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Akinosoglou K, Rigopoulos EA, Papageorgiou D, Schinas G, Polyzou E, Dimopoulou E, Gogos C, Dimopoulos G. Amphotericin B in the Era of New Antifungals: Where Will It Stand? J Fungi (Basel) 2024; 10:278. [PMID: 38667949 PMCID: PMC11051097 DOI: 10.3390/jof10040278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
Amphotericin B (AmB) has long stood as a cornerstone in the treatment of invasive fungal infections (IFIs), especially among immunocompromised patients. However, the landscape of antifungal therapy is evolving. New antifungal agents, boasting novel mechanisms of action and better safety profiles, are entering the scene, presenting alternatives to AmB's traditional dominance. This shift, prompted by an increase in the incidence of IFIs, the growing demographic of immunocompromised individuals, and changing patterns of fungal resistance, underscores the continuous need for effective treatments. Despite these challenges, AmB's broad efficacy and low resistance rates maintain its essential status in antifungal therapy. Innovations in AmB formulations, such as lipid complexes and liposomal delivery systems, have significantly mitigated its notorious nephrotoxicity and infusion-related reactions, thereby enhancing its clinical utility. Moreover, AmB's efficacy in treating severe and rare fungal infections and its pivotal role as prophylaxis in high-risk settings highlight its value and ongoing relevance. This review examines AmB's standing amidst the ever-changing antifungal landscape, focusing on its enduring significance in current clinical practice and exploring its potential future therapeutic adaptations.
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Affiliation(s)
- Karolina Akinosoglou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Rio, Greece
| | | | - Despoina Papageorgiou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - Georgios Schinas
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - Eleni Polyzou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | | | - Charalambos Gogos
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - George Dimopoulos
- 3rd Department of Critical Care, Evgenidio Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
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2
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Hagiya H, Nishimura Y, Otsuka F. Safety and usefulness of nebulized liposomal amphotericin B: Systematic scoping review. Pulm Pharmacol Ther 2023; 82:102233. [PMID: 37414132 DOI: 10.1016/j.pupt.2023.102233] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/15/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE Invasive fungal infections potentially result in fatal outcomes in immunocompromised hosts. Compared to intravenous administration, a nebulization therapy can achieve a high concentration of drug delivered in the respiratory tract, without a systematic absorption. We herein summarized the study findings on the safety and clinical utility of nebulized liposomal amphotericin B therapy. METHODS According to the PRISMA Extension for Scoping Reviews, we performed a search on MEDLINE and EMBASE for articles with relevant keywords, including "inhaled liposomal amphotericin B″, "nebulized liposomal amphotericin B″, or "aerosolized liposomal amphotericin B″, from the inception of these databases to August 31, 2022. RESULTS Of the 172 articles found, 27 articles, including 13 case reports, 11 observational studies, and 3 clinical trials, were selected. Generally, findings showed that nebulized liposomal amphotericin B treatment appeared to be safe and without severe adverse effects. We found an accumulated evidence for the safety, tolerability, and effectiveness of nebulized liposomal amphotericin B prophylaxis among lung transplantation recipients; however, a randomized controlled study has yet to be reported. Data on hemato-oncological patients are relatively scarce; however, a randomized controlled study suggested the prophylactic effect of nebulized liposomal amphotericin B on invasive pulmonary aspergillosis. Observational and randomized controlled studies to evaluate therapeutic efficacy of the nebulized liposomal amphotericin B therapy have not been performed. CONCLUSION In conclusion, we found increasing evidence for the effectiveness of the inhalation therapy among patients after lung transplantation and with hemato-oncological diseases.
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Affiliation(s)
- Hideharu Hagiya
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 7008558, Japan.
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 7008558, Japan; Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, USA
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 7008558, Japan
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3
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Brunet K, Martellosio JP, Tewes F, Marchand S, Rammaert B. Inhaled Antifungal Agents for Treatment and Prophylaxis of Bronchopulmonary Invasive Mold Infections. Pharmaceutics 2022; 14:pharmaceutics14030641. [PMID: 35336015 PMCID: PMC8949245 DOI: 10.3390/pharmaceutics14030641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Pulmonary mold infections are life-threatening diseases with high morbi-mortalities. Treatment is based on systemic antifungal agents belonging to the families of polyenes (amphotericin B) and triazoles. Despite this treatment, mortality remains high and the doses of systemic antifungals cannot be increased as they often lead to toxicity. The pulmonary aerosolization of antifungal agents can theoretically increase their concentration at the infectious site, which could improve their efficacy while limiting their systemic exposure and toxicity. However, clinical experience is poor and thus inhaled agent utilization remains unclear in term of indications, drugs, and devices. This comprehensive literature review aims to describe the pharmacokinetic behavior and the efficacy of inhaled antifungal drugs as prophylaxes and curative treatments both in animal models and humans.
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Affiliation(s)
- Kévin Brunet
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Laboratoire de Mycologie-Parasitologie, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
- Correspondence: (K.B.); (B.R.)
| | - Jean-Philippe Martellosio
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
| | - Frédéric Tewes
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
| | - Sandrine Marchand
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
| | - Blandine Rammaert
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
- Correspondence: (K.B.); (B.R.)
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4
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Drew RH, Perfect JR. Conventional Antifungals for Invasive Infections Delivered by Unconventional Methods; Aerosols, Irrigants, Directed Injections and Impregnated Cement. J Fungi (Basel) 2022; 8:212. [PMID: 35205966 PMCID: PMC8879564 DOI: 10.3390/jof8020212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 12/10/2022] Open
Abstract
The administration of approved antifungals via unapproved formulations or administration routes (such as aerosol, direct injection, irrigation, topical formulation and antifungal-impregnated orthopedic beads or cement) may be resorted to in an attempt to optimize drug exposure while minimizing toxicities and/or drug interactions associated with conventional (systemic) administrations. Existing data regarding such administrations are mostly restricted to uncontrolled case reports of patients with diseases refractory to conventional therapies. Attribution of efficacy and tolerability is most often problematic. This review updates prior published summaries, reflecting the most recent data and its application by available prevention and treatment guidelines for invasive fungal infections. Of the various dosage forms and antifungals, perhaps none is more widely reported than the application of amphotericin B-containing aerosols for the prevention of invasive mold infections (notably Aspergillus spp.).
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Affiliation(s)
- Richard H. Drew
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC 27710, USA;
- College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA
| | - John R. Perfect
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC 27710, USA;
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5
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Otu AA, Langridge P, Denning DW. An evaluation of nebulised amphotericin B deoxycholate (Fungizone ® ) for treatment of pulmonary aspergillosis in the UK National Aspergillosis Centre. Mycoses 2020; 62:1049-1055. [PMID: 31479538 DOI: 10.1111/myc.12996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 12/12/2022]
Abstract
Antifungal treatment options for allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitisation (SAFS) are largely limited to itraconazole based on the outcome of randomised controlled trials. It is unclear if nebulised amphotericin B deoxycholate (Fungizone® ) is a viable therapeutic option. We evaluated the safety and efficacy of nebulised Fungizone® in the long-term treatment of various forms of pulmonary aspergillosis. We assessed the records of 177 patients with various forms of pulmonary aspergillosis attending the National Aspergillosis Centre in Manchester who had received Fungizone® . Patients first received a challenge test with nebulised Fungizone® in hospital with spirometry pre/post-Fungizone® and nebulised salbutamol given pre-Fungizone® . Tolerability and changes in Aspergillus IgE, Aspergillus IgG and total IgE were evaluated. Sixty-six per cent (117/177) were able to tolerate the test dose of Fungizone® and in all cases, the reason for discontinuation of the first test dose was worsening breathlessness. Twenty six (21%) stopped therapy within 4-6 weeks, and the commonest reason cited for discontinuation of therapy was increased breathlessness, hoarseness and cough. Eighteen (10.2%) patients continued the Fungizone® for >3 months of which 5 (27.8%) recorded an improvement in total IgE, Aspergillus-specific IgE and Aspergillus IgG. Eleven had ABPA, four had SAFS, two had Aspergillus bronchitis and one had Aspergillus sensitisation with cavitating nodules. Among these 18 patients, sputum fungal culture results went from positive to negative in five patients, became positive in one patient, remained positive in three patients, and remained negative in seven patients. Nebulised Fungizone® appears to be a poorly tolerated treatment for pulmonary Aspergillosis with high dropout rates. There appears to be both clinical and serological benefits following sustained treatment with nebulised Fungizone® in some patients.
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Affiliation(s)
- Akaninyene A Otu
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Philip Langridge
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - David W Denning
- The National Aspergillosis Centre, 2nd Floor Education and Research Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, 2nd Floor Education and Research Centre, University Hospital of South Manchester, Manchester, UK
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6
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Chirgwin ME, Dedloff MR, Holban AM, Gestal MC. Novel Therapeutic Strategies Applied to Pseudomonas aeruginosa Infections in Cystic Fibrosis. MATERIALS 2019; 12:ma12244093. [PMID: 31817881 PMCID: PMC6947192 DOI: 10.3390/ma12244093] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/25/2019] [Accepted: 12/05/2019] [Indexed: 11/16/2022]
Abstract
Cystic fibrosis (CF) is one of the most prevalent genetic diseases and a total of 1700 different genetic mutations can cause this condition. Patients that suffer this disease have a thickening of the mucus, creating an environment that promotes bacterial infections. Pseudomonas aeruginosa is a ubiquitous bacterium, which is frequently found in the lungs of CF patients. P. aeruginosa is known for its high level of antibiotic resistance as well as its high rate of mutation that allows it to rapidly evolve and adapt to a multitude of conditions. When a CF lung is infected with P. aeruginosa, the decay of the patient is accelerated, but there is little that can be done apart from controlling the infection with antibiotics. Novel strategies to control P. aeruginosa infection are imperative, and nanotechnology provides novel approaches to drug delivery that are more efficient than classic antibiotic treatments. These drug delivery systems are offering new prospects, especially for these patients with special mucus conditions and bacterial characteristics that limit antibiotic use.
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Affiliation(s)
- Michael E. Chirgwin
- Department of Chemical Engineering, Clarkson University, Potsdam, NY 13699, USA;
| | | | - Alina Maria Holban
- Department of Microbiology, Faculty of Biology, University of Bucharest, 030018 Bucharest, Romania;
- Research Institute of the University of Bucharest (ICUB), 050107 Bucharest, Romania
- Department of Science and Engineering of Oxide Materials and Nanomaterials, Faculty of Applied Chemistry and Materials Science, University Politechnica of Bucharest, 1-7 Polizu Street, 011061 Bucharest, Romania
| | - Monica C. Gestal
- Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
- Correspondence: or
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7
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Duckwall MJ, Gales MA, Gales BJ. Inhaled Amphotericin B as Aspergillosis Prophylaxis in Hematologic Disease: An Update. Microbiol Insights 2019; 12:1178636119869937. [PMID: 31496719 PMCID: PMC6716174 DOI: 10.1177/1178636119869937] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/22/2019] [Indexed: 12/12/2022] Open
Abstract
This review summarizes the literature on inhaled amphotericin B for invasive
aspergillosis prophylaxis in patients with neutropenia secondary to hematologic
malignancy treatment or stem cell transplant. Six trials, 2 randomized
controlled and 4 with historical controls, were identified. Three inhaled
amphotericin B deoxycholate trials found a reduced invasive aspergillosis
incidence, 1 reaching statistical significance. Three inhaled liposomal
amphotericin B trials demonstrated similar reductions with 2 finding statistical
significance. Relative risk reductions for invasive aspergillosis were routinely
40-60%. Both formulations were without reported systemic or severe adverse
effects. The most common adverse events were cough, bad taste, and nausea.
Discontinuation rates ranged from 0-45%. The only randomized, placebo-controlled
trial utilized inhaled liposomal amphotericin B reported a nearly 60% relative
risk reduction. Inhaled liposomal amphotericin B 12.5 mg twice weekly is an alternative for
invasive aspergillosis prophylaxis in high risk neutropenic patients with
hematologic malignancies and stem cell transplant recipients when recommended
azole agents are contraindicated or should not be used.
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Affiliation(s)
- Madison J Duckwall
- Department of Pharmacy, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Mark A Gales
- Department of Pharmacy, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA.,College of Pharmacy, Southwestern Oklahoma State University, Weatherford, OK, USA.,Great Plains Family Medicine Residency, Oklahoma City, OK, USA
| | - Barry J Gales
- Department of Pharmacy, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA.,College of Pharmacy, Southwestern Oklahoma State University, Weatherford, OK, USA.,Great Plains Family Medicine Residency, Oklahoma City, OK, USA
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8
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Venanzi E, Martín-Dávila P, López J, Maiz L, de la Pedrosa EGG, Gioia F, Escudero R, Filigheddu E, Moreno S, Fortún J. Aerosolized Lipid Amphotericin B for Complementary Therapy and/or Secondary Prophylaxis in Patients with Invasive Pulmonary Aspergillosis: A Single-Center Experience. Mycopathologia 2019; 184:239-250. [PMID: 30903580 DOI: 10.1007/s11046-019-00331-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/14/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Experience with aerosolized lipid amphotericin B (aeLAB) as therapy or secondary prophylaxis in patients with invasive pulmonary aspergillosis (IPA) is anecdotal. METHODS We performed a single-center retrospective cohort study to evaluate the efficacy of systemic antifungal therapy with and without aeLAB in patients with proven or probable IPA. Complete or partial response at 3 months was the primary end-point. Clinical response and mortality at 12 months, occurrence of adverse drug reactions and respiratory fungal colonization were secondary end-point. RESULTS Eleven patients (39%) received aeLAB in addition to systemic antifungal therapy (group A), and 22 (61%) received systemic antifungal therapy only (group B). The use of aeLAB was not standardized. Amphotericin B lipid complex was used in all patients but one, who received liposomal amphotericin B. Five patients received aeLAB as antifungal complementary therapy and 6 received it as secondary prophylaxis. Except for the requirement of inhaled corticosteroids and home oxygen therapy, more frequent in group A, both groups were similar in baseline conditions. A better (nonsignificant) clinical outcome was observed at 3 months in patients receiving aeLAB. Only uncontrolled baseline condition was associated with one-year mortality in univariate analysis (p = 0.002). A multivariate Cox regression analysis suggests that aeLAB, corrected for uncontrolled underlying disease, reduces mortality at 12 months (HR 0.258; 95% CI 0.072-0.922; p = 0.037). CONCLUSION Although no significant difference was observed in the main variable (3-month clinical response) and in spite of methodological limitations of the study, the possible survival benefit of aeLAB, adjusted for the control of the underlying disease, could justify the performance of well-controlled studies with a greater number of patients.
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Affiliation(s)
- E Venanzi
- Department of Infectious Diseases, Hospital Universitario Ramon y Cajal, Carretera Colmenar km 9,1, 28034, Madrid, Spain
| | - P Martín-Dávila
- Department of Infectious Diseases, Hospital Universitario Ramon y Cajal, Carretera Colmenar km 9,1, 28034, Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - J López
- Hematology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - L Maiz
- Pneumology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - E Gómez-García de la Pedrosa
- Microbiology Department, Hospital Ramón y Cajal, Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - F Gioia
- Department of Infectious Diseases, Hospital Universitario Ramon y Cajal, Carretera Colmenar km 9,1, 28034, Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - R Escudero
- Department of Infectious Diseases, Hospital Universitario Ramon y Cajal, Carretera Colmenar km 9,1, 28034, Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - E Filigheddu
- Department of Infectious Diseases, Hospital Universitario Ramon y Cajal, Carretera Colmenar km 9,1, 28034, Madrid, Spain
| | - S Moreno
- Department of Infectious Diseases, Hospital Universitario Ramon y Cajal, Carretera Colmenar km 9,1, 28034, Madrid, Spain
| | - J Fortún
- Department of Infectious Diseases, Hospital Universitario Ramon y Cajal, Carretera Colmenar km 9,1, 28034, Madrid, Spain.
- Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain.
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9
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Muraglia KA, Chorghade RS, Kim BR, Tang XX, Shah VS, Grillo AS, Daniels PN, Cioffi AG, Karp PH, Zhu L, Welsh MJ, Burke MD. Small-molecule ion channels increase host defences in cystic fibrosis airway epithelia. Nature 2019; 567:405-408. [PMID: 30867598 PMCID: PMC6492938 DOI: 10.1038/s41586-019-1018-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/11/2019] [Indexed: 01/10/2023]
Abstract
Loss-of-function mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) compromise epithelial HCO3− and Cl− secretion, reduce airway surface liquid (ASL) pH, and impair respiratory host defenses in people with cystic fibrosis (CF) 1–3. Here we report that apical addition of an unselective ion channel-forming small molecule, amphotericin B (AmB), restored HCO3− secretion and increased ASL pH in cultured human CF airway epithelia. These effects required the basolateral Na+/K+ ATPase, indicating that apical AmB channels functionally interfaced with this driver of anion secretion. AmB also restored ASL pH, viscosity, and antibacterial activity in primary cultures of airway epithelia from people with CF caused by different mutations, including ones that yield no CFTR, and increased ASL pH in CFTR-null pigs in vivo. Thus, unselective small molecule ion channels can restore CF airway host defenses via a mechanism that is CFTR-independent and therefore genotype-independent.
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Affiliation(s)
- Katrina A Muraglia
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Rajeev S Chorghade
- Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Bo Ram Kim
- Department of Internal Medicine and HHMI, Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Xiao Xiao Tang
- Department of Internal Medicine and HHMI, Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Viral S Shah
- Department of Internal Medicine and HHMI, Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Anthony S Grillo
- Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Page N Daniels
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Alexander G Cioffi
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Philip H Karp
- Department of Internal Medicine and HHMI, Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Lingyang Zhu
- Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Michael J Welsh
- Department of Internal Medicine and HHMI, Pappajohn Biomedical Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Department of Molecular Physiology and Biophysics, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Martin D Burke
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, IL, USA. .,Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, IL, USA. .,Carle Illinois College of Medicine, University of Illinois at Urbana-Champaign, Champaign, IL, USA. .,Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Champaign, IL, USA. .,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Champaign, IL, USA.
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10
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Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K, Lass-Flörl C, Lewis RE, Munoz P, Verweij PE, Warris A, Ader F, Akova M, Arendrup MC, Barnes RA, Beigelman-Aubry C, Blot S, Bouza E, Brüggemann RJM, Buchheidt D, Cadranel J, Castagnola E, Chakrabarti A, Cuenca-Estrella M, Dimopoulos G, Fortun J, Gangneux JP, Garbino J, Heinz WJ, Herbrecht R, Heussel CP, Kibbler CC, Klimko N, Kullberg BJ, Lange C, Lehrnbecher T, Löffler J, Lortholary O, Maertens J, Marchetti O, Meis JF, Pagano L, Ribaud P, Richardson M, Roilides E, Ruhnke M, Sanguinetti M, Sheppard DC, Sinkó J, Skiada A, Vehreschild MJGT, Viscoli C, Cornely OA. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect 2018; 24 Suppl 1:e1-e38. [PMID: 29544767 DOI: 10.1016/j.cmi.2018.01.002] [Citation(s) in RCA: 832] [Impact Index Per Article: 138.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.
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Affiliation(s)
- A J Ullmann
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J M Aguado
- Infectious Diseases Unit, University Hospital Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - S Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D W Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; European Confederation of Medical Mycology (ECMM)
| | - A H Groll
- Department of Paediatric Haematology/Oncology, Centre for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - K Lagrou
- Department of Microbiology and Immunology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lass-Flörl
- Institute of Hygiene, Microbiology and Social Medicine, ECMM Excellence Centre of Medical Mycology, Medical University Innsbruck, Innsbruck, Austria; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R E Lewis
- Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - P Munoz
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - F Ader
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France; Inserm 1111, French International Centre for Infectious Diseases Research (CIRI), Université Claude Bernard Lyon 1, Lyon, France; European Respiratory Society (ERS)
| | - M Akova
- Department of Medicine, Section of Infectious Diseases, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M C Arendrup
- Department Microbiological Surveillance and Research, Statens Serum Institute, Copenhagen, Denmark; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R A Barnes
- Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK; European Confederation of Medical Mycology (ECMM)
| | - C Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; European Respiratory Society (ERS)
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; European Respiratory Society (ERS)
| | - E Bouza
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R J M Brüggemann
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG)
| | - D Buchheidt
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Cadranel
- Department of Pneumology, University Hospital of Tenon and Sorbonne, University of Paris, Paris, France; European Respiratory Society (ERS)
| | - E Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India; European Confederation of Medical Mycology (ECMM)
| | - M Cuenca-Estrella
- Instituto de Salud Carlos III, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - G Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece; European Respiratory Society (ERS)
| | - J Fortun
- Infectious Diseases Service, Ramón y Cajal Hospital, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J-P Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Garbino
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - W J Heinz
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R Herbrecht
- Department of Haematology and Oncology, University Hospital of Strasbourg, Strasbourg, France; ESCMID Fungal Infection Study Group (EFISG)
| | - C P Heussel
- Diagnostic and Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany; European Confederation of Medical Mycology (ECMM)
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, London, UK; European Confederation of Medical Mycology (ECMM)
| | - N Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia; European Confederation of Medical Mycology (ECMM)
| | - B J Kullberg
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lange
- International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany; Clinical Infectious Diseases, Research Centre Borstel, Leibniz Center for Medicine & Biosciences, Borstel, Germany; German Centre for Infection Research (DZIF), Tuberculosis Unit, Hamburg-Lübeck-Borstel-Riems Site, Lübeck, Germany; European Respiratory Society (ERS)
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Confederation of Medical Mycology (ECMM)
| | - J Löffler
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Lortholary
- Department of Infectious and Tropical Diseases, Children's Hospital, University of Paris, Paris, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Maertens
- Department of Haematology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - L Pagano
- Department of Haematology, Universita Cattolica del Sacro Cuore, Roma, Italy; European Confederation of Medical Mycology (ECMM)
| | - P Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Richardson
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece; Hippokration General Hospital, Thessaloniki, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Ruhnke
- Department of Haematology and Oncology, Paracelsus Hospital, Osnabrück, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Sanguinetti
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Rome, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D C Sheppard
- Division of Infectious Diseases, Department of Medicine, Microbiology and Immunology, McGill University, Montreal, Canada; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Sinkó
- Department of Haematology and Stem Cell Transplantation, Szent István and Szent László Hospital, Budapest, Hungary; ESCMID Fungal Infection Study Group (EFISG)
| | - A Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M J G T Vehreschild
- Department I of Internal Medicine, ECMM Excellence Centre of Medical Mycology, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology, Cologne-Bonn, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; European Confederation of Medical Mycology (ECMM)
| | - C Viscoli
- Ospedale Policlinico San Martino and University of Genova (DISSAL), Genova, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O A Cornely
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; CECAD Cluster of Excellence, University of Cologne, Cologne, Germany; Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM); ESCMID European Study Group for Infections in Compromised Hosts (ESGICH).
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11
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Menotti J, Alanio A, Sturny-Leclère A, Vitry S, Sauvage F, Barratt G, Bretagne S. A cell impedance-based real-time in vitro assay to assess the toxicity of amphotericin B formulations. Toxicol Appl Pharmacol 2017; 334:18-23. [DOI: 10.1016/j.taap.2017.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 08/02/2017] [Accepted: 08/29/2017] [Indexed: 10/18/2022]
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13
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Velkov T, Abdul Rahim N, Zhou Q(T, Chan HK, Li J. Inhaled anti-infective chemotherapy for respiratory tract infections: successes, challenges and the road ahead. Adv Drug Deliv Rev 2015; 85:65-82. [PMID: 25446140 PMCID: PMC4429008 DOI: 10.1016/j.addr.2014.11.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 11/04/2014] [Accepted: 11/05/2014] [Indexed: 12/31/2022]
Abstract
One of the most common causes of illnesses in humans is from respiratory tract infections caused by bacterial, viral or fungal pathogens. Inhaled anti-infective drugs are crucial for the prophylaxis and treatment of respiratory tract infections. The benefit of anti-infective drug delivery via inhalation is that it affords delivery of sufficient therapeutic dosages directly to the primary site of infection, while minimizing the risks of systemic toxicity or avoiding potential suboptimal pharmacokinetics/pharmacodynamics associated with systemic drug exposure. This review provides an up-to-date treatise of approved and novel developmental inhaled anti-infective agents, with particular attention to effective strategies for their use, pulmonary pharmacokinetic properties and safety.
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Aerosolised liposomal amphotericin B to prevent aspergillosis in acute myeloid leukaemia: Efficacy and cost effectiveness in real-life. Int J Antimicrob Agents 2015; 46:82-7. [PMID: 25956843 DOI: 10.1016/j.ijantimicag.2015.02.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/04/2015] [Accepted: 02/19/2015] [Indexed: 11/20/2022]
Abstract
Chemotherapy-induced neutropenia can be complicated by invasive pulmonary aspergillosis (IPA). In 2008, liposomal amphotericin B (L-AmB) inhalation was shown to prevent IPA in a placebo-controlled trial. Patients with acute myeloid leukaemia (AML) are the subset of haematology patients at high risk for IPA. In 2008, L-AmB inhalation prophylaxis became the standard of care for all AML patients in Erasmus MC. In this study, the efficacy and cost effectiveness of L-AmB inhalation were evaluated in a prospective cohort of AML patients. In total, 127 consecutive AML patients received chemotherapy and prophylactically inhaled L-AmB during their first and second chemotherapy cycles; 108 patients treated for AML at the same sites from 2005-2008 served as controls. A standardised diagnostic protocol was used and probable/proven IPA served as the primary endpoint. Diagnostic and therapeutic costs were also comprehensively analysed and compared. A significant decrease in probable/proven IPA in the L-AmB inhalation group was observed (L-AmB 9.5% vs. controls 23.4%; P=0.0064). Systemic antifungal therapy given at any time during the entire AML therapy decreased from 52.8% to 29.9%. Per-patient equipment and drug costs for L-AmB inhalation (1292 €/patient) were more than compensated for by a decrease in costs for diagnostics and therapeutic voriconazole use (-1816 €/patient). No serious adverse events related to L-AmB inhalation were observed. In an unselected AML patient group, L-AmB inhalation resulted in a significant and substantial decrease in IPA and was cost saving. Now that azole resistance is more frequent, non-azole-based prophylaxis may become an attractive strategy.
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Xia D, Sun WK, Tan MM, Zhang M, Ding Y, Liu ZC, Su X, Shi Y. Aerosolized amphotericin B as prophylaxis for invasive pulmonary aspergillosis: a meta-analysis. Int J Infect Dis 2014; 30:78-84. [PMID: 25461661 DOI: 10.1016/j.ijid.2014.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Invasive pulmonary aspergillosis (IPA) is associated with high mortality in high-risk (immunosuppressed) patients. Many studies have investigated whether prophylactic inhalation of amphotericin B (AMB) reduces the incidence of IPA, but no definitive conclusions have been reached. The present meta-analysis was performed to evaluate the efficacy of prophylactic inhalation of AMB for the prevention of IPA. METHODS MEDLINE and other databases were searched for relevant articles published until December 2013. Randomized controlled trials that compared aerosolized AMB with placebo were included. Two reviewers independently assessed and extracted the data of all trials. RESULTS Six animal studies and two clinical trials involving 768 high-risk patients were eligible. The animal studies showed lower overall mortality rate among animals that underwent aerosolized AMB prophylaxis (odds ratio (OR) 0.13, 95% confidence interval (CI) 0.08-0.21). Similarly, the clinical trials showed a lower incidence of IPA among patients who underwent aerosolized AMB prophylaxis (OR 0.42, 95% CI 0.22-0.79). CONCLUSIONS This analysis provides evidence supporting the notion that the prophylactic use of aerosolized AMB effectively reduces the incidence of IPA among high-risk patients.
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Affiliation(s)
- Di Xia
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Wen-Kui Sun
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Ming-Ming Tan
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Ming Zhang
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Yuan Ding
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Zhi-Cheng Liu
- Southern Medical University, Guangdong, People's Republic of China
| | - Xin Su
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China.
| | - Yi Shi
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China.
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Chishimba L, Langridge P, Powell G, Niven RM, Denning DW. Efficacy and safety of nebulised amphotericin B (NAB) in severe asthma with fungal sensitisation (SAFS) and allergic bronchopulmonary aspergillosis (ABPA). J Asthma 2014; 52:289-95. [PMID: 25158109 DOI: 10.3109/02770903.2014.958853] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND RATIONALE Antifungal therapy for severe asthma with fungal sensitisation (SAFS) and allergic bronchopulmonary aspergillosis (ABPA) remains poorly studied. We assessed the efficacy and safety of NAB as second and third line therapy in SAFS and ABPA. METHODS 21 adult asthmatics with SAFS (n = 11) and ABPA (n = 10) who had either failed itraconazole (n = 8), voriconazole proceeded by itraconazole (n = 5) or developed adverse events (AEs) to either agent (n = 7) were treated with 10mg of NAB (Fungizone) twice daily. We audited clinical and immunological response, using the Asthma Quality of Life Questionnaire (AQLQ-J) scores, asthma control, FEV1, healthcare utilisation and IgE. Patients were followed up for 12 months. RESULTS Twenty-one patients were treated (SAFS, n = 11) and (ABPA, n = 10), M: F = 8:12, median age 65 years (range, 24-78). The median duration of therapy was 30 days (0-1825). Clinical benefit was observed in three (14.3 %) in which overall mean AQLQ-J score improved by + 2.9, mean FEV1 improved by 0.5 L and there was improvement in overall asthma control. Seven (33%) failed initial dose (bronchospasm). Eleven (52.4%) discontinued within 12 months of therapy due to delayed bronchospasm (n = 3, within 4 weeks), equipment problems (n = 2, within 4 weeks) and lack of clinical benefit (n = 4, within 16 weeks). CONCLUSION Our data suggest that the overall efficacy of NAB in this group of patients is poor and associated with bronchospasm. However, the excellent response in 3 patients, suggest it may be considered when other alternatives have been exhausted. Overcoming the initial bronchospasm may improve tolerability.
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Affiliation(s)
- Livingstone Chishimba
- Manchester Academic Health Science Centre, University Hospital South Manchester NHS Foundation Trust, The University of Manchester , Manchester , UK
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Cipolla D, Shekunov B, Blanchard J, Hickey A. Lipid-based carriers for pulmonary products: preclinical development and case studies in humans. Adv Drug Deliv Rev 2014; 75:53-80. [PMID: 24819218 DOI: 10.1016/j.addr.2014.05.001] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 04/16/2014] [Accepted: 05/01/2014] [Indexed: 12/31/2022]
Abstract
A number of lipid-based technologies have been applied to pharmaceuticals to modify their drug release characteristics, and additionally, to improve the drug loading for poorly soluble drugs. These technologies, including solid-state lipid microparticles, many of which are porous in nature, liposomes, solid lipid nanoparticles and nanostructured lipid carriers, are increasingly being developed for inhalation applications. This article provides a review of the rationale for the use of these technologies in the pulmonary delivery of drugs, and summarizes the manufacturing processes and their limitations, the in vitro and in vivo performance of these systems, the safety of these lipid-based systems in the lung, and their promise for commercialization.
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Affiliation(s)
- David Cipolla
- Aradigm Corporation, 3929 Point Eden Way, Hayward, CA 94545, USA.
| | - Boris Shekunov
- Shire Corporation, 725 Chesterbrook Blvd, Wayne, PA 19087, USA
| | - Jim Blanchard
- Aradigm Corporation, 3929 Point Eden Way, Hayward, CA 94545, USA
| | - Anthony Hickey
- RTI International, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA.
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Safdar A, Rodriguez GH. Aerosolized amphotericin B lipid complex as adjunctive treatment for fungal lung infection in patients with cancer-related immunosuppression and recipients of hematopoietic stem cell transplantation. Pharmacotherapy 2013; 33:1035-43. [PMID: 23784915 PMCID: PMC3791151 DOI: 10.1002/phar.1309] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
STUDY OBJECTIVE Aerosolized amphotericin B lipid complex (aeABLC) has been successfully used to prevent fungal disease. Experience with aeABLC as treatment of fungal lung disease is limited. DESIGN We evaluated the safety and efficacy of aeABLC adjunct therapy for fungal lung disease in a retrospective study of 32 immunosuppressed adults. All values are given as ± standard deviation. SETTING National Cancer Institute-designated Comprehensive Cancer Center. PATIENTS Acute leukemia (69%) and severe neutropenia (63%) were common. Fifty-six percent of patients had undergone allogeneic hematopoietic stem cell transplantation 185 ± 424 days prior to aeABLC was commenced. MEASUREMENT AND MAIN RESULTS High-dose corticosteroids were administered during aeABLC in 28% of patients. Fungal lung disease was proven or probable in 41% of patients. Most patients (78%) received concurrent systemic antifungal therapy for a median of 14 ± 18 days before aeABLC. The median cumulative aeABLC dose was 1050 ± 2368 mg, and the median duration of aeABLC therapy was 28 ± 130 days. Most patients (78%) received 50 mg aeABLC twice daily. Partial or complete resolution of fungal lung disease was noted in 50% of patients. In three patients (9%) modest cough, mild bronchospasm, and transient chest pain with accompanying nausea and vomiting resolved completely after discontinuation of aeABLC. No patient required hospitalization for drug toxicity or had a serious (grade III or IV) drug-related adverse event. CONCLUSION Treatment with aeABLC was tolerated without serious toxicity and may be considered in the setting of severe immunosuppression, cancer, and/or hematopoietic stem cell transplantation in patients with difficult-to-treat fungal lung disease.
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Affiliation(s)
- Amar Safdar
- The University of Texas MD Anderson Cancer Center, Houston, Texas
- New York University Langone Medical Center, New York, New York
| | - Gilhen H. Rodriguez
- The University of Texas MD Anderson Cancer Center, Houston, Texas
- The University of Texas, Texas Medical Center, Houston, Texas
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Abstract
No marketed inhaled products currently use sustained release formulations such as liposomes to enhance drug disposition in the lung, but that may soon change. This review focuses on the interaction between liposomal formulations and the inhalation technology used to deliver them as aerosols. There have been a number of dated reviews evaluating nebulization of liposomes. While the information they shared is still accurate, this paper incorporates data from more recent publications to review the factors that affect aerosol performance. Recent reviews have comprehensively covered the development of dry powder liposomes for aerosolization and only the key aspects of those technologies will be summarized. There are now at least two inhaled liposomal products in late-stage clinical development: ARIKACE® (Insmed, NJ, USA), a liposomal amikacin, and Pulmaquin™ (Aradigm Corp., CA, USA), a liposomal ciprofloxacin, both of which treat a variety of patient populations with lung infections. This review also highlights the safety of inhaled liposomes and summarizes the clinical experience with liposomal formulations for pulmonary application.
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Aerosolized liposomal amphotericin B: Prediction of lung deposition, in vitro uptake and cytotoxicity. Int J Pharm 2012; 436:106-10. [DOI: 10.1016/j.ijpharm.2012.07.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 07/06/2012] [Accepted: 07/09/2012] [Indexed: 11/21/2022]
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Nasr M, Nawaz S, Elhissi A. Amphotericin B lipid nanoemulsion aerosols for targeting peripheral respiratory airways via nebulization. Int J Pharm 2012; 436:611-6. [PMID: 22842623 DOI: 10.1016/j.ijpharm.2012.07.028] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 07/14/2012] [Accepted: 07/17/2012] [Indexed: 11/26/2022]
Abstract
Amphotericin B (AmB) lipid nanoemulsions were prepared and characterized and their suitability for pulmonary delivery via nebulization was evaluated. AmB nanoemulsions were prepared by sonicating and vortexing the drug with two commercially available lipid nanoemulsions: the Intralipid(®) or Clinoleic(®). Loading the nanoemulsions with the drug slightly increased the size of the lipid droplets and did not affect the zeta potential of the nanoemulsions. The loading efficiency of AmB was found to be 87.46±2.21% in the Intralipid(®) nanoemulsions and 80.7±0.70% in the Clinoleic(®) formulation. This respectively corresponded to 21.86 mg and 20.19 mg of AmB being successfully loaded in the nanoemulsions. On aerosolization using a Pari Sprint jet nebulizer, both nanoemulsions produced very high drug output which was approximately 90% for both formulations. Using the two-stage impinger, the Clinoleic(®) emulsion had higher fine particle fraction (FPF) than the Intralipid(®), since the Clinoleic(®) displayed higher deposition of AmB in the lower impinger stage (exceeding 80%), compared to 57% for the Intralipid(®). Overall, the ease of preparation of the AmB lipid nanoemulsions, along with their in vitro nebulization performance suggest that lipid nanoemulsions could be successful nanocarriers for delivery of AmB to the peripheral respiratory airways.
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Affiliation(s)
- Maha Nasr
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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Therapeutic liposomal dry powder inhalation aerosols for targeted lung delivery. Lung 2012; 190:251-62. [PMID: 22274758 DOI: 10.1007/s00408-011-9360-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 12/17/2011] [Indexed: 10/14/2022]
Abstract
Therapeutic liposomal powders (i.e., lipospheres and proliposomes) for dry powder inhalation aerosol delivery, formulated with phospholipids similar to endogenous lung surfactant, offer unique opportunities in pulmonary nanomedicine while offering controlled release and enhanced stability. Many pulmonary diseases such as lung cancer, tuberculosis (TB), cystic fibrosis (CF), bacterial and fungal lung infections, asthma, and chronic obstructive pulmonary disease (COPD) could greatly benefit from this type of pulmonary nanomedicine approach that can be delivered in a targeted manner by dry powder inhalers (DPIs). These delivery systems may require smaller doses for efficacy, exhibit reduced toxicity, fewer side effects, controlled drug release over a prolonged time period, and increased formulation stability as inhaled powders. This state-of-the-art review presents these novel aspects in depth.
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Le J, Ashley ED, Neuhauser MM, Brown J, Gentry C, Klepser ME, Marr AM, Schiller D, Schwiesow JN, Tice S, VandenBussche HL, Wood GC. Consensus Summary of Aerosolized Antimicrobial Agents: Application of Guideline Criteria. Pharmacotherapy 2010; 30:562-84. [DOI: 10.1592/phco.30.6.562] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Pulmonary infections caused by Aspergillus species are associated with significant morbidity and mortality in immunocompromised patients. Although the treatment of pulmonary fungal infections requires the use of systemic agents, aerosolized delivery is an attractive option in prevention because the drug can concentrate locally at the site of infection with minimal systemic exposure. Current clinical evidence for the use of aerosolized delivery in preventing fungal infections is limited to amphotericin B products, although itraconazole, voriconazole, and caspofungin are under investigation. Based on conflicting results from clinical trials that evaluated various amphotericin B formulations, the routine use of aerosolized delivery cannot be recommended. Further research with well-designed clinical trials is necessary to elucidate the therapeutic role and risks associated with aerosolized delivery of antifungal agents. This article provides an overview of aerosolized delivery systems, the intrapulmonary pharmacokinetic properties of aerosolized antifungal agents, and key findings from clinical studies.
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Affiliation(s)
- Jennifer Le
- UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive MC 0714, La Jolla, CA 92093-0714 USA
| | - Daryl S. Schiller
- Saint Barnabas Medical Center, 94 Old Short Hills Rd, Livingston, NJ 07039 USA
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