Fluconazole in Candida albicans sepsis during pregnancy: case report and review of the literature

Vulvovaginal yeast infections, gestational diabetes and pregnancy outcome

BACKGROUND

The primary aim was to evaluate the association between gestational diabetes and blood glucose levels and vulvovaginal yeast infections in pregnancy. Secondly, we clarified the possible associations between maternal and prenatal factors, and birth outcomes and yeast infections.

METHODS

Three thousand nine hundred sixty-five pregnant women of the Kuopio Birth Cohort Study (KuBiCo) reported vulvovaginal yeast infections during pregnancy, via electronic questionnaires. Maternal and prenatal data, as well as clinical obstetric and early neonatal outcomes were registered during and after birth. The oral glucose tolerance test was performed on 3,079 women during pregnancy. Logistic regression analysis evaluated the possible multivariable associations between yeast infections, gestational diabetes and other prenatal and maternal factors.

RESULTS

No association was detected between gestational diabetes or blood glucose levels and vulvovaginal yeast infections during pregnancy. In multivariable analysis, women with yeast infections were more often multiparous, with higher education and had used more often antibiotics during pregnancy compared to others. No significant associations were detected in multivariable analysis between infections, the mode of delivery, preterm birth, birth weight or Apgar scores.

CONCLUSIONS

Women with reported vulvovaginal yeast infections managed generally well during pregnancy. They had no more gestational diabetes or higher blood glucose levels and their newborns managed equally well during early neonatal period.

Cryptococcosis in pregnancy and the postpartum period: Case series and systematic review with recommendations for management

Cryptococcal meningitis causes 15% of AIDS-related deaths. Optimal management and clinical outcomes of pregnant women with cryptococcosis are limited to case reports, as pregnant women are often excluded from research. Amongst pregnant women with asymptomatic cryptococcosis, no treatment guidelines exist. We prospectively identified HIV-infected women who were pregnant or recently pregnant with cryptococcosis, screened during a series of meningitis research studies in Uganda from 2012 to 2018. Among 571 women screened for cryptococcosis, 13 were pregnant, one was breastfeeding, three were within 14 days postpartum, and two had recently miscarried. Of these 19 women (3.3%), 12 had cryptococcal meningitis, six had cryptococcal antigenemia, and one had a history of cryptococcal meningitis and was receiving secondary prophylaxis. All women with meningitis received amphotericin B deoxycholate (0.7-1.0 mg/kg). Five were exposed to 200-800 mg fluconazole during pregnancy. Of these five, three delivered healthy babies with no gross physical abnormalities at birth, one succumbed to meningitis, and one outcome was unknown. Maternal meningitis survival rate at hospital discharge was 75% (9/12), and neonatal/fetal survival rate was 44% (4/9) for those mothers who survived. Miscarriages and stillbirths were common (n = 4). Of six women with cryptococcal antigenemia, two received fluconazole, one received weekly amphotericin B, and three had unknown treatment courses. All women with antigenemia survived, and none developed clinical meningitis. We report good maternal outcomes but poor fetal outcomes for cryptococcal meningitis using amphotericin B, without fluconazole in the first trimester, and weekly amphotericin B in place of fluconazole for cryptococcal antigenemia.

Lethal candida sepsis associated with myeloperoxidase deficiency and pre-eclampsia

We report on a 27-year-old primipara suffering from pre-eclampsia who died within 2 days postpartum. Toxemia with disseminated intravascular coagulation (DIC) and acute renal failure had masked the symptoms of invasive candida esophagitis and disseminated candidiasis in both lungs. Candida sepsis was discovered as the cause of death at postmortem examination. Myeloperoxidase (MPO) deficiency was identified as having supported the invasive candida infection. We conclude that a combination of MPO-deficiency and gestational toxemia may indicate increased susceptibility to severe candida infections.

Postulated pathogenic pathway in triazole fungicide induced dysmorphogenic effects

Triazole fungicides are used in medicine as well as in agricultural treatment of mycoses. The pharmacological mechanism is related to the inhibition of CYP enzymes involved in the formation of the fungal walls. A similar inhibition of human CYP enzymes has been suggested as the cause of triazole side effects in humans. An important role of some CYP isoforms (CYP26 isoforms) expressed during mammalian development is the catabolism of retinoic acid, a known morphogen in vertebrates and invertebrates. The adverse effects on morphogenesis, observed after exposure of mammalian, amphibian and ascidiacea, are compared to the reported effects of triazole in humans. The possible pathogenic pathway in triazole-related teratogenesis is discussed on the basis of different experimental approaches.

The Use of Dermatologic Drugs in Pregnancy and Lactation

Physicians are generally reluctant to prescribe dermatologic drugs to pregnant or nursing women because treatment is often elective and can be harmful to the patient, her fetus, or nursing infant; concerns for potential litigation also give pause. Yet, some effective dermatologic drugs have been determined to be safe during pregnancy and lactation. Of great practicality is an easily accessed reference guide that condenses information on such drugs into a set of tables that list pregnancy and teratogenicity ratings. Indications and contraindications are ordered in relation to the phases and trimesters of pregnancy. A discussion of the necessity of considering stages of childbearing in choosing drug therapies introduces the tables. A summary list of cautions spells out the steps physicians should take in treating women of childbearing age.

Study on the common teratogenic pathway elicited by the fungicides triazole-derivatives

Triazole-derivatives alter the pharyngeal apparatus morphogenesis of rodent embryos cultured in vitro. The hindbrain segmentation and the rhombencephalic neural crest cell (NCCs) migration are altered by Fluconazole exposure in vitro. The aim of the present work is to identify if a common pathogenic pathway is detectable also for other molecules of this class of compounds. 9.5 days post coitum (d.p.c.) old rat embryos were exposed in vitro to the teratogenic concentrations of Flusilazole, Triadimefon and Triadimenol and cultured for 24, 48 or 60 h. The expression and localisation of Hox-b1 and Krox-20 proteins (used as markers for hindbrain segmentation) were evaluated after 24 h of culture. The localisation and distribution of NCC was evaluated after 24, 30 and 48 h of culture. The morphology of the embryos was analysed after 48 h, while the branchial nerve structures were evaluated after 60 h of culture. Hindbrain segmentation and NCC migration alteration as well as pharyngeal arch and cranial nerve abnormalities were detected after exposure of the tested molecules. A common severe teratogenic intrinsic property for the tested molecules of this chemical class has been found, acting through alteration of the normal hindbrain developmental pattern.

Craniofacial and axial skeletal defects induced by the fungicide triadimefon in the mouse

BACKGROUND

Triadimefon is an antifungal derived from triazole. In in vitro whole-rodent embryo cultures, triazole-derivatives showed specific teratogenic effects at the branchial apparatus. The aim of the present work was to test in vivo triadimefon (FON), in order to verify a relationship between triazole exposure, embryonic abnormalities, and/or fetal malformations.

METHODS

Pregnant CD-1 mice were treated with 0-300 mg/kg FON by gavage on day 8 post coitum (p.c.) at 10:00 AM, and sacrificed on day 8 p.c. at 1:00 PM, on day 9 p.c. at 10:00 AM, on day 10 p.c. at 10:00 AM, and at term of gestation (day 18 p.c.). At midgestation, the embryos were processed for specific immunostainings to visualize the hindbrain segmentation (day 8 p.c.) and the neural crest cell migration (days 8 and 9 p.c.). Fetuses explanted at term were all processed for skeletal examination after double-staining of osseous and cartilaginous tissues.

RESULTS

At midgestation, the immunostaining of rhombomeres 3 and 5 showed a light scattering of the immunostained areas; the neural crest cell migration was unaffected, but their localization at the branchial arch level was abnormal. At term, several severe malformations were observed at the craniofacial and at the axial skeletal level. Ectopic cartilage was observed at the upper jaw.

CONCLUSIONS

Triadimefon is teratogenic. The observed craniofacial malformations could be explained by an alteration of the rhombomeric organization and neural crest migration to the branchial arches; the axial abnormalities could be explained by the abnormal segmental identity specification.

Antifungal triazoles induce malformations in vitro

Triazole-derivatives are antimycotics used in agriculture as well as in clinical and veterinary therapy. The aim of the present work is the in vitro comparative study of the teratogenic activity of triazole (the parental compound), flusilazole (an agricultural triazole mono-derivative fungicide), and fluconazole (a clinically used bis-triazole derivative). Rat embryos, 9.5 days old (1 to 3 somites) were exposed in vitro to triazole 500 to 5000 microM, flusilazole 3.125 to 250 microM, or fluconazole 62.5 to 500 microM. After 48 h in culture, the embryos were morphologically examined and processed for histologic and biochemical analysis. Flusilazole and fluconazole showed similar teratogenic effects (abnormalities at the branchial apparatus level and cell death at the level of the branchial mesenchyme) at concentration levels of 6.25 microM and higher for flusilazole and of 125 microM and higher for fluconazole. By contrast, only slight developmental retardation and blood discoloration were observed at the highest concentrations of triazole, suggesting no teratogenic activity for the triazole group.

Use of antifungal drugs in pregnancy: a focus on safety

The use of antifungals in pregnancy requires special consideration for the safety of the developing fetus. Clinicians now have an increased repertoire of both topical and systemic antimycotics available to treat superficial or mucotaneous fungal infections including Candida vaginitis. The ability of many nontopical antifungals to penetrate the placenta and achieve measurable, often therapeutic, concentrations in cord blood, fetal tissue and amniotic fluid means that evidence exists of successful treatment of all varieties of systemic fungal disease in pregnant women, even with placental involvement. However, for the same reasons, safety considerations remain a concern. Although the use of azoles as topical agents for superficial infections is both efficacious and well tolerated, especially when used for short periods, systemic azole therapy is not recommended in pregnancy. Accordingly, amphotericin B remains the drug of choice for systemic, invasive mycotic infections, whether life-threatening or less severe. Unfortunately little if any information is available regarding the safety of the newer lipid formulations of amphotericin B. There is a general reluctance to perform randomised, comparative studies involving antifungal agents in pregnancy, hence cumulative anecdotal reports form much of the available data; animal studies, although useful, have several drawbacks. There is a need for additional safe and effective new antifungal agents for widespread use in pregnant women.

[Status of fluconazole in the therapy of endogenous Candida endophthalmitis]

During the clinical course of invasive candidosis, endogenous Candida endophthalmitis (ECE) is associated with a higher mortality. In patients with candidemia, an ECE-incidence of 28 to 37% was reported. In i.v.-drug users, the incidence of Candida infections was 21%. Besides surgical procedures including vitrectomy and enucleation, early initiation of systemic antifungal therapy is decisive for the outcome. The clinical use of fluconazole in ECE is documented in 96 patients and in a minimum of 108 eyes. The mean duration of therapy was 6-8 weeks (maximum duration: lifelong) with an average dosage of 200-400 mg/d (maximum dosage: 800 mg/d and 14 mg/kg BW, resp.). The results reported in the literature show a good clinical efficacy of fluconazole in ECE: 90% response rate (19/21) in patients with/without concomitant vitrectomy and with/without concomitant use of other antifungals, complete disappearance of all eye lesions in 94% (15/16) non-neutropenic patients with candidemia and in 86% (6/7) ECE-patients addicted to heroin. With respect to these favorable results, fluconazole plays an important role in the standard therapy of ECE.