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Kato H, Shiraishi C, Hagihara M, Mikamo H, Iwamoto T. Association between voriconazole-induced visual hallucination and dopamine in an analysis of the food and drug administration (FDA) adverse event reporting system database. Sci Rep 2024; 14:12519. [PMID: 38822123 PMCID: PMC11143338 DOI: 10.1038/s41598-024-63504-y] [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: 02/13/2024] [Accepted: 05/29/2024] [Indexed: 06/02/2024] Open
Abstract
Voriconazole is a second-generation azole used to treat serious fungal infections. Visual hallucinations constitute a representative adverse event caused by voriconazole. However, its mechanism of action remains unclear. In patients with schizophrenia or Parkinson's disease, the frequency of visual hallucinations is associated with brain dopamine levels. This study investigated the frequency of visual hallucinations in patients treated with voriconazole alone or in combination with dopaminergic medicines or dopamine antagonists, using data collected from the Food and Drug Administration Adverse event Reporting System (FAERS). The frequency of visual hallucinations with voriconazole alone and in combination with a dopaminergic medicine (levodopa) or dopamine antagonists (risperidone and chlorpromazine) was compared using data from the FAERS between 2004 and 2023, using the reporting odds ratio (ROR) with relevant 95% confidence intervals (CI). The reference group comprised patients who had been administered voriconazole without dopaminergic medication or dopamine antagonists. Of the patients, 22,839, 90,810, 109,757, 6,435, 20, 83, and 26, respectively were treated with voriconazole, levodopa, risperidone, chlorpromazine, voriconazole plus levodopa, voriconazole plus risperidone, and voriconazole plus chlorpromazine. The occurrence of visual hallucinations increased when used in combination with levodopa (ROR = 12.302, 95% CI = 3.587-42.183). No increase in incidence was associated with the concomitant use of dopamine antagonists (risperidone, ROR = 1.721, 95% CI = 0.421-7.030; chlorpromazine, ROR = none, 95% CI = none). Dopaminergic medicine may increase the risk of visual hallucinations in patients treated with voriconazole. Whether voriconazole positively modulates dopamine production warrants further investigation using a translational research approach.
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Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, 174-2, Edobashi, Tsu, Mie, 514-8507, Japan.
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Mie, Japan.
- Department of Clinical Infectious Diseases, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan.
| | - Chihiro Shiraishi
- Department of Pharmacy, Mie University Hospital, 174-2, Edobashi, Tsu, Mie, 514-8507, Japan
| | - Mao Hagihara
- Department of Molecular Epidemiology and Biomedical Sciences, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, 174-2, Edobashi, Tsu, Mie, 514-8507, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Mie, Japan
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2
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Chastain DB, White BP, Tu PJ, Chan S, Jackson BT, Kubbs KA, Bandali A, McDougal S, Henao-Martínez AF, Cluck DB. Candidemia in Adult Patients in the ICU: A Reappraisal of Susceptibility Testing and Antifungal Therapy. Ann Pharmacother 2024; 58:305-321. [PMID: 37272474 DOI: 10.1177/10600280231175201] [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] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVE To provide updates on the epidemiology and recommendations for management of candidemia in patients with critical illness. DATA SOURCES A literature search using the PubMed database (inception to March 2023) was conducted using the search terms "invasive candidiasis," "candidemia," "critically ill," "azoles," "echinocandin," "antifungal agents," "rapid diagnostics," "antifungal susceptibility testing," "therapeutic drug monitoring," "antifungal dosing," "persistent candidemia," and "Candida biofilm." STUDY SELECTION/DATA EXTRACTION Clinical data were limited to those published in the English language. Ongoing trials were identified through ClinicalTrials.gov. DATA SYNTHESIS A total of 109 articles were reviewed including 25 pharmacokinetic/pharmacodynamic studies and 30 studies including patient data, 13 of which were randomized controlled clinical trials. The remaining 54 articles included fungal surveillance data, in vitro studies, review articles, and survey data. The current 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Management of Candidiasis provides recommendations for selecting empiric and definitive antifungal therapies for candidemia, but data are limited regarding optimized dosing strategies in critically ill patients with dynamic pharmacokinetic changes or persistent candidemia complicated. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Outcomes due to candidemia remain poor despite improved diagnostic platforms, antifungal susceptibility testing, and antifungal therapy selection for candidemia in critically ill patients. Earlier detection and identification of the species causing candidemia combined with recognition of patient-specific factors leading to dosing discrepancies are crucial to improving outcomes in critically ill patients with candidemia. CONCLUSIONS Treatment of candidemia in critically ill patients must account for the incidence of non-albicans Candida species and trends in antifungal resistance as well as overcome the complex pathophysiologic changes to avoid suboptimal antifungal exposure.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical & Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Bryan P White
- University of Oklahoma Health Medical Center, Oklahoma City, OK, USA
| | - Patrick J Tu
- Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Sophea Chan
- Department of Clinical & Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
- Department of Pharmacy, Phoebe Putney Memorial Hospital, Albany, GA, USA
| | | | - Kara A Kubbs
- University of Oklahoma Health Medical Center, Oklahoma City, OK, USA
| | - Aiman Bandali
- Overlook Medical Center, Atlantic Health System, Summit, NJ, USA
| | | | - Andrés F Henao-Martínez
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David B Cluck
- Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
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3
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Elalouf A, Elalouf H, Rosenfeld A. Modulatory immune responses in fungal infection associated with organ transplant - advancements, management, and challenges. Front Immunol 2023; 14:1292625. [PMID: 38143753 PMCID: PMC10748506 DOI: 10.3389/fimmu.2023.1292625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Organ transplantation stands as a pivotal achievement in modern medicine, offering hope to individuals with end-stage organ diseases. Advancements in immunology led to improved organ transplant survival through the development of immunosuppressants, but this heightened susceptibility to fungal infections with nonspecific symptoms in recipients. This review aims to establish an intricate balance between immune responses and fungal infections in organ transplant recipients. It explores the fundamental immune mechanisms, recent advances in immune response dynamics, and strategies for immune modulation, encompassing responses to fungal infections, immunomodulatory approaches, diagnostics, treatment challenges, and management. Early diagnosis of fungal infections in transplant patients is emphasized with the understanding that innate immune responses could potentially reduce immunosuppression and promise efficient and safe immuno-modulating treatments. Advances in fungal research and genetic influences on immune-fungal interactions are underscored, as well as the potential of single-cell technologies integrated with machine learning for biomarker discovery. This review provides a snapshot of the complex interplay between immune responses and fungal infections in organ transplantation and underscores key research directions.
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Affiliation(s)
- Amir Elalouf
- Department of Management, Bar-Ilan University, Ramat Gan, Israel
| | - Hadas Elalouf
- Information Science Department, Bar-Ilan University, Ramat Gan, Israel
| | - Ariel Rosenfeld
- Information Science Department, Bar-Ilan University, Ramat Gan, Israel
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Rekha HS, Paramasivam S, Raja K, Bharadwaj B. Voriconazole-induced psychosis in rhino-orbital invasive aspergillosis. BMJ Case Rep 2023; 16:e254790. [PMID: 37821144 PMCID: PMC10583028 DOI: 10.1136/bcr-2023-254790] [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] [Indexed: 10/13/2023] Open
Abstract
Aspergillosis is a challenging fungal infection. Voriconazole is an antifungal drug belonging to the triazole group, commonly used for treating invasive aspergillosis, Cryptococcus neoformans and candida infections. We present a case of a man in his late 70s diagnosed with rhino-orbital invasive aspergillosis who developed voriconazole-induced psychosis as an idiosyncratic, adverse drug reaction (ADR); however, he responded to the cessation of intravenous voriconazole and, after starting on an oral antipsychotic, haloperidol. Clinicians need to be cognizant of this rare, idiosyncratic and iatrogenic ADR to voriconazole.
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Affiliation(s)
- H Swarna Rekha
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
- Department of Psychiatry, NIMHANS, Bangalore, Karnataka, India
| | - Sabharisan Paramasivam
- Department of ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Kalaiarasi Raja
- Department of ENT, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Balaji Bharadwaj
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Soriano A, Honore PM, Puerta-Alcalde P, Garcia-Vidal C, Pagotto A, Gonçalves-Bradley DC, Verweij PE. Invasive candidiasis: current clinical challenges and unmet needs in adult populations. J Antimicrob Chemother 2023:7176280. [PMID: 37220664 DOI: 10.1093/jac/dkad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Invasive candidiasis (IC) is a serious infection caused by several Candida species, and the most common fungal disease in hospitals in high-income countries. Despite overall improvements in health systems and ICU care in the last few decades, as well as the development of different antifungals and microbiological techniques, mortality rates in IC have not substantially improved. The aim of this review is to summarize the main issues underlying the management of adults affected by IC, focusing on specific forms of the infection: IC developed by ICU patients, IC observed in haematological patients, breakthrough candidaemia, sanctuary site candidiasis, intra-abdominal infections and other challenging infections. Several key challenges need to be tackled to improve the clinical management and outcomes of IC patients. These include the lack of global epidemiological data for IC, the limitations of the diagnostic tests and risk scoring tools currently available, the absence of standardized effectiveness outcomes and long-term data for IC, the timing for the initiation of antifungal therapy and the limited recommendations on the optimal step-down therapy from echinocandins to azoles or the total duration of therapy. The availability of new compounds may overcome some of the challenges identified and increase the existing options for management of chronic Candida infections and ambulant patient treatments. However, early identification of patients that require antifungal therapy and treatment of sanctuary site infections remain a challenge and will require further innovations.
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Affiliation(s)
- Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | - Patrick M Honore
- CHU UCL Godinne Namur, UCL Louvain Medical School, Namur, Belgium
| | - Pedro Puerta-Alcalde
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | | | | | - Paul E Verweij
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
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6
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Vena A, Bovis F, Tutino S, Santagostino Barbone A, Mezzogori L, Ponzano M, Taramasso L, Baldi F, Dettori S, Labate L, Russo C, Giacobbe DR, Mikulska M, Dentone C, Magnasco L, Marchese A, Robba C, Ball L, Battaglini D, Pelosi P, Crea F, Di Pilato V, Di Biagio A, Bouza E, Muñoz P, Bassetti M. Short Course of Antifungal Therapy in Patients With Uncomplicated Candida Bloodstream Infection: Another Case of Less Is More in the Clinical Setting? Open Forum Infect Dis 2022; 10:ofac656. [PMID: 36655192 PMCID: PMC9835756 DOI: 10.1093/ofid/ofac656] [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: 06/20/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Background The objective of this study was to compare the clinical outcomes of patients receiving a short course (SC) vs a prolonged course (PC) of antifungal therapy for uncomplicated Candida bloodstream infections (BSIs). Methods All episodes of uncomplicated Candida BSI from September 1, 2018, to August 31, 2020, were reviewed. We compared the primary (all-cause 90-day mortality) and secondary study end points (1-year recurrent Candida BSI and all-cause 1-year mortality) among patients who underwent SC (5-11 days) or PC (12-24 days) therapy using propensity score analysis with the inverse probability of treatment weighting (IPTW) method. Results A total of 114 patients with uncomplicated Candida BSI were included: 35 (30.7%) were classified into the SC group (median [interquartile range {IQR}], 9 [7-11] days) and 79 (69.3%) into the PC group (median [IQR], 14 [14-16] days). Patients in the SC group compared with the PC group had a higher rate of hospitalization in the surgical ward (40.0% vs 19.0%; P = .02) or septic shock at the time of Candida BSI onset (11.4% vs 1.3%; P = .03). The risk of 90-day mortality was not different between the SC and PC groups (n = 8 [22.9%] vs 17 [21.5%], respectively; IPTW-adjusted subdistribution hazard ratio [sHR], 0.67; 95% CI, 0.31-1.47; P = .20). The risk for recurrent Candida BSI within 1 year of completing therapy (IPTW-adjusted sHR, 1.07; 95% CI, 0.20-5.80; P = .94) or for all-cause 1-year mortality (IPTW-adjusted HR, 0.72; 95% CI, 0.35-1.50; P = .38) did not differ between groups. Conclusions Receiving a short vs prolonged course of antifungal therapy did not affect mortality or BSI recurrence in patients with uncomplicated candidemia.
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Affiliation(s)
- Antonio Vena
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Stefania Tutino
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | | | - Laura Mezzogori
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Marta Ponzano
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Lucia Taramasso
- Correspondence: Lucia Taramasso, MD, PhD, Infectious Diseases Unit, Ospedale Policlinico San Martino—IRCCS, University of Genoa, L.go R. Benzi, 10–16132 Genoa, Italy ()
| | - Federico Baldi
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Silvia Dettori
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Laura Labate
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Chiara Russo
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Malgorzata Mikulska
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Chiara Dentone
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Laura Magnasco
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Anna Marchese
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Denise Battaglini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Francesca Crea
- Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Vincenzo Di Pilato
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Antonio Di Biagio
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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7
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De Bels D, Maillart E, Van Bambeke F, Redant S, Honoré PM. Existing and emerging therapies for the treatment of invasive candidiasis and candidemia. Expert Opin Emerg Drugs 2022; 27:405-416. [PMID: 36317695 DOI: 10.1080/14728214.2022.2142207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Invasive candidiasis or candidemia is a severe infection affecting more than 250,000 people worldwide every year. It is present in up to 16% of ICU patients. The prognosis of these infections is unfavorable, with global death estimated around 50,000 per year, which corresponds to up to 40% depending on patient severity and comorbidities. Therapeutic failure is not rare due to the emergence of multiresistant strains and of new species poorly responsive to current therapies like Candida auris. AREAS COVERED We first review the positioning of antifungal drugs used to treat candidiasis, namely polyenes, azoles, echinocandins and pyrimidine analogues. We then discuss the progresses brought by new formulations, new derivatives within these classes, compounds acting on new targets or repurposed drugs in terms of pharmacokinetic profile, spectrum of activity, potency, safety or risk of drug-drug interactions. EXPERT OPINION While new formulations (amphotericin B cochleate) improve oral bioavailability of the corresponding drugs, new azoles or echinocandins offer higher potency including against strains resistant to former generations of drugs. Repurposed drugs show synergism with current therapies in vitro. Results from ongoing and future clinical trials will be decisive to establish the interest for these drugs in our arsenal.
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Affiliation(s)
- David De Bels
- Intensive Care Department, Brugmann University Hospital, Brussels, Belgium
| | - Evelyne Maillart
- Department of Infectious Disease, Brugmann University Hospital, Brussels, Belgium
| | - Françoise Van Bambeke
- Louvain Drug Research Institute, Department of Pharmacology, Université Catholique de Louvain, Brussels, Belgium
| | - Sebastien Redant
- Intensive Care Department, Brugmann University Hospital, Brussels, Belgium
| | - Patrick M Honoré
- Intensive Care Department, Brugmann University Hospital, Brussels, Belgium.,Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium.,Department of ICU, CHU UCL Godinne-Namur, UCL Louvain Medical School
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8
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Barantsevich N, Barantsevich E. Diagnosis and Treatment of Invasive Candidiasis. Antibiotics (Basel) 2022; 11:antibiotics11060718. [PMID: 35740125 PMCID: PMC9219674 DOI: 10.3390/antibiotics11060718] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/14/2022] [Accepted: 05/18/2022] [Indexed: 02/06/2023] Open
Abstract
Candida species, belonging to commensal microbial communities in humans, cause opportunistic infections in individuals with impaired immunity. Pathogens encountered in more than 90% cases of invasive candidiasis include C. albicans, C. glabrata, C. krusei, C. tropicalis, and C. parapsilosis. The most frequently diagnosed invasive infection is candidemia. About 50% of candidemia cases result in deep-seated infection due to hematogenous spread. The sensitivity of blood cultures in autopsy-proven invasive candidiasis ranges from 21% to 71%. Non-cultural methods (beta-D-glucan, T2Candida assays), especially beta-D-glucan in combination with procalcitonin, appear promising in the exclusion of invasive candidiasis with high sensitivity (98%) and negative predictive value (95%). There is currently a clear deficiency in approved sensitive and precise diagnostic techniques. Omics technologies seem promising, though require further development and study. Therapeutic options for invasive candidiasis are generally limited to four classes of systemic antifungals (polyenes, antimetabolite 5-fluorocytosine, azoles, echinocandins) with the two latter being highly effective and well-tolerated and hence the most widely used. Principles and methods of treatment are discussed in this review. The emergence of pan-drug-resistant C. auris strains indicates an insufficient choice of available medications. Further surveillance, alongside the development of diagnostic and therapeutic methods, is essential.
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9
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Zhou ZX, Yin XD, Zhang Y, Shao QH, Mao XY, Hu WJ, Shen YL, Zhao B, Li ZL. Antifungal Drugs and Drug-Induced Liver Injury: A Real-World Study Leveraging the FDA Adverse Event Reporting System Database. Front Pharmacol 2022; 13:891336. [PMID: 35571077 PMCID: PMC9098189 DOI: 10.3389/fphar.2022.891336] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/28/2022] [Indexed: 12/02/2022] Open
Abstract
Aims: We aimed to estimate the risk of drug-induced liver injury (DILI) from various antifungal treatments with azoles and echinocandins causing in real-world practice. Methods: We performed disproportionality and Bayesian analyses based on data from the first quarter in 2004 to the third quarter in 2021 in the Food and Drug Administration Adverse Event Reporting System to characterize the signal differences of antifungal drugs-related DILI. We also compared the onset time and mortality differences of different antifungal agents. Results: A total of 2943 antifungal drugs-related DILI were identified. Affected patients tended to be aged >45 years (51.38%), with more males than females (49.03% vs. 38.09%). Antifungal drug-induced liver injury is most commonly reported with voriconazole (32.45%), fluconazole (19.37%), and itraconazole (14.51%). Almost all antifungal drugs were shown to be associated with DILI under disproportionality and Bayesian analyses. The intraclass analysis of correlation between different antifungal agents and DILI showed the following ranking: caspofungin (ROR = 6.12; 95%CI: 5.36–6.98) > anidulafungin (5.15; 3.69–7.18) > itraconazole (5.06; 4.58–5.60) > voriconazole (4.58; 4.29–4.90) > micafungin (4.53; 3.89–5.27) > posaconazole (3.99; 3.47–4.59) > fluconazole (3.19; 2.93–3.47) > ketoconazole (2.28; 1.96–2.64). The onset time of DILI was significantly different among different antifungal drugs (p < 0.0001), and anidulafungin result in the highest mortality rate (50.00%), while ketoconazole has the lowest mortality rate (9.60%). Conclusion: Based on the Food and Drug Administration Adverse Event Reporting System database, antifungal drugs are significantly associated with DILI, and itraconazole and voriconazole had the greatest risk of liver injury. Due to indication bias, more clinical studies are needed to confirm the safety of echinocandins.
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Affiliation(s)
- Zhi-Xuan Zhou
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue-Dong Yin
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zhang
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Department of Pharmacy, Nanyang Central Hospital, Affiliated Hospital of Zhengzhou University, Nanyang, China
| | - Qi-Hui Shao
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin-Yu Mao
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-Juan Hu
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yun-Lin Shen
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
| | - Bin Zhao
- Pharmacy Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
| | - Zhi-Ling Li
- Department of Pharmacy, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Yun-Lin Shen, ; Bin Zhao, ; Zhi-Ling Li,
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10
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Lin J, Zhou M, Chen J, Zhang L, Lu M, Liu Z. De-escalation from Echinocandins to Azole Treatment in Critically Ill Patients with Candidemia. Int J Infect Dis 2022; 121:69-74. [PMID: 35472525 DOI: 10.1016/j.ijid.2022.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study aims to further explore the duration of echinocandins and analyze the de-escalation (DE) strategy in patients with candidemia. METHODS Multivariable logistic regression was used to evaluate the association between the duration of echinocandins (≤ 5-day group vs > 5-day group) and in-hospital mortality. RESULTS Of the 357 cases of candidemia, 200 patients (56.02%) were identified in the ≤5-day group. The ≤5-day group did not have a higher in-hospital mortality than the >5-day group in the multivariable model (odds ratio [OR] 1.536, 95% confidence interval (CI) 0.837-2.819, P-value = 0.166), and the finding was validated by the propensity score matching and inverse probability of treatment weighting models. Subgroup analyses showed that patients in the ≤5-day group without DE may have a poor prognosis (OR 4.223, 95% CI 1.773-10.055, P-value = 0.001). The patients in the ≤5-day group, with a sequential organ failure assessment (SOFA) score of ≥3 evaluated at the time of stopping echinocandins, may have a poor prognosis (OR 2.164, 95% CI 1.009-4.641, P-value = 0.047). CONCLUSION In critically ill adult patients with candidemia, the ≤5-day group with DE was feasible. However, the SOFA score was recommended when stopping echinocandins to ensure the safety of DE therapy.
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Affiliation(s)
- Jing Lin
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Menglan Zhou
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Jialong Chen
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China; Department of Respiratory and Critical Care Medicine, Peking Hospital, Beijing, China
| | - Li Zhang
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Minya Lu
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Zhengyin Liu
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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11
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Tortorano AM, Prigitano A, Morroni G, Brescini L, Barchiesi F. Candidemia: Evolution of Drug Resistance and Novel Therapeutic Approaches. Infect Drug Resist 2022; 14:5543-5553. [PMID: 34984009 PMCID: PMC8702982 DOI: 10.2147/idr.s274872] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Candidemia and invasive candidiasis are the most common healthcare-associated invasive fungal infections, with a crude mortality rate of 25–50%. Candida albicans remains the most frequent etiology, followed by C. glabrata, C. parapsilosis and C. tropicalis. With the exception of a limited number of species (ie: C. krusei, C. glabrata and rare Candida species), resistance to fluconazole and other triazoles are quite uncommon. However, recently fluconazole-resistant C. parapsilosis, echinocandin-resistant C. glabrata and the multidrug resistant C. auris have emerged. Resistance to amphotericin B is even more rare due to the reduced fitness of resistant isolates. The mechanisms of antifungal resistance in Candida (altered drug-target interactions, reduced cellular drug concentrations, and physical barriers associated with biofilms) are analyzed. The choice of the antifungal therapy for candidemia must take into account several factors such as type of patient, presence of devices, severity of illness, recent exposure to antifungals, local epidemiology, organs involvement, and Candida species. The first-line therapy in non-neutropenic critical patient is an echinocandin switching to fluconazole in clinically stable patients with negative blood cultures and azole susceptible isolate. Similarly, an echinocandin is the drug of choice also in neutropenic patients. The treatment duration is 14 days after the first negative blood culture or longer in cases of organ involvement. An early removal of vascular catheter improves the outcome. The promising results of new antifungal molecules, such as the terpenoid derivative ibrexafungerp, the novel echinocandin with an enhanced half-life rezafungin, oteseconazole and fosmanogepix, representative of new classes of antifungals, are discussed.
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Affiliation(s)
- Anna Maria Tortorano
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | - Anna Prigitano
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | - Gianluca Morroni
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia Brescini
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Clinic of Infectious Diseases, Azienda Ospedaliero Universitaria, Ospedali Riuniti Umberto I-Lancisi-Salesi, Ancona, Italy
| | - Francesco Barchiesi
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Clinic of Infectious Diseases, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
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12
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Chau MM, Daveson K, Alffenaar JWC, Gwee A, Ho SA, Marriott DJE, Trubiano JA, Zhao J, Roberts JA. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy and haemopoietic stem cell transplant recipients, 2021. Intern Med J 2021; 51 Suppl 7:37-66. [PMID: 34937141 DOI: 10.1111/imj.15587] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.
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Affiliation(s)
- Maggie M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases and Microbiology, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Jan-Willem C Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Camperdown, New South Wales, Australia.,Pharmacy Department, Westmead Hospital, Westmead, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Su Ann Ho
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Faculty of Science, University of Technology, Ultimo, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Zhao
- Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason A Roberts
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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13
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DeJarnette C, Meyer CJ, Jenner AR, Butts A, Peters T, Cheramie MN, Phelps GA, Vita NA, Loudon-Hossler VC, Lee RE, Palmer GE. Identification of Inhibitors of Fungal Fatty Acid Biosynthesis. ACS Infect Dis 2021; 7:3210-3223. [PMID: 34786940 DOI: 10.1021/acsinfecdis.1c00404] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fungal fatty acid (FA) synthase and desaturase enzymes are essential for the growth and virulence of human fungal pathogens. These enzymes are structurally distinct from their mammalian counterparts, making them attractive targets for antifungal development. However, there has been little progress in identifying chemotypes that target fungal FA biosynthesis. To accomplish this, we applied a whole-cell-based method known as Target Abundance-based FItness Screening using Candida albicans. Strains with varying levels of FA synthase or desaturase expression were grown in competition to screen a custom small-molecule library. Hit compounds were defined as preferentially inhibiting the growth of the low target-expressing strains. Dose-response experiments confirmed that 16 hits (11 with an acyl hydrazide core) differentially inhibited the growth of strains with an altered desaturase expression, indicating a specific chemical-target interaction. Exogenous unsaturated FAs restored C. albicans growth in the presence of inhibitory concentrations of the most potent acyl hydrazides, further supporting the primary mechanism being inhibition of FA desaturase. A systematic analysis of the structure-activity relationship confirmed the acyl hydrazide core as essential for inhibitory activity. This collection demonstrated broad-spectrum activity against Candida auris and mucormycetes and retained the activity against azole-resistant candida isolates. Finally, a preliminary analysis of toxicity to mammalian cells identified potential lead compounds with desirable selectivities. Collectively, these results establish a scaffold that targets fungal FA biosynthesis with a potential for development into novel therapeutics.
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Affiliation(s)
- Christian DeJarnette
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee 38163, United States
| | - Chris J. Meyer
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, United States
| | - Alexander R. Jenner
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, United States
| | - Arielle Butts
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee 38163, United States
| | - Tracy Peters
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee 38163, United States
| | - Martin N. Cheramie
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, United States
| | - Gregory A. Phelps
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, United States
- Graduate School of Biomedical Sciences, St. Jude Children’s Research Hospital, Memphis Tennessee 38103, United States
| | - Nicole A. Vita
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee 38163, United States
| | - Victoria C. Loudon-Hossler
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, United States
| | - Richard E. Lee
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, United States
| | - Glen E. Palmer
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee 38163, United States
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14
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Methodological and reporting quality of non-inferiority randomized controlled trials comparing antifungal therapies: a systematic review. Clin Microbiol Infect 2021; 28:640-648. [PMID: 34763055 DOI: 10.1016/j.cmi.2021.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Detailed reporting is essential in non-inferiority randomized controlled trials (NI-RCTs) to assess evidence quality, as these trials inform standards of care. OBJECTIVES The primary objective was to evaluate the methodological and reporting quality of antifungal NI-RCTs. DATA SOURCES Medline, EMBASE, the Cochrane CENTRAL and the United States Federal Drug Administration (FDA) drugs database were searched to 9 September 2020. STUDY ELIGIBILITY CRITERIA NI-RCTs differing by antifungal formulation, type, dose, administration and/or duration were included. Articles were independently assessed in duplicate using quality indicators developed by the Consolidated Standards of Reporting Trials (CONSORT) group. PARTICIPANTS Patients enrolled in antifungal trials for prophylactic and therapeutic use. METHODS The Cochrane RoB 2.0 tool was used to assess risk of bias. Descriptive statistics were used; all statistical tests were two sided. RESULTS Of 32 included studies, 22 (68.7%) did not justify the NIM. Handling of missing data was not described in 20 (62.5%). Intention-to-treat (ITT) and per-protocol (PP) analyses were both reported in 12/32 (37.5%) studies. Eleven of 32 studies (34.3%) reported potentially misleading conclusions. Industry-financed studies were more likely to report only the ITT analysis (n = 14/27, 51.9%). Methodological and reporting quality was unaffected by publication year; risk of bias from missing data changed over time. Overall risk of bias across included studies was moderate to high, with high risk in randomization process (n = 8/32, 25%), missing outcome data (n = 5/32, 15.6%), and selection of reported result (n = 9/32, 28.1%). CONCLUSIONS Justification of the non-inferiority margin, reporting of ITT and PP analyses, missing data handling description, and ensuring conclusions are consistent with reported data is necessary to improve CONSORT adherence. Small sample size and overall risk of bias are study limitations. (Systematic Review Registration Number PROSPERO CRD42020219497).
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15
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Are antifungal non-inferiority trials at risk of eroding effectiveness because of bio-creep? A secondary analysis of a systematic review. Antimicrob Agents Chemother 2021; 66:e0162721. [PMID: 34662190 DOI: 10.1128/aac.01627-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Non-inferiority randomized controlled trial (RCT) effectiveness may erode when results favour the active control over time, and when a decreasingly effective control arm is used in serial trials. We analyzed 32 antifungal noninferiority RCTs (NI-RCTs) for these scenarios in this secondary analysis of a systematic review. Our exploratory analysis suggests that the erosion risk in the effectiveness of antifungal non-inferiority trials is uncommon. Findings are limited by small sample size, and overall risk of bias.
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16
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Geersing TH, Franssen EJF, Spronk PE, van Kan HJM, den Reijer M, van der Voort PHJ. Nephrotoxicity of continuous amphotericin B in critically ill patients with abdominal sepsis: a retrospective analysis with propensity score matching. J Antimicrob Chemother 2021; 77:246-252. [PMID: 34613383 DOI: 10.1093/jac/dkab372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 09/14/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Continuous infusion of conventional amphotericin B (CCAB) is used in ICUs for pre-emptive treatment of invasive fungal infections. Amphotericin B has previously been associated with nephrotoxicity. OBJECTIVES To investigate if CCAB with therapeutic drug monitoring (TDM) results in renal impairment over time in critically ill patients with abdominal sepsis. PATIENTS AND METHODS The study was conducted at mixed medical-surgical ICUs of two large teaching hospitals in the Netherlands. Consecutive patients who were treated on the ICUs between 2006 and 2019 for abdominal sepsis, with or without CCAB, were included. CCAB dosing was guided by TDM. Serum creatinine concentrations and renal failure scores of patients with CCAB treatment were compared with those without CCAB treatment. Excluded were: (i) patients treated with CCAB for less than 72 h; and (ii) patients with renal replacement therapy. RESULTS A total of 319 patients were included (185 treated with CCAB and 134 controls). A multiple linear regression model showed that the serum creatinine concentration was independent of CCAB treatment (β = -0.023; 95% CI = -12.2 to 7.2; P = 0.615). Propensity score matching resulted in 134 pairs of CCAB-treated and non-treated patients. Again, the analysis of these pairs showed that the cumulative CCAB dose was not associated with serum creatinine concentration during intensive care treatment (β = 0.299; 95% CI = -0.38 to 0.98; P = 0.388). CONCLUSIONS CCAB with TDM did not result in renal impairment over time in critically ill patients with abdominal sepsis.
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Affiliation(s)
- T H Geersing
- Department of Clinical Pharmacy, OLVG, Amsterdam, The Netherlands
| | - E J F Franssen
- Department of Clinical Pharmacy, OLVG, Amsterdam, The Netherlands
| | - P E Spronk
- Department of Intensive Care Medicine, Gelre Hospitals Apeldoorn, Apeldoorn, The Netherlands
| | - H J M van Kan
- Department of Clinical Pharmacy, Gelre Hospitals Apeldoorn, Apeldoorn, The Netherlands
| | - M den Reijer
- Department of Clinical Microbiology & Infection Prevention, Gelre Hospitals Apeldoorn, Apeldoorn, The Netherlands
| | - P H J van der Voort
- Department of Critical Care, University Medical Center Groningen, University of Groningen, The Netherlands.,TIAS School for Business and Society, Tilburg University, Tilburg, The Netherlands
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17
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Wang L, Zhang Z. Comment about the safety of intravenous voriconazole formulated with sulfobutylether beta-cyclodextrin. Expert Opin Drug Saf 2021; 21:133-134. [PMID: 34494496 DOI: 10.1080/14740338.2021.1978976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Linlin Wang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China.,Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zanling Zhang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China.,Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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18
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Rahi MS, Jindal V, Pednekar P, Parekh J, Gunasekaran K, Sharma S, Stender M, Jaiyesimi IA. Fungal infections in hematopoietic stem-cell transplant patients: a review of epidemiology, diagnosis, and management. Ther Adv Infect Dis 2021; 8:20499361211039050. [PMID: 34434551 PMCID: PMC8381463 DOI: 10.1177/20499361211039050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/24/2021] [Indexed: 12/18/2022] Open
Abstract
The advent of bone marrow transplant has opened doors to a different approach and
offered a new treatment modality for various hematopoietic stem-cell-related
disorders. Since the first bone marrow transplant in 1957, there has been
significant progress in managing patients who undergo bone marrow transplants.
Plasma-cell disorders, lymphoproliferative disorders, and myelodysplastic
syndrome are the most common indications for hematopoietic stem-cell transplant.
Despite the advances, invasive fungal infections remain a significant cause of
morbidity and mortality in this high-risk population. The overall incidence of
invasive fungal infection in patients with hematopoietic stem-cell transplant is
around 4%, but the mortality in patients with allogeneic stem-cell transplant is
as high as 13% in one study. Type of stem-cell transplant, conditioning regimen,
and development of graft-versus-host disease are some of the
risk factors that impact the risk and outcomes in patients with invasive fungal
infections. Aspergillus and candida remain the two most common organisms causing
invasive fungal infections. Molecular diagnostic methods have replaced some
traditional methods due to their simplicity of use and rapid turnaround time.
Primary prophylaxis has undoubtedly shown to improve outcomes even though
breakthrough infection rates remain high. The directed treatment has seen a
significant shift from amphotericin B to itraconazole, voriconazole, and
echinocandins, which have shown better efficacy and fewer adverse effects. In
this comprehensive review, we aim to detail epidemiology, risk factors,
diagnosis, and management, including prophylaxis, empiric and directed
management of invasive fungal infections in patients with hematopoietic
stem-cell transplant.
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Affiliation(s)
- Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA
| | - Vishal Jindal
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Prachi Pednekar
- Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Jay Parekh
- Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Sorabh Sharma
- Department of Internal Medicine, Banner University Medical Center, Tucson, AZ, USA
| | - Michael Stender
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ishmael A Jaiyesimi
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
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19
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Nagata J, Kawasaki T, Iesato K, Sugiura T, Yamauchi K, Tsuyusaki J, Fujimura M, Kuroda F, Mikami K, Dudek SM, Tanabe N. A Case of Candidemia after Long-term Presence of Urethral Foreign Bodies. IDCases 2021; 25:e01176. [PMID: 34159054 PMCID: PMC8196048 DOI: 10.1016/j.idcr.2021.e01176] [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: 04/13/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 11/21/2022] Open
Abstract
A 52-year-old man presented to our hospital complaining of general malaise, cough, and fever. Total body computed tomography revealed scattered pneumonia and urethral foreign bodies that had been inserted during adolescence. Candida glabrata was detected in blood and urine cultures. Based on these findings, the patient was diagnosed with candidemia that developed due to Candida urinary tract infection, complicated by septic pulmonary embolism and severe diabetes mellitus. Candidemia likely persisted despite the initiation of intravenous antifungal therapy and control of blood sugar level. Therefore, surgical removal of the urethral foreign bodies was performed, which resulted in resolution of the patient’s symptoms. Herein, we report a rare case of candidemia complicated by Candida urinary tract infection that developed due to the long-term presence of urethral foreign bodies. A multidisciplinary therapeutic approach, including surgical removal of the infected foreign bodies, is effective in such cases. This case indicates that long-term presence of foreign bodies and acquired immune dysfunction can be risk factors for candidemia. Therefore, detailed history should be obtained and systemic examination should be performed to identify the complicating risk factors on diagnosis of candidemia.
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Affiliation(s)
- Jun Nagata
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan.,Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Takeshi Kawasaki
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan
| | - Ken Iesato
- Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Toshihiko Sugiura
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan.,Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Keita Yamauchi
- Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Junichi Tsuyusaki
- Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Masaaki Fujimura
- Department of Urology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Fuminobu Kuroda
- Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Kazuo Mikami
- Department of Urology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Steven M Dudek
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, USA
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan.,Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
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20
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Abstract
Invasive candidiasis (IC) is a collective term that refers to a group of infectious syndromes caused by a variety of species of Candida, 6 of which cause most cases globally. Candidemia is probably the most commonly recognized syndrome associated with IC; however, Candida can cause invasive infection of any organ, especially visceral organs, vasculature, bones and joints, the eyes and central nervous system. Targeted prevention and empirical therapy are important interventions for patients at high risk for IC, and the current approach should be based on a combination of clinical risk factors and non-culture-based diagnostics, when available.
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Affiliation(s)
- Todd P McCarty
- University of Alabama at Birmingham, Birmingham VA Medical Center, 1900 University Boulevard, THT 229, Birmingham, AL 35294, USA.
| | - Cameron M White
- University of Alabama at Birmingham, 1900 University Boulevard, THT 229, Birmingham, AL 35294, USA
| | - Peter G Pappas
- University of Alabama at Birmingham, 1900 University Boulevard, THT 229, Birmingham, AL 35294, USA
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21
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Assessing the Bioactive Profile of Antifungal-Loaded Calcium Sulfate against Fungal Biofilms. Antimicrob Agents Chemother 2021; 65:AAC.02551-20. [PMID: 33753336 PMCID: PMC8316021 DOI: 10.1128/aac.02551-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/14/2021] [Indexed: 11/20/2022] Open
Abstract
Calcium sulfate (CS) has been used clinically as a bone- or void-filling biomaterial, and its resorptive properties have provided the prospect for its use as a release mechanism for local antibiotics to control biofilms. Here, we aimed to test CS beads loaded with three antifungal drugs against planktonic and sessile fungal species to assess whether these antifungal beads could be harnessed to provide consistent release of antifungals at biofilm-inhibitory doses. A panel of different fungal species (n = 15) were selected for planktonic broth microdilution testing with fluconazole (FLZ), amphotericin B (AMB), and caspofungin (CSP). After establishing planktonic inhibition, antifungal CS beads were introduced to fungal biofilms (n = 5) to assess biofilm formation and cell viability through a combination of standard quantitative and qualitative biofilm assays. Inoculation of a hydrogel substrate, packed with antifungal CS beads, was also used to assess diffusion through a semidry material, to mimic active infection in vivo In general, antifungals released from loaded CS beads were all effective at inhibiting the pathogenic fungi over 7 days within standard MIC ranges for these fungi. We observed a significant reduction of pregrown fungal biofilms across key fungal pathogens following treatment, with visually observable changes in cell morphology and biofilm coverage provided by scanning electron microscopy. Assessment of biofilm inhibition also revealed reductions in total and viable cells across all organisms tested. These data show that antifungal-loaded CS beads produce a sustained antimicrobial effect that inhibits and kills clinically relevant fungal species in vitro as planktonic and biofilm cells.
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Demir KK, Butler-Laporte G, Del Corpo O, Ekmekjian T, Sheppard DC, Lee TC, Cheng MP. Comparative effectiveness of amphotericin B, azoles and echinocandins in the treatment of candidemia and invasive candidiasis: A systematic review and network meta-analysis. Mycoses 2021; 64:1098-1110. [PMID: 33894072 DOI: 10.1111/myc.13290] [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: 01/25/2021] [Revised: 04/11/2021] [Accepted: 04/14/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND + OBJECTIVES: The echinocandins, amphotericin B preparations, voriconazole and fluconazole are approved for the treatment of invasive candidiasis, though it remains unclear which agent is most effective. In order to answer this question, we performed a systematic review and network meta-analysis of the randomised controlled trials (RCTs) which evaluated these agents in comparison. METHODS Four electronic databases were searched from database inception to 8 October 2020. RCTs comparing triazoles, echinocandins or amphotericin B for the treatment of invasive candidiasis or candidemia were included. Random effect Bayesian network meta-analysis methods were used to compare treatment outcomes. RESULTS Thirteen RCTs met inclusion criteria. Of the 3528 patients included from these trials, 1531 were randomised to receive an echinocandin, 944 to amphotericin B and 1053 to a triazole. For all forms of invasive candidiasis, echinocandins were associated with the highest rate of treatment success when compared to amphotericin B (OR 1.41, 95% CI 1.04-1.92) and the triazoles (OR 1.82, 95% CI 1.35-2.51). Rank probability analysis favoured echinocandins as the most effective choice 98% of the time. Overall survival did not significantly differ between groups. CONCLUSIONS Among patients with invasive candidiasis, echinocandins had the best clinical outcomes and should remain the first-line agents in the treatment of invasive candidiasis.
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Affiliation(s)
- Koray K Demir
- Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Guillaume Butler-Laporte
- Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.,Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Olivier Del Corpo
- Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Taline Ekmekjian
- Medical Libraries, McGill University Health Centre, Montréal, QC, Canada
| | - Donald C Sheppard
- Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.,Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montréal, QC, Canada.,McGill Interdisciplinary Initiative in Infection and Immunity, Montréal, QC, Canada
| | - Todd C Lee
- Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.,McGill Interdisciplinary Initiative in Infection and Immunity, Montréal, QC, Canada.,Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, QC, Canada
| | - Matthew P Cheng
- Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.,Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montréal, QC, Canada.,McGill Interdisciplinary Initiative in Infection and Immunity, Montréal, QC, Canada
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Timing for Step-Down Therapy of Candidemia in Non-Neutropenic Patients: An International Multi-Center Study. Mediterr J Hematol Infect Dis 2021; 13:e2021031. [PMID: 34007419 PMCID: PMC8114892 DOI: 10.4084/mjhid.2021.031] [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: 02/03/2021] [Accepted: 04/09/2021] [Indexed: 11/29/2022] Open
Abstract
Background Candida bloodstream infection (BSI) remains one of the leading causes of BSI in critically ill and immunosuppressed cancer patients. In light of the changing epidemiology and rising resistant species, duration of treatment and appropriate timing of stepdown therapy from intravenous (IV) to oral antifungal agents are crucial for utmost disease control and overall survival. Method We performed a multicenter retrospective study, with 119 non-neutropenic patients enrolled from four different medical institutions in Brazil, Lebanon, Spain and the United States, to assess the duration of IV therapy and appropriate time to step-down to oral therapy in adult patients, 14 years of age and older, with documented candidemia. The analysis was done using the statistical program R and SAS v9.4. Descriptive statistics are presented as frequencies and tables and the Fisher exact test was used to test the association between the categorical variables: organism, cancer, country, antifungal drug and duration of therapy, and time of step-down. Results Candida albicans contributed to 45% of bloodstream infection versus 55% of infection caused by Candida non-albicans. The three most common Candida non-albicans are: Candida glabrata 24%, Candida parapsilosis 13% and Candida tropicalis 8%. Most (57%) of the patients were admitted to ICU, whereas 52% had underlying malignancy. Multivariate analysis showed that a stay at ICU or an underlying cancer requiring chemotherapy were independently associated with failure and death (p <0.001). The average total duration of therapy was 14 days in all patients and 16 days in those who responded and survived. Forty-five patients were stepped down to either fluconazole and/or voriconazole in association with clinical and microbiologic resolution of the candidemia. The average (and median) day of step-down was 5 days. Patients who had a stepdown had more favorable outcomes (78% survival) as compared to those with no stepdown (56% survival) (P = 0.022). However, the 20 patients who received 1–4 days of first IV treatment before a stepdown to oral azoles had a comparable outcome (20% mortality) to the 25 patients who received >5 days of treatment (24% mortality - p = 0.75). Conclusion Our data support the IDSA guidelines in that the total duration of treatment for candidemia should be at least 14 days after a negative blood culture. However, in non-neutropenic cancer patients with candidemia, a step-down to oral azole therapy can safely take place early (within 4 days of initiating IV therapy) as long as the patient had clinical and microbiologic resolution of the bloodstream infections.
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Zheng R, Li Y, Guo C, Pei Y, Ke Z, Huang L. Voriconazole Induced Hallucinations and Visual Disturbances in a Female Child: A Case Report and Literature Review. Front Pediatr 2021; 9:655327. [PMID: 33968855 PMCID: PMC8102700 DOI: 10.3389/fped.2021.655327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/24/2021] [Indexed: 11/25/2022] Open
Abstract
Voriconazole is a second-generation azole widely used for the prevention and treatment of fungal infection in leukemia patients. We report a case of 9-year-old girl with T-cell acute lymphoblastic leukemia who developed hallucinations and visual disturbance after using voriconazole twice. These symptoms began acutely after treatment with voriconazole and resolved rapidly when the voriconazole was stopped. No specific cause was identified, and thus the symptoms were considered to be the adverse drug reactions (ADRs) of voriconazole. Simultaneous development of hallucinations and visual disturbance caused by voriconazole in children rarely have been reported before and the causes of these ADRs are unknown. Several other cases of hallucinations and (or) visual disturbance caused by voriconazole among 15-81 years old patients have been reported in the literature, and are reviewed. Those patients reminded us of the importance of being aware of hallucinations and visual disturbance associated with voriconazole treatment. In addition, we speculate that the hallucinations and visual disturbance are not related to the dosage form of voriconazole. We emphasize that it is also important to monitor the concentration of voriconazole regularly to avoid potential toxicity.
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8th European Conference on Infections in Leukaemia: 2020 guidelines for the diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or post-haematopoietic cell transplantation. Lancet Oncol 2021; 22:e254-e269. [PMID: 33811813 DOI: 10.1016/s1470-2045(20)30723-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/24/2022]
Abstract
Paediatric patients with cancer and those undergoing allogeneic haematopoietic cell transplantation have an increased susceptibility to invasive fungal diseases. In addition to differences in underlying conditions and comorbidities relative to adults, invasive fungal diseases in infants, children, and adolescents are unique in terms of their epidemiology, the validity of current diagnostic methods, the pharmacology and dosing of antifungal agents, and the absence of phase 3 clinical trials to provide data to guide evidence-based interventions. To re-examine the state of knowledge and to further improve invasive fungal disease diagnosis, prevention, and management, the 8th European Conference on Infections in Leukaemia (ECIL-8) reconvened a Paediatric Group to review the literature and to formulate updated recommendations according to the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and European Confederation of Medical Mycology (ECMM) grading system, which are summarised in this Review.
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Adequate duration of therapy in severe fungal infections. Curr Opin Crit Care 2021; 26:466-472. [PMID: 32773617 DOI: 10.1097/mcc.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To highlight recent findings on the adequate duration of antifungal therapy in patients with invasive fungal disease (IFD). RECENT FINDINGS Plenty of published data available suggest that there is no additional clinical benefit at a certain point after initiation of antifungal treatment in patients with confirmed IFD. Moreover, the prolonged antifungal exposure can be associated with an increased risk of side effects and toxicity as well as striking risk for developing antifungal resistance or rising unnecessary healthcare costs. Recent data suggest that, in the presence of an adequate initial antifungal therapy and adequate source control of the infection, new stratified approaches integrating clinical judgment, biomarkers and microbiological eradication, should be considered as an alternative to the 'one-size-fits-all' treatment duration currently used worldwide. SUMMARY The optimal duration of antifungal therapy is still an unresolved issue that depends by many key elements including the host; the pathogen and its microbiological eradication, the adequateness of initial antifungal therapy and the promptness of source control of the infection. In general, many patients with invasive candidiasis can be treated with a 2 weeks course of antifungal therapy. Longer antifungal course (6 weeks or more) is generally required for patients with invasive aspergilosis.
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Curtis RV, Kabchi BA, Alqalyoobi S. High-flow nasal cannula can't be considered non-inferior to noninvasive ventilation in patients with chronic obstructive pulmonary disease who develop respiratory failure after extubation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:659. [PMID: 33228758 PMCID: PMC7684711 DOI: 10.1186/s13054-020-03363-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Robert V Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, East Carolina University-Brody School of Medicine, Mail Stop 628, 3E-149, Greenville, NC, 27834, USA
| | - Badih A Kabchi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, East Carolina University-Brody School of Medicine, Mail Stop 628, 3E-149, Greenville, NC, 27834, USA
| | - Shehabaldin Alqalyoobi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, East Carolina University-Brody School of Medicine, Mail Stop 628, 3E-149, Greenville, NC, 27834, USA.
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Osa S, Tashiro S, Igarashi Y, Watabe Y, Liu X, Enoki Y, Taguchi K, Mayumi T, Miyazaki Y, Takesue Y, Matsumoto K. Azoles versus conventional amphotericin B for the treatment of candidemia: A meta-analysis of randomized controlled trials. J Infect Chemother 2020; 26:1232-1236. [PMID: 32828679 DOI: 10.1016/j.jiac.2020.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/25/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
Abstract
Because exclusive use of echinocandins can induce the drug-resistant strains, appropriate use of azoles and polyenes is still necessary in the treatment of candidemia. In this study, we conducted a meta-analysis of randomized controlled trials regarding the efficacy and safety of azole and polyene antifungals in the treatment of candidemia. MEDLINE and the Cochrane Register of Controlled Trials were used as reference databases, and papers published up to June 10, 2019 were searched. The search results were carefully scrutinized, duplicate references were removed, and the study was ultimately carried out using three reports. Among azole antifungals, fluconazole and voriconazole were extracted, however; only conventional amphotericin B (AMPH-B) was extracted among polyene antifungals. Treatment successes with the use of azoles and AMPH-B were compared, and findings showed that AMPH-B was significantly superior (RR = 0.90, 95% CI 0.82-1.00, p = 0.04). However, there was no significant difference in mortality (RR = 0.87, 95% CI 0.72-1.07, p = 0.19). Analysis of adverse events showed that renal disorders were significantly less common with azoles than with AMPH-B (RR = 0.26, 95% CI 0.10-0.68, p = 0.006). In conclusion, AMPH-B were superior to azoles in terms of efficacy, but had a risk of causing renal disorders.
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Affiliation(s)
- Sumika Osa
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Sho Tashiro
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Yuki Igarashi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Yuki Watabe
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Xiaoxi Liu
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan.
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Toshihiko Mayumi
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 By the Japanese Society for Medical Mycology, Japan; Department of Emergency Medicine, School of Medicine University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yoshitsugu Miyazaki
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 By the Japanese Society for Medical Mycology, Japan; Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yoshio Takesue
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 By the Japanese Society for Medical Mycology, Japan; Department of Infection Control and Prevention, Hyogo College of Medicine, Hyogo, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan; Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 By the Japanese Society for Medical Mycology, Japan
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Kullberg BJ, Viscoli C, Pappas PG, Vazquez J, Ostrosky-Zeichner L, Rotstein C, Sobel JD, Herbrecht R, Rahav G, Jaruratanasirikul S, Chetchotisakd P, Van Wijngaerden E, De Waele J, Lademacher C, Engelhardt M, Kovanda L, Croos-Dabrera R, Fredericks C, Thompson GR. Isavuconazole Versus Caspofungin in the Treatment of Candidemia and Other Invasive Candida Infections: The ACTIVE Trial. Clin Infect Dis 2020; 68:1981-1989. [PMID: 30289478 DOI: 10.1093/cid/ciy827] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 10/04/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Isavuconazole was compared to caspofungin followed by oral voriconazole in a Phase 3, randomized, double-blind, multinational clinical trial for the primary treatment of patients with candidemia or invasive candidiasis. METHODS Adult patients were randomized 1:1 to isavuconazole (200 mg intravenous [IV] three-times-daily [TID] for 2 days, followed by 200 mg IV once-daily [OD]) or caspofungin (70 mg IV OD on day 1, followed by 50 mg IV OD [70 mg in patients > 80 kg]) for a maximum of 56 days. After day 10, patients could switch to oral isavuconazole (isavuconazole arm) or voriconazole (caspofungin arm). Primary efficacy endpoint was successful overall response at the end of IV therapy (EOIVT) in patients with proven infections who received ≥1 dose of study drug (modified-intent-to-treat [mITT] population). The pre-specified noninferiority margin was 15%. Secondary outcomes in the mITT population were successful overall response at 2 weeks after the end of treatment, all-cause mortality at days 14 and 56, and safety. RESULTS Of 450 patients randomized, 400 comprised the mITT population. Baseline characteristics were balanced between groups. Successful overall response at EOIVT was observed in 60.3% of patients in the isavuconazole arm and 71.1% in the caspofungin arm (adjusted difference -10.8, 95% confidence interval -19.9--1.8). The secondary endpoints, all-cause mortality, and safety were similar between arms. Median time to clearance of the bloodstream was comparable between groups. CONCLUSIONS This study did not demonstrate non-inferiority of isavuconazole to caspofungin for primary treatment of invasive candidiasis. Secondary endpoints were similar between both groups. CLINICAL TRIALS REGISTRATION NCT00413218.
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Affiliation(s)
- Bart Jan Kullberg
- Radboud Center for Infectious Diseases, and Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Claudio Viscoli
- Dipartimento di Scienze della Salute, University of Genova.,Ospedale Policlinico San Martino, Genova, Italy
| | | | | | | | - Coleman Rotstein
- University Health Network, University of Toronto, Ontario, Canada
| | | | - Raoul Herbrecht
- Hôpitaux Universitaires de Strasbourg and Université de Strasbourg, Inserm, UMR-S1113/IRFAC, France
| | - Galia Rahav
- Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | | | | | | | | | - Marc Engelhardt
- Basilea Pharmaceutica International Ltd., Basel, Switzerland
| | - Laura Kovanda
- Astellas Pharma Global Development, Inc, Northbrook, Illinois
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Cuenca-Estrella M, Kett DH, Wauters J. Defining standards of CARE for invasive fungal diseases in the ICU. J Antimicrob Chemother 2020; 74:ii9-ii15. [PMID: 31222308 DOI: 10.1093/jac/dkz038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The aim of this article is to review the current recommendations for the diagnosis and treatment of invasive fungal infection in the ICU setting and to explore whether there are standards of care for this patient population. The text focuses mainly on the two most common invasive fungal diseases that afflict non-neutropenic patients: candidaemia and invasive candidosis (IC), and invasive pulmonary aspergillosis (IPA).
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Affiliation(s)
- Manuel Cuenca-Estrella
- Instituto de Salud Carlos III, Ctra. Majadahonda-Pozuelo Km 2, Majadahonda, Madrid, Spain
| | - Daniel H Kett
- Division of Pulmonary, Critical Care and Sleep Medicine at the University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joost Wauters
- Clinical Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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Tashiro S, Osa S, Igarashi Y, Watabe Y, Liu X, Enoki Y, Taguchi K, Mayumi T, Miyazaki Y, Takesue Y, Matsumoto K. Echinocandins versus non-echinocandins for the treatment of invasive candidiasis: A meta-analysis of randomized controlled trials. J Infect Chemother 2020; 26:1164-1176. [PMID: 32620421 DOI: 10.1016/j.jiac.2020.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/02/2020] [Accepted: 06/06/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Echinocandins are frequent use antifungals in the treatment of invasive candidiasis, and it is important to update information on their efficacy and safety for optimal antifungal drug treatment. The aim of this study is to clarify whether echinocandins are superior to non-echinocandins for the treatment of invasive candidiasis. METHODS We conducted a meta-analysis of RCTs of echinocandins and non-echinocandins for adult invasive candidiasis. The MEDLINE, Web of Sciences, Cochrane Register of Controlled Trials, and ClinicalTrials.gov databases before June 2019 were used. The risk ratio (RR) and 95% confidence interval (95% CI) were calculated using the Mantel-Haenszel method random-effects model. RESULTS We identified 14,846 articles and screened, and five studies were included meta-analysis. The treatment success ratio for echinocandins was significantly higher than that for non-echinocandins (RR = 1.14, 95% CI 1.06-1.22, p = 0.0003). In regard to adverse events, there was no significant difference between the two treatment groups. A subgroup analysis showed that the treatment success ratio for echinocandins was significantly higher than that for azoles (RR = 1.20, 1.08-1.34, p = 0.001), whereas no significant differences were observed between echinocandins and polyenes. In safety analysis, the incidence ratio of electrolyte disorder (RR = 0.50, 0.33-0.76, p = 0.001), renal disorder (RR = 0.19, 0.09-0.40, p < 0.0001), and fever (RR = 0.46, 0.23-0.93, p = 0.03) were significantly lower in patients receiving echinocandins than in those receiving polyenes. CONCLUSIONS This meta-analysis based on RCTs was first to show that use of echinocandins was associated with improved clinical success. Echinocandins may be useful as a first-line drug for invasive candidiasis.
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Affiliation(s)
- Sho Tashiro
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Sumika Osa
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Yuki Igarashi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Yuki Watabe
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Xiaoxi Liu
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan.
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Toshihiko Mayumi
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Emergency Medicine, School of Medicine University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yoshitsugu Miyazaki
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yoshio Takesue
- Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan; Department of Infection Control and Prevention, Hyogo College of Medicine, Hyogo, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan; Committee of Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis 2020 by the Japanese Society for Medical Mycology, Japan
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Dihydrofolate Reductase Is a Valid Target for Antifungal Development in the Human Pathogen Candida albicans. mSphere 2020; 5:5/3/e00374-20. [PMID: 32581079 PMCID: PMC7316490 DOI: 10.1128/msphere.00374-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The folate biosynthetic pathway is a promising and understudied source for novel antifungals. Even dihydrofolate reductase (DHFR), a well-characterized and historically important drug target, has not been conclusively validated as an antifungal target. Here, we demonstrate that repression of DHFR inhibits growth of Candida albicans, a major human fungal pathogen. Methotrexate, an antifolate, also inhibits growth but through pH-dependent activity. In addition, we show that C. albicans has a limited ability to take up or utilize exogenous folates as only the addition of high concentrations of folinic acid restored growth in the presence of methotrexate. Finally, we show that repression of DHFR in a mouse model of infection was sufficient to eliminate host mortality. Our work conclusively establishes DHFR as a valid antifungal target in C. albicans. While the folate biosynthetic pathway has provided a rich source of antibacterial, antiprotozoal, and anticancer therapies, it has not yet been exploited to develop uniquely antifungal agents. Although there have been attempts to develop fungal-specific inhibitors of dihydrofolate reductase (DHFR), the protein itself has not been unequivocally validated as essential for fungal growth or virulence. The purpose of this study was to establish dihydrofolate reductase as a valid antifungal target. Using a strain with doxycycline-repressible transcription of DFR1 (PTETO-DFR1 strain), we were able to demonstrate that Dfr1p is essential for growth in vitro. Furthermore, nutritional supplements of most forms of folate are not sufficient to restore growth when Dfr1p expression is suppressed or when its activity is directly inhibited by methotrexate, indicating that Candida albicans has a limited capacity to acquire or utilize exogenous sources of folate. Finally, the PTETO-DFR1 strain was rendered avirulent in a mouse model of disseminated candidiasis upon doxycycline treatment. Collectively, these results confirm the validity of targeting dihydrofolate reductase and, by inference, other enzymes in the folate biosynthetic pathway as a strategy to devise new and efficacious therapies to combat life-threatening invasive fungal infections. IMPORTANCE The folate biosynthetic pathway is a promising and understudied source for novel antifungals. Even dihydrofolate reductase (DHFR), a well-characterized and historically important drug target, has not been conclusively validated as an antifungal target. Here, we demonstrate that repression of DHFR inhibits growth of Candida albicans, a major human fungal pathogen. Methotrexate, an antifolate, also inhibits growth but through pH-dependent activity. In addition, we show that C. albicans has a limited ability to take up or utilize exogenous folates as only the addition of high concentrations of folinic acid restored growth in the presence of methotrexate. Finally, we show that repression of DHFR in a mouse model of infection was sufficient to eliminate host mortality. Our work conclusively establishes DHFR as a valid antifungal target in C. albicans.
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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Surgical management of invasive fungal infections in adult leukemia patients: experience from a large tertiary center in Southeast-Asia. BLOOD SCIENCE 2020; 2:59-65. [PMID: 35402820 PMCID: PMC8974899 DOI: 10.1097/bs9.0000000000000022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/22/2019] [Indexed: 11/25/2022] Open
Abstract
Objectives: Invasive fungal infections (IFIs) are a major cause of morbidity and mortality in acute leukemia patients undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT). Surgical interventions may be necessary to improve the survival outcomes of these patients. The aim of this study is to report a single-center experience using surgical intervention as adjunctive treatment for IFI in adult leukemia patients. Methods: A retrospective review was conducted to obtain clinical characteristics and outcomes of surgically managed IFI patients diagnosed between January 2005 and December 2015 in our center. Results: Nineteen acute leukemia patients, median age 46 years (range 19–65), underwent 20 surgical procedures as management for IFI. Three patients had proven IFI diagnoses prior to surgery. Sixteen patients underwent surgery for both diagnostic and therapeutic purposes. Post-surgery, the diagnostic yield for proven IFI increased by a factor of 5, and 15 patients had definitive IFI diagnoses. Surgical complications included 2 pleural effusions, 4 pneumothoraxes, and 1 hydropneumothorax. The median duration of hospitalization for patients with complications was 9 days (range 3–64). Thirteen patients benefited overall from the procedure, 3 had temporary clinical benefits, and 2 had progression of IFI. After surgery, the 3-month and 2-year overall survival rates were 89.5% and 57.9%, respectively. The median time from surgery to resumption of chemotherapy or HSCT was 25 days. Conclusions: Surgical interventions for IFI are feasible in selected leukemia patients, as they yield valuable information to guide antifungal therapy or enable therapeutic outcomes with acceptable risk, thereby allowing patients to proceed with curative chemotherapy and HSCT.
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Novak AR, Bradley ME, Kiser TH, Mueller SW. Azole-resistant Aspergillus and Echinocandin-resistant Candida - What are the treatment options? CURRENT FUNGAL INFECTION REPORTS 2020; 14:141-152. [PMID: 32699568 DOI: 10.1007/s12281-020-00379-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review This review summarizes current treatment options for echinocandin-resistant Candida spp. (ERC) and azole-resistant Aspergillus fumigatus (ARAF), emphasizing recent in vitro/in vivo data, clinical reports, and consensus statements. Recent Findings Advances in ERC and ARAF treatment are limited to specific antifungal combinations and dose optimization but remain reliant on amphotericin products. Although novel antifungals may provide breakthroughs in the treatment of resistant fungi, these agents are not yet available. Early identification and appropriate treatment remain a paramount, albeit elusive, task. Summary When either ERC or ARAF are suspected or proven, amphotericin products remain the cornerstone of initial therapy. For ERC, azoles are de-escalation options for susceptible isolates in stable patients to avoid amphotericin toxicities. Although combination echinocandin with high-dose salvage posaconazole or isavuconazole may be attempted in ARAF, it requires careful consideration following patient stabilization. Future research defining optimal therapies and early identification of ERC and ARAF is of extreme importance.
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Affiliation(s)
- Alison R Novak
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Mary E Bradley
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Scott W Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
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Santos CAQ, Rhee Y, Czapka MT, Kazi AS, Proia LA. Make Sure You Have a Safety Net: Updates in the Prevention and Management of Infectious Complications in Stem Cell Transplant Recipients. J Clin Med 2020; 9:jcm9030865. [PMID: 32245201 PMCID: PMC7141503 DOI: 10.3390/jcm9030865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/11/2020] [Indexed: 12/11/2022] Open
Abstract
Hematopoietic stem cell transplant recipients are at increased risk of infection and immune dysregulation due to reception of cytotoxic chemotherapy; development of graft versus host disease, which necessitates treatment with immunosuppressive medications; and placement of invasive catheters. The prevention and management of infections in these vulnerable hosts is of utmost importance and a key “safety net” in stem cell transplantation. In this review, we provide updates on the prevention and management of CMV infection; invasive fungal infections; bacterial infections; Clostridium difficile infection; and EBV, HHV-6, adenovirus and BK infections. We discuss novel drugs, such as letermovir, isavuconazole, meropenem-vaborbactam and bezlotoxumab; weigh the pros and cons of using fluoroquinolone prophylaxis during neutropenia after stem cell transplantation; and provide updates on important viral infections after hematopoietic stem cell transplant (HSCT). Optimizing the prevention and management of infectious diseases by using the best available evidence will contribute to better outcomes for stem cell transplant recipients, and provide the best possible “safety net” for these immunocompromised hosts.
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Andes D. Has the Optimal Therapy for Invasive Candidiasis Now Been Defined? Clin Infect Dis 2020; 68:1990-1992. [PMID: 30289475 DOI: 10.1093/cid/ciy830] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/28/2018] [Indexed: 01/05/2023] Open
Affiliation(s)
- David Andes
- Department of Medicine and Microbiology and Immunology, University of Wisconsin, Madison
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Aslam S, Rotstein C. Candida infections in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13623. [PMID: 31155770 DOI: 10.1111/ctr.13623] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice provide recommendations for the diagnosis and management of Candida infections in solid organ transplant recipients. Candida infections manifest primarily as candidemia and invasive candidiasis and cause considerable morbidity and mortality. Early diagnosis and initiation of treatment are necessary to reduce mortality. For both candidemia and invasive candidiasis, an echinocandin is recommended for initial therapy. However, early transition to oral therapy is encouraged when patients are stable and the organism is susceptible. Candida prophylaxis should be targeted for high-risk patients in liver, small bowel, and pancreas transplant recipients. Future research should address which patient groups may benefit most from preventative antifungal therapy strategies.
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Affiliation(s)
- Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California
| | - Coleman Rotstein
- Multi-organ Transplant Program, Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Pfaller MA, Diekema DJ, Turnidge JD, Castanheira M, Jones RN. Twenty Years of the SENTRY Antifungal Surveillance Program: Results for Candida Species From 1997-2016. Open Forum Infect Dis 2019; 6:S79-S94. [PMID: 30895218 PMCID: PMC6419901 DOI: 10.1093/ofid/ofy358] [Citation(s) in RCA: 433] [Impact Index Per Article: 86.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background The emergence of antifungal resistance threatens effective treatment of invasive fungal infection (IFI). Invasive candidiasis is the most common health care–associated IFI. We evaluated the activity of fluconazole (FLU) against 20 788 invasive isolates of Candida (37 species) collected from 135 medical centers in 39 countries (1997–2016). The activity of anidulafungin, caspofungin, and micafungin (MCF) was evaluated against 15 308 isolates worldwide (2006–2016). Methods Species identification was accomplished using phenotypic (1997–2001), genotypic, and proteomic methods (2006–2016). All isolates were tested using reference methods and clinical breakpoints published in the Clinical and Laboratory Standards Institute documents. Results A decrease in the isolation of Candida albicans and an increase in the isolation of Candida glabrata and Candida parapsilosis were observed over time. Candida glabrata was the most common non–C. albicans species detected in all geographic regions except for Latin America, where C. parapsilosis and Candida tropicalis were more common. Six Candida auris isolates were detected: 1 each in 2009, 2013, 2014, and 2015 and 2 in 2016; all were from nosocomial bloodstream infections and were FLU-resistant (R). The highest rates of FLU-R isolates were seen in C. glabrata from North America (NA; 10.6%) and in C. tropicalis from the Asia-Pacific region (9.2%). A steady increase in isolation of C. glabrata and resistance to FLU was detected over 20 years in the United States. Echinocandin-R (EC-R) ranged from 3.5% for C. glabrata to 0.1% for C. albicans and C. parapsilosis. Resistance to MCF was highest among C. glabrata (2.8%) and C. tropicalis (1.3%) from NA. Mutations on FKS hot spot (HS) regions were detected among 70 EC-R isolates (51/70 were C. glabrata). Most isolates harboring FKS HS mutations were resistant to 2 or more ECs. Conclusions EC-R and FLU-R remain uncommon among contemporary Candida isolates; however, a slow and steady emergence of resistance to both antifungal classes was observed in C. glabrata and C. tropicalis isolates.
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Affiliation(s)
- Michael A Pfaller
- JMI Laboratories, North Liberty, Iowa.,University of Iowa College of Medicine, Iowa City, Iowa
| | | | - John D Turnidge
- Departments of Pathology and Molecular and Cellular Biology, University of Adelaide, Adelaide, SA, Australia
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Espinel-Ingroff A, Sanguinetti M, Posteraro B. Usefulness of Antifungal Reference In Vitro Susceptibility Tests as a Guide in Therapeutic Management. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-0336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mourad A, Perfect JR. Tolerability profile of the current antifungal armoury. J Antimicrob Chemother 2019; 73:i26-i32. [PMID: 29304209 DOI: 10.1093/jac/dkx446] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The tolerability of available antifungal agents is essential to the final outcome of the management of invasive mycoses. There are limited classes of antifungal agents for use, and they can have serious direct toxicities and/or drug-drug interactions. In this review, we examine the common toxicities noted for antifungal agents and attempt to both identify the issues around the adverse events and provide clinical context for their occurrence in these fragile patients.
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Affiliation(s)
- Ahmad Mourad
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Nami S, Aghebati-Maleki A, Morovati H, Aghebati-Maleki L. Current antifungal drugs and immunotherapeutic approaches as promising strategies to treatment of fungal diseases. Biomed Pharmacother 2019; 110:857-868. [DOI: 10.1016/j.biopha.2018.12.009] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/20/2018] [Accepted: 12/02/2018] [Indexed: 12/21/2022] Open
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Lausch KR, Søgaard M, Rosenvinge FS, Johansen HK, Boysen T, Røder BL, Mortensen KL, Nielsen L, Lemming L, Olesen B, Leitz C, Kristensen L, Dzajic E, Østergaard LJ, Schønheyder HC, Arendrup MC. Treatment of candidemia in a nationwide setting: increased survival with primary echinocandin treatment. Infect Drug Resist 2018; 11:2449-2459. [PMID: 30538511 PMCID: PMC6260183 DOI: 10.2147/idr.s176384] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background In accordance with international guidelines, primary antifungal treatment (AFT) of candidemia with echinocandins has been nationally recommended in Denmark since 2009. Our nationwide cohort study describes the management of candidemia treatment focusing on the impact of prophylactic AFT on species distribution, the rate of adherence to the recommended national guidelines for AFT, and the effect of AFT on patient outcomes. Materials and methods Incident candidemia cases from a 2-year period, 2010-2011, were included. Information on AFT was retrospectively collected from patient charts. Vital status was obtained from the Danish Civil Registration System. HRs of mortality were reported with 95% CIs using Cox regression. Results A total of 841 candidemia patients was identified. Prior to candidemia diagnosis, 19.3% of patients received AFT (162/841). The risk of non-albicans candidemia increased after prior AFT (59.3% vs 45.5% among nontreated). Echinocandins as primary AFT were given for 44.2% (302/683) of patients. Primary treatment with echinocandins resulted in adequate treatment in a higher proportion of patients (97.7% vs 72.1%) and was associated with lower 0- to 14-day mortality compared with azole treatment (adj. HR 0.76, 95% CI: 0.55-1.06). Significantly lower 0- to 14-day mortality was observed for patients with Candida glabrata and Candida krusei with echinocandin treatment compared with azole treatment (adj. HR 0.50, 95% CI: 0.28-0.89), but not for patients with Candida albicans or Candida tropicalis. Conclusion The association shown between prior AFT and non-albicans species underlines the importance of treatment history when selecting treatment for candidemia. Compliance with national recommendations was low, but similar to previously reported international rates. Primary treatment of candidemia with echinocandins compared with azoles yielded both a higher proportion of adequately treated patients and improved mortality rates. This real-life setting supports guidelines recommendation, and further focus on compliance with these seems warranted.
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Affiliation(s)
| | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, 9000 Aalborg, Denmark
| | - Flemming Schønning Rosenvinge
- Department of Clinical Microbiology, Odense University Hospital, 5000 Odence C, Denmark.,Department of Clinical Microbiology, Lillebaelt Hospital, 5500 Middelfart, Denmark
| | | | - Trine Boysen
- Department of Clinical Microbiology, Hvidovre Hospital, 2650 Hvidovre, Denmark
| | - Bent Løwe Røder
- Department of Clinical Microbiology, Hospital of Slagelse, Slagelse Sygehus, 4200 Slagelse, Denmark
| | - Klaus Leth Mortensen
- Department of Infectious Disease, Aarhus University Hospital, 8200 Aarhus, Denmark, .,Department of Clinical Microbiology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Lene Nielsen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, 2730 Herlev, Denmark
| | - Lars Lemming
- Department of Clinical Microbiology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Bente Olesen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, 2730 Herlev, Denmark
| | - Christine Leitz
- Department of Clinical Microbiology, Viborg Regionshospital, 8800 Viborg, Denmark
| | - Lise Kristensen
- Department of Clinical Microbiology, Aarhus University Hospital, 8200 Aarhus, Denmark.,Department of Clinical Microbiology, Herning Regionshospital, 7400 Herning, Denmark
| | - Esad Dzajic
- Department of Clinical Microbiology, Sydvestjysk Sygehus, 6700 Esbjerg, Denmark
| | | | - Henrik Carl Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, 9000 Aalborg, Denmark.,Department of Clinical Medicine, University of Aalborg, 9000 Aalborg, Denmark
| | - Maiken Cavling Arendrup
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark.,Unit of Mycology, Statens Serum Institute, 2300 København, Denmark.,Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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Sakagami T, Kawano T, Yamashita K, Yamada E, Fujino N, Kaeriyama M, Fukuda Y, Nomura N, Mitsuyama J, Suematsu H, Watanabe H, Asai N, Koizumi Y, Yamagishi Y, Mikamo H. Antifungal susceptibility trend and analysis of resistance mechanism for Candida species isolated from bloodstream at a Japanese university hospital. J Infect Chemother 2018; 25:34-40. [PMID: 30401513 DOI: 10.1016/j.jiac.2018.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/01/2018] [Accepted: 10/09/2018] [Indexed: 11/15/2022]
Abstract
We compared the susceptibility of six commercially available antifungal agents (fluconazole, itraconazole, voriconazole, caspofungin, micafungin, and amphotericin B) against 133 Candida bloodstream isolates between 2008 and 2013 at Aichi Medical University Hospital. C. albicans was the most common isolate, followed by C. parapsilosis, C. glabrata, and C. tropicalis. MIC90s of voriconazole against C. albicans, C. parapsilosis, and C. tropicalis were the lowest and that of micafungin against C. glabrata was the lowest among the agents tested. Of the 133 isolates, two strains were identified as drug-resistant. One was a fluconazole-resistant C. glabrata strain, in which the ATP-binding cassette (ABC) transporter gene expression was upregulated. The other was a micafungin-resistant C. glabrata strain, that had 13 amino acid substitutions in FKS1 and FKS2, including a novel substitution V1342I in FKS1 hotspot 2. We also evaluated the susceptibility of T-2307, a novel class of antifungal agents used in clinical trials, against the fluconazole- and micafungin-resistant C. glabrata strain; the MICs of T-2307 were 0.0039 and 0.0078 μg/mL, respectively. In conclusion, the incidence of bloodstream infection caused by drug-resistant Candida spp. was rare from 2008 to 2013 at our hospital. Of 133 isolates, only two strains of C. glabrata were resistant to azoles or echinocandins, that upregulated the ABC transporter genes or had novel FKS mutations, respectively.
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Affiliation(s)
- Toru Sakagami
- Department of Clinical Infectious Diseases, Aichi Medical University Graduate School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan; Pharmaceutical & Healthcare Research Laboratories Research & Development Management Headquarters, FUJIFILM Corporation, 577 Ushijima, Kaisei-Machi, Ashigarakami-Gun, Kanagawa, 258-8577, Japan.
| | - Takaki Kawano
- Pharmaceutical & Healthcare Research Laboratories Research & Development Management Headquarters, FUJIFILM Corporation, 577 Ushijima, Kaisei-Machi, Ashigarakami-Gun, Kanagawa, 258-8577, Japan
| | - Kohei Yamashita
- Pharmaceutical & Healthcare Research Laboratories Research & Development Management Headquarters, FUJIFILM Corporation, 577 Ushijima, Kaisei-Machi, Ashigarakami-Gun, Kanagawa, 258-8577, Japan
| | - Eio Yamada
- Development Division, Toyama Chemical Co., Ltd., 3-2-5 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Noritomo Fujino
- Development Division, Toyama Chemical Co., Ltd., 3-2-5 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Makoto Kaeriyama
- Development Division, Toyama Chemical Co., Ltd., 3-2-5 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Yoshiko Fukuda
- Product Planning Division, Toyama Chemical Co., Ltd., 2-4-1 Shimookui, Toyama, 930-8508, Japan
| | - Nobuhiko Nomura
- Product Planning Division, Toyama Chemical Co., Ltd., 2-4-1 Shimookui, Toyama, 930-8508, Japan
| | - Junichi Mitsuyama
- Quality Assurance Division, Toyama Chemical Co., Ltd., 3-2-5 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hiroyuki Suematsu
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hiroki Watanabe
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yusuke Koizumi
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Aichi Medical University Graduate School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan; Department of Clinical Infectious Diseases, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University Graduate School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan; Department of Clinical Infectious Diseases, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
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Keane S, Geoghegan P, Povoa P, Nseir S, Rodriguez A, Martin-Loeches I. Systematic review on the first line treatment of amphotericin B in critically ill adults with candidemia or invasive candidiasis. Expert Rev Anti Infect Ther 2018; 16:839-847. [PMID: 30257597 DOI: 10.1080/14787210.2018.1528872] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Invasive candidiasis is the most common fungal infection affecting critically ill adults. International guidelines provide differing recommendations for first-line antifungal therapy, with echinocandins considered first-line in the majority. Amphotericin B has broad activity and low minimum inhibitory concentration resistance patterns across most Candida species and guidance away from its use should be supported by the available evidence. Areas Covered: A systematic literature review was conducted from August to September 2017 to determine whether treatment with echinocandins or other available drugs, namely voriconazole, confers a therapeutic or survival benefit over amphotericin B in critically ill adults with invasive candidiasis. Inclusion criteria were: (1) studies describing critically ill adults with invasive candidiasis, (2) studies describing therapeutic benefit or survival as an outcome, and (3) studies comparing amphotericin B, deoxycholate or lipid preparations, with any newer antifungal agent. Eight studies were included in the final review, incorporating 2352 unique patients. No difference in treatment efficacy or mortality outcomes in critically ill patients with invasive candidiasis receiving an amphotericin B formulation compared with those receiving an echinocandin or voriconazole was shown. Expert Commentary: We conclude that in the existing literature, there is no evidence that choice between echinocandins, voriconazole, or amphotericin B formulations as first-line therapy for critically ill adults with invasive candidiasis is associated with a therapeutic or survival benefit. Clinicians must therefore consider other factors in the selection of first-line therapy.
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Affiliation(s)
- Sean Keane
- a Department of Anaesthesia and Critical Care Medicine , St. James's Hospital , Dublin , Ireland
| | - Pierce Geoghegan
- a Department of Anaesthesia and Critical Care Medicine , St. James's Hospital , Dublin , Ireland
| | - Pedro Povoa
- b Polyvalent Intensive Care Unit , Hospital de São Francisco Xavier, Centro Hospital de Lisboa Ocidental , Lisboa , Portugal.,c NOVA Medical School , New University of Lisbon , Lisboa , Portugal
| | - Saad Nseir
- d Centre de Réanimation , CHU Lille , Lille , France.,e Medicine School , Lille University , Lille , France
| | - Alejandro Rodriguez
- f Critical Care Department , Hospital Universitario de Tarragona Joan XXIII, URV, IISPV, CIBERES , Tarragona , Spain
| | - Ignacio Martin-Loeches
- g Pulmonary Intensive Care Unit , Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS , Barcelona , Spain.,h St. James's Hospital , Multidisciplinary Intensive Care Research Organization (MICRO) , Dublin , Ireland
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The association between treatment appropriateness according to EUCAST and CLSI breakpoints and mortality among patients with candidemia: a retrospective observational study. Eur J Clin Microbiol Infect Dis 2018; 37:2397-2404. [PMID: 30284179 DOI: 10.1007/s10096-018-3389-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Abstract
To evaluate the association between appropriate antifungal treatment and mortality among patients with candidemia using different breakpoint definitions. In a retrospective study, we included all adults with candidemia in a tertiary center between 2009 and 2015. We defined three versions of appropriate (covering) antifungal treatment, according to Clinical and Laboratory Standards Institute (CLSI) 2008, CLSI 2012, and European Committee on Antimicrobial Susceptibility Testing (EUCAST) (2017 update) breakpoints. For empiric treatment, we evaluated the association with 30-day mortality. For definitive treatment, we evaluated the association with 90-day mortality among patients surviving the first week after candidemia onset. Adjusted odds ratios (OR) from a bivariate logistic regression with 95% confidence intervals are reported. We identified 302 patients with 308 separate candidemia episodes. The crude 30-day mortality was 55% (168/308). Resistance to anidulafungin increased from 3.5 to 51.6% and to fluconazole from 15.2 to 44.1%, when applying CLSI 2008 and EUCAST definitions, respectively. Appropriate empirical treatment was significantly associated with lower 30-day mortality using the CLSI 2008 definitions, adjusted OR 0.56 (0.33-0.96). The associations were similar, though not statistically significant for EUCAST, 0.58 (0.33-1.00), and CLSI 2012, OR 0.62 (0.37-1.04). Appropriate definitive treatment according to CLSI 2012 and EUCAST was independently associated with lower 90-day mortality, ORs 0.31 (0.13-0.75) and 0.44 (0.23-0.8), respectively. With CLSI 2008, the association was similar but not statistically significant, OR 0.4 (0.11-1.41), with few isolates classified as resistant. Considering the major shift in resistance prevalence when applying CLSI 2008, CLSI 2012, and EUCAST breakpoint definitions, no major differences were observed in their association with mortality.
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Joseph M, Brady R, Attridge R, Cota J, Horlen C, Lusk K, Attridge RL. Critically Ill Recipients of Weight-Based Fluconazole Meeting Drug-Induced Liver Injury Network Criteria. Hosp Pharm 2018; 54:378-384. [PMID: 31762485 DOI: 10.1177/0018578718802583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Fluconazole-associated liver injury is estimated to occur in <10% of patients; however, effect of weight-based fluconazole dosing on liver injury is unknown. Furthermore, no studies have systematically applied the Drug-Induced Liver Injury Network (DILIN) Criteria to identify patients who may have drug-induced liver injury in an intensive care unit (ICU) setting. Objective: This study evaluated how often patients met DILIN criteria when receiving fluconazole daily doses of <6 mg/kg versus ⩾6 mg/kg. Methods: This dual-center, retrospective cohort study was performed in hospitalized critically ill fluconazole recipients. We compared liver function tests (LFTs) upon fluconazole initiation to peak LFTs within 2 weeks after discontinuation using DILIN criteria. The primary objective was to evaluate the number of patients meeting DILIN criteria when receiving fluconazole daily doses of <6 mg/kg versus ⩾6 mg/kg. Secondary objectives were to evaluate incidence of patients meeting DILIN criteria in patients with renal dysfunction, cirrhosis, septic shock, or those receiving a loading dose. Results: Of 248 patients included, 90% had a documented fungal infection or received empiric therapy for suspected invasive candidiasis. In patients receiving <6 mg/kg of fluconazole, 55% (110/199) met DILIN criteria versus 46.9% (23/49) in the ⩾6 mg/kg cohort (P = .20). Only 14.5% of patients meeting DILIN criteria also met the definition for hepatocellular damage. Weight-based fluconazole dose and creatinine clearance <50 mL/min were not independent risk factors for meeting DILIN criteria. However, 77.3% of patients with cirrhosis met DILIN criteria (OR 4.84 [95% confidence interval, CI, 2.61-9.28]) and 76.3% with septic shock met DILIN criteria (OR 4.56 [95% CI, 2.44-8.88]). Conclusion: Weight-based fluconazole dosing did not affect the number of critically ill recipients who met DILIN criteria. However, DILIN criteria may overestimate the incidence of fluconazole-associated liver injury in critically ill patients.
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Affiliation(s)
- Merlyn Joseph
- Irma Lerma Rangel College of Pharmacy, Texas A&M University, Houston, TX, USA.,South Texas Veterans Health Care System, Audie L. Murphy VA Hospital, San Antonio, TX, USA
| | | | - Russell Attridge
- South Texas Veterans Health Care System, Audie L. Murphy VA Hospital, San Antonio, TX, USA.,Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
| | - Jason Cota
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
| | - Cheryl Horlen
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
| | - Kathleen Lusk
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA.,University of Texas Health San Antonio, San Antonio, TX USA
| | - Rebecca L Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA.,University of Texas Health San Antonio, San Antonio, TX USA
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Ben-Ami R. Treatment of Invasive Candidiasis: A Narrative Review. J Fungi (Basel) 2018; 4:jof4030097. [PMID: 30115843 PMCID: PMC6162658 DOI: 10.3390/jof4030097] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/08/2018] [Accepted: 08/12/2018] [Indexed: 12/29/2022] Open
Abstract
Invasive candidiasis occurs frequently in hospitalized patients, and is associated with high mortality rates due to delays in recognition and initiation of appropriate antifungals. Management of invasive candidiasis must take into account multiple host, pathogen, and drug-related factors, including the site of infection, host immune status, severity of sepsis, resistance and tolerance to antifungal agents, biofilm formation, and pharmacokinetic/pharmacodynamic considerations. Recent treatment directives have been shaped by the widespread introduction of echinocandins, highly potent and safe antifungals, into clinical use, as well as important changes in drug susceptibility patterns and the emergence of known and novel drug-resistant Candida species. Advances in molecular diagnostics have the potential to guide early targeted treatment of high-risk patients.
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Affiliation(s)
- Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel.
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Abstract
Invasive candidiasis is an important health-care-associated fungal infection that can be caused by several Candida spp.; the most common species is Candida albicans, but the prevalence of these organisms varies considerably depending on geographical location. The spectrum of disease of invasive candidiasis ranges from minimally symptomatic candidaemia to fulminant sepsis with an associated mortality exceeding 70%. Candida spp. are common commensal organisms in the skin and gut microbiota, and disruptions in the cutaneous and gastrointestinal barriers (for example, owing to gastrointestinal perforation) promote invasive disease. A deeper understanding of specific Candida spp. virulence factors, host immune response and host susceptibility at the genetic level has led to key insights into the development of early intervention strategies and vaccine candidates. The early diagnosis of invasive candidiasis is challenging but key to the effective management, and the development of rapid molecular diagnostics could improve the ability to intervene rapidly and potentially reduce mortality. First-line drugs, including echinocandins and azoles, are effective, but the emergence of antifungal resistance, especially among Candida glabrata, is a matter of concern and underscores the need to administer antifungal medications in a judicious manner, avoiding overuse when possible. A newly described pathogen, Candida auris, is an emerging multidrug-resistant organism that poses a global threat.
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Affiliation(s)
- Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institutes of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Maiken Cavling Arendrup
- Unit for Mycology, Statens Serum Institute, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, University of Texas Health Science Center, Houston, TX, USA
| | - Bart Jan Kullberg
- Department of Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
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Appropriate Duration of Intravenous Treatment of Candidemia and Timing of Step Down to Oral Therapy in Non-neutropenic Patients. Mediterr J Hematol Infect Dis 2018; 10:e2018028. [PMID: 29755705 PMCID: PMC5937951 DOI: 10.4084/mjhid.2018.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/04/2018] [Indexed: 12/16/2022] Open
Abstract
In this review, we have analyzed the available literature pertaining to the total duration of intravenous (IV) therapy and the appropriate timing of step down to oral therapy in the management of candidemia. Overview of the guidelines and literature seem to indicate that a minimum of 14 days of antifungal therapy is required in the treatment of candidemia without deeply seated infection. However, this was never based on evidence. Furthermore, step down to oral therapy seems to be dependent on the clinical stability criteria of the patient with candidemia after 4 to 7 days of IV therapy. Further studies are required to evaluate the appropriate total duration of IV therapy, appropriate timing of step down to oral therapy and to validate the clinical criteria that would allow the switch to happen.
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