Miconazole in coccidiodomycosis. II. Therapeutic and pharmacologic studies in man

Antifungal Cationic Nanoemulsion Ferrying Miconazole Nitrate with Synergism to Control Fungal Infections: In Vitro, Ex Vivo, and In Vivo Evaluations

This study aimed to deliver a cationic nanoemulsion carrying miconazole nitrate (MCN) to control fungal infections using excipients for synergism. Peceol (oil) and labrasol (surfactant) were selected based on maximum solubility and zone of inhibition values against Candida albicans and Aspergillus niger. Optimized MCNE11 was evaluated [size, zeta potential, % entrapment efficiency (%EE), % transmittance, viscosity, refractive index, extrudability, polydispersity (PDI), morphology, and pH]. An in vitro drug release study was conducted for comparison between DS (drug suspension) and MNE11. In vitro hemolysis was studied at two different concentrations (0.625 and 2.5 μg/mL). Permeation profiles were generated using rat skin. A Draize test was conducted using rabbit to negate irritability issues. Finally, a stability test of MCNE11 was conducted for 12 months. The results showed that MCNE11 (cationic) was the most optimized in term of size, %EE, and PDI. The drug release from MCNE11 was higher compared to DS but comparable to MNE11 (anionic), suggesting no impact of the imposed cationic charge on the release behavior. Moreover, permeation parameters of MCNE11 were significantly (p < 0.05) greater than MNE11, which may be attributed to the combined impact of size (low), surfactant (for reversible changes), and electrostatic interaction (nanoglobules-skin surface). Thus, stable MCN11 possessing high %EE (89.8%), low size (145 nm), maximum flux (5.7 ± 0.1 μg/cm²/h), high drug deposition (932.7 ± 41.6 μg/cm²), optimal viscosity (44.17 ± 0.8 cP), low PDI (0.21), optimal zeta potential (+28.1 mV), and low hemolysis can be promising alternatives to conventional cream to control resistant and recurring types of fungal infections.

Preparation, Optimization, and Evaluation of Hyaluronic Acid-Based Hydrogel Loaded with Miconazole Self-Nanoemulsion for the Treatment of Oral Thrush

Miconazole nitrate (MZ) is a BCS class II antifungal poorly water-soluble drug with limited dissolution properties and gastrointestinal side effects. Self-nanoemulsifying delivery system-based gel of MZ can improve both solubility and oral mucosal absorption with enhanced antifungal activity. The study aims to formulate MZ self-nanoemulsion (MZ-NE) and combine it within hyaluronic acid-based gel. MZ solubility in various oils, surfactants, and cosurfactant used in NE formulations were evaluated. Mixture design was implemented to optimize the levels of NE components as a formulation variable to study their effects on the mean globule size and antifungal inhibition zones. Further, the optimized MZ-NE was loaded into a hyaluronic acid gel base. Rheological behavior of the prepared gel was assessed. Ex vivo permeability of optimized formulation across buccal mucous of sheep and inhibition against Candida albicans were examined. Mixture design was used to optimize the composition of MZ-NE formulation as 22, 67, and 10% for clove oil, Labrasol, and propylene glycol, respectively. The optimized formulation indicated globule size of 113 nm with 29 mm inhibition zone. Pseudoplastic flow with thixotropic behavior was observed, which is desirable for oral gels. The optimized formulation exhibited higher ex vivo skin permeability and enhanced antifungal activity by 1.85 and 2.179, respectively, compared to MZ-SNEDDS, and by 1.52 and 1.72 folds, respectively, compared to marketed gel. Optimized MZ-NE hyaluronic acid-based oral gel demonstrated better antifungal activity, indicating its potential in oral thrush pharmacotherapy.

Functionalization of acrylic hydrogels with alpha-, beta- or gamma-cyclodextrin modulates protein adsorption and antifungal delivery

Poly(hydroxyethyl methacrylate) (pHEMA) hydrogels were functionalized with pendant alpha-, beta- and gamma-cyclodextrins (CD) with the aim of improving the biocompatibility and increasing the ability to host drug molecules. Pendant alpha-, beta- and gamma-CDs did not affect swelling of the hydrogels but slightly decreased the water contact angle. Protein deposition was notably dependent on the nature of the CD, due to their different affinities for hydrophobic moieties of proteins. Lysozyme and albumin sorption was hindered by gamma-CD. Functionalization with beta-CD also reduced protein sorption, although less so, while alpha-CD decreased lysozyme deposition but enhanced albumin sorption compared with control pHEMA hydrogels. Loading of the hydrogels with miconazole was carried out by immersion in drug suspension followed by autoclaving. Functionalization with gamma-CD doubled the affinity of the network for the drug and resulted in the highest amount loaded (up to 170 mgg(-1)). Sustained delivery was observed for several days. Some miconazole-loaded hydrogels completely prevented Candida albicans biofilm formation as assayed in an in vitro microbiological test.

Prophylactic treatment with miconazole in patients highly predisposed to fungal infection. A placebo-controlled double-blind study

In a placebo-controlled double-blind study the prophylactic value of oral systemic treatment with the antimycotic agent miconazole was assessed in 30 highly predisposed patients receiving intensive cytostatic chemotherapy because of haematological malignancies. Patients colonized with Candida before treatment were not freed from this micro-organism by miconazole treatment. However, only 3 out of 6 initially non-colonized miconazole-treated patients became colonized during the study, against 10 out of 10 placebo-treated patients (p = 0.036). Seven out of 15 patients in the placebo group developed clinical mycosis, against only two out of 15 in the miconazole group. The miconazole-treated patients remained clinically free of mycosis for 252 out of 264 treatment days, while the placebo-treated patients remained free of mycosis for only 263 out or 338 treatment days (p = 0.0001). The results indicate that systemic miconazole treatment protects highly predisposed patients from colonization with Candida and prevents or postpones clinically established candidosis.

Drug-Drug Interaction of Antifungal Drugs

This article reviews the in vitro metabolic and the in vivo pharmacokinetic drug-drug interactions with antifungal drugs, including fluconazole, itraconazole, micafungin, miconazole, and voriconazole. In the in vitro interaction studies, the effects of antifungal drugs on specific activities of cytochrome P450s (CYPs), including CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP2E1, and CYP3A4, in human liver microsomes are compared to predict the possibility of drug interactions in vivo. Fluconazole, micafungin, and voriconazole have lower inhibitory effects on CYP3A4 activities than itraconazole and miconazole, and IC(50) and/or K(i) values against CYP2C9 and CYP2C19 activities are the lowest for miconazole, followed by voriconazole and fluconazole. In in vivo pharmacokinetic studies, it is well known that itraconazole is a potent clinically important inhibitor of the clearance of CYP3A4 substrates, and fluconazole and voriconazole are reported to increase the blood or plasma concentrations of not only midazolam and cyclosporine (CYP3A4 substrates) but also of phenytoin (CYP2C9 substrate) and/or omeprazole (CYP2C19/CYP3A4 substrate). On the other hand, no inhibition of CYP activities except for CYP3A4 activity by micafungin is observed in vitro, and the blood concentrations of cyclosporine and tacrolimus are not affected by coadministration of micafungin in vivo, suggesting that micafungin would not cause clinically significant interactions with drugs that are metabolized by CYPs via the inhibition of metabolism. Miconazole is a potent inhibitor of all CYPs investigated in vitro, although there are few detailed studies on the clinical significance of this except for CYP2C9. Therefore the differential effects of these antifungal drugs on CYP activities must be considered in the choice of antifungal drugs in patients receiving other drugs.

The possible association between the combination of vaginal metronidazole and miconazole treatment and poly-syndactyly Population-based case-control teratologic study

The objective of the study was to investigate the human teratogenic potential of vaginal metronidazole+miconazole treatment during pregnancy, because these antimicrobial drugs separately did not indicate human teratogenic potential in our and other studies. The analysis of cases with 21 groups of congenital abnormalities and their all matched controls was carried out in the population-based data set of the Hungarian Case-Control Surveillance of Congenital Abnormalities, 1980-1996 including 38,151 pregnant women who had newborn infants without any congenital abnormalities (control group) and 22,843 pregnant women who had newborn infants or fetuses with congenital abnormalities. The prevalence of vaginal metronidazole+miconazole treatment during pregnancy was 2.5% (N=576) in the case group and 2.2% (N=846) in the control group [crude prevalence odds ratio (POR) with 95% confidence interval (CI): 1.2, 1.0-1.3]. The analysis of cases and their matched controls indicated an association between vaginal metronidazole+miconazole use and poly/syndactyly during the second through third months of gestation (adjusted POR 6.0, 95% CI 2.4-15.2). This finding may be connected with recall bias, although this bias was restricted by the evaluation of maternal drug use only during the critical period of poly/syndactyly and by evaluating only medically recorded metronidazole+miconazole treatment. The conclusion of the study is that this finding can be regarded as a signal for the possible association between vaginal treatment of metronidazole+miconazole during pregnancy and poly/syndactyly without any plausible biological hypothesis.

Blockade of HERG cardiac K+ current by antifungal drug miconazole

1. Miconazole, an imidazole antifungal agent, is associated with acquired long QT syndrome and ventricular arrhythmias. Miconazole increases the plasma concentration of QT-prolonging drugs by inhibiting the hepatic cytochrome P450 metabolic pathway, but whether it has direct effects on cardiac ion channels has not been elucidated. 2. To determine the mechanism underlying these clinical findings, we investigated the effect of miconazole on human ether-a-go-go-related gene (HERG) K+ channels. 3. HERG channels were heterologously expressed in human embryonic kidney 293 (HEK293) cells and whole-cell currents were recorded using a patch-clamp technique (23 degrees C). 4. Miconazole inhibited HERG peak tail current in a concentration-dependent manner (0.4-40 microM) with an IC50 of 2.1 microM (n=3-5 cells at each concentration, Hill coefficient 1.2). HERG block was not frequency-dependent. It required channel activation, occurred rapidly, and had very slow dissociation properties. 5. The activation curve was shifted in a negative direction (V(1/2): -9.5+/-2.3 mV in controls and -15.3+/-2.4 mV after 4 microM miconazole, P<0.05, n=6). Miconazole did not change other channel kinetics (activation, deactivation, onset of inactivation, recovery from inactivation, steady-state inactivation). 6. The S6 domain mutation, F656C, abolished the inhibitory action of miconazole on HERG current indicating that miconazole preferentially binds to an aromatic amino-acid residue within the pore-S6 region. 7. Our findings indicate that miconazole causes HERG channel block by binding to a common drug receptor, and this involves preferential binding to activated channels. Thus, miconazole prolongs the QT interval by direct inhibition of HERG channels.

Population-based case-control teratologic study of topical miconazole

Miconazole cream is used in Hungary to treat fungal genital and skin infections in pregnant women, but it causes anxiety for both patients and medical doctors due to the category C classification of the drug regarding teratogenic or fetotoxic risk. The objective of this case-control study was to analyze the teratogenic potential of topical miconazole used during pregnancy in the mothers of babies with congenital abnormalities and in matched control mothers of babies without congenital abnormalities. The population-based data set of the Hungarian Case-Control Surveillance of Congenital Abnormalities between 1980 and 1996 included 22 843 women who had newborns or fetuses with congenital abnormalities, and 38 151 pregnant women who had newborn infants without any defects (controls). In the case group, 24 (0.11%) and in the control group, 46 (0.12%) pregnant women were treated with miconazole (crude odd ratio [OR]: 0.9 with 95% confidence interval [CI]: 0.6-1.6). Different congenital abnormality groups were evaluated in case-control pairs and a higher prevalence of miconazole treatment was not found during the second or third month of pregnancy. Thus, treatment with topical miconazole during pregnancy does not increase the risk of congenital abnormalities.

Structure and Generation Mechanism of a Novel Degradation Product Formed by Oxidatively Induced Coupling of Miconazole Nitrate with Butylated Hydroxytoluene in a Topical Ointment Studied by HPLC-ESI-MS and Organic Synthesis

In a petrolatum based topical ointment formulation containing miconazole nitrate (1) as the active ingredient and 2,6-di-t-butyl-4-methylphenol (BHT) as a vehicle antioxidant, an oxidatively induced coupling reaction between miconazole nitrate and BHT occurred to form a novel adduct 1-(3,5-di-tert-butyl-4-hydroxy-benzyl)-3-[2-(2,4-dichloro-benzyloxy)-2-(2,4-dichloro-phenyl)-ethyl]-3H-imidazol-1-ium nitrate (2). The structure of 2 was established using high-performance liquid chromatography coupled with electrospray ionization mass spectrometry and was confirmed by comparing with a synthesized reference compound. The reaction proceeded through a quinone methide intermediate from BHT. Two synthetic methods were established for preparing 2.

Bioavailability study of a 1200 mg miconazole nitrate vaginal ovule in healthy female adults

This study was undertaken to determine the bioavailabilityof a 1200 mg miconazole nitrate vaginal ovule in 20 healthy premenopausal females following a single application (Day 1, Group 1) and two applications, 48 hours apart (Day 1 and Day 3, Group 2). In Dose Group 1 (n = 10), the mean Cmax of 10.7 ng/ml occurred at 18.4 hours. The average plasma miconazole concentration was calculated to be 5.7 ng/ml during the 4- to 96-hour time interval. In Dose Group 2 (n = 10), mean Cmax values were 10.8 ng/ml and 12.0 ng/ml and occurred at 18.4 hours (Day 1) and 16.0 hours (Day 3), respectively. Comparing AUC0-48 on Days 1 and 3 (338 vs. 408 ng x h/ml) indicated small accumulation of plasma miconazole, while AUC0-48 obtained from Dose Group 2, Day 1 was similar to that of Dose Group 1 (338 vs. 329 ng x h/ml, respectively). Plasma miconazole profiles were best described by a monoexponential equation with zero-order input. Pharmacokinetic simulations performed on the pooled data from two dose groups (n = 20) suggest a steady-state accumulation after five doses administered daily or three doses taken once every other day. Drug exposure was similar to that of the marketed formulation (MONISTAT 7 vaginal cream), applied once daily for 7 days and more than 100-fold less than that reported when given intravenously or orally.

Pharmacokinetics of miconazole in serum and exudate of pelvic retroperitoneal space after radical hysterectomy and pelvic lymphadenectomy

Due to the increased number of compromised hosts with fungal infections, doctors have recently started prescribing antifungal agents. In the field of gynecology, however, the choice of which drug to use has been difficult. The efficacies of these drugs depend on their antifungal spectra, potencies and concentrations in tissues. The present study was designed to investigate the pharmacokinetics of miconazole in the exudate of the retroperitoneal space that is formed after radical hysterectomy and pelvic lymphadenectomy. A total of 600 mg of miconazole was administered to the patients for exactly 60 min using an automatic drip-infusion pump. The parameters of the formulas analyzed by the two-compartment model were determined using the least-squares method, and a simulation curve was made. The maximum drug concentration (Cmax) of miconazole in serum was 6.26 mg/l 1 h after drip infusion commencement and the t1/2 in serum was 8.86 h. The value of the area under the time-serum concentration curve (AUC) in serum was 19.13 mg/h per l. The Cmax of miconazole in the exudate of the retroperitoneal space was 0.13 mg/l 2.48 h after the drip infusion was started. The value of AUC in the exudate was 2.52 mg/h per l.

Influence of serum protein binding on the in vitro activity of anti-fungal agents

Historically it has been assumed that the pharmacological effect is related to the free drug concentration. In exposing Candida albicans to itraconazole and ketoconazole serum concentration-time profiles, however, antifungal activity was not diminished despite intense albumin binding. The relevance of serum protein binding was further investigated, by in vitro susceptibility testing of C. albicans (40 clinical isolates) and Trichophyton rubrum (ten strains) against antifungal agents using microdilution tests allowing the determination of IC30- and MIC-values. The range of serum protein binding ranges from 11% with fluconazole to > 99% with itraconazole and terbinafine. The ratios of IC30- and MIC-values with and without serum protein (albumin, alpha- and gamma-globulin, human plasma) were related to the loss of susceptibility expected according to the free-drug hypothesis. A difference in the albumin effect with the test strains was not observed. With most antifungals including terbinafine, the activity declined as expected. IC30- and MIC-ratios for miconazole were 7 and 13 (observed) vs. 12-20 (expected), for fluconazole 1.5 and 3.5 vs. 1.1, for amphotericin B 10 vs. 11-20, for griseofulvin 3.6 vs. 4, and for terbinafine 61 vs. 100. Itraconazole activity, however, was not diminished by albumin (expected ratio 286), and ketoconazole effects decreased less than expected (ratio 5-15, expected about 100). alpha-globulin, but not gamma-globulin induced a major loss in anti-Candida activity of itraconazole and ketoconazole, which is paralleled by a decline in ketoconazole (but not itraconazole) activity due to plasma. With the other antifungals (except for ciclopiroxolamine) IC30-values for C. albicans increased, too. Due to the complete inhibition of T. rubrum growth by gamma-globulin, this species proved unsuitable for studying the gamma-globulin effects. The present study demonstrates that the effects of intense protein binding on drug activity are only partly predictable from binding studies in vitro.

Miconazole as inflammatory agent--I. Cellular and pathophysiological effects

1. Subcutaneous injection of miconazole into the rat paw evoked an acute, circumscribed and long-lasting inflammation. 2. Miconazole edema presented two defined phases of rapid swelling. 3. Miconazole edema was antagonized by chlorpheniramine, dexamethasone and phenylbutazone. 4. This edema was 1.5-2 times more intense than edema due to econazole. 5. It is suggested that miconazole paw edema might be useful in the process of screening anti-inflammatory drugs.

Microtiter method for MIC testing with spherule-endospore-phase Coccidioides immitis

A method was developed for susceptibility testing with spherule-endospore-phase Coccidioides immitis by using a microtiter format. Isolated endospores were used to inoculate wells containing modified Converse medium with various concentrations of azole or nikkomycin antifungal substances which then were sealed with an acetate film. The plate was incubated at 37 degrees C with shaking for 96 h, after which the control wells had visible turbidity and endpoints were discernible. Microscopic examination revealed that both control and treatment wells maintained cells predominantly in the spherule-endospore phase of growth.

Overview of medically important antifungal azole derivatives

Fungal infections are a major burden to the health and welfare of modern humans. They range from simply cosmetic, non-life-threatening skin infections to severe, systemic infections that may lead to significant debilitation or death. The selection of chemotherapeutic agents useful for the treatment of fungal infections is small. In this overview, a major chemical group with antifungal activity, the azole derivatives, is examined. Included are historical and state of the art information on the in vitro activity, experimental in vivo activity, mode of action, pharmacokinetics, clinical studies, and uses and adverse reactions of imidazoles currently marketed (clotrimazole, miconazole, econazole, ketoconazole, bifonazole, butoconazole, croconazole, fenticonazole, isoconazole, oxiconazole, sulconazole, and tioconazole) and under development (aliconazole and omoconazole), as well as triazoles currently marketed (terconazole) and under development (fluconazole, itraconazole, vibunazole, alteconazole, and ICI 195,739).

Intravenous miconazole therapy for experimental keratomycosis in rabbits

Intravenous miconazole (90 mg daily for 3 weeks) reduced the intensity of experimental fungal keratitis due to Candida albicans in a group of 10 rabbits. Clinical scores of affected eyes were statistically significantly lower in the treated group than in a control group of 10 untreated rabbits. All cultures of corneal scrapings were negative on 18th day after inoculation in the treated group, but four cultures were still positive on the 21st day in the control animals. Histopathological examination of eyes from treated and untreated rabbits showed great differences in the severity of inflammatory changes in the two groups.

The Effects of Intravenous Miconazole on Fungal Keratitis

Two patients, a 44-year-old man and a 53-year-old man, with fungal keratitis were successfully treated with intravenously infused miconazole, a synthetic imidazole derivative. In these cases healing and regression of the corneal ulcer began four or five days after initiation of miconazole treatment. The clinical evidence of corneal infection disappeared completely after four weeks and visual acuities improved markedly (from 20/500 to 20/20 in Case 1 and from 20/400 to 20/40 in Case 2). Aside from a transient increase of serum triglycerides and beta-lipoproteins, the drug appeared to be well tolerated.

Petriellidium (Allescheria) boydii orbital and brain abscess treated with intravenous miconazole

A previously healthy 4-year-old boy suffered a penetrating injury to his left orbit and left frontal lobe, which resulted in an infection by Petriellidium boydii. The patient was successfully treated with intravenous miconazole and multiple debridements.

In vitro susceptibilities of human and wild-type isolates of Basidiobolus and Conidiobolus species

The in vitro activities of amphotericin B, miconazole, ketoconazole, 5-fluorocytosine, and potassium iodide (KI) were studied on human and wild-type isolates of Basidiobolus and Conidiobolus species. Of the antifungal agents tested, the imidazole derivatives, especially ketoconazole, were the most active against the agents of entomophthoromycosis. Transmission electron microscopy showed severe morphological alteration of Basidiobolus sp. exposed to 0.78 micrograms of ketoconazole per ml. The MIC and minimal fungicidal concentration of ketoconazole was often lowered in the presence of 10% fetal calf serum or antibiotic medium no. 3. Half of the Basidiobolus isolates and all Conidiobolus isolates were inhibited by amphotericin B at 0.39 micrograms/ml. None of the strains tested were inhibited or killed at maximum concentrations of 5-fluorocytosine and KI. The in vitro resistance of these fungi to KI at high concentrations suggests that the reported favorable treatment with KI may not be due to its direct effect on these fungi but rather to other, undefined factors in combination with KI. These data suggest that ketoconazole may be of use in the treatment of entomophthoromycosis, particularly in cases which are not responsive to KI.

Inhibition and killing of Candida albicans in vitro by five imidazoles in clinical use

Five imidazoles (clotrimazole, econazole, ketoconazole, miconazole, and tioconazole) in clinical use were compared for their ability to inhibit and kill Candida albicans. Eleven isolates were obtained from patients before therapy. By spectrophotometric determination of 50% growth inhibition, all isolates were inhibited at low concentrations, with clotrimazole slightly less active than the other four drugs. By the conventional MIC determination, tioconazole was more active than all of the others (P less than 0.01) except clotrimazole. In killing (minimum fungicidal concentration [MFC] assay), tioconazole was the most active by several analyses. Studies of the kinetics of killing indicated that the drugs studied could kill under conditions used for the MFC determination and that tioconazole and ketoconazole could kill particularly rapidly. If the drug was washed from the cells before subculturing, concentrations above the MFC were required to kill, but tioconazole could produce a lethal lesion in all cells virtually instantaneously. These findings are pertinent to MFC and killing kinetics methodology and to the observation of drug persistence after topical application. The results differ from some previous in vitro comparisons made with different methods. They are relevant to conclusions about drug mechanisms based on their abilities to inhibit and to kill, and they underscore the need to study various assay methods and fungal species.

Modification of polymorphonuclear leucocyte function by imidazoles

The effect of five imidazole derivatives (metronidazole, tinidazole, clotrimazole, miconazole and ketoconazole) on human polymorphonuclear leucocytes (PMNL) was examined in vitro. Metronidazole and tinidazole had no apparent effect on either PMNL chemotactic response or PMNL fungal/bacterial killing. In contrast, clotrimazole, miconazole and ketoconazole inhibited PMNL chemotaxis. In addition, miconazole and ketoconazole were shown to depress the ability of PMNL to kill bacteria and fungi.

Miconazole in the treatment of coccidioidomycosis

Intravenous miconazole can produce responses in patients with various manifestations of coccidioidal disease, even if they have failed to respond to amphotericin B. In 4 large series of 33, 33, 46 and 31 courses of miconazole for skin and soft tissue, chronic pulmonary, meningeal and skeletal coccidioidomycosis, response rates of 40, 72, 31 and 32%, respectively, were achieved; 60, 75, 78 and 56%, respectively, of those responding subsequently relapsed at the site(s) of earlier involvement. This suggests that the therapeutic effect of the relatively brief courses used (mean, 1 to 3 months) is fungistatic in vivo. Common side effects of intravenous miconazole include phlebitis, pruritus, anaemia, thrombocytosis, hyponatraemia, nausea, hyperlipidaemia, vomiting, central nervous system effects, and rashes. The place of miconazole relative to amphotericin B and ketoconazole has not been determined, and requires further comparative studies. Information on the results of different regimens, particularly longer courses, would also be of interest.

Antifungal chemotherapy

When the decision to treat a fungal infection is made, there are several antifungal agents available for use. AmB remains the first-line drug in the treatment of most systemic fungal infections. Miconazole should be used to treat patients who cannot tolerate AmB or who are infected with AmB-resistant organisms. Ketoconazole has a distinct advantage in that it is a relatively nontoxic oral agent and may prove very effective in treating non-life-threatening chronic fungal infections. Clinical experience with miconazole and ketoconazole is too limited at present to recommend them as first-line therapeutic agents, except in a limited number of clinical situations. 5-FC should only be used in combination with AmB to treat yeast infections.

Ketoconazole treatment of fungal infection in acute renal failure

A patient with diabetes mellitus and acute renal failure requiring hemodialysis developed Candida sepsis which was effectively treated with the oral antifungal drug, ketoconazole. Plasma drug levels during hemodialysis suggested that ketoconazole was not dialyzed, but that its pharmacokinetics, specifically gastrointestinal absorption, may be altered in renal failure.

Toxicity of amphotericin B, miconazole, and ketoconazole to human granulocyte progenitor cells in vitro

Granulocyte progenitor cells were grown in culture with amphotericin B, miconazole, and ketoconazole. Significant suppression of progenitor cell growth could be demonstrated with all three drugs at increasing concentrations. No additive suppression was seen when amphotericin B and ketoconazole were combined.

Pharmacokinetics of ketoconazole in patients with neoplastic diseases

Twenty-seven patients with advanced malignancies were given 200 mg of ketoconazole orally every 6 or 12 h. Blood samples were collected during these intervals and after the last dose to determine plasma concentrations and half-lives. The mean plasma concentrations measured after the initial dose were 1.7 +/- 1.1 microgram/ml at 2 h, 0.9 +/- 0.2 microgram/ml at 6 h, and 0.7 +/- 0.4 microgram/ml at 8 h. Plasma concentrations rose significantly in patients on the every-6-h schedule. Concentrations were more variable in patients on the every-12-h schedule, and changes in mean plasma concentrations after 7 and 14 days were not significant. Half-lives ranged from 1.3 to 11.6 h in individual patients. The mean half-life for all patients studied was 3.7 +/- 0.6 h on day 1. The calculated area under the curve was 12.0 +/- 4.7 micrograms-h/ml on day 1; it increased after 7 and 14 days of administration (every-6-h schedule), suggesting plasma binding or wide drug distribution or both. Saturation of storage compartments is also suggested. Less than 1% of the administered dose was recoverable as active drug from the urine over 6 h.

Cryptococcal meningitis: treatment of three patients with miconazole

Three patients with cryptococcal meningitis who were treated with miconazole are reported. All patients had previously received combination therapy with amphotericin B and flucytosine which was unsuccessful. All patients showed clinical improvement, and one obtained a mycological remission. Miconazole was well tolerated, and would appear to be a relatively non-toxic and effective drug in the treatment of cryptococcal meningitis which is refractory to conventional chemotherapy.

Treatment of fungal infections of the central nervous system

The recent development of new antifungal antimicrobials that can be administered in combination with amphotericin B or as alternatives to it has expanded the dimensions of treatment for fungal infections of the central nervous system. These disorders have acquired increasing importance as patients with malignant and other illnesses associated with immunosuppression survive longer and as renal transplantation is more widely applied. Amphotericin B has remained the most effective therapeutic preparation for most types of neurological fungal disease, although important roles for 5-fluorocytosine, miconazole, and, more recently, ketoconazole are being recognized.

Miconazole therapy for treatment of fungal infections in cancer patients

The effectiveness of miconazole was evaluated in 37 documented fungal infections, 32 of which were major infections. All patients were receiving therapy for advanced malignancy, with 28 patients having acute leukemia. The overall cure rate was 41% and it was also 41% for major fungal infections. Nine of 22 patients with Candida albicans infections were cured, and 3 of 11 patients with Candida tropicalis infections were cured. A total of 183 patients who received miconazole for presumed or documented fungal infection were evaluated for toxicity. Nausea and vomiting and central nervous system toxicity were the most common side effects, occurring in 25 and 16% of the patients, respectively. Overall, the drug was tolerated well, with only four patients requiring the drug to be permanently discontinued because of toxicity.