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Liu MZ, Dai XH, Zeng MT, Chen EQ. Clinical treatment of cryptococcal meningitis: an evidence-based review on the emerging clinical data. J Neurol 2024; 271:2960-2979. [PMID: 38289535 DOI: 10.1007/s00415-024-12193-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/07/2024] [Accepted: 01/13/2024] [Indexed: 05/30/2024]
Abstract
Cryptococcal meningitis (CM) is a fatal fungal central nervous system (CNS) infection caused by Cryptococcus infecting the meninges and/or brain parenchyma, with fever, headache, neck stiffness, and visual disturbances as the primary clinical manifestations. Immunocompromised individuals with human immunodeficiency virus (HIV) infection or who have undergone organ transplantation, as well as immunocompetent people can both be susceptible to CM. Without treatment, patients with CM may have a mortality rate of up to 100% after hospital admission. Even after receiving therapy, CM patients may still suffer from problems such as difficulty to cure, poor prognosis, and high mortality. Therefore, timely and effective treatment is essential to improve the mortality and prognosis of CM patients. Currently, the clinical outcomes of CM are frequently unsatisfactory due to limited drug choices, severe adverse reactions, drug resistance, etc. Here, we review the research progress of CM treatment strategies and discuss the suitable options for managing CM, hoping to provide a reference for physicians to select the most appropriate treatment regimens for CM patients.
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Affiliation(s)
- Mao-Zhu Liu
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin-Hua Dai
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ming-Tang Zeng
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - En-Qiang Chen
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China.
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Nepal B, McCormick-Baw C, Patel K, Firmani S, Wetzel DM. Cutaneous Leishmania mexicana infections in the United States: defining strains through endemic human pediatric cases in northern Texas. mSphere 2024; 9:e0081423. [PMID: 38421172 PMCID: PMC10964424 DOI: 10.1128/msphere.00814-23] [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: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 03/02/2024] Open
Abstract
Over a 6-month span, three patients under 5 years old with cutaneous leishmaniasis presented to the Pediatric Infectious Diseases Clinic at the University of Texas Southwestern Medical Center/Children's Health Dallas. None had traveled outside of northern Texas/southern Oklahoma; all had Leishmania mexicana infections confirmed by PCR. We provide case descriptions and images to increase the awareness of this disease among United States (US) physicians and scientists. Two patients responded to fluconazole, but the youngest required topical paromomycin. Combining these cases with guidelines and our literature review, we suggest that (i) higher doses (10-12 mg/kg/day) of fluconazole should be considered in young children to maximize likelihood and rapidity of response and (ii) patients should transition to alternate agents if they do not respond to high-dose fluconazole within 6 weeks. Furthermore, and of particular interest to the broad microbiology community, we used samples from these cases as a proof of concept to propose a mechanism to strain-type US-endemic L. mexicana. For our analysis, we sequenced three housekeeping genes and the internal transcribed sequence 2 of the ribosomal RNA gene. We identified genetic changes that not only allow us to distinguish US-based L. mexicana strains from strains found in other areas of the Americas but also establish polymorphisms that differ between US isolates. These techniques will allow documentation of genetic changes in this parasite as its range expands. Hence, our cases of cutaneous leishmaniasis provide significant evolutionary, treatment, and public health implications as climate change increases exposure to formerly tropical diseases in previously non-endemic areas. IMPORTANCE Leishmaniasis is a parasitic disease that typically affects tropical regions worldwide. However, the vector that carries Leishmania is spreading northward into the United States (US). Within a 6-month period, three young cutaneous leishmaniasis patients were seen at the Pediatric Infectious Diseases Clinic at the University of Texas Southwestern Medical Center/Children's Health Dallas. None had traveled outside of northern Texas and southern Oklahoma. We document their presentations, treatments, and outcomes and compare their management to clinical practice guidelines for leishmaniasis. We also analyzed the sequences of three critical genes in Leishmania mexicana isolated from these patients. We found changes that not only distinguish US-based strains from strains found elsewhere but also differ between US isolates. Monitoring these sequences will allow tracking of genetic changes in parasites over time. Our findings have significant US public health implications as people are increasingly likely to be exposed to what were once tropical diseases.
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Affiliation(s)
- Binita Nepal
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Clare McCormick-Baw
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Karisma Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah Firmani
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Dawn M. Wetzel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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3
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Nepal B, McCormick-Baw C, Patel K, Firmani S, Wetzel DM. Cutaneous Leishmania mexicana Infections in the United States: Defining Strains Through Endemic Human Pediatric Cases in Northern Texas. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.11.23300611. [PMID: 38260515 PMCID: PMC10802665 DOI: 10.1101/2024.01.11.23300611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Over a six-month span, three patients under five years old with cutaneous leishmaniasis presented to the Pediatric Infectious Diseases Clinic at the University of Texas Southwestern Medical Center/Children's Health Dallas. None had traveled outside of the United States (US); all had confirmed L. mexicana infections by PCR. We provide case descriptions and images to increase the awareness of this disease among US physicians and scientists. Two patients responded to fluconazole, but one required topical paromomycin. Combining these cases with guidelines and our literature review, we suggest that: 1) higher doses (ten-twelve mg/kg/day) of fluconazole should be considered in young children to maximize likelihood and rapidity of response and 2) patients should transition to alternate agents if they do not respond to high-dose fluconazole within six weeks. Furthermore, and of particular interest to the broad microbiology community, we used samples from these cases as a proof-of-concept to propose a mechanism to strain-type US-endemic L. mexicana. For our analysis, we sequenced three housekeeping genes and the internal transcribed sequence 2 of the ribosomal RNA gene. We identified genetic changes that not only allow us to distinguish US-based L. mexicana strains from strains found in other areas of the Americas, but also establish polymorphisms that differ between US isolates. These techniques will allow documentation of genetic changes in this parasite as its range expands. Hence, our cases of cutaneous leishmaniasis provide significant evolutionary, treatment and public health implications as climate change increases exposure to formerly tropical diseases in previously non-endemic areas.
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Affiliation(s)
- Binita Nepal
- Department of Pediatrics, University of Texas Southwestern Medical Center
- Department of Biochemistry, University of Texas Southwestern Medical Center
| | | | - Karisma Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center
| | - Sarah Firmani
- Department of Pediatrics, University of Texas Southwestern Medical Center
| | - Dawn M. Wetzel
- Department of Pediatrics, University of Texas Southwestern Medical Center
- Department of Biochemistry, University of Texas Southwestern Medical Center
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Scott BL, Hornik CD, Zimmerman K. Pharmacokinetic, efficacy, and safety considerations for the use of antifungal drugs in the neonatal population. Expert Opin Drug Metab Toxicol 2020; 16:605-616. [PMID: 32508205 DOI: 10.1080/17425255.2020.1773793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal infections are an important cause of morbidity and mortality in infants, particularly in extreme prematurity. Successful systemic treatment requires consideration of antifungal efficacy, safety, and pharmacokinetics, including optimization of dosing in this population. AREAS COVERED This review summarizes published pharmacokinetic data on four classes of antifungal agents used in the neonatal population. Alterations in absorption, distribution, drug metabolism and clearance in infants compared to adult populations are highlighted. Additionally, pharmacodynamics, safety, and therapeutic drug monitoring are discussed. Recent advancements in neonatal antifungal pharmacotherapies are examined, with emphasis on clinical application. EXPERT OPINION Over the last two decades, published studies have provided increased knowledge on pharmacokinetic considerations in the neonatal population. Future research should focus on filling in the knowledge gaps that remain regarding the benefits and risks of combination antifungal therapy, the rising use of micafungin for invasive candidiasis given its fungicidal activity against polyene and azole-resistant Candida species and its minimal adverse effect profile, and the need for pharmacokinetic and safety data of broad spectrum triazoles, like voriconazole and posaconazole, in infants. Furthermore, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations with subsequent implementation into clinical practice.
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Affiliation(s)
- Briana L Scott
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA.,Duke University School of Medicine, Duke Clinical Research Institute , Durham, NC, USA
| | - Kanecia Zimmerman
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA.,Duke University School of Medicine, Duke Clinical Research Institute , Durham, NC, USA
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Abstract
Invasive fungal infections are a significant cause of morbidity and mortality in infants and children. Early diagnosis is critical, and treatment with the appropriate drug and dose should be initiated promptly. Although an increasing number of studies have examined dosing of antifungals in this population, pediatric safety and efficacy data are lacking.
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Affiliation(s)
- Mihai Puia-Dumitrescu
- Department of Pediatrics, Division of Neonatal Medicine, Duke University Medical Center, 2424 Erwin Road, Suite 504, Durham, NC 27705, USA; Department of Pediatrics, Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715, USA
| | - P Brian Smith
- Department of Pediatrics, Division of Neonatal Medicine, Duke University Medical Center, 2424 Erwin Road, Suite 504, Durham, NC 27705, USA; Department of Pediatrics, Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715, USA.
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Cryptococcal Meningitis Presenting as a Complication in HIV-infected Children: A Case Series From Sub-Saharan Africa. Pediatr Infect Dis J 2016; 35:979-80. [PMID: 27187754 PMCID: PMC4987191 DOI: 10.1097/inf.0000000000001212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cryptococcal meningitis is a leading infectious disease worldwide as a result of the high burden of HIV and AIDS, although its cumulative incidence is very low in children compared with that in adults. Very few studies involving the disease in children have been reported including sub-Saharan Africa, with the highest prevalence of HIV-infected children in the world. We summarize 5 cases of children diagnosed with cryptococcal meningitis at a tertiary hospital in Harare, Zimbabwe, between October 1, 2013, and September 30, 2014.
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Assessment of echinocandin regimens by pharmacokinetic/pharmacodynamic analysis against Candida spp. in paediatric patients. Int J Antimicrob Agents 2015; 46:631-41. [DOI: 10.1016/j.ijantimicag.2015.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 08/10/2015] [Indexed: 11/18/2022]
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First dose in neonates: are juvenile mice, adults and in vitro-in silico data predictive of neonatal pharmacokinetics of fluconazole. Clin Pharmacokinet 2015; 53:1005-18. [PMID: 25154507 DOI: 10.1007/s40262-014-0169-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Selection of the first-dose-in-neonates is challenging. The objective of this proof-of-concept study was to evaluate a pharmacokinetic bridging approach to predict a neonatal dosing regimen. METHODS We selected fluconazole as a paradigm compound. We used data from studies in juvenile mice and adults to develop population pharmacokinetic models using NONMEM. We also develop a physiologically-based pharmacokinetic model from in vitro-in silico data using Simcyp. These three models were then used to predict neonatal pharmacokinetics and dosing regimens for fluconazole. RESULTS From juvenile mice to neonates, a correction factor of maximum lifespan potential should be used for extrapolation, while a "renal factor" taking into account renal maturation was required for successful bridging based on adult and in vitro-in silico data. Simulations results demonstrated that the predicted drug exposure based on bridging approach was comparable to the observed value in neonates. The prediction errors were -2.2, +10.1 and -4.6 % for juvenile mice, adults and in vitro-in silico data, respectively. CONCLUSION A model-based bridging approach provided consistent predictions of fluconazole pharmacokinetic parameters in neonates and demonstrated the feasibility of this approach to justify the first-dose-in-neonates, based on all data available from different sources (including physiological informations, preclinical studies and adult data), allowing evidence-based decisions of neonatal dose rather than empiricism.
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Abstract
We report 7 HIV-infected children with cryptococcosis. Median age and CD4 counts were 9.3 years and 12 cells/mm, respectively. Two children died early. Of 4 children requiring prolonged amphotericin B and fluconazole at a dosage above 12 mg/kg/d, 3 presented with meningitis and 1 with fever. Immune reconstitution inflammatory syndrome contributed to morbidity through exacerbations at the primary site and elsewhere.
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Abstract
BACKGROUND Invasive fungal infections cause excessive morbidity and mortality in premature neonates and severely ill infants. METHODS Safety and efficacy outcomes of micafungin were compared between prematurely and non-prematurely born infants <2 years of age. Data were obtained from all completed phase I-III clinical trials with micafungin that had enrolled infants (<2 years of age) that were listed in the Astellas Clinical Study Database. Demographics, adverse events, hepatic function tests and treatment success data were extracted and validated by the Astellas biostatistical group for all micafungin-treated patients, <2 years of age, using the unique patient identifier. RESULTS One-hundred and sixteen patients included in 9 clinical trials, 48% premature [birth weight (BW) <2500 g and/or gestational age <37 weeks], 52% non-premature, received ≥ 1 dose of micafungin. Among premature patients, 14.5% were low BW (1500-2499 g), 36.4% very low BW (1000-1499 g) and 49.1% extremely low BW (<1000 g). Ninety patients (78%) completed the studies; 13 [11% (4 premature)] died. Significantly more non-premature than premature patients discontinued treatment (P = 0.003). Treatment-related adverse events were recorded in 23% of patients with no difference between groups. More extremely low BW (n = 4, 15%) and very low BW (n = 8, 40%) infants experienced treatment-related adverse events than low BW (n = 0) and there was no relation to micafungin dose or duration. For a subgroup of 30 patients with invasive candidiasis, treatment success was achieved in 73% in both premature and non-premature groups. Prophylaxis was successful in 4/5 non-premature hematopoietic stem cell transplant patients. CONCLUSION Micafungin has a safe profile in premature and non-premature infants with substantial efficacy.
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Roberts JK, Stockmann C, Constance JE, Stiers J, Spigarelli MG, Ward RM, Sherwin CMT. Pharmacokinetics and Pharmacodynamics of Antibacterials, Antifungals, and Antivirals Used Most Frequently in Neonates and Infants. Clin Pharmacokinet 2014; 53:581-610. [DOI: 10.1007/s40262-014-0147-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Vogiatzi L, Katragkou A, Roilides E. Antifungal Prophylaxis in the Pediatric Intensive Care Unit. CURRENT FUNGAL INFECTION REPORTS 2013. [DOI: 10.1007/s12281-013-0154-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Uso actual de los antifúngicos triazoles en niños. INFECTIO 2012. [DOI: 10.1016/s0123-9392(12)70031-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Invasive fungal infections remain a significant cause of infection-related mortality and morbidity in preterm infants. Central nervous system involvement is the hallmark of neonatal candidiasis, differentiating the disease's impact on young infants from that among all other patient populations. Over the past decade, the number of antifungal agents in development has grown, but most are not labeled for use in newborns. We summarize the findings of several antifungal studies that have been completed to date, emphasizing those including infant populations. We conclude that more studies are required for antifungals to be used safely and effectively in infants.
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Affiliation(s)
- Daniela Testoni
- Duke Clinical Research Institute, 2400 Pratt Street, Durham NC, 27705; phone: 919-668-8700; ;
| | - P. Brian Smith
- Duke Clinical Research Institute, 2400 Pratt Street, Durham NC, 27705; phone: 919-668-8700; ;
- Department of Pediatrics, Duke University, Box 3352, DUMC, Durham, NC 27710
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, 2400 Pratt Street, Durham NC, 27705; phone: 919-668-8700; ;
- Department of Pediatrics, Duke University, Box 3352, DUMC, Durham, NC 27710
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