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Lu L, Prajna NV, Lalitha P, Rajaraman R, Srinivasan M, Arnold BF, Acharya N, Lietman T, Rose-Nussbaumer J. Association between in vitro susceptibility and clinical outcomes in fungal keratitis. J Ophthalmic Inflamm Infect 2024; 14:42. [PMID: 39222170 PMCID: PMC11368879 DOI: 10.1186/s12348-024-00418-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/19/2024] [Indexed: 09/04/2024] Open
Abstract
PURPOSE The purpose of this study was to assess the association between antifungal susceptibility as measured by minimum inhibitory concentration (MIC) and clinical outcomes in fungal keratitis. METHODS This pre-specified secondary analysis of the Mycotic Ulcer Treatment Trial II (MUTT II) involved patients with filamentous fungal keratitis presenting to Aravind Eye Hospitals in South India. Antifungal susceptibility testing for natamycin and voriconazole was performed on all samples with positive fungal culture results according to Clinical and Laboratory Standards Institute Guidelines. The relationship between MIC and clinical outcomes of best-corrected visual acuity, infiltrate or scar size, corneal perforation, need for therapeutic penetrating keratoplasty, and time to re-epithelialization were assessed. RESULTS We obtained MIC values from 141 patients with fungal keratitis. The most commonly cultured organisms were Aspergillus (46.81%, n = 66) and Fusarium (44.68%, n = 63) species. Overall, there was no association between antifungal MICs and clinical outcomes. Subgroup analysis revealed that among Fusarium-positive cases, higher voriconazole MIC was correlated with worse three-month best-corrected visual acuity (p = 0.03), increased need for therapeutic penetrating keratoplasty (p = 0.04), and time to re-epithelialization (p = 0.03). No significant correlations were found among Aspergillus-positive cases. There were no significant correlations found between natamycin MIC and clinical outcomes among organism subgroups. CONCLUSIONS Decreased susceptibility to voriconazole was associated with increased odds of requiring a therapeutic penetrating keratoplasty in Fusarium-positive cases. Susceptibility to natamycin was not associated with any of the measured outcomes.
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Affiliation(s)
- Louisa Lu
- Department of Ophthalmology, Byers Eye Institute, Stanford University, 2542 Watson Ct, Palo Alto, Stanford, CA, 94303, USA
| | | | | | | | | | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
| | - Nisha Acharya
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Thomas Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Rose-Nussbaumer
- Department of Ophthalmology, Byers Eye Institute, Stanford University, 2542 Watson Ct, Palo Alto, Stanford, CA, 94303, USA.
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
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Hatmaker EA, Barber AE, Drott MT, Sauters TJC, Alastruey-Izquierdo A, Garcia-Hermoso D, Kurzai O, Rokas A. Pathogenicity is associated with population structure in a fungal pathogen of humans. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.07.05.602241. [PMID: 39026826 PMCID: PMC11257439 DOI: 10.1101/2024.07.05.602241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Aspergillus flavus is a clinically and agriculturally important saprotrophic fungus responsible for severe human infections and extensive crop losses. We analyzed genomic data from 250 (95 clinical and 155 environmental) A. flavus isolates from 9 countries, including 70 newly sequenced clinical isolates, to examine population and pan-genome structure and their relationship to pathogenicity. We identified five A. flavus populations, including a new population, D, corresponding to distinct clades in the genome-wide phylogeny. Strikingly, > 75% of clinical isolates were from population D. Accessory genes, including genes within biosynthetic gene clusters, were significantly more common in some populations but rare in others. Population D was enriched for genes associated with zinc ion binding, lipid metabolism, and certain types of hydrolase activity. In contrast to the major human pathogen Aspergillus fumigatus, A. flavus pathogenicity in humans is strongly associated with population structure, making it a great system for investigating how population-specific genes contribute to pathogenicity.
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Affiliation(s)
- E. Anne Hatmaker
- Department of Biological Sciences, Vanderbilt University, Nashville, TN, USA
- Evolutionary Studies Initiative, Vanderbilt University, Nashville, TN, USA
| | - Amelia E. Barber
- Institute for Microbiology, Friedrich Schiller University, Jena, Germany
| | - Milton T. Drott
- Cereal Disease Laboratory, Agricultural Research Service, USDA, Saint Paul, MN, USA
| | - Thomas J. C. Sauters
- Department of Biological Sciences, Vanderbilt University, Nashville, TN, USA
- Evolutionary Studies Initiative, Vanderbilt University, Nashville, TN, USA
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
- Center for Biomedical Research in Network in Infectious Diseases (CIBERINFEC), Carlos III Heath Institute, Madrid, Spain
| | - Dea Garcia-Hermoso
- Institut Pasteur, Université Paris Cité, National Reference Center for Invasive Mycoses and Antifungals, Translational Mycology Research Group, Mycology Department, Paris, France
| | - Oliver Kurzai
- National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institute for Natural Product Research and Infection Biology – Hans-Knoell-Institute, Jena, Germany
- Institute for Hygiene and Microbiology, University of Würzburg. Würzburg, Germany
| | - Antonis Rokas
- Department of Biological Sciences, Vanderbilt University, Nashville, TN, USA
- Evolutionary Studies Initiative, Vanderbilt University, Nashville, TN, USA
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Tuft S, Stone NRH, Burton MJ, Johnson EM, Borman AM. Antifungal susceptibility profiles for fungal isolates from corneas and contact lenses in the United Kingdom. Eye (Lond) 2024; 38:529-536. [PMID: 37684376 PMCID: PMC10858215 DOI: 10.1038/s41433-023-02719-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/09/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE To report the identification and results of susceptibility testing for fungal isolates from the cornea or contact lens care systems. MATERIALS AND METHODS In this retrospective epidemiological study, we searched the results of fungal cultures from cornea or contact lens systems referred for identification and susceptibility testing to the United Kingdom National Mycology Reference Laboratory between October 2016 and March 2022. For each fungal isolate, we recorded the genus and species of the fungus and the minimum inhibitory concentration (MIC) to six antifungal agents available to treat corneal infection (amphotericin, econazole, itraconazole, natamycin, posaconazole, and voriconazole). RESULTS There were 600 isolates from 585 patients, comprising 374 (62%) from corneal samples and 226 from contact lenses and care systems, of which 414 (69%) isolates were moulds (filamentous fungi) and 186 (31%) were yeasts. The most frequent moulds isolated were Fusarium spp (234 isolates, 39%) and Aspergillus spp (62, 10%). The most frequent yeasts isolated were Candida spp (112, 19%), predominantly Candida parapsilosis (65, 11%) and Candida albicans (33, 6%), with 35 isolates (6%) of Meyerozyma guilliermondii. In vitro susceptibility was greatest for natamycin (347 moulds tested, mode 4 mg/L, range 0.25-64 mg/L; 98 yeasts tested, mode 4 mg/L, range 0.5-32 mg/L), with susceptibility for 94% for moulds and 99% yeasts. Of the 16 isolates interpreted as highly resistant to natamycin (MIC ≥16 mg/L), 13 were Aspergillus flavus complex. CONCLUSIONS In vitro susceptibility supports the use of natamycin for the empiric treatment of fungal keratitis in the UK.
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Affiliation(s)
- Stephen Tuft
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK.
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK.
| | - Neil R H Stone
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Matthew J Burton
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Elizabeth M Johnson
- UK National Mycology Reference Laboratory, UK Health Security Agency South-West, Bristol, and MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Andrew M Borman
- UK National Mycology Reference Laboratory, UK Health Security Agency South-West, Bristol, and MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
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Gunasekaran R, Chandrasekaran A, Rajarathinam K, Duncan S, Dhaliwal K, Lalitha P, Prajna NV, Mills B. Rapid Point-of-Care Identification of Aspergillus Species in Microbial Keratitis. JAMA Ophthalmol 2023; 141:966-973. [PMID: 37768674 PMCID: PMC10540059 DOI: 10.1001/jamaophthalmol.2023.4214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/30/2023] [Indexed: 09/29/2023]
Abstract
Importance Microbial keratitis (MK) is a common cause of unilateral visual impairment, blindness, and eye loss in low-income and middle-income countries. There is an urgent need to develop and implement rapid and simple point-of-care diagnostics for MK to increase the likelihood of good outcomes. Objective To evaluate the diagnostic performance of the Aspergillus-specific lateral-flow device (AspLFD) to identify Aspergillus species causing MK in corneal scrape and corneal swab samples of patients presenting with microbial keratitis. Design, Setting, and Participants This diagnostic study was conducted between May 2022 and January 2023 at the corneal clinic of Aravind Eye Hospital in Madurai, Tamil Nadu, India. All study participants were recruited during their first presentation to the clinic. Patients aged 15 years or older met the eligibility criteria if they were attending their first appointment, had a corneal ulcer that was suggestive of a bacterial or fungal infection, and were about to undergo diagnostic scrape and culture. Main Outcomes and Measures Sensitivity and specificity of the AspLFD with corneal samples collected from patients with MK. During routine diagnostic scraping, a minimally invasive corneal swab and an additional corneal scrape were collected and transferred to aliquots of sample buffer and analyzed by lateral-flow device (LFD) if the patient met the inclusion criteria. Photographs of devices were taken with a smartphone and analyzed using a ratiometric approach, which was developed for this study. The AspLFD results were compared with culture reports. Results The 198 participants who met the inclusion criteria had a mean (range) age of 51 (15-85) years and included 126 males (63.6%). Overall, 35 of 198 participants with corneal scrape (17.7%) and 17 of 40 participants with swab samples (42.5%) had positive culture results for Aspergillus species. Ratiometric analysis results for the scrape samples found that the AspLFD achieved high sensitivity (0.89; 95% CI, 0.74-0.95), high negative predictive value (0.97; 95% CI, 0.94-0.99), low negative likelihood ratio (0.12; 95% CI, 0.05-0.30), and an accuracy of 0.94 (95% CI, 0.90-0.97). Ratiometric analysis results for the swab samples showed that the AspLFD had high sensitivity (0.94; 95% CI, 0.73-1.00), high negative predictive value (0.95; 95% CI, 0.76-1.00), low negative likelihood ratio (0.07; 95% CI, 0.01-0.48), and an accuracy of 0.88 (95% CI, 0.73-0.96). Conclusions and Relevance Results of this diagnostic study suggest that AspLFD along with the ratiometric analysis of LFDs developed for this study has high diagnostic accuracy in identifying Aspergillus species from corneal scrapes and swabs. This technology is an important step toward the provision of point-of-care diagnostics for MK and could inform the clinical management strategy.
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Affiliation(s)
- Rameshkumar Gunasekaran
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Abinaya Chandrasekaran
- Department of Cornea and Refractive Surgery Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Karpagam Rajarathinam
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Sheelagh Duncan
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
| | - Kevin Dhaliwal
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
| | - Prajna Lalitha
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - N Venkatesh Prajna
- Department of Cornea and Refractive Surgery Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Bethany Mills
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
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Tuft S, Evans J, Gordon I, Leck A, Stone N, Neal T, Macleod D, Kaye S, Burton MJ. Antimicrobial resistance in topical treatments for microbial keratitis: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e069338. [PMID: 36882242 PMCID: PMC10008341 DOI: 10.1136/bmjopen-2022-069338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/13/2023] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION There is evidence for increased resistance against the antimicrobials used to treat keratitis. This review aims to provide global and regional prevalence estimates of antimicrobial resistance in corneal isolates and the range of minimum inhibitory concentrations (MIC) with their associated resistance breakpoints. METHODS AND ANALYSIS We report this protocol following Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols guidelines. We will conduct an electronic bibliographic search in MEDLINE, EMBASE, Web of Science and the Cochrane Library. Eligible studies will report in any language data for the resistance or MIC for antimicrobials against bacterial, fungal or amoebic organisms isolated from suspected microbial keratitis. Studies that only report on viral keratitis will not be included. There will be no time restrictions on the date of publication. Screening for eligible studies, assessment of risk of bias and data extraction will be conducted by two reviewers independently, using predefined inclusion criteria and prepiloted data extraction forms. We will resolve disagreements between the reviewers by discussion and, if required, a third (senior) reviewer will arbitrate. We will assess the risk of bias using a tool validated in prevalence studies. The certainty of the evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation approach. Pooled proportion estimates will be calculated using a random-effects model. Heterogeneity will be assessed using the I2 statistic. We will explore differences between Global Burden of Disease regions and temporal trends. ETHICS APPROVAL AND DISSEMINATION Ethics approval is not required as this is a protocol for a systematic review of published data. The findings of this review will be published in an open-access, peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023331126.
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Affiliation(s)
- Stephen Tuft
- Cornea and External Disease Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Jennifer Evans
- Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Iris Gordon
- Department of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Astrid Leck
- Department of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Neil Stone
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Timothy Neal
- Department of Microbiology, Royal Liverpool University Hospital, Liverpool, UK
| | - David Macleod
- Department of Medical Statistics, LSHTM, London, London, UK
| | - Stephen Kaye
- Department of Eye and Vision Science, University of Liverpool, Liverpool, Merseyside, UK
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Yang K, Geng Q, Luo Y, Xie R, Sun T, Wang Z, Qin L, Zhao W, Liu M, Li Y, Tian J. Dysfunction of FadA-cAMP signalling decreases Aspergillus flavus resistance to antimicrobial natural preservative Perillaldehyde and AFB1 biosynthesis. Environ Microbiol 2022; 24:1590-1607. [PMID: 35194912 DOI: 10.1111/1462-2920.15940] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 01/02/2023]
Abstract
Aspergillus flavus is an opportunistic fungal pathogen that colonizes agriculture crops with aflatoxin contamination. We found that Perillaldehyde (PAE) effectively inhibited A. flavus viability and aflatoxin production by inducing excess reactive oxygen species (ROS). Transcriptome analysis indicated that the Gα protein FadA was significantly induced by PAE. Functional characterization of FadA showed it is important for asexual development and aflatoxin biosynthesis by regulation of cAMP-PKA signalling. The ΔfadA mutant was more sensitive to PAE, while ΔpdeL and ΔpdeH mutants can tolerate excess PAE compared to wild-type A. flavus. Further RNA-sequence analysis showed that fadA was important for expression of genes involved in oxidation-reduction and cellular metabolism. The flow cytometry and fluorescence microscopy demonstrated that ΔfadA accumulated more concentration of ROS in cells, and the transcriptome data indicated that genes involved in ROS scavenging were downregulated in ΔfadA mutant. We further found that FadA participated in regulating response to extracellular environmental stresses by increasing phosphorylation levels of MAPK Kinase Slt2 and Hog1. Overall, our results indicated that FadA signalling engages in mycotoxin production and A. flavus resistance to antimicrobial PAE, which provide valuable information for controlling this fungus and AF biosynthesis in pre- and postharvest of agricultural crops.
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Affiliation(s)
- Kunlong Yang
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
| | - Qingru Geng
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
| | - Yue Luo
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
| | - Rui Xie
- Key Laboratory of Pathogenic Fungi and Mycotoxins of Fujian Province, School of Life Sciences, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Tongzheng Sun
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
| | - Zhen Wang
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
| | - Ling Qin
- Key Laboratory of Pathogenic Fungi and Mycotoxins of Fujian Province, School of Life Sciences, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Wei Zhao
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
| | - Man Liu
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
| | - Yongxin Li
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
| | - Jun Tian
- School of Life Science, Jiangsu Normal University, Xuzhou, Jiangsu, 221116, China
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Diagnosing Fungal Keratitis and Simultaneously Identifying Fusarium and Aspergillus Keratitis with a Dot Hybridization Array. J Fungi (Basel) 2022; 8:jof8010064. [PMID: 35050004 PMCID: PMC8777873 DOI: 10.3390/jof8010064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 02/05/2023] Open
Abstract
Fungal keratitis (FK) is one of the most common microbial keratitis, which often leads to poor prognosis as a result of delayed diagnosis. Several studies implied that early differentiation of the two major FK, Fusarium and Aspergillus keratitis, could be helpful in selecting effective anti-fungal regimens. Therefore, a novel dot hybridization array (DHA) was developed to diagnose FK and differentiate Fusarium and Aspergillus keratitis in this study. One hundred forty-six corneal scrapes obtained from one hundred forty-six subjects impressed with clinically suspected FK were used to evaluate the performance of the DHA. Among these patients, 107 (73.3%) patients had actual FK confirmed by culture and DNA sequencing. We found that the DHA had 93.5% sensitivity and 97.4% specificity in diagnosing FK. In addition, this array had 93.2% sensitivity and 93.8% specificity in diagnosing Fusarium keratitis, as well as 83.3% sensitivity and 100% specificity in diagnosing Aspergillus keratitis. Furthermore, it had 83.9% sensitivity and 100% specificity in identifying Fusarium solani keratitis. Thus, this newly developed DHA will be beneficial to earlier diagnosis, more precise treatment, and improve prognosis of FK, by minimizing medical refractory events and surgical needs.
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Hazarika M, Prajna NV, Senthilkumari S. Drug reservoir function of voriconazole impregnated human amniotic membrane: An in vitro study. Indian J Ophthalmol 2021; 69:1068-1072. [PMID: 33913834 PMCID: PMC8186651 DOI: 10.4103/ijo.ijo_2649_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose: Earlier our group has demonstrated the drug reservoir function of the human amniotic membrane (HAM) using stable moxifloxacin and fortified cefazolin ophthalmic formulations and found it as a suitable tool to deliver drugs for an extended duration. The purpose of this study was to evaluate the extended-release kinetics of voriconazole from the impregnated human amniotic membrane (HAM) in vitro. Methods: HAM buttons were incubated with freshly prepared 1% topical ophthalmic formulation of voriconazole for 5 different exposure time to investigate the ideal exposure time for the extended-release of voriconazole from HAM. The drug release kinetics was studied in simulated tear fluid for 5 weeks and the amount of voriconazole released at different intervals was estimated using high-performance liquid chromatography (HPLC) with photodiode array (PDA) detector. Results: There was a marginal increase in drug entrapment efficiency with increased drug exposure time but neither the drug entrapment nor the drug release was found to be statistically significant (P ≥ 0.5). Voriconazole was detectable even at 5 weeks. Conclusion: A sustained release of voriconazole was achieved up to 5 weeks, when voriconazole was incubated with amniotic membrane for all the studied drug soaking times. Thus, voriconazole impregnated amniotic membrane can be considered for the sustained delivery for its in fungal keratitis.
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Affiliation(s)
- Manali Hazarika
- Department of Cornea and Refractive Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | | | - Srinivasan Senthilkumari
- Department of Ocular Pharmacology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
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9
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Tananuvat N, Upaphong P, Tangmonkongvoragul C, Niparugs M, Chaidaroon W, Pongpom M. Fungal keratitis at a tertiary eye care in Northern Thailand: Etiology and prognostic factors for treatment outcomes. J Infect 2021; 83:112-118. [PMID: 34038772 DOI: 10.1016/j.jinf.2021.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/28/2021] [Accepted: 05/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate etiology and prognostic factors for treatment outcomes of fungal keratitis (FK). METHODS Culture-positive FK patients between 2012 and 2017 were reviewed. Treatment outcomes were categorized into success (resolved within two weeks), slow response and medication failure (no improvement or required surgery). Etiology and risk factors for poor treatment outcomes were analyzed. RESULTS A total of 113 eyes of 113 patients (77% males) were recruited. Ocular trauma (69.0%) was the most common predisposing factor. Of this, 80% were exposed to organic foreign bodies. The most common pathogen was Fusarium spp. (45.2%), while dematiaceous fungi were discovered in 29.6%. Medical treatment was successful in 24.8% of eyes, while 29.2% had a slow response and 42.5% failed medication. Therapeutic keratoplasty was performed in 22.1% of eyes and 11.5% eventually required eye removal. Significant risk factors for medication failure were advanced age (P = 0.005), delayed antifungal treatment (P = 0.038) and large-size lesion (P = 0.003). CONCLUSIONS Ocular trauma was the major predisposing factor of FK in the Northern Thailand. Fusarium was the most common identified pathogen. Many cases were refractory to medications and required surgical intervention. Aging, delayed treatment and a large lesion were predictors for poor outcomes.
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Affiliation(s)
- Napaporn Tananuvat
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Phit Upaphong
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Muanploy Niparugs
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Winai Chaidaroon
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Monsicha Pongpom
- Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Human Corneal Epithelial Cells Internalize Aspergillus flavus Spores by Actin-Mediated Endocytosis. Infect Immun 2021; 89:IAI.00794-20. [PMID: 33753415 DOI: 10.1128/iai.00794-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/03/2021] [Indexed: 01/09/2023] Open
Abstract
Human corneal epithelial (HCE) cells play a significant role in the innate immune response by secreting cytokines and antimicrobial peptides when they encounter fungal pathogens. But the detailed mechanism of attachment and engulfment of the fungal conidia by HCE cells is not well understood. Here, we show the phagocytosis of Aspergillus flavus conidia by RCB2280 cells and primary HCE cultures using confocal microscopy and proteomic analysis of conidium-containing phagosomes. Phalloidin staining showed actin polymerization, leading to an actin ring around engulfed conidia. Cytochalasin D inhibited the actin-mediated endocytosis of the conidia. Immunolabeling of the early endosomal markers CD71 and early endosomal antigen (EEA1) and the late endosomal markers lysosome-associated membrane protein 1 (LAMP1), Rab7, and cathepsin G showed that endosomal proteins were recruited to the site of conidia and showed maturation of the conidium-containing phagosomes. Lysotracker red DND 99 labeling showed the acidification of the phagosomes containing conidia. Phagosome-specific proteome analysis confirmed the recruitment of various phagosomal and endosomal proteins to the conidium-containing phagosomes. These results show that the ocular surface epithelium contributes actively to antifungal defense by the phagocytosis of invading fungal conidia.
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11
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Edwar L, Janna YM, Rozaliyani A, Louisa M. Therapeutic response time of topical voriconazole 1% and intrastromal voriconazole 0.05% versus topical natamycin 5% monotherapy in Fusarium keratitis in rabbit. Mycoses 2020; 63:1128-1132. [PMID: 32780874 DOI: 10.1111/myc.13160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Fungal keratitis can be more difficult to treat than bacterial keratitis with worse outcomes. OBJECTIVE To evaluate the therapeutic response time of topical voriconazole combined with intrastromal voriconazole, and topical natamycin on Fusarium keratitis. METHODS The stroma of corneas of twelve New Zealand White rabbits was inoculated with Fusarium sp spores. Seven days after inoculation, they were divided into 2 groups randomly. Group A was treated with topical natamycin 5% for 21 days. Group B was treated with intrastromal voriconazole 0.05% single injection at the beginning of treatment, continued with topical voriconazole 1% for 21 days. Clinical evaluations for epithelial defect size and clinical scores in each group were performed on 1st, 3rd, 7th, 10th, 14th and 21st days after treatment. Mycological examinations were performed before and after the treatment. RESULTS After treatment, there was no statistically significant difference between natamycin and voriconazole in reducing epithelial defect size at first, second or third week after treatment (P = .15; P = .39; and P = .90). The clinical scores on both groups also showed no statistically significant differences at first, second and third weeks after treatment (P = .24; P = .09; and P = .32). Qualitative mycological evaluation before and after the treatment showed no statistically significant difference in KOH examination (P = 1; P = 1) and culture in Sabouraud dextrose agar (P = 1; P = 1). CONCLUSION Intrastromal voriconazole injection combined with topical voriconazole seems to give similar response time but not earlier in improving clinical presentation of Fusarium keratitis as topical natamycin.
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Affiliation(s)
- Lukman Edwar
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Indonesia
| | - Yulia M Janna
- Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Indonesia
| | - Anna Rozaliyani
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Indonesia
| | - Melva Louisa
- Department of Clinical and Therapeutic Pharmacology, Faculty of Medicine, Universitas Indonesia, Indonesia
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12
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Mora-Pereira M, Abarca EM, Duran S, Ravis W, McMullen RJ, Fischer BM, Lee YHP, Wooldridge AA. Sustained-release voriconazole-thermogel for subconjunctival injection in horses: ocular toxicity and in-vivo studies. BMC Vet Res 2020; 16:115. [PMID: 32295599 PMCID: PMC7160932 DOI: 10.1186/s12917-020-02331-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 04/05/2020] [Indexed: 12/13/2022] Open
Abstract
Background Keratomycosis is a relatively common, sight threatening condition in horses, where treatment is often prolonged and costly. Subconjunctival (SCo) injections offer less resistance to drug diffusion than the topical route, resulting in better penetration to the ocular anterior segment. Voriconazole, a second generation triazole antifungal, is effective against common fungal organisms causing keratomycosis. If combined with a thermogel biomaterial, voriconazole can be easily injected in the SCo space to provide sustained drug release. The purpose of this study was to evaluate the drug concentrations in the anterior segment and clinical effects after SCo injections of voriconazole-containing thermogel: poly (DL-lactide-co-glycolide-b-ethylene glycol-b-DL-lactide-co-glycolide) (PLGA-PEG-PLGA) in healthy equine eyes. Results Voriconazole aqueous humor (AH) and tear concentrations were compared between 6 horses, receiving 1% voriconazole applied topically (0.2 mL, q4h) (Vori-Top) or 1.7% voriconazole-thermogel (0.3 mL) injected SCo (Vori-Gel). For the Vori-Gel group, voriconazole concentrations were measured in AH and tears at day 2 and then weekly for 23 days, and at day 2 only for the Vori-Top group. Ocular inflammation was assessed weekly (Vori-Gel) using the modified Hackett-McDonald scoring system. Ocular tissue concentrations of voriconazole following SCo 1.7% voriconazole-thermogel (0.3 mL) injections were evaluated post euthanasia in 6 additional horses at 3 different time points. Three horses received bilateral injections at 2 h (n = 3, right eye (OD)) and 48 h (n = 3, left eye (OS)) prior to euthanasia, and 3 horses were injected unilaterally (OS), 7 days prior to euthanasia. Voriconazole-thermogel was easily injected and well tolerated in all cases, with no major adverse effects. On day 2, drug concentrations in tears were higher in the Vori-Top, but not statistically different from Vori-Gel groups. For the Vori-Gel group, voriconazole was non-quantifiable in the AH at any time point. Total voriconazole concentrations in the cornea were above 0.5 μg/g (the target minimum inhibitory concentration (MIC) for Aspergillus sp.) for up to 48 h; however, concentrations were below this MIC at 7 days post treatment. Conclusions Voriconazole-thermogel was easily and safely administered to horses, and provided 48 h of sustained release of voriconazole into the cornea. This drug delivery system warrants further clinical evaluation.
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Affiliation(s)
- Mariano Mora-Pereira
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - Eva M Abarca
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA.
| | - Sue Duran
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - William Ravis
- Department of Drug Discovery and Development, Auburn University, Auburn, AL, USA
| | - Richard J McMullen
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - Britta M Fischer
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | | | - Anne A Wooldridge
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
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13
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Kunt Z, Yağmur M, Kandemir H, Harbiyeli I, Erdem E, Kalkancı A, De Hoog GS, Ilkit M. In Vitro Efficacy of Chlorhexidine and a riboflavin/UVA Combination on Fungal Agents of Keratitis. Curr Eye Res 2019; 45:7-11. [PMID: 31403321 DOI: 10.1080/02713683.2019.1652916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: Mycotic keratitis is a global ophthalmological problem because it is difficult to diagnose and treat. The aim of the current study was to evaluate the efficiency of using antifungal agents amphotericin B (AMB), voriconazole (VRC), 0.02% chlorhexidine (CHX), and a combination of riboflavin and UVA treatment against two fungal genera (Aspergillus and Fusarium) responsible for keratitis.Methods: We evaluated antifungal efficiencies of riboflavin/UVA and the antifungal drugs VRC, AMB, and CHX (alone and in combination) against fungal inocula at four concentrations. We recorded colony counts of isolates for Aspergillus terreus, A. flavus, A. fumigatus, Fusarium falciforme, F. proliferatum, and F. solani on Mueller-Hinton agar plates.Results: Fungal suspensions exposed to the following treatment combinations did not allow fungal growth: riboflavin/UVA and VRC, riboflavin/UVA and AMB, riboflavin/UVA and CHX, and CHX alone. We observed a statistically significant reduction (P < .05) in the number of colonies on agar plates when fungal suspensions were treated with riboflavin/UVA, VRC, and AMB only.Conclusions: Riboflavin/UVA treatment in combination with AMB, VRC, and CHX are capable of killing keratitis-inducing fungi (P < .05). The antiseptic CHX exerted a considerable antifungal effect on all strains we examined. Therefore, we recommend CHX as additional therapy against mycotic keratitis, particularly when keratitis is caused by multi-resistant members of Fusarium.
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Affiliation(s)
- Zeynep Kunt
- Department of Ophthalmology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Meltem Yağmur
- Department of Ophthalmology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Hazal Kandemir
- Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Inan Harbiyeli
- Department of Ophthalmology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Elif Erdem
- Department of Ophthalmology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Ayşe Kalkancı
- Department of Microbiology, Faculty of Medicine, University of Gazi, Ankara, Turkey
| | - G Sybren De Hoog
- Fungal Biodiversity Centre (CBC), Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands.,Centre of Expertise in Mycology Radboud, University Medical Centre/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Macit Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Cukurova, Adana, Turkey
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14
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Dogan C, Aygun G, Bahar-Tokman H, Yazgan Z, Mergen B, Ozdamar A, Arslan OS. In Vitro Antifungal Effect of Acrylic Corneal Glue (N-Butyl-2-Cyanoacrylate). Cornea 2019; 38:1563-1567. [DOI: 10.1097/ico.0000000000002061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Rudramurthy SM, Paul RA, Chakrabarti A, Mouton JW, Meis JF. Invasive Aspergillosis by Aspergillus flavus: Epidemiology, Diagnosis, Antifungal Resistance, and Management. J Fungi (Basel) 2019; 5:jof5030055. [PMID: 31266196 PMCID: PMC6787648 DOI: 10.3390/jof5030055] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/28/2019] [Accepted: 06/29/2019] [Indexed: 12/12/2022] Open
Abstract
Aspergillus flavus is the second most common etiological agent of invasive aspergillosis (IA) after A. fumigatus. However, most literature describes IA in relation to A. fumigatus or together with other Aspergillus species. Certain differences exist in IA caused by A. flavus and A. fumigatus and studies on A. flavus infections are increasing. Hence, we performed a comprehensive updated review on IA due to A. flavus. A. flavus is the cause of a broad spectrum of human diseases predominantly in Asia, the Middle East, and Africa possibly due to its ability to survive better in hot and arid climatic conditions compared to other Aspergillus spp. Worldwide, ~10% of cases of bronchopulmonary aspergillosis are caused by A. flavus. Outbreaks have usually been associated with construction activities as invasive pulmonary aspergillosis in immunocompromised patients and cutaneous, subcutaneous, and mucosal forms in immunocompetent individuals. Multilocus microsatellite typing is well standardized to differentiate A. flavus isolates into different clades. A. flavus is intrinsically resistant to polyenes. In contrast to A. fumigatus, triazole resistance infrequently occurs in A. flavus and is associated with mutations in the cyp51C gene. Overexpression of efflux pumps in non-wildtype strains lacking mutations in the cyp51 gene can also lead to high voriconazole minimum inhibitory concentrations. Voriconazole remains the drug of choice for treatment, and amphotericin B should be avoided. Primary therapy with echinocandins is not the first choice but the combination with voriconazole or as monotherapy may be used when the azoles and amphotericin B are contraindicated.
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Affiliation(s)
- Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research, Chandigarh 160012, India.
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, 3015GD Rotterdam, The Netherlands.
| | - Raees A Paul
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research, Chandigarh 160012, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research, Chandigarh 160012, India
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, 3015GD Rotterdam, The Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ) and Center of Expertise, 6532SZ Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, 6532SZ Nijmegen, The Netherlands
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16
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Yang K, Shadkchan Y, Tannous J, Landero Figueroa JA, Wiemann P, Osherov N, Wang S, Keller NP. Contribution of ATPase copper transporters in animal but not plant virulence of the crossover pathogen Aspergillus flavus. Virulence 2019; 9:1273-1286. [PMID: 30027796 PMCID: PMC6177249 DOI: 10.1080/21505594.2018.1496774] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The ubiquitous fungus Aspergillus flavus is notorious for contaminating many important crops and food-stuffs with the carcinogenic mycotoxin, aflatoxin. This fungus is also the second most frequent Aspergillus pathogen after A. fumigatus infecting immunosuppressed patients. In many human fungal pathogens including A. fumigatus, the ability to defend from toxic levels of copper (Cu) is essential in pathogenesis. In A. fumigatus, the Cu-fist DNA binding protein, AceA, and the Cu ATPase transporter, CrpA, play critical roles in Cu defense. Here, we show that A. flavus tolerates higher concentrations of Cu than A. fumigatus and other Aspergillus spp. associated with the presence of two homologs of A. fumigatus CrpA termed CrpA and CrpB. Both crpA and crpB are transcriptionally induced by increasing Cu concentrations via AceA activity. Deletion of crpA or crpB alone did not alter high Cu tolerance, suggesting they are redundant. Deletion of both genes resulted in extreme Cu sensitivity that was greater than that following deletion of the regulatory transcription factor aceA. The ΔcrpAΔcrpB and ΔaceA strains were also sensitive to ROI stress. Compared to wild type, these mutants were impaired in the ability to colonize maize seed treated with Cu fungicide but showed no difference in virulence on non-treated seed. A mouse model of invasive aspergillosis showed ΔcrpAΔcrpB and to a lesser degree ΔaceA to be significantly reduced in virulence, following the greater sensitivity of ΔcrpAΔcrpB to Cu than ΔaceA.
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Affiliation(s)
- Kunlong Yang
- a Fujian Key Laboratory of Pathogenic Fungi and Mycotoxins, Key Laboratory of Biopesticide and Chemical Biology of Education Ministry, and School of Life Sciences , Fujian Agriculture and Forestry University , Fuzhou , China.,b Department of Medical Microbiology and Immunology , University of Wisconsin , Madison , WI , USA
| | - Yana Shadkchan
- c Aspergillus and Antifungal Research Laboratory, Department of Clinical Microbiology and Immunology, Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Joanna Tannous
- b Department of Medical Microbiology and Immunology , University of Wisconsin , Madison , WI , USA
| | - Julio A Landero Figueroa
- d Agilent Metallomics Center, College of Arts & Science, Chemistry Department , University of Cincinnati , Cincinnati , OH , USA
| | - Philipp Wiemann
- b Department of Medical Microbiology and Immunology , University of Wisconsin , Madison , WI , USA
| | - Nir Osherov
- c Aspergillus and Antifungal Research Laboratory, Department of Clinical Microbiology and Immunology, Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Shihua Wang
- a Fujian Key Laboratory of Pathogenic Fungi and Mycotoxins, Key Laboratory of Biopesticide and Chemical Biology of Education Ministry, and School of Life Sciences , Fujian Agriculture and Forestry University , Fuzhou , China
| | - Nancy P Keller
- b Department of Medical Microbiology and Immunology , University of Wisconsin , Madison , WI , USA
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17
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Efficacy of Luliconazole Against Broad-Range Filamentous Fungi Including Fusarium solani Species Complex Causing Fungal Keratitis. Cornea 2019; 38:238-242. [PMID: 30422866 PMCID: PMC6343950 DOI: 10.1097/ico.0000000000001812] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE Fungal keratitis can be difficult to medically treat. Topical antifungals are usually applied empirically as the initial option in treating fungal keratitis. Natamycin (NAT) and/or voriconazole (VRCZ) have been widely used in the treatment of fungal keratitis. However, Fusarium solani species complex (FSSC), which are the dominant species of fungal keratitis, are resistant to VRCZ. This study investigated in vitro efficacy of luliconazole (LLCZ), a new imidazole antifungal, against FSSC and other filamentous fungi. METHODS A total of 18 Fusarium isolates and 7 others were grown on potato dextrose agar at 30 and 37°C. For Fusarium, species identification and phylogenetic tree analysis were performed based on elongation factor-1α (EF-1α) DNA sequencing. The broth microdilution method was used for antifungal susceptibility testing of 11 antifungal drugs including LLCZ. RESULTS The 18 identified Fusarium isolates belonged to FSSC (n = 13), Fusarium oxysporum species complex (FOSC; n = 2), Fusarium chlamydosporum species complex (FCSC; n = 1), Fusarium incarnatum-equiseti species complex (FIESC; n = 1), and Fusarium fujikuroi species complex (FFSC; n = 1). We further divided 13 FSSC isolates into 3 clades, FSSC5 (n = 8), FSSC3 + 4 (n = 4), and FSSC9-a (n = 1), with 8 FSSC strains growing at 37°C. LLCZ showed lowest minimum inhibitory concentrations (MICs) against all tested filamentous fungi, with a MIC90 against the Fusarium species of 0.06 μg/mL, whereas MIC90 for NAT and VRCZ were 4 and 8 μg/mL, respectively. CONCLUSIONS LLCZ has the strongest in vitro antifungal activity among all drugs used against broad-range filamentous fungi including FSSC. LLCZ may potentially be a new medical treatment option for fungal keratitis.
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18
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Epidemiology of antifungal susceptibility: Review of literature. J Mycol Med 2019; 28:574-584. [PMID: 29773435 DOI: 10.1016/j.mycmed.2018.04.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 11/24/2022]
Abstract
Fungal infections are a major cause of morbidity and mortality despite the latest developments of diagnostic tools and therapeutic options. Early initiation of the appropriate antifungal therapy has been demonstrated to have a direct impact on the patient's outcome. Antifungal susceptibility testing methods are available to detect antifungal resistance and to determine the best treatment for a specific fungus. American and European standards have been developed, as well as equivalent commercial systems, which are more appropriate for clinical laboratories. These studies have allowed the development of interpretative breakpoints against the most frequent agents of fungal infections in the world. Surveillance of antifungal susceptibility patterns can provide the local drug resistance data to the clinicians, which can further aid better management of patients. Antifungal susceptibility tests have become essential tools to identify resistance to antifungals, to know the local and global disease epidemiology and to guide the treatment of fungal diseases. The distribution of species and the prevalence of antifungal resistance in fungi isolates varied among different areas. Here we summarize the epidemiology of antifungal susceptibility pattern of different fungal species.
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19
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Affiliation(s)
- Prashant Garg
- Tej Kohli Cornea Institute, KAR campus, L. V. Prasad Eye Institute, Hyderabad, India
| | - Aravind Roy
- Tej Kohli Cornea Institute, KVC campus, L. V. Prasad Eye Institute, Vijayawada, India
| | - Paavan Kalra
- Tej Kohli Cornea Institute, KAR campus, L. V. Prasad Eye Institute, Hyderabad, India
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20
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Determination and Prevalence of Bacterial and Fungal Keratitis among Patients in Baghdad City. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2018. [DOI: 10.22207/jpam.12.3.49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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21
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Oldenburg CE, Prajna NV, Krishnan T, Rajaraman R, Srinivasan M, Ray KJ, O’Brien KS, Glymour MM, Porco TC, Acharya NR, Rose-Nussbaumer J, Lietman TM. Regression Discontinuity and Randomized Controlled Trial Estimates: An Application to The Mycotic Ulcer Treatment Trials. Ophthalmic Epidemiol 2018; 25:315-322. [PMID: 29718751 PMCID: PMC5980795 DOI: 10.1080/09286586.2018.1469156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/20/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE We compare results from regression discontinuity (RD) analysis to primary results of a randomized controlled trial (RCT) utilizing data from two contemporaneous RCTs for treatment of fungal corneal ulcers. METHODS Patients were enrolled in the Mycotic Ulcer Treatment Trials I and II (MUTT I & MUTT II) based on baseline visual acuity: patients with acuity ≤ 20/400 (logMAR 1.3) enrolled in MUTT I, and >20/400 in MUTT II. MUTT I investigated the effect of topical natamycin versus voriconazole on best spectacle-corrected visual acuity. MUTT II investigated the effect of topical voriconazole plus placebo versus topical voriconazole plus oral voriconazole. We compared the RD estimate (natamycin arm of MUTT I [N = 162] versus placebo arm of MUTT II [N = 54]) to the RCT estimate from MUTT I (topical natamycin [N = 162] versus topical voriconazole [N = 161]). RESULTS In the RD, patients receiving natamycin had mean improvement of 4-lines of visual acuity at 3 months (logMAR -0.39, 95% CI: -0.61, -0.17) compared to topical voriconazole plus placebo, and 2-lines in the RCT (logMAR -0.18, 95% CI: -0.30, -0.05) compared to topical voriconazole. CONCLUSIONS The RD and RCT estimates were similar, although the RD design overestimated effects compared to the RCT.
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Affiliation(s)
| | | | | | | | | | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
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22
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Mahmoudi S, Masoomi A, Ahmadikia K, Tabatabaei SA, Soleimani M, Rezaie S, Ghahvechian H, Banafsheafshan A. Fungal keratitis: An overview of clinical and laboratory aspects. Mycoses 2018; 61:916-930. [PMID: 29992633 DOI: 10.1111/myc.12822] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/28/2018] [Indexed: 12/22/2022]
Abstract
Mycotic keratitis or keratomycosis is a fungal infection with global distribution. The dominant aetiology of this disease varies based on geographical origin, socioeconomic status, and climatic condition. Generally, Aspergillus spp. and Fusarium spp. are common in tropical and subtropical regions and Candida spp. are dominant in temperate areas. Demonstration of fungal elements in microscopic examination besides the isolation of fungi in culture is the gold standard of laboratory diagnosis. As the culture is a time-consuming procedure, other approaches such as in vivo confocal microscopy which produces real-time imaging of corneal tissue and molecular techniques have been developed to facilitate rapid diagnosis of fungal keratitis. The first choice of treatment is topical natamycin, although topical amphotericin B is the best choice for Aspergillus and Candida keratitis. Regarding the diversity of fungal aetiology and the emergence of drug resistance in some genera and species, proper identification using molecular methods and antifungal susceptibility testing could provide useful data. Furthermore, as the better efficacy of combination therapy in comparison to monotherapy is reported, in vitro determination of interactions between various drugs seem informative. This review aims to provide a general and updated view on the aetiology, risk factors, epidemiology, clinical and laboratory diagnosis, and management of fungal keratitis.
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Affiliation(s)
- Shahram Mahmoudi
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Masoomi
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Ahmadikia
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Ali Tabatabaei
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Soleimani
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sassan Rezaie
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ghahvechian
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Banafsheafshan
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
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23
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Dallé da Rosa P, Nunes A, Borges R, Batista B, Meneghello Fuentefria A, Goldani LZ. In vitro susceptibility and multilocus sequence typing of Fusarium isolates causing keratitis. J Mycol Med 2018; 28:482-485. [PMID: 29779647 DOI: 10.1016/j.mycmed.2018.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/28/2018] [Accepted: 05/03/2018] [Indexed: 01/07/2023]
Abstract
Fungal keratitis is recognized as a significant cause of ocular morbidity and blindness especially in developing countries. In this study, we aimed to present the molecular identification and susceptibility of Fusarium isolates causing fungal keratitis in a university hospital in southern Brazil. The samples were identified using the second largest subunit of the RNA polymerase gene (RPB2) and the translation elongation factor 1-alpha (TEF1), while the antifungal susceptibility was tested by the broth microdilution method according to the Clinical and Laboratory Standards Institute (CLSI) methodology. The majority of the isolates belonged to the Fusarium solani species complex (F. solani, F. keratoplasticum and F. falciforme) and Fusarium oxysporum species complex. Antifungal susceptibility has shown that amphotericin B and natamycin were the most effective antifungals across all isolates, followed by voriconazole. Variation among Fusarium complexes in their antifungal sensitivities was observed in our study. The identification of Fusarium species from human samples is important not only from an epidemiological viewpoint, but also for choosing the appropriate antifungal agent for difficult-to-treat Fusarium infections such as keratitis.
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Affiliation(s)
- P Dallé da Rosa
- Programa de Pós-graduação em Medicina: Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - A Nunes
- Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - R Borges
- Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - B Batista
- Programa de Pós-graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - A Meneghello Fuentefria
- Programa de Pós-graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - L Z Goldani
- Programa de Pós-graduação em Medicina: Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Natamycin and Azithromycin Are Synergistic In Vitro against Ocular Pathogenic Aspergillus flavus Species Complex and Fusarium solani Species Complex Isolates. Antimicrob Agents Chemother 2018; 62:AAC.00077-18. [PMID: 29735563 DOI: 10.1128/aac.00077-18] [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] [Received: 01/12/2018] [Accepted: 05/01/2018] [Indexed: 11/20/2022] Open
Abstract
The interaction of natamycin-azithromycin combination against 60 ocular fungal isolates was tested in vitro The combination produced 100% synergistic interactions when natamycin was added to azithromycin 20, 40, and 50 μg/ml against Aspergillus flavus species complex (AFSC) isolates and to azithromycin 50 μg/ml against Fusarium solani species complex isolates. Addition of 50 μg/ml azithromycin enhanced natamycin's effect against AFSC isolates by reducing natamycin MIC90 from 64 to 0.031 μg/ml. No antagonism was observed.
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da Rosa PD, Locatelli C, Scheid K, Marinho D, Kliemann L, Fuentefria A, Goldani LZ. Antifungal Susceptibility, Morphological and Molecular Characterization of Lasiodiplodia theobromae Isolated from a Patient with Keratitis. Mycopathologia 2018; 183:565-571. [PMID: 29383575 DOI: 10.1007/s11046-017-0234-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/05/2017] [Indexed: 11/27/2022]
Abstract
Lasiodiplodia theobromae is a rare ocular pathogen. We report a patient with fungal keratitis caused by L. theobromae. The patient was a 75-year-old male, a farmer with diabetes type II, and no previous history of ocular trauma. Histopathology analysis revealed the presence fungi invading Descemet's membrane of the cornea. The fungus was characterized by septate, highly bulged fungal filaments involving full corneal thickness in the corresponding histopathology specimens. A dematiaceous mold was isolated and initally identified as L. theobromae by microscopic and macroscopic morphology, and further confirmed by PCR-based determination of internal transcribed spacer (ITS) regions of ribosomal DNA. Antifungal susceptibility tests showed sensitivity to amphotericin B (AMB) and voriconazole ( VRC), and resistance to other azoles, including itraconazole (ITC) and fluconazole (FLC). Corneal transplant was performed. Despite in vitro itraconazole resistance, the patient was successfully treated with oral itraconazole, topical voriconazole and natamycin, combined with ocular injections of amphotericin B and voriconazole.
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MESH Headings
- Aged
- Antifungal Agents/administration & dosage
- Antifungal Agents/pharmacology
- Ascomycota/cytology
- Ascomycota/drug effects
- Ascomycota/genetics
- Ascomycota/isolation & purification
- Cornea/pathology
- Corneal Transplantation
- DNA, Fungal/chemistry
- DNA, Fungal/genetics
- DNA, Ribosomal Spacer/chemistry
- DNA, Ribosomal Spacer/genetics
- Diabetes Mellitus, Type 2/complications
- Drug Resistance, Fungal
- Eye Infections, Fungal/drug therapy
- Eye Infections, Fungal/microbiology
- Eye Infections, Fungal/surgery
- Histocytochemistry
- Humans
- Keratitis/drug therapy
- Keratitis/microbiology
- Keratitis/surgery
- Male
- Microbial Sensitivity Tests
- Microbiological Techniques
- Polymerase Chain Reaction
- Sequence Analysis, DNA
- Treatment Outcome
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Affiliation(s)
- Priscila Dallé da Rosa
- Programa de Pós-Graduação em Medicina: Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Claudete Locatelli
- Serviço de Oftalmologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Karla Scheid
- Serviço de Oftalmologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Diane Marinho
- Serviço de Oftalmologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Lúcia Kliemann
- Departamento de Patologia da Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Alexandre Fuentefria
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Luciano Zubaran Goldani
- Programa de Pós-Graduação em Medicina: Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Infectious Diseases Unit, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Sradhanjali S, Yein B, Sharma S, Das S. In vitro synergy of natamycin and voriconazole against clinical isolates of Fusarium, Candida, Aspergillus and Curvularia spp. Br J Ophthalmol 2017; 102:142-145. [DOI: 10.1136/bjophthalmol-2017-310683] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/23/2017] [Accepted: 08/21/2017] [Indexed: 11/04/2022]
Abstract
AimTo determine the minimum inhibitory concentrations (MICs) of voriconazole and natamycin, alone and in combination, against the clinical isolates of Fungus and to evaluate the synergy between the drugs in an experimental in vitro study.MethodsIn an experimental in vitro study, clinical isolates of Fusarium, Aspergillus, Candida and Curvularia spp were maintained on Sabouraud Dextrose Agar and used for the study. The MICs of natamycin and voriconazole, used alone and in combination, were evaluated by checkerboard microdilution technique based on the standard protocol proposed by the Clinical Laboratory Standards Institute. The interactions were assessed using the fractional inhibitory concentration (FIC) Index model.ResultsTested with all the clinical isolates, the MICs ranged between 0.125 and 8 µg/mL both for natamycin and voriconazole. In descending order, maximum synergism (FIC ≤0.5) was observed in Candida spp (33.3%) followed by Curvularia spp and Fusarium spp (23.1%). Synergism was least for Aspergillus spp (22.2%). However, at 61.5% (8/13), maximum additive effect (>0.5–1) was observed in Aspergillus spp and minimum (33.3%, 2/6) in Candida spp. Indifference (FIC value >1 and≤4) was observed in 22.2% (2/9) of Aspergillus spp, 15.4% (2/13) of Fusarium spp, 33.3% (2/6) of Candida spp and 23.1% (3/13) of Curvularia spp. No cases of antagonism (FIC >4) were observed.ConclusionsNatamycin and voriconazole in combination demonstrated more effective antifungal activity than single-use in vitro treatment in all species tested, which implies that these combinations may be helpful in treating fungal keratitis. There was no antagonism between these two drugs.
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27
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Management of Fungal Keratitis in Pediatric Patients. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2017. [DOI: 10.5812/pedinfect.61625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Maharana PK, Sharma N, Nagpal R, Jhanji V, Das S, Vajpayee RB. Recent advances in diagnosis and management of Mycotic Keratitis. Indian J Ophthalmol 2017; 64:346-57. [PMID: 27380973 PMCID: PMC4966371 DOI: 10.4103/0301-4738.185592] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mycotic keratitis is a major cause of corneal blindness, especially in tropical and subtropical countries. The prognosis is markedly worse compared to bacterial keratitis. Delayed diagnosis and scarcity of effective antifungal agents are the major factors for poor outcome. Over the last decade, considerable progress has been made to rapidly diagnose cases with mycotic keratitis and increase the efficacy of treatment. This review article discusses the recent advances in diagnosis and management of mycotic keratitis with a brief discussion on rare and emerging organisms. A MEDLINE search was carried out for articles in English language, with the keywords, mycotic keratitis, fungal keratitis, emerging or atypical fungal pathogens in mycotic keratitis, investigations in mycotic keratitis, polymerase chain reaction in mycotic keratitis, confocal microscopy, treatment of mycotic keratitis, newer therapy for mycotic keratitis. All relevant articles were included in this review. Considering the limited studies available on newer diagnostic and therapeutic modalities in mycotic keratitis, case series as well as case reports were also included if felt important.
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Affiliation(s)
- Prafulla K Maharana
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Namrata Sharma
- Cornea and Refractive Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Nagpal
- Department of Ophthalmology, L.V. Prasad Eye Institute, Hyderabad, India
| | - Vishal Jhanji
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Sujata Das
- Department of Ophthalmology, L.V. Prasad Eye Institute, Bhubaneswar, India
| | - Rasik B Vajpayee
- Department of Ophthalmology, Vision Eye Institute, Royal Victorian Eye and Ear Hospital, North West Academic Centre, University of Melbourne, Australia
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29
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Al-Hatmi AMS, Bonifaz A, Ranque S, Sybren de Hoog G, Verweij PE, Meis JF. Current antifungal treatment of fusariosis. Int J Antimicrob Agents 2017; 51:326-332. [PMID: 28705676 DOI: 10.1016/j.ijantimicag.2017.06.017] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/28/2017] [Accepted: 06/24/2017] [Indexed: 12/12/2022]
Abstract
Fungi of the genus Fusarium are well known as major plant pathogens and soil inhabitants, but also cause a broad spectrum of human infections. Fusariosis is the second most common mould infection after aspergillosis, and keratitis is the most encountered implantation infection in immunocompetent individuals. Natamycin is active against Fusarium species both in vitro and in vivo, and is used along with voriconazole as the mainstay of treatment for Fusarium keratitis. Onychomycosis is treated with terbinafine, voriconazole and sometimes itraconazole. Cure is possible despite high in vitro minimum inhibitory concentrations (MICs). Recently, disseminated infections have increased dramatically, mainly affecting severely immunocompromised patients. The remarkable intrinsic resistance of Fusarium species to most antifungal agents results in high mortality rates in this patient population. Recovery of neutropenia is essential for patient survival and treatment should include voriconazole or amphotericin B as first-line and posaconazole as salvage therapy.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Directorate General of Health Services, Ministry of Health, Ibri Hospital, Ibri, Oman; Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands.
| | - Alexandro Bonifaz
- Hospital General de México, 'Dr. Eduardo Liceaga', Mexico City, Mexico
| | - Stephane Ranque
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands; Basic Pathology Department, Federal University of Paraná State, Curitiba, Paraná, Brazil; Biological Sciences Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paul E Verweij
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jacques F Meis
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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30
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Srinivasan M, Das M, Ray KJ, O'Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Porco TC, Acharya NR, Lietman TM, Rose-Nussbaumer J. Effect of Oral Voriconazole on Fungal Keratitis in the Mycotic Ulcer Treatment Trial II (MUTT II): A Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:1365-1372. [PMID: 27787540 DOI: 10.1001/jamaophthalmol.2016.4096] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective To compare oral voriconazole with placebo in addition to topical antifungals in the treatment of filamentous fungal keratitis. Design, Setting, and Participants The Mycotic Ulcer Treatment Trial II (MUTT II), a multicenter, double-masked, placebo-controlled, randomized clinical trial, was conducted in India and Nepal, with 2133 individuals screened for inclusion. Patients with smear-positive filamentous fungal ulcers and visual acuity of 20/400 (logMAR 1.3) or worse were randomized to receive oral voriconazole vs oral placebo; all participants received topical antifungal eyedrops. The study was conducted from May 24, 2010, to November 23, 2015. All trial end points were analyzed on an intent-to-treat basis. Interventions Study participants were randomized to receive oral voriconazole vs oral placebo; a voriconazole loading dose of 400 mg was administered twice daily for 24 hours, followed by a maintenance dose of 200 mg twice daily for 20 days, with dosing altered to weight based during the trial. All participants received topical voriconazole, 1%, and natamycin, 5%. Main Outcomes and Measures The primary outcome of the trial was rate of corneal perforation or the need for therapeutic penetrating keratoplasty (TPK) within 3 months. Secondary outcomes included microbiologic cure at 6 days, rate of re-epithelialization, best-corrected visual acuity and infiltrate and/or scar size at 3 weeks and 3 months, and complication rates associated with voriconazole use. Results A total of 2133 patients in India and Nepal with smear-positive ulcers were screened; of the 787 who were eligible, 240 (30.5%) were enrolled. Of the 119 patients (49.6%) in the oral voriconazole treatment group, 65 were male (54.6%), and the median age was 54 years (interquartile range, 42-62 years). Overall, no difference in the rate of corneal perforation or the need for TPK was determined for oral voriconazole vs placebo (hazard ratio, 0.82; 95% CI, 0.57-1.18; P = .29). In prespecified subgroup analyses comparing treatment effects among organism subgroups, there was some suggestion that Fusarium species might have a decreased rate of perforation or TPK in the oral voriconazole-treated arm; however, this was not a statistically significant finding after Holms-Šidák correction for multiple comparisons (effect coefficient, 0.49; 95% CI, 0.26-0.92; P = .03). Patients receiving oral voriconazole experienced a total of 58 adverse events (48.7%) compared with 28 adverse events (23.1%) in the placebo group (P < .001 after Holms-Šidák correction for multiple comparisons). Conclusions and Relevance There appears to be no benefit to adding oral voriconazole to topical antifungal agents in the treatment of severe filamentous fungal ulcers. All patients in this study were enrolled in India and Nepal; therefore, it is possible that organisms in this region may exhibit characteristics different from those in other regions of the world. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | | | - Muthiah Srinivasan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | | | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
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Al-Hatmi AMS, Curfs-Breuker I, de Hoog GS, Meis JF, Verweij PE. Antifungal Susceptibility Testing of Fusarium: A Practical Approach. J Fungi (Basel) 2017; 3:jof3020019. [PMID: 29371537 PMCID: PMC5715922 DOI: 10.3390/jof3020019] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 04/14/2017] [Accepted: 04/19/2017] [Indexed: 12/12/2022] Open
Abstract
In vitro susceptibility testing of Fusarium is becoming increasingly important because of frequency and diversity of infections and because resistance profiles are species-specific. Reference methods for antifungal susceptibility testing (AFST) are those of Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility (EUCAST), but breakpoints (BPs) have not yet been established. One of the problems is that phylogenetic distances between Fusarium species are much smaller than between species of, e.g., Candida. Epidemiological cutoff values (ECVs) for some Fusarium species have been determined in order to differentiate wild-type from non-wild-type isolates. In clinical routine, commercially available assays such as Etest, Sensititre or others provide essential agreement with reference methods. Our objective is to summarize antifungal susceptibility testing of Fusarium genus in the clinical laboratory: how to do it, when to do it, and how to interpret it.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- Westerdijk Fungal Biodiversity Institute, PO Box 85167, 3508 AD Utrecht, The Netherlands.
- Centre of Expertise in Mycology Radboud University Medical Centre, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
- Ministry of Health, Directorate General of Health Services, PO Box 393, 100 Muscat, Oman.
| | - Ilse Curfs-Breuker
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, PO Box 85167, 3508 AD Utrecht, The Netherlands.
- Basic Pathology Department, Federal University of Paraná State, Curitiba, 81540-970 Paraná, Brazil.
- Biological Sciences Department, Faculty of Science, King Abdulaziz University, PO Box 80203 Jeddah, Saudi Arabia.
| | - Jacques F Meis
- Centre of Expertise in Mycology Radboud University Medical Centre, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
| | - Paul E Verweij
- Centre of Expertise in Mycology Radboud University Medical Centre, Canisius Wilhelmina Hospital, 6500HB Nijmegen, The Netherlands.
- Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, 6500GS Nijmegen, The Netherlands.
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Rifampin Enhances the Activity of Amphotericin B against Fusarium solani Species Complex and Aspergillus flavus Species Complex Isolates from Keratitis Patients. Antimicrob Agents Chemother 2017; 61:AAC.02069-16. [PMID: 28115342 DOI: 10.1128/aac.02069-16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/15/2017] [Indexed: 11/20/2022] Open
Abstract
The in vitro activities of amphotericin B in combination with rifampin were assessed against 95 ocular fungal isolates. The interactions between amphotericin B and rifampin at 4, 8, 16, and 32 μg/ml were synergistic for 11.8%, 51.0%, 90.2%, and 94.1%, respectively, of Fusarium solani species complex isolates and for 13.6%, 45.5%, 93.2%, and 95.5%, respectively, of Aspergillus flavus species complex isolates. Antagonism was never observed for the amphotericin B-rifampin combinations.
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Chidambaram JD, Prajna NV, Larke N, Macleod D, Srikanthi P, Lanjewar S, Shah M, Lalitha P, Elakkiya S, Burton MJ. In vivo confocal microscopy appearance of Fusarium and Aspergillus species in fungal keratitis. Br J Ophthalmol 2017; 101:1119-1123. [PMID: 28043985 PMCID: PMC5537506 DOI: 10.1136/bjophthalmol-2016-309656] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/07/2016] [Accepted: 11/27/2016] [Indexed: 11/12/2022]
Abstract
Background Clinical outcomes in fungal keratitis vary between Fusarium and Aspergillus spp, therefore distinguishing between species using morphological features such as filament branching angles, sporulation along filaments (adventitious sporulation) or dichotomous branching may be useful. In this study, we assessed these three features within Heidelberg Retina Tomograph 3 in vivo confocal microscopy (IVCM) images from culture-positive Fusarium and Aspergillus spp keratitis participants. Methods Prospective observational cohort study in Aravind Eye Hospital (February 2011–February 2012). Eligibility criteria: age ≥18 years, stromal infiltrate ≥3 mm diameter, Fusarium or Aspergillus spp culture-positive. Exclusion criteria: previous/current herpetic keratitis, visual acuity <6/60 in fellow eye, >80% corneal thinning. IVCM was performed and images analysed for branch angle, presence/absence of adventitious sporulation or dichotomous branching by a grader masked to the microbiological diagnosis. Results 98 participants were included (106 eligible, 8 excluded as no measurable branch angles); 68 were positive for Fusarium spp, 30 for Aspergillus spp. Mean branch angle for Fusarium spp was 59.7° (95% CI 57.7° to 61.8°), and for Aspergillus spp was 63.3° (95% CI 60.8° to 65.8°), p=0.07. No adventitious sporulation was detected in Fusarium spp ulcers. Dichotomous branching was detected in 11 ulcers (7 Aspergillus spp, 4 Fusarium spp). Conclusions There was very little difference in the branching angle of Fusarium and Aspergillus spp. Adventitious sporulation was not detected and dichotomous branching was infrequently seen. Although IVCM remains a valuable tool to detect fungal filaments in fungal keratitis, it cannot be used to distinguish Fusarium from Aspergillus spp and culture remains essential to determine fungal species.
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Affiliation(s)
- Jaya Devi Chidambaram
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Natasha Larke
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Manisha Shah
- Aravind Eye Hospital, Madurai, Tamil Nadu, India.,Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Prajna Lalitha
- Aravind Eye Hospital, Madurai, Tamil Nadu, India.,Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Shanmugam Elakkiya
- Aravind Eye Hospital, Madurai, Tamil Nadu, India.,Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
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Davies EC, Daly MK, Siracuse-Lee D. A rare case of Phialemonium obovatum keratitis. Am J Ophthalmol Case Rep 2016; 5:81-84. [PMID: 29503953 PMCID: PMC5758013 DOI: 10.1016/j.ajoc.2016.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 12/01/2016] [Indexed: 11/13/2022] Open
Abstract
Purpose We report a rare case of Phialemonium obovatum fungal keratitis in a patient sustaining a corneal laceration from impact with a piece of moldy plaster. Observations The patient was treated with topical voriconazole with resolution of active keratitis and formation of a stromal scar. The patient's final visual acuity was 20/20 in the affected eye. Conclusions and importance There is only one other case of Phialemonium obovatum keratitis reported in the literature. The patient in the previous case required amniotic membrane transplantation for persistent stromal melting with resultant visual acuity of hand motions only. The present case demonstrates that the early use of topical antifungal medication with close follow-up can prevent corneal perforation and result in excellent visual acuity.
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Affiliation(s)
- Emma C Davies
- Department of Ophthalmology, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, USA.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, USA
| | - Mary K Daly
- Department of Ophthalmology, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, USA.,Department of Ophthalmology, Boston University School of Medicine, 85 East Concord Street, Boston, MA, USA.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, USA
| | - Donna Siracuse-Lee
- Department of Ophthalmology, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, USA.,Department of Ophthalmology, Boston University School of Medicine, 85 East Concord Street, Boston, MA, USA
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35
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Streekstra H, Verkennis AE, Jacobs R, Dekker A, Stark J, Dijksterhuis J. Fungal strains and the development of tolerance against natamycin. Int J Food Microbiol 2016; 238:15-22. [DOI: 10.1016/j.ijfoodmicro.2016.08.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/21/2016] [Accepted: 08/03/2016] [Indexed: 11/26/2022]
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36
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Hagiwara D, Watanabe A, Kamei K, Goldman GH. Epidemiological and Genomic Landscape of Azole Resistance Mechanisms in Aspergillus Fungi. Front Microbiol 2016; 7:1382. [PMID: 27708619 PMCID: PMC5030247 DOI: 10.3389/fmicb.2016.01382] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/22/2016] [Indexed: 11/13/2022] Open
Abstract
Invasive aspergillosis is a life-threatening mycosis caused by the pathogenic fungus Aspergillus. The predominant causal species is Aspergillus fumigatus, and azole drugs are the treatment of choice. Azole drugs approved for clinical use include itraconazole, voriconazole, posaconazole, and the recently added isavuconazole. However, epidemiological research has indicated that the prevalence of azole-resistant A. fumigatus isolates has increased significantly over the last decade. What is worse is that azole-resistant strains are likely to have emerged not only in response to long-term drug treatment but also because of exposure to azole fungicides in the environment. Resistance mechanisms include amino acid substitutions in the target Cyp51A protein, tandem repeat sequence insertions at the cyp51A promoter, and overexpression of the ABC transporter Cdr1B. Environmental azole-resistant strains harboring the association of a tandem repeat sequence and punctual mutation of the Cyp51A gene (TR34/L98H and TR46/Y121F/T289A) have become widely disseminated across the world within a short time period. The epidemiological data also suggests that the number of Aspergillus spp. other than A. fumigatus isolated has risen. Some non-fumigatus species intrinsically show low susceptibility to azole drugs, imposing the need for accurate identification, and drug susceptibility testing in most clinical cases. Currently, our knowledge of azole resistance mechanisms in non-fumigatus Aspergillus species such as A. flavus, A. niger, A. tubingensis, A. terreus, A. fischeri, A. lentulus, A. udagawae, and A. calidoustus is limited. In this review, we present recent advances in our understanding of azole resistance mechanisms particularly in A. fumigatus. We then provide an overview of the genome sequences of non-fumigatus species, focusing on the proteins related to azole resistance mechanisms.
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Affiliation(s)
| | - Akira Watanabe
- Medical Mycology Research Center, Chiba University Chiba, Japan
| | - Katsuhiko Kamei
- Medical Mycology Research Center, Chiba University Chiba, Japan
| | - Gustavo H Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo Ribeirão Preto, Brazil
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Abashina T, Laurinavichius K, Vainshtein M. Suppositional area for the search of bacterial products for anticancer therapy. Med Hypotheses 2016; 92:54-6. [PMID: 27241255 DOI: 10.1016/j.mehy.2016.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 10/21/2022]
Abstract
It is well-known that bacteria can produce compounds which show anticancer effects. In present time, it is impossible to check all bacterial species on their possible production of anticancer compounds (AC) under different conditions. Thus, it is necessary to limit the area for search of bacterial products for the anticancer therapy. We propose that production of AC by bacteria is a part of microbial biological strategy under natural conditions. We propose that bacteria in soils, in water and on plants do not meet human tumors and their AC serve for the competition with eukaryotic organisms. Most probably, an epiphytic growth of bacilli is accompanied with production of compounds inhibiting eukaryotes. According to awaited profit for the AC-producing bacteria, the epiphytic groups of bacilli show inhibition of mycelial fungi which are a natural model of eukaryotic cells. An example of strain isolation and a primary test is presented.
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Affiliation(s)
- Tatiana Abashina
- Institute of Biochemistry and Physiology of Microorganisms, Russ. Ac. Sci., Prospekt Nauki 5, Pushchino, Moscow Region 142290, Russia.
| | - Kestutis Laurinavichius
- Institute of Biochemistry and Physiology of Microorganisms, Russ. Ac. Sci., Prospekt Nauki 5, Pushchino, Moscow Region 142290, Russia.
| | - Mikhail Vainshtein
- Institute of Biochemistry and Physiology of Microorganisms, Russ. Ac. Sci., Prospekt Nauki 5, Pushchino, Moscow Region 142290, Russia; Pushchino State Institute of Natural Sciences, Prospekt Nauki 5, Pushchino, Moscow Region 142290, Russia.
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Öz Y, Özdemir HG, Gökbolat E, Kiraz N, Ilkit M, Seyedmousavi S. Time-Kill Kinetics and In Vitro Antifungal Susceptibility of Non-fumigatus Aspergillus Species Isolated from Patients with Ocular Mycoses. Mycopathologia 2015; 181:225-33. [PMID: 26612621 PMCID: PMC4786614 DOI: 10.1007/s11046-015-9969-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/12/2015] [Indexed: 11/25/2022]
Abstract
Aspergillus species can cause ocular morbidity and blindness, and thus, appropriate antifungal therapy is needed. We investigated the in vitro activity of itraconazole, voriconazole, posaconazole, caspofungin, anidulafungin, and amphotericin B against 14 Aspergillus isolates obtained from patients with ocular mycoses, using the CLSI reference broth microdilution methodology. In addition, time-kill assays were performed, exposing each isolate separately to 1-, 4-, and 16-fold concentrations above the minimum inhibitory concentration (MIC) of each antifungal agent. A sigmoid maximum-effect (Emax) model was used to fit the time-kill curve data. The drug effect was further evaluated by measuring an increase/decrease in the killing rate of the tested isolates. The MICs of amphotericin B, itraconazole, voriconazole, and posaconazole were 0.5–1.0, 1.0, 0.5–1.0, and 0.25 µg/ml for A. brasiliensis, A. niger, and A. tubingensis isolates, respectively, and 2.0–4.0, 0.5, 1.0 for A. flavus, and 0.12–0.25 µg/ml for A. nomius isolates, respectively. A. calidoustus had the highest MIC range for the azoles (4.0–16.0 µg/ml) among all isolates tested. The minimum effective concentrations of caspofungin and anidulafungin were ≤0.03–0.5 µg/ml and ≤0.03 µg/ml for all isolates, respectively. Posaconazole demonstrated maximal killing rates (Emax = 0.63 h−1, r2 = 0.71) against 14 ocular Aspergillus isolates, followed by amphotericin B (Emax = 0.39 h−1, r2 = 0.87), voriconazole (Emax = 0.35 h−1, r2 = 0.098), and itraconazole (Emax = 0.01 h−1, r2 = 0.98). Overall, the antifungal susceptibility of the non-fumigatusAspergillus isolates tested was species and antifungal agent dependent. Analysis of the kinetic growth assays, along with consideration of the killing rates, revealed that posaconazole was the most effective antifungal against all of the isolates.
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Affiliation(s)
- Yasemin Öz
- Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Eskisehir Osmangazi, Eskisehir, Turkey
| | - Havva Gül Özdemir
- Division of Ophthalmology, Medicosocial Health Center, University of Çukurova, Adana, Turkey
| | - Egemen Gökbolat
- Department of Microbiology, Faculty of Medicine, University of Eskisehir Osmangazi, Eskisehir, Turkey
| | - Nuri Kiraz
- Division of Mycology, Department of Microbiology, Cerrahpasa Faculty of Medicine, University of Istanbul, Istanbul, Turkey
| | - Macit Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Çukurova, Adana, Turkey
| | - Seyedmojtaba Seyedmousavi
- Department of Medical Microbiology and Infectious Diseases, ErasmusMC, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. .,Department of Medical Microbiology, Radboud UMC, Nijmegen, The Netherlands. .,Invasive Fungi Research Center, Mazandaran University of Medical Sciences, Sari, Iran.
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Araujo R, Oliveira M, Amorim A, Sampaio-Maia B. Unpredictable susceptibility of emerging clinical moulds to tri-azoles: review of the literature and upcoming challenges for mould identification. Eur J Clin Microbiol Infect Dis 2015; 34:1289-301. [PMID: 25894985 DOI: 10.1007/s10096-015-2374-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 03/23/2015] [Indexed: 02/06/2023]
Abstract
Tri-azoles represent the front-line drugs for the treatment of mould diseases; nevertheless, some emerging moulds, such as Fusarium spp., Scedosporium spp., Mucorales and others, may be less susceptible or resistant to these antifungals. A review of the literature was conducted on the susceptibility of rare moulds to the tri-azoles itraconazole, posaconazole and voriconazole. Particular attention was paid to isolates identified by molecular analyses. The range of susceptibility values described for the three tri-azoles was frequently large (from 0.06 to >16), and a high variability was found within each species; isolates were rarely reported as entirely susceptible to all tri-azoles. In addition, the susceptibility of 76 emerging moulds from our collection (including Hypocreales, Dothideomycetes, Scedosporium spp., Mucorales and rare Aspergillus spp.) to itraconazole and voriconazole was determined by the Clinical and Laboratory Standards Institute (CLSI) M38-A2 and European Committee for Antimicrobial Susceptibility Testing (EUCAST) methods. Susceptibility discrepancies (of two dilutions) were found comparing CLSI and EUCAST for Dothideomycetes; the values for the remaining moulds were similar. More practical, faster and inexpensive susceptibility tools are welcome for testing emerging moulds, as these tests still represent a critical tool to support clinicians on the selection of proper antifungal treatment. The susceptibility of emerging moulds to tri-azoles cannot be predicted exclusively following mould identification, as the isolates' susceptibilities showed highly variable values. Some emerging moulds still remain very difficult to identity, even following standard molecular analyses which result in complex fungal collections. This fact limits the definition of epidemiological cut-offs and clinical breakpoints that are still imperative for emerging moulds.
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Affiliation(s)
- R Araujo
- IPATIMUP, Institute of Molecular Pathology and Immunology, University of Porto, Rua Dr. Roberto Frias s/n, 4200-465, Porto, Portugal,
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Abstract
BACKGROUND Fungal keratitis is a fungal infection of the cornea. It is common in lower income countries, particularly in agricultural areas but relatively uncommon in higher income countries. Although there are medications available, their effectiveness is unclear. OBJECTIVES To assess the effects of different antifungal drugs in the management of fungal keratitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 2), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to March 2015), EMBASE (January 1980 to March 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to March 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 16 March 2015. SELECTION CRITERIA We included randomised controlled trials of medical therapy for fungal keratitis. DATA COLLECTION AND ANALYSIS Two review authors selected studies for inclusion in the review, assessed trials for risk of bias and extracted data. The primary outcome was clinical cure at two to three months. Secondary outcomes included best-corrected visual acuity, time to clinical cure, compliance with treatment, adverse outcomes and quality of life. MAIN RESULTS We included 12 trials in this review; 10 trials were conducted in India, one in Bangladesh and one in Egypt. Seven of these trials were at high risk of bias in one or more domains, two of these studies were at low risk of bias in all domains. Participants were randomised to the following comparisons: topical 5% natamycin compared to topical 1% voriconazole; topical 5% natamycin compared to topical 2% econazole; topical 5% natamycin compared to topical chlorhexidine gluconate (0.05%, 0.1% and 0.2%); topical 1% voriconazole compared to intrastromal voriconazole 50 g/0.1 mL (both treatments combined with topical 5% natamycin); topical 1% voriconazole combined with oral voriconazole compared to both oral voriconazole and oral itraconazole (both combined with topical 5% natamycin); topical 1% itraconazole compared to topical 1% itraconazole combined with oral itraconazole; topical amphotericin B compared to topical amphotericin B combined with subconjunctival injection of fluconazole; intracameral injection of amphotericin B with conventional treatment compared to conventional treatment alone (severe fungal ulcers); topical 0.5% and 1% silver sulphadiazine compared to topical 1% miconazole. Overall the results were inconclusive because for most comparisons only one small trial was available. The exception was the comparison of topical natamycin and topical voriconazole for which three trials were available. In one of these trials clinical cure (healed ulcer) was reported in all 15 people allocated to natamycin and in 14/15 people allocated to voriconazole (risk ratio (RR) 1.07; 95% confidence interval (CI) 0.89 to 1.28, low quality evidence). In one trial people randomised to natamycin were more likely to have a microbiological cure at six days (RR 1.64; 95% CI 1.38 to 1.94, 299 participants). On average, people randomised to natamycin had better spectacle-corrected visual acuity at two to three months compared to people randomised to voriconazole but the estimate was uncertain and the 95% confidence intervals included 0 (no difference) (mean difference -0.12 logMAR, 95% CI -0.31 to 0.06, 434 participants; 3 studies, low quality evidence) and a decreased risk of corneal perforation or therapeutic penetrating keratoplasty, or both (RR 0.61; 95% CI 0.40 to 0.94, 434 participants, high quality evidence). There was inconclusive evidence on time to clinical cure. Compliance with treatment and quality of life were not reported. One trial comparing natamycin and voriconazole found the effect of treatment greater in Fusarium species, but this subgroup analysis was not prespecified by this review. AUTHORS' CONCLUSIONS The trials included in this review were of variable quality and were generally underpowered. There is evidence that natamycin is more effective than voriconazole in the treatment of fungal ulcers. Future research should evaluate treatment effects according to fungus species.
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Affiliation(s)
- Nilo Vincent FlorCruz
- University of the Phillipines‐Philippine General HospitalDepartment of Ophthalmology and Visual SciencesTaft AvenueManilaPhilippines1000
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision Group, ICEHKeppel StreetLondonUKWC1E 7HT
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In vitro susceptibility of filamentous fungi from mycotic keratitis to azole drugs. J Mycol Med 2014; 25:44-9. [PMID: 25541256 DOI: 10.1016/j.mycmed.2014.10.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/29/2014] [Accepted: 10/20/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The in vitro antifungal activities of azole drugs viz., itraconazole, voriconazole, ketoconazole, econazole and clotrimazole were investigated in order to evaluate their efficacy against filamentous fungi isolated from mycotic keratitis. METHODS The specimen collection was carried out from fungal keratitis patients attending Aravind eye hospital and Post-graduate institute of ophthalmology, Coimbatore, India and was subsequently processed for the isolation of fungi. The dilutions of antifungal drugs were prepared in RPMI 1640 medium. Minimum inhibitory concentrations (MICs) were determined and MIC50 and MIC90 were calculated for each drug tested. RESULTS A total of 60 fungal isolates were identified as Fusarium spp. (n=30), non-sporulating moulds (n=9), Aspergillus flavus (n=6), Bipolaris spp. (n=6), Exserohilum spp. (n=4), Curvularia spp. (n=3), Alternaria spp. (n=1) and Exophiala spp. (n=1). The MICs of ketoconazole, clotrimazole, voriconazole, econazole and itraconazole for all the fungal isolates ranged between 16 μg/mL and 0.03 μg/mL, 4 μg/mL and 0.015 μg/mL, 8 μg/mL and 0.015 μg/mL, 8 μg/mL and 0.015 μg/mL and 32 μg/mL and 0.06 μg/mL respectively. From the MIC50 and MIC90 values, it could be deciphered that in the present study, clotrimazole was more active against the test isolates at lower concentrations (0.12-5 μg/mL) when compared to other drugs tested. CONCLUSION The results suggest that amongst the tested azole drugs, clotrimazole followed by voriconazole and econazole had lower MICs against moulds isolated from mycotic keratitis.
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Spadea L, Abbouda A, Abicca I, Paroli MP. Aspergillus flavus endophthalmitis after penetrating keratoplasty combined with cataract phacoemulsification and IOL implantation. Int Ophthalmol 2014; 35:145-8. [PMID: 25488017 DOI: 10.1007/s10792-014-0030-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/04/2014] [Indexed: 11/29/2022]
Abstract
To report the clinical findings and management of a case of Aspergillus flavus endophthalmitis following penetrating keratoplasty (PKP) and combined cataract extraction. Clinical cornea appearance was evaluated by slit-lamp examination. Ocular ultrasonography was performed to evaluate the anterior chamber and vitreous cavity. The cornea was scraped. The corneal-scleral donor rim and media were cultured. The diagnosis of A. flavus infection was made. The patient received fortified antifungal drops (voriconazole 1 % solution) plus systemic voriconazole 400 mg/die. A second corneal transplant was performed, and the anterior chamber was cleaned and washed with a solution of voriconazole 1 %. At the end of follow-up, CDVA was 20/20 and slit-lamp examination showed a clear cornea graft. This case illustrates a severe A. flavus endophthalmitis after PKP and demonstrates the possibilities of visual function restoration. Furthermore, this case describes the different sources of fungal infection after PKP and the different clinical appearances.
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Affiliation(s)
- Leopoldo Spadea
- Department of Medical-Surgical Sciences and Biotechnology, "Sapienza" University of Rome, Latina, Italy. .,, Via Benozzo Gozzoli 34, 00142, Rome, Italy.
| | | | - Irene Abicca
- Department of Ophthalmology, "Sapienza" University of Rome, Rome, Italy
| | - Maria Pia Paroli
- Department of Ophthalmology, "Sapienza" University of Rome, Rome, Italy
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Jain A, Shah SG, Chugh A. Cell Penetrating Peptides as Efficient Nanocarriers for Delivery of Antifungal Compound, Natamycin for the Treatment of Fungal Keratitis. Pharm Res 2014; 32:1920-30. [DOI: 10.1007/s11095-014-1586-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 11/24/2014] [Indexed: 12/01/2022]
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Sun CQ, Lalitha P, Prajna NV, Karpagam R, Geetha M, O'Brien KS, Oldenburg CE, Ray KJ, McLeod SD, Acharya NR, Lietman TM. Association between in vitro susceptibility to natamycin and voriconazole and clinical outcomes in fungal keratitis. Ophthalmology 2014; 121:1495-500.e1. [PMID: 24746358 PMCID: PMC4122634 DOI: 10.1016/j.ophtha.2014.03.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 03/01/2014] [Accepted: 03/04/2014] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To assess the association between minimum inhibitory concentration (MIC) and clinical outcomes in a fungal keratitis clinical trial. DESIGN Experimental study using data from a randomized comparative trial. PARTICIPANTS Of the 323 patients enrolled in the trial, we were able to obtain MIC values from 221 patients with monocular fungal keratitis. METHODS The Mycotic Ulcer Treatment Trial I was a randomized, double-masked clinical trial comparing clinical outcomes of monotherapy with topical natamycin versus voriconazole for the treatment of fungal keratitis. Speciation and determination of MIC to natamycin and voriconazole were performed according to Clinical and Laboratory Standards Institute guidelines. The relationship between MIC and clinical outcome was assessed. MAIN OUTCOME MEASURES The primary outcome was 3-month best spectacle-corrected visual acuity. Secondary outcomes included 3-month infiltrate or scar size; corneal perforation and/or therapeutic penetrating keratoplasty; and time to re-epithelialization. RESULTS A 2-fold increase in MIC was associated with a larger 3-month infiltrate or scar size (0.21 mm; 95% confidence interval [CI], 0.10-0.31; P < 0.001) and increased odds of perforation (odds ratio, 1.32; 95% CI, 1.04-1.69; P = 0.02). No correlation was found between MIC and 3-month visual acuity. For natamycin-treated cases, an association was found between higher natamycin MIC with larger 3-month infiltrate or scar size (0.29 mm; 95% CI, 0.15-0.43; P < 0.001) and increased perforations (odds ratio, 2.41; 95% CI, 1.46-3.97; P < 0.001). Among voriconazole-treated cases, the voriconazole MIC did not correlate with any of the measured outcomes in the study. CONCLUSIONS Decreased susceptibility to natamycin was associated with increased infiltrate or scar size and increased odds of perforation. There was no association between susceptibility to voriconazole and outcome.
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Affiliation(s)
- Catherine Q Sun
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | | | | | | | | | - Kieran S O'Brien
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Catherine E Oldenburg
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Kathryn J Ray
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Stephen D McLeod
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Nisha R Acharya
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Thomas M Lietman
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California.
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Mimouni M, Tam G, Paitan Y, Kidron D, Segev F. Safety and efficacy of intrastromal injection of 5% natamycin in experimental fusarium keratitis. J Ocul Pharmacol Ther 2014; 30:543-7. [PMID: 24919100 DOI: 10.1089/jop.2014.0004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To compare the efficacy of combined intrastromal injection and topical natamycin 5% to standard topical therapy alone in an experimental rabbit model of Fusarium keratitis. METHODS Fungal keratitis was induced in the right eyes of 12 New Zealand rabbits by stromal injection of Fusarium solani spore suspension into the cornea. Four days after inoculation, animals were randomly assigned to 2 different treatment groups (n=6 in each group). The study group received intrastromal injections of natamycin 5% on treatment day 1 and 4, combined with topical natamycin 5% eye drops given hourly between 8:00 and 20:00 for the first 2 days, followed by 4 times daily on days 3-11. The control group received only topical natamycin 5% at identical intervals. Eyes were examined clinically on days 1, 4, 7, and 11 for status of corneal healing, corneal vascularization, and hypopyon. Animals were sacrificed on day 11, and corneas were subjected to histopathological examination. RESULTS Both groups showed significant improvement in terms of conjunctival hyperemia, size and density of corneal infiltrate, corneal edema, and total clinical score. In the study group, there was a significant improvement in the height of hypopyon in the anterior chamber, while there was also an increased amount of vascularization. CONCLUSIONS This study showed that intrastromal injection of natamycin 5% combined with topical treatment has little beneficial effect over topical therapy in a Fusarium keratitis rabbit model. The addition of intrastromal injection should be reserved to the most severe or recalcitrant cases.
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Affiliation(s)
- Michael Mimouni
- 1 Department of Ophthalmology, Meir Medical Center , Kfar Sava, Israel
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