montero-Feijoo A, Salgado P, Gimenez MJ, García-Bernedo CA, Gilsanz F, Roberts JA. Population pharmacokinetics/pharmacodynamics of micafungin against Candida species in obese, critically ill, and morbidly obese critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:94. [PMID: 29655372 PMCID: PMC5899833 DOI: 10.1186/s13054-018-2019-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/26/2018] [Indexed: 01/05/2023]
Abstract
Background Dosing in obese critically ill patients is challenging due to pathophysiological changes derived from obesity and/or critical illness, and it remains fully unexplored. This study estimated the micafungin probability of reaching adequate 24-h area under the curve (AUC0–24h)/minimum inhibitory concentration (MIC) values against Candida spp. for an obese/nonobese, critically ill/noncritically ill, large population. Methods Blood samples for pharmacokinetic analyses were collected from 10 critically ill nonobese patients, 10 noncritically ill obese patients, and 11 critically ill morbidly obese patients under empirical/directed micafungin treatment. Patients received once daily 100–150 mg micafungin at the discretion of the treating physician following the prescribing information and hospital guidelines. Total micafungin concentrations were determined by high-performance liquid chromatography (HPLC). Monte-Carlo simulations were performed and the probability of target attainment (PTA) was calculated using the AUC0–24/MIC cut-offs 285 (C. parapsilosis), 3000 (all Candida spp.), and 5000 (nonparapsilosis Candida spp.). Intravenous once-daily 100-mg, 150-mg, and 200-mg doses were simulated at different body weights (45, 80, 115, 150, and 185 kg) and age (30, 50, 70 and 90 years old). PTAs ≥ 90% were considered optimal. Fractional target attainment (FTA) was calculated using published MIC distributions. A dosing regimen was considered successful if the FTA was ≥ 90%. Results Overall, 100 mg of micafungin was once-daily administered for nonobese and obese patients with body mass index (BMI) ≤ 45 kg/m2 and 150 mg for morbidly obese patients with BMI > 45 kg/m2 (except two noncritically ill obese patients with BMI ~ 35 kg/m2 receiving 150 mg, and one critically ill patient with BMI > 45 kg/m2 receiving 100 mg). Micafungin concentrations in plasma were best described using a two-compartment model. Weight and age (but not severity score) were significant covariates and improved the model. FTAs > 90% were obtained against C. albicans with the 200 mg/24 h dose for all body weights (up to 185 kg), and with the 150 mg/24 h for body weights < 115 kg, and against C. glabrata with the 200 mg/24 h dose for body weights < 115 kg. Conclusion The lack of adequacy for the 100 mg/24 h dose suggested the need to increase the dose to 150 mg/24 h for C. albicans infections. Further pharmacokinetic/pharmacodynamic studies should address optimization of micafungin dosing for nonalbicans Candida infections.
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Affiliation(s)
- Emilio Maseda
- Department of Anesthesia and Surgical Intensive Care, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain. .,Universidad Autónoma de Madrid, Madrid, Spain.
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Barcelona, Spain.,Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Sonia Luque
- Pharmacy Department, Hospital del Mar, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Maria-Pilar Castillo-Mafla
- Department of Anesthesia and Surgical Intensive Care, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Alejandro Suárez-de-la-Rica
- Department of Anesthesia and Surgical Intensive Care, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Ana Montero-Feijoo
- Department of Anesthesia and Surgical Intensive Care, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Patricia Salgado
- Department of Anesthesia and Surgical Intensive Care, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | | | | | - Fernando Gilsanz
- Department of Anesthesia and Surgical Intensive Care, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.,Universidad Autónoma de Madrid, Madrid, Spain
| | - Jason A Roberts
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.,Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Louis-Auguste JR, Micallef C, Ambrose T, Upponi S, Butler AJ, Massey D, Middleton SJ, Russell N, Rutter CS, Sharkey LM, Woodward J, Gkrania-Klotsas E, Enoch DA. Fatal breakthrough mucormycosis in a multivisceral transplant patient receiving micafungin: Case report and literature review. IDCases 2018; 12:76-79. [PMID: 29942755 PMCID: PMC6010962 DOI: 10.1016/j.idcr.2018.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Antifungal agents are routinely used in the post-transplant setting for both prophylaxis and treatment of presumed and proven fungal infections. Micafungin is an echinocandin-class antifungal with broad antifungal cover and favorable side effect profile but, notably, it has no activity against molds of the order Mucorales. Presentation of case A 47-year-old woman underwent multivisceral transplantation for intestinal failure-associated liver disease. She had a prolonged post-operative recovery complicated by invasive candidiasis and developed an intolerance to liposomal amphotericin B. In view of her immunosuppression, she was commenced on micafungin as prophylaxis to prevent invasive fungal infection. However, she developed acute graft versus host disease with bone marrow failure complicated by disseminated mucormycosis which was only diagnosed post mortem. Discussion Non-Aspergillus breakthrough mold infections with micafungin therapy are rare with only eight other cases having been described in the literature. Breakthrough infections have occurred within one week of starting micafungin. Diagnosis is problematic and requires a high degree of clinical suspicion and microscopic/histological examination of an involved site. The management of these aggressive infections involves extensive debridement and appropriate antifungal cover. Conclusion A high level of suspicion of invasive fungal infection is required at all times in immunosuppressed patients, even those receiving antifungal prophylaxis. Early biopsy is required. Even with early recognition and aggressive treatment of these infections, prognosis is poor.
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Affiliation(s)
- John R Louis-Auguste
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christianne Micallef
- Clinical Microbiology & Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tim Ambrose
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sara Upponi
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew J Butler
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dunecan Massey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen J Middleton
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Russell
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charlotte S Rutter
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Lisa M Sharkey
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeremy Woodward
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David A Enoch
- Clinical Microbiology & Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Kovács R, Saleh Q, Bozó A, Tóth Z, Gesztelyi R, Kardos T, Kardos G, Takacs I, Majoros L. Killing Activity of Micafungin Against Candida albicans, C. dubliniensis and Candida africana in the Presence of Human Serum. Mycopathologia 2017; 182:979-987. [PMID: 28699056 DOI: 10.1007/s11046-017-0178-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/06/2017] [Indexed: 11/26/2022]
Abstract
We compared killing activity of micafungin in time-kill experiments in RPMI-1640 with and without 50% serum against Candida albicans, Candida dubliniensis and Candida africana reference strains and clinical isolates. Killing rates (k values) were determined for each strain and concentration. In RPMI-1640 MIC ranges were 0.015-0.03, 0.015-0.03 and 0.015 mg/L against C. albicans, C. dubliniensis and C. africana, respectively. In 50% serum MIC values for the three species increased 16- to 64-fold. In RPMI-1640 micafungin was fungicidal against two of three C. albicans isolates at 16 and 32 mg/L within 14.54 h and fungistatic against all C. africana and C. dubliniensis. Fifty per cent serum significantly decreased the growth rate of C. africana, but not of the other two species; weak in vivo replication ability of C. africana was confirmed in murine model. In 50% serum micafungin at 0.25 and 1 mg/L did not inhibit any of the three species (k values were always negative). Micafungin killing rate in 50% serum at 4, 16 and 32 mg/L was significantly decreased for C. albicans, but increased for C. dubliniensis compared to RPMI-1640. Killing activity of micafungin against C. africana was comparable or higher in 50% serum than in RPMI-1640. Although micafungin is a highly protein-bound drug, it was equally effective against the species of the C. albicans complex in 50% serum at therapeutic trough concentration (4 mg/L). Both in vitro and in vivo data confirmed the low virulence of C. africana compared to the two sibling species.
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Affiliation(s)
- Renátó Kovács
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Debrecen, Nagyerdei krt. 98., 4032, Hungary
- Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Qasem Saleh
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Debrecen, Nagyerdei krt. 98., 4032, Hungary
| | - Aliz Bozó
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Debrecen, Nagyerdei krt. 98., 4032, Hungary
| | - Zoltán Tóth
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Debrecen, Nagyerdei krt. 98., 4032, Hungary
| | - Rudolf Gesztelyi
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tamás Kardos
- Department of Pulmonology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gábor Kardos
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Debrecen, Nagyerdei krt. 98., 4032, Hungary
| | - István Takacs
- Faculty of Health, University of Miskolc, Miskolc, Hungary
| | - László Majoros
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Debrecen, Nagyerdei krt. 98., 4032, Hungary.
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Chang CC, Slavin MA, Chen SCA. New developments and directions in the clinical application of the echinocandins. Arch Toxicol 2017; 91:1613-1621. [DOI: 10.1007/s00204-016-1916-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/13/2016] [Indexed: 01/05/2023]
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Saleh Q, Kovács R, Kardos G, Gesztelyi R, Kardos T, Bozó A, Majoros L. Decreased Killing Activity of Micafungin Against Candida guilliermondii, Candida lusitaniae, and Candida kefyr in the Presence of Human Serum. Microb Drug Resist 2017; 23:764-770. [PMID: 28072553 DOI: 10.1089/mdr.2016.0241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Currently, echinocandins are first-line drugs for treatment of invasive candidiasis. However, data on how serum influences killing activity of echinocandins against uncommon Candida species are limited. Therefore, the killing activity of micafungin in RPMI-1640 and in 50% serum was compared against Candida guilliermondii, Candida lusitaniae, and Candida kefyr. Minimum inhibitory concentration (MIC) ranges in RPMI-1640 were 0.5-1, 0.12-0.25, and 0.06-0.12 mg/L, respectively. In 50% serum, MICs increased 32- to 256-fold. In RPMI-1640 ≥ 0.25, ≥4, and 32 mg/L micafungin was fungicidal against all four C. kefyr (≤4.04 hours), two of three C. lusitaniae (≤16.10 hours), and two of three C. guilliermondii (≤12.30 hours), respectively. In 50% serum, all three species grew at ≤4 mg/L. Micafungin at 16-32 mg/L was fungicidal against all C. kefyr isolates (≤3.03 hours) and at 32 mg/L was fungistatic against one of three C. lusitaniae isolates. Two C. lusitaniae isolates and all three C. guilliermondii grew at all tested concentrations. Adding human serum to susceptibility test media drew attention to loss of fungicidal or fungistatic activity of micafungin in the presence of serum proteins, which is not predicted by MICs in case of C. kefyr and C. lusitaniae in RPMI-1640. Our results strongly suggest that micafungin and probably other echinocandins should be used with caution against rare Candida species.
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Affiliation(s)
- Qasem Saleh
- 1 Department of Medical Microbiology, Faculty of Medicine, University of Debrecen , Debrecen, Hungary
| | - Renátó Kovács
- 1 Department of Medical Microbiology, Faculty of Medicine, University of Debrecen , Debrecen, Hungary
| | - Gábor Kardos
- 1 Department of Medical Microbiology, Faculty of Medicine, University of Debrecen , Debrecen, Hungary
| | - Rudolf Gesztelyi
- 2 Department of Pharmacology and Pharmacodynamics, University of Debrecen , Debrecen, Hungary
| | - Tamás Kardos
- 1 Department of Medical Microbiology, Faculty of Medicine, University of Debrecen , Debrecen, Hungary .,3 Department of Pulmonology, Faculty of Medicine, University of Debrecen , Debrecen, Hungary
| | - Aliz Bozó
- 1 Department of Medical Microbiology, Faculty of Medicine, University of Debrecen , Debrecen, Hungary
| | - László Majoros
- 1 Department of Medical Microbiology, Faculty of Medicine, University of Debrecen , Debrecen, Hungary
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Neofytos D, Huang YT, Cheng K, Cohen N, Perales MA, Barker J, Giralt S, Jakubowski A, Papanicolaou G. Safety and Efficacy of Intermittent Intravenous Administration of High-Dose Micafungin. Clin Infect Dis 2016; 61 Suppl 6:S652-61. [PMID: 26567284 DOI: 10.1093/cid/civ818] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The use of mold-active azoles for antifungal prophylaxis after allogeneic stem cell transplantation (SCT) is hindered by adverse events and drug-drug interactions. Higher doses of echinocandins administered intermittently may be an alternative in this setting. METHODS This was a single-center, observational 5-year study to characterize the safety and efficacy of intermittent administration of high-dose intravenous micafungin (≥5 doses of ≥300 mg micafungin 2-3 times weekly) in patients with acute leukemia and allogeneic SCT recipients. RESULTS A total of 104 patients (84 allogeneic SCT recipients and 20 patients with leukemia) received intermittent high-dose intravenous micafungin, 83 (79.8%) as prophylaxis. Large variability in the micafungin dosing regimen was observed; 78 (75%) patients received >75% of their course as 300 mg micafungin 3 times weekly. Liver function tests decreased from baseline to end of treatment (EOT; P < .001). Patients with normal baseline liver function (n = 55 [52%]) maintained similar enzyme levels throughout the study. For patients with abnormal baseline liver function (n = 49 [47%]), liver function tests significantly improved from baseline to EOT (P ≤ .005). Duration and/or micafungin dosing algorithms were not associated with liver toxicity at EOT. There were no significant changes in renal function, and infusion-related reactions or deaths were not observed. Five of 83 (6.0%) patients in the prophylaxis group developed a breakthrough fungal infection. CONCLUSIONS In this largest cohort of patients to date, intermittent administration of high-dose micafungin was well tolerated, without any associated liver or renal function abnormalities, and may be considered an alternative antifungal prophylactic strategy. Prospective studies are needed to further validate these findings.
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Affiliation(s)
| | | | | | | | - Miguel-Angel Perales
- Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center Department of Medicine, Weill Medical College of Cornell University, New York, New York
| | - Juliet Barker
- Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center Department of Medicine, Weill Medical College of Cornell University, New York, New York
| | - Sergio Giralt
- Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center Department of Medicine, Weill Medical College of Cornell University, New York, New York
| | - Ann Jakubowski
- Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center Department of Medicine, Weill Medical College of Cornell University, New York, New York
| | - Genovefa Papanicolaou
- Infectious Diseases Service Department of Medicine, Weill Medical College of Cornell University, New York, New York
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Jeong SH, Kim DY, Jang JH, Mun YC, Choi CW, Kim SH, Kim JS, Park JS. Efficacy and safety of micafungin versus intravenous itraconazole as empirical antifungal therapy for febrile neutropenic patients with hematological malignancies: a randomized, controlled, prospective, multicenter study. Ann Hematol 2015; 95:337-44. [PMID: 26596974 PMCID: PMC4710659 DOI: 10.1007/s00277-015-2545-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 11/01/2015] [Indexed: 12/04/2022]
Abstract
Micafungin, a clinically important echinocandin antifungal drug, needs to be investigated as empirical therapy in febrile neutropenia in comparison with azole compounds. A prospective randomized study was conducted to compare clinical outcomes between micafungin and intravenous itraconazole as an empirical therapy for febrile neutropenia in hematological malignancies. The antifungal drug (micafungin 100 mg or itraconazole 200 mg IV once daily) was given for high fever that was sustained despite the administration of appropriate antibiotics. Treatment success was determined by composite end points based on breakthrough invasive fungal infection (IFI), survival, premature discontinuation, defervescence, and treatment of baseline fungal infection. Duration of fever, hospital stay, and overall survival (OS) were studied. A total of 153 patients were randomized to receive micafungin or itraconazole. The overall success rate was 7.1 % point higher in the micafungin group (64.4 vs. 57.3 %, p = 0.404), satisfying the statistical criteria for the non-inferiority of micafungin. The duration of fever and hospital stay were significantly shorter in the micafungin group (6 vs. 7 days, p = 0.014; 22 vs. 27 days, p = 0.033, respectively). Grade 3 adverse events including hyperbilirubinemia (2 vs. 7), elevation of transaminase levels (2 vs. 4), electrolyte imbalance (1 vs. 2), atrial fibrillation (1 vs. 0), and anaphylaxis (1 vs. 0) occurred in 7 and 13 patients in the micafungin (10.4 %) and itraconazole (18.8 %) groups, respectively. Micafungin, when compared with itraconazole, had favorably comparable success rate and toxicity profiles on febrile neutropenia in patients with hematological malignancies. In addition, it showed superior effect on shortening the hospital stay.
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Affiliation(s)
- Seong Hyun Jeong
- Department of Hematology-Oncology, Ajou University Hospital, Ajou Univesity School of Medicine, Suwon, South Korea
| | - Dae Young Kim
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun Ho Jang
- Division of Hematology and Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeung-Chul Mun
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans Univerity School of Medicine, Seoul, South Korea
| | - Chul Won Choi
- Division of Oncology-Hematology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, South Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Joon Seong Park
- Department of Hematology-Oncology, Ajou University Hospital, Ajou Univesity School of Medicine, Suwon, South Korea.
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Álvarez-Lerma F, Grau S, López C, Jiménez JD, Trasmonte MV, Nieto M, Parra G, Herrero E. [Patients treated with micafungin during their stay in intensive care unit]. Med Intensiva 2015; 39:467-76. [PMID: 25798955 DOI: 10.1016/j.medin.2014.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the reasons of prescription, the characteristics of patients and factors that affected the outcome of critically ill patients treated with micafungin (MCF) during their stay in Spanish ICUs. MATERIAL AND METHODS Observational, retrospective and multicenter study. Patients admitted to the ICU between March 2011 and October 2012 (20-month period) treated with MCF for any reason were included in the study. Severity of patients at the beginning of treatment was measured with the APACHE II, SOFA, Child-Pugh and MELD scores. Reasons for the use of MCF were classified as prophylaxis, preemptive treatment, empirical treatment and directed treatment. Continuous variables are expressed as mean and standard deviation or median, and categorical variables as percentages. A multivariate analysis was performed to identify variables related to intra-ICU mortality. RESULTS The study population included 139 patients admitted to 19 Spanish ICUs, with a mean age of 57.3 (17.1) years, 89 (64%) men, with surgical (53.2%) and/or medical (44.6%) conditions, APACHE II score of 20.6 (7.7) and SOFA score of 8.4 (4.3), with 84.2% of patients requiring mechanical ventilation, 59% parenteral nutrition, 37.4% extrarenal depuration procedures and 37.4% treatment with steroids. MCF was indicated as empirical treatment of a proven infection in 51 (36.7%) cases, pre-emptive treatment in 50 (36%) especially as a result of the application of the Candida score (32 cases), directed treatment of fungal infection in 23 (16.5%) and as prophylactic treatment in 15 (10.8%) cases. In 108 (77%) cases, a daily dose of 100mg was administered, with a loading dose in only 9 cases (6.5%). The mean duration of treatment was 13.1 (13) days. A total of 59 (42.4%) patients died during their stay in the ICU and 16 after ICU discharge (hospital mortality 53.9%). Independent risk factors for intra-ICU mortality were the Child-Pugh score (OR 1.45, 95% CI 1.162-1.813; P=.001) and the MELD score (OR 1.05, 95% CI 1.011-1.099; P=.014). CONCLUSIONS MCF is usually administered at a dose of 100mg/day, without loading dose and in 72.7% of cases as pre-emptive or empirical treatment. Factors that better predicted mortality were indicators of liver insufficiency at the time of starting treatment.
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Affiliation(s)
- F Álvarez-Lerma
- Servicio de Medicina Intensiva, Hospital del Mar, Parc de Salut Mar, Barcelona, España.
| | - S Grau
- Servicio de Farmacia, Hospital del Mar, Parc de Salut Mar, Barcelona, España
| | - C López
- Servicio de Medicina Intensiva, Hospital Vall d'Hebrón, Barcelona, España
| | - J D Jiménez
- Servicio de Medicina Intensiva, Hospital Don Benito, Villanueva Badajoz, España
| | - M V Trasmonte
- Servicio de Medicina Intensiva, Hospital Infanta Cristina, Badajoz, España
| | - M Nieto
- Servicio de Medicina Intensiva, Hospital Clínico San Carlos, Madrid, España
| | - G Parra
- Servicio de Medicina Intensiva, Hospital La Vega, Murcia, España
| | - E Herrero
- Servicio de Medicina Intensiva, Hospital Torrevieja Salud, Torrevieja, Alicante, España
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Enoch D, Idris S, Aliyu S, Micallef C, Sule O, Karas J. Micafungin for the treatment of invasive aspergillosis. J Infect 2014; 68:507-26. [DOI: 10.1016/j.jinf.2014.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 01/06/2014] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
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Yamazaki S, Nakamura F, Yoshimi A, Ichikawa M, Nannya Y, Kurokawa M. Safety of high-dose micafungin for patients with hematological diseases. Leuk Lymphoma 2014; 55:2572-6. [PMID: 24460099 DOI: 10.3109/10428194.2014.885514] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study was conducted as a retrospective, observational, exploratory cohort study with the aim of elucidating the safety profile of micafungin at doses exceeding 150 mg daily. We identified adult patients with hematological diseases who had received micafungin therapy for ≥ 7 consecutive days. Twenty-six patients administered micafungin at 300 mg daily (high-dose group) were compared with 58 patients administered micafungin at 150 mg daily (standard-dose group). The most frequent adverse events (AEs) were hepatotoxicity, hypertension and diarrhea. AEs were recorded in 42 (72%) and 19 (73%) patients in the standard-dose and high-dose groups, respectively (p = 1.00). Hepatobiliary AEs were noted in 28 (48%) and 15 (58%) patients, respectively (p = 0.48). Serious AEs and resultant treatment discontinuation were infrequent. Our results suggest that micafungin was safe and well tolerated at 300 mg daily.
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Affiliation(s)
- Sho Yamazaki
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
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de la Torre P, Reboli AC. Micafungin: an evidence-based review of its place in therapy. CORE EVIDENCE 2014; 9:27-39. [PMID: 24596542 PMCID: PMC3940642 DOI: 10.2147/ce.s36304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Invasive fungal infections have increased throughout the world. Many of these infections occur in patients with multiple comorbidities who are receiving medications with the potential for interactions with antifungal therapy that could lead to renal and hepatic dysfunction. The second marketed echinocandin, micafungin, was approved in 2005 for the treatment of esophageal candidiasis and prophylaxis of invasive Candida infections in patients undergoing hematopoietic stem cell transplantation. The indication for use was later expanded to include candidemia, acute disseminated candidiasis, Candida abscesses, and peritonitis. Like other echinocandins it is fungicidal against Candida species, including those that are polyene- and azole-resistant and fungistatic against Aspergillus species. Its formulation is by the intravenous route only and it is dosed once daily without a loading dose as 85% of the steady state concentration is achieved after three daily doses. It has a favorable tolerability profile with no significant drug interactions and does not need adjustment for renal or hepatic insufficiency.
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Mizuno H, Sawa M, Yanada M, Shirahata M, Watanabe M, Kato T, Nagai H, Ozawa Y, Morishita T, Tsuzuki M, Goto E, Tsujimura A, Suzuki R, Atsuta Y, Emi N, Naoe T. Micafungin for empirical antifungal therapy in patients with febrile neutropenia: multicenter phase 2 study. Int J Hematol 2013; 98:231-6. [DOI: 10.1007/s12185-013-1396-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/05/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022]
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Assessment of efficacy of antifungals against Aspergillus fumigatus: value of real-time bioluminescence imaging. Antimicrob Agents Chemother 2013; 57:3046-59. [PMID: 23587947 DOI: 10.1128/aac.01660-12] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aspergillus fumigatus causes life-threatening infections, especially in immunocompromised patients. Common drugs for therapy of aspergillosis are polyenes, azoles, and echinocandins. However, despite in vitro efficacy of these antifungals, treatment failure is frequently observed. In this study, we established bioluminescence imaging to monitor drug efficacy under in vitro and in vivo conditions. In vitro assays confirmed the effectiveness of liposomal amphotericin B, voriconazole, and anidulafungin. Liposomal amphotericin B and voriconazole were fungicidal, whereas anidulafungin allowed initial germination of conidia that stopped elongation but allowed the conidia to remain viable. In vivo studies were performed with a leukopenic murine model. Mice were challenged by intranasal instillation with a bioluminescent reporter strain (5 × 10(5) and 2.5 × 10(5) conidia), and therapy efficacies of liposomal amphotericin B, voriconazole, and anidulafungin were monitored. For monotherapy, the highest treatment efficacy was observed with liposomal amphotericin B, whereas the efficacies of voriconazole and anidulafungin were strongly dependent on the infectious dose. When therapy efficacy was studied with different drug combinations, all combinations improved the rate of treatment success compared to that with monotherapy. One hundred percent survival was obtained for treatment with a combination of liposomal amphotericin B and anidulafungin, which prevented not only pulmonary infections but also infections of the sinus. In conclusion, combination therapy increases treatment success, at least in the murine infection model. In addition, our novel approach based on real-time imaging enables in vivo monitoring of drug efficacy in different organs during therapy of invasive aspergillosis.
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Racil Z, Toskova M, Kocmanova I, Buresova L, Kouba M, Drgona L, Masarova L, Guman T, Tothova E, Gabzdilova J, Forsterova K, Haber J, Ziakova B, Bojtarova E, Rolencova M, Timilsina S, Cetkovsky P, Mayer J. Micafungin as empirical antifungal therapy in hematological patients: a retrospective, multicenter study in the Czech and Slovak Republics. Leuk Lymphoma 2012; 54:1042-7. [DOI: 10.3109/10428194.2012.729057] [Citation(s) in RCA: 5] [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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Földi R, Szilágyi J, Kardos G, Berényi R, Kovács R, Majoros L. Effect of 50% human serum on the killing activity of micafungin against eight Candida species using time-kill methodology. Diagn Microbiol Infect Dis 2012; 73:338-42. [PMID: 22726529 DOI: 10.1016/j.diagmicrobio.2012.05.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Revised: 05/08/2012] [Accepted: 05/09/2012] [Indexed: 10/28/2022]
Abstract
Micafungin activity was determined against 24 wild-type clinical isolates and 5 American Type Culture Collection strains belonging to 8 Candida species in RPMI-1640 with and without 50% serum using broth microdilution and time-kill methodology. MIC values increased from 4- to 128-folds in 50% serum for all Candida species. Micafungin was not fungicidal against C. albicans, C. tropicalis, and against 2 of 3 C. metapsilosis at ≥0.25, 1, and 1 μg/mL, respectively, after 48 h with 50% serum, showing good fungistatic activity. Fungicidal activity at ≥2, 4, and 32 μg/mL was noticed against C. glabrata, C. inconspicua, and C. krusei isolates, respectively. Micafungin at 8-32 μg/mL showed fungistatic activity against C. parapsilosis and C. orthopsilosis. Serum decreased the in vitro activity of micafungin. With serum binding of echinocandins taken into account, safely fungistatic or fungicidal concentrations seem to require elevated doses against some Candida species, including C. parapsilosis, C. orthopsilosis, and C. krusei.
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Affiliation(s)
- Richárd Földi
- Department of Medical Microbiology, Medical and Health Science Center, University of Debrecen, 4032 Debrecen, Hungary
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23
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Abstract
It has been nearly a decade since caspofungin was approved for clinical use as the first echinocandin class antifungal agent, followed by micafungin and anidulafungin. The echinocandin drugs target the fungal cell wall by inhibiting the synthesis of β-1,3-D-glucan, a critical cell wall component of many pathogenic fungi. They are fungicidal for Candida spp. and fungistatic for moulds, such as Aspergillus fumigatus, where they induce abnormal morphology and growth properties. The echinocandins have a limited antifungal spectrum but are highly active against most Candida spp., including azole-resistant strains and biofilms. As they target glucan synthase, an enzyme absent in mammalian cells, the echinocandins have a favorable safety profile. They show potent MIC and epidemiological cutoff values against susceptible Candida and Aspergillus isolates, and the frequency of resistance is low. When clinical breakthrough occurs, it is associated with high MIC values and mutations in Fks subunits of glucan synthase, which can reduce the sensitivity of the enzyme to the drug by several thousand-fold. Such strains were not adequately captured by an early clinical breakpoint for susceptibility prompting a revised lower value, which addresses the FKS resistance mechanism and new pharmacokinetic/pharmacodynamic studies. Elevated MIC values unlinked to therapeutic failure can occur and result from adaptive cell behavior, which is FKS-independent and involves the molecular chaperone Hsp90 and the calcineurin pathway. Mutations in FKS1 and/or FKS2 alter the kinetic properties of glucan synthase, which reduces the relative fitness of mutant strains causing them to be less pathogenic. The echinocandin drugs also modify the cell wall architecture exposing buried glucans, which in turn induce a variety of important host immune responses. Finally, the future for glucan synthase inhibitors looks bright with the development of new orally active compounds.
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Affiliation(s)
- David S Perlin
- Public Health Research Institute, New Jersey Medical School-UMDNJ, Newark, NJ 07103, USA.
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Yoshida M, Tamura K, Imamura M, Niitsu Y, Sasaki T, Urabe A, Ohyashiki K, Naoe T, Kanamaru A, Tanimoto M, Masaoka T. Efficacy and safety of micafungin as an empirical antifungal therapy for suspected fungal infection in neutropenic patients with hematological disorders. Ann Hematol 2011; 91:449-57. [DOI: 10.1007/s00277-011-1316-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 08/22/2011] [Indexed: 01/23/2023]
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Fractal geometry and the pharmacometrics of micafungin in overweight, obese, and extremely obese people. Antimicrob Agents Chemother 2011; 55:5107-12. [PMID: 21876061 DOI: 10.1128/aac.05193-11] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The majority of Americans are overweight, and the incidence of obesity continues to increase. This trend predisposes people to a number of deleterious consequences, including the metabolic syndrome and other conditions that lead to a greater number of hospital admissions. Invasive candidiasis is an important nosocomial infection that results from these admissions. Echinocandins such as micafungin are indicated for treatment. We have previously demonstrated that overweight patients exhibit higher micafungin systemic clearance (SCL) than leaner patients. We hypothesized that obese and extremely obese people would show even higher SCL than merely overweight patients. To test this, we performed a prospective study of 36 adult volunteers randomized to receive a single dose of either 100 mg or 300 mg of micafungin whose body mass index fell within one of the following categories: <25, 25 to 40, and >40 kg/m(2). The male-to-female ratio was 1:1. The minimum weight was 43 kg, the median 97 kg, and the maximum weight 155 kg. A two-compartment model was examined using the maximum likelihood solution via the expectation-maximization algorithm. Men had a higher median SCL of 1.53 liters/h versus 1.29 liters/h (P = 0.01) in the Mann-Whitney U-test. The typical SCL was 1.04 liters/h but increased by a factor of (weight/66)(0.75) as weight increased above 66 kg. Thus, the relationship between micafungin SCL and weight in adults is best described by fractal-geometry-based laws. Furthermore, micafungin SCL continues to increase as weight increases, with no obvious plateau. This leads to a requirement for strategies to determine individualized dosing levels for obese and extremely obese patients.
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