The Role of Novel Antifungals in the Management of Candidiasis: A Clinical Perspective

Maintenance pharmacological therapy of recurrent vulvovaginal candidiasis. A Bayesian network meta-analysis of randomized studies

OBJECTIVE

Several topical and oral drugs are available for maintenance therapy of recurrent vulvovaginal candidiasis (RVVC)(≥ 3 episodes of symptomatic Candida infection per year). The study aimed to assess the risk of early (24 weeks) and late (48-52 weeks) clinical and mycological recurrences associated with oral/topical pharmacological maintenance therapy of RVVC.

METHODS

Search strategy: PubMed, EMBASE, Cochrane Library, OVID and clinical trials registers,from inception until January 2024.

SELECTION CRITERIA

Blinded and unblinded randomized studies of pharmacological prevention of RVVC recurrences during active treatment and after discontinuation of therapy.

DATA COLLECTION AND ANALYSIS

Risk of bias, indirectness, imprecision, heterogeneity and incoherence of the network were evaluated by a semi-automated software.Bayesian network meta-analysis was used to evaluate effects of interventions on outcomes,league table and ranking of effects.

RESULTS

The network included 17 studies with 2304 women for early and 2179 for late recurrences. During active treatment weekly oral oteseconazole (OR = 0.05,95 %CI = 0.02-0.12, moderate confidence),weekly oral fluconazole/itraconazole (OR = 0.12,95 %CI = 0.052-0.35,moderate confidence) and weekly topical clotrimazole (OR = 0.087,95 %CI = 0.018-0.48,moderate confidence) were associated with a significant reduction in RVVC recurrence risk compared to placebo/untreated subjects.Weekly use of fluconazole/itraconazole (OR = 0.44,95 %CI = 0.24-0.80,moderate confidence) and monthly topical treatment (OR = 0.34,95 %CI = 0.18-0.66,moderate confidence) maintained efficacy after discontinuation of therapy (48-52 weeks). Weekly oteseconazole was significantly more effective in reducing the occurrence of late clinical (OR = 0.065,95 %CI = 0.036-0.11,moderate confidence) and mycological (OR = 0.073,95 %CI = 0.044-0.12,moderate confidence) RVVC recurrences than all other types of treatment tested.

CONCLUSIONS

Weekly maintenance therapy with oral fluconazole/itraconazole,oteseconazole, or topical clotrimazole was equally effective in preventing early RVVC recurrence.After therapy discontinuation, oteseconazole outperformed all other oral or topical regimens, lowering RVVC clinical and mycological recurrence rates by more than 90%.

Ecotoxicity and Mutagenicity Assessment of Novel Antifungal Agents VT-1161 and T-2307

Antifungal substances are essential for managing fungal infections in humans, animals, and plants, and their usage has significantly increased due to the global rise in fungal infections. However, the extensive application of antifungal agents in pharmaceuticals, personal care products, and agriculture has led to their widespread environmental dissemination through various pathways, such as excretion, improper disposal, and agricultural runoff. Despite advances in wastewater treatment, many antifungal compounds persist in the environment, affecting non-target organisms and contributing to resistance development. This study investigates the environmental impact of two novel antifungal agents, VT-1161 and T-2307, recently introduced as alternatives for treating resistant Candida spp. We assessed their ecotoxicity and mutagenicity using multiple bioassays: immobilization of Daphnia magna, growth inhibition of Raphidocelis subcapitata, luminescence inhibition of Aliivibrio fischeri, and mutagenicity on Salmonella typhimurium strain TA100. Results indicate that both VT-1161 and T-2307 exhibit lower toxicity compared to existing antifungal compounds, with effective concentrations (EC50) causing 50% response ranging from 14.34 to 27.92 mg L-1. Furthermore, both agents were classified as less hazardous based on the Globally Harmonized System of Classification and Labeling of Chemicals. Despite these favorable results, further research is needed to understand their environmental behavior, interactions, and potential resistance development among non-target species. Our findings highlight the importance of comprehensive environmental risk assessments to ensure the sustainable use of new antifungal agents.

Photocatalyzed Imino-Difluoromethylation of Alkenes with Bifunctional Oxime Esters

Herein, we report a simple and versatile difluoromethylene-imide reaction in which a series of olefins can undergo a difluoromethylenimine reaction under photocatalytic conditions through an energy transfer (EnT) process. The reaction has mild conditions and a wide range of applicability. We successfully synthesized 27 molecules containing difluoromethylene units, featuring easily accessible starting materials and operational simplicity.

Comparative efficacy of antifungal drugs for the treatment of oral candidiasis in HIV-positive patients: A Bayesian network meta-analysis

Oral candidiasis infection is particularly prevalent among individuals in HIV-positive patients. Antifungal drugs have shown promising therapeutic effects in treating oral candidiasis in HIV-positive patients. However, the selection of specific antifungal drugs for the treatment of oral candidiasis in HIV-positive patients lacks evidence-based guidelines. This study aims to address this gap by conducting a comprehensive review of relevant randomized controlled trials (RCTs) and performing a network meta-analysis to assess the efficacy of different antifungal drugs in treating oral candidiasis in HIV-positive patients. A systematic search was conducted in databases including EMBASE, Web of Science, Medline, and Cochrane databases to identify relevant articles. Additionally, key pertinent sources in the literatures were also reviewed. All studies published prior to August 2023 were eligible for inclusion. Two researchers independently conducted the screening of literature, extraction of data, and evaluation of quality. Pairwise and network meta-analysis were then performed to assess the primary outcomes of the randomized controlled trials (RCTs) included. The protocol was registered on the PROSPERO database (CRD42024513912). Twenty-six RCTs were included in this meta-analysis, involving a total of 3145 patients and evaluating seven interventions (placebo, fluconazole, itraconazole, nystatin, clotrimazole, ketoconazole, miconazole). Pairwise meta-analysis and network meta-analysis showed fluconazole was significantly efficacy in increasing mycological cure rates when compared with placebo, clotrimazole, and nystatin. Ketoconazole and miconazole were significantly efficacy in increasing mycological cure rates when compared with nystatin. Network meta-analysis also suggested the efficacy of the seven interventions in increasing mycological cure rates was ranked as follows: placebo (35.3%), fluconazole (95.2%), itraconazole (61.6%), nystatin (17.0%), clotrimazole (52.7%), ketoconazole (69.2%), miconazole (69.1%). The available evidence indicates that fluconazole had the greatest possibility to increase mycological cure rates in HIV-positive patients, while, nystatin was the least effective antifungal drug in increasing mycological cure rates in HIV-positive patients.

Safety of rezafungin as a long-term treatment option in two patients with complicated fungal infections: two cases from Lecco Hospital (Italy)

Rezafungin is an echinocandin characterized by a long elimination half-life which allows for weekly administration. It has been recently approved for the treatment of candidemia. Few data are available about the long-term use of rezafungin and its use for deep infections like endocarditis and osteomyelitis. We describe our experience with its prolonged use in two azole-resistant Candida infections: a case of sacral osteomyelitis and a prosthetic valve endocarditis also involving a thoracic endovascular aneurysm repair.

Therapies in preclinical and in early clinical development for the treatment of urinary tract infections: from pathogens to therapies

INTRODUCTION

Urinary tract infections (UTIs) are a prevalent health challenge characterized by the invasion and multiplication of microorganisms in the urinary system. The continuous exploration of novel therapeutic interventions is imperative. Advances in research offer hope for revolutionizing the management of UTIs and improving the overall health outcomes for individuals affected by these infections.

AREAS COVERED

This review aimed to provide an overview of existing treatments for UTIs, highlighting their strengths and limitations. Moreover, we explored and analyzed the latest therapeutic modalities under clinical development. Finally, the review offered a picture into the potential implications of these therapies on the future landscape of UTIs treatment, discussing possible advancements and challenges for further research.

EXPERT OPINION

Comprehensions into the pathogenesis of UTIs have been gleaned from foundational basic science studies, laying the groundwork for the exploration of novel therapeutic interventions. The primary source of evidence originates predominantly from animal studies conducted on murine models. Nevertheless, the lack of clinical trials interferes the acquisition of robust evidence in humans. The challenges presented by the heterogeneity and virulence of uropathogens add an additional layer of complexity, posing an obstacle that scientists and clinicians are actively grappling with in their pursuit of effective solutions.

Management of invasive candidiasis: A focus on rezafungin, ibrexafungerp, and fosmanogepix

Management of invasive fungal infections is challenging with growing antifungal resistance. Broad antifungal use has resulted in greater intrinsic and acquired resistance among Candida spp. It is important for clinicians to recognize the relationship between host susceptibility, site of infection, Candida resistance profiles, specific drug pharmacokinetics and pharmacodynamics, and the role of novel antifungal agents. This narrative review covers the role of rezafungin, ibrexafungerp, and fosmanogepix in the management of invasive candidiasis (IC). The PubMed Database, Embase, and ClinicalTrials.gov were searched between January 2006 and January 2024 using the following terms: rezafungin, CD101, ibrexafungerp, SCY-078, fosmanogepix, APX001, candidemia, and invasive candidiasis. Review articles, prospective clinical trials, and observational studies published in the English language were reviewed. Studies evaluating pharmacology, pharmacokinetics, efficacy, and safety in animals and humans were also reviewed. Promising data continues to emerge in support of novel drug therapies for IC and candidemia. Rezafungin possesses a unique pharmacodynamic profile that might be advantageous compared to other echinocandins, with a practical, once-weekly dosing interval. Ibrexafungerp, currently approved for vulvovaginal candidiasis, has been studied off-label for use in IC and candidemia, and initial data is encouraging. Lastly, fosmanogepix, a mechanistically novel, investigational antifungal agent, may be a potential future option in the management of IC and candidemia. Future research is needed to evaluate the potential use of these agents among diverse patient populations.

Candida albicans skin infection in diabetic patients: An updated review of pathogenesis and management

Candida species, commensal residents of human skin, are recognized as the cause of cutaneous candidiasis across various body surfaces. Individuals with weakened immune systems, particularly those with immunosuppressive conditions, are significantly more susceptible to this infection. Diabetes mellitus, a major metabolic disorder, has emerged as a critical factor inducing immunosuppression, thereby facilitating Candida colonization and subsequent skin infections. This comprehensive review examines the prevalence of different types of Candida albicans-induced cutaneous candidiasis in diabetic patients. It explores the underlying mechanisms of pathogenicity and offers insights into recommended preventive measures and treatment strategies. Diabetes notably increases vulnerability to oral and oesophageal candidiasis. Additionally, it can precipitate vulvovaginal candidiasis in females, Candida balanitis in males, and diaper candidiasis in young children with diabetes. Diabetic individuals may also experience candidal infections on their nails, hands and feet. Notably, diabetes appears to be a risk factor for intertrigo syndrome in obese individuals and periodontal disorders in denture wearers. In conclusion, the intricate relationship between diabetes and cutaneous candidiasis necessitates a comprehensive understanding to strategize effective management planning. Further investigation and interdisciplinary collaborative efforts are crucial to address this multifaceted challenge and uncover novel approaches for the treatment, management and prevention of both health conditions, including the development of safer and more effective antifungal agents.

New treatment options for critically important WHO fungal priority pathogens

BACKGROUND

Yet often overlooked in public health discourse, fungal infections pose a crucial global disease burden associated with annual mortality rates approximately equal to tuberculosis and HIV. In response, the WHO published its first global priority list of fungal pathogens in 2022 assigning Aspergillus fumigatus, Candida albicans, Candida auris, and Cryptococcus neoformans to the critical group.

OBJECTIVES

This review provides succinct insights into novel antifungals in development, aiming to contribute valuable information and perspectives with a focus on recent clinical findings and new treatment approaches for critical members of the WHO fungal pathogen priority list.

SOURCES

PubMed literature search using 'Aspergillus fumigatus', 'Cryptococcus neoformans', 'Candida auris', and 'Candida albicans', along with the names of novel antifungal substances, including 'fosmanogepix', 'ibrexafungerp', 'opelconazole', 'oteseconazole', 'MAT2203', 'olorofim', and 'rezafungin' was conducted.

CONTENT

For each critical pathogen, current issues and global clinical data from recent trials are covered. The remarkable development of three new antifungal therapeutics recently receiving Food and Drug Administration approval (ibrexafungerp-June 2021, oteseconazole -April 2022, and rezafungin-March 2023) is outlined, with two more exciting new antifungal substances, namely, olorofim and fosmanogepix expecting approval within the next years. Ibrexafungerp, fosmanogepix, and rezafungin have additionally been granted orphan drug status by the European Medicines Agency in Europe (ibrexafungerp-November 2021, fosmanogepix-July 2022, and rezafungin-January 2024).

IMPLICATIONS

Although the limited number of targets and the emergence of resistance have posed challenges to antifungal treatment, new drugs such as ibrexafungerp, rezafungin, fosmanogepix, or olorofim have shown promising clinical efficacy. These drugs not only provide alternative options for invasive fungal infections but also alleviate treatment in outpatient settings. More clinical data, implementation of stewardship programmes, and surveillance, including utilization of drugs in agriculture, are necessary to prevent resistance development and to ensure the safety and efficacy of these new agents.

An evaluation of Rezafungin: the latest treatment option for adults with candidemia and invasive candidiasis

INTRODUCTION

Invasive fungal infections, especially candidemia and invasive candidiasis, continue to cause substantial morbidity and mortality. In addition, the emergence of drug-resistant Candida species, notably C. glabrata and C. auris, along with limitations in available treatments, highlights the urgent need for novel, effective antifungal agents.

AREAS COVERED

This review discusses the results of in vitro studies evaluating the spectrum and highlights the pharmacokinetic/pharmacodynamic properties. It also includes discussions on two key clinical studies that assess safety, tolerability, and efficacy.

EXPERT OPINION

Rezafungin has demonstrated comparable efficacy to other echinocandins in two clinical studies and exhibits in vitro activity against a broad range of Candida species and Aspergillus spp. It has a favorable safety profile with minimal side effects, and no drug interactions or effects on QT intervals. In contrast to other echinocandins, it demonstrates dose-dependent killing, a prolonged half-life, and low clearance make it suitable for once-weekly dosing, which is supported by clinical trials confirming its efficacy. Rezafungin offers a promising option for the outpatient management of difficult to treat fungal infections. It has become a valuable addition to the antifungal arsenal, with the potential to reduce hospital length of stay and hospitalization costs and combat drug-resistant Candida species.

Spectrum and management of rare Candida/yeast infections in Kuwait in the Middle East

Invasive fungal infections (IFIs) are associated with high mortality rates and mostly affect patients with compromised immunity. The incidence of IFIs is increasing worldwide with the expanding population of susceptible patients. Candida and other yeast infections represent a major component of IFIs. Rare Candida/yeast infections have also increased in recent years and pose considerable diagnostic and management challenges as they are not easily recognized by routine phenotypic characteristic-based diagnostic methods and/or by the automated yeast identification systems. Rare Candida/yeasts also exhibit reduced susceptibility to antifungal drugs making proper management of invasive infections challenging. Here, we review the diagnosis and management of 60 cases of rare Candida/yeast IFIs described so far in Kuwait, an Arabian Gulf country in the Middle East. Interestingly, majority (34 of 60, 56.7%) of these rare Candida/yeast invasive infections occurred among neonates or premature, very-low-birth-weight neonates, usually following prior bacteremia episodes. The clinical details, treatment given, and outcome were available for 28 of 34 neonates. The crude mortality rate among these neonates was 32.2% as 19 of 28 (67.8%) survived the infection and were discharged in healthy condition, likely due to accurate diagnosis and frequent use of combination therapy. Physicians treating patients with extended stay under intensive care, on mechanical ventilation, receiving broad spectrum antibiotics and with gastrointestinal surgery/complications should proactively investigate IFIs. Timely diagnosis and early antifungal treatment are essential to decrease mortality. Understanding the epidemiology and spectrum of rare Candida/yeast invasive infections in different geographical regions, their susceptibility profiles and management will help to devise novel diagnostic and treatment approaches and formulate guidelines for improved patient outcome.

Pharmacokinetic and pharmacodynamic considerations for antifungal therapy optimisation in the treatment of intra-abdominal candidiasis

Intra-abdominal candidiasis (IAC) is one of the most common of invasive candidiasis observed in critically ill patients. It is associated with high mortality, with up to 50% of deaths attributable to delays in source control and/or the introduction of antifungal therapy. Currently, there is no comprehensive guidance on optimising antifungal dosing in the treatment of IAC among the critically ill. However, this form of abdominal sepsis presents specific pharmacokinetic (PK) alterations and pharmacodynamic (PD) challenges that risk suboptimal antifungal exposure at the site of infection in critically ill patients. This review aims to describe the peculiarities of IAC from both PK and PD perspectives, advocating an individualized approach to antifungal dosing. Additionally, all current PK/PD studies relating to IAC are reviewed in terms of strength and limitations, so that core elements for the basis of future research can be provided.