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Goscicki BK, Yan SQ, Mathew S, Mauguen A, Cohen N. A Retrospective Analysis of Micafungin Prophylaxis in Children Under 12 Years Undergoing Chemotherapy or Hematopoietic Stem Cell Transplantation. J Pediatr Pharmacol Ther 2024; 29:379-384. [PMID: 39144392 PMCID: PMC11321804 DOI: 10.5863/1551-6776-29.4.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/03/2024] [Indexed: 08/16/2024]
Abstract
OBJECTIVES Literature is limited regarding ideal micafungin dosing in pediatric patients with hematologic malignancies receiving chemotherapy or hematopoietic stem cell transplantation. Micafungin is an intravenous echinocandin with activity against Candida and Aspergillus species and has a favorable safety profile compared with other antifungal classes. Our objective was to evaluate the breakthrough invasive fungal infection (IFI) rate in pediatric patients who received a prophylactic micafungin course at our institution. METHODS A single-center, retrospective study was conducted between January 1, 2011, and July 31, 2017, to determine the IFI rate in patients receiving micafungin prophylaxis. Patients with suspected IFI were evaluated for probable or proven infection based on European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group Consensus Group invasive fungal disease definitions. Statistical analyses were descriptive. RESULTS A total of 170 prophylactic micafungin courses from 129 unique patients ages <12 years at a median dose of 3 mg/kg daily were identified. The rate of probable or proven breakthrough IFIs was 2.4% as determined by clinical, radiologic, microbiologic, and histopathologic criteria. CONCLUSIONS A low rate of breakthrough IFI was seen with micafungin prophylaxis that is consistent with prior published adult hematopoietic stem cell transplantation studies. Micafungin was well tolerated, with liver function test elevations being transient in most cases and thought to be related to alternative factors.
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Affiliation(s)
- Breana K. Goscicki
- Department of Pharmacy (BKG), UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Shirley Q. Yan
- Department of Pharmacy (SQY, NC), Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Audrey Mauguen
- Department of Epidemiology and Biostatistics (AM), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nina Cohen
- Department of Pharmacy (SQY, NC), Memorial Sloan Kettering Cancer Center, New York, NY
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Molecular Mechanisms of Antifungal Resistance in Mucormycosis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6722245. [PMID: 36277891 PMCID: PMC9584669 DOI: 10.1155/2022/6722245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/25/2022] [Accepted: 09/24/2022] [Indexed: 11/24/2022]
Abstract
Mucormycosis is one among the life-threatening fungal infections with high morbidity and mortality. It is an uncommon and rare infection targeting people with altered immunity. This lethal infection induced by fungi belonging to the Mucorales family is very progressive in nature. The incidence has increased in recent decades owing to the rise in immunocompromised patients. Disease management involves a multimodal strategy including early administration of drugs and surgical removal of infected tissues. Among the antifungals, azoles and amphotericin B remain the gold standard drugs of choice for initial treatment. The order Mucorales are developing a high level of resistance to the available systemic antifungal drugs, and the efficacy still remains below par. Deciphering the molecular mechanisms behind the antifungal resistance in Mucormycosis would add vital information to our available antifungal armamentarium and design novel therapies. Therefore, in this review, we have discussed the mechanisms behind Mucormycosis antifungal resistance. Moreover, this review also highlights the basic mechanisms of action of antifungal drugs and the resistance landscape which is expected to augment future treatment strategies.
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Kim BK, Choi JY, Hong KT, An HY, Shin HY, Kang HJ. Prospective Study on Prophylactic Micafungin Sodium against Invasive Fungal Disease during Neutropenia in Pediatric & Adolescent Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation. CHILDREN 2022; 9:children9030372. [PMID: 35327744 PMCID: PMC8947337 DOI: 10.3390/children9030372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 11/20/2022]
Abstract
Background: Invasive fungal diseases (IFDs) increase the mortality rate of patients with neutropenia who receive chemotherapy or have previously undergone hematopoietic stem cell transplantation (HSCT). Micafungin is a broad-spectrum echinocandin with minimal toxicity and low drug interactions. We therefore investigated the efficacy and safety of prophylactic micafungin in pediatric and adolescent patients who underwent autologous HSCT. Methods: This was a phase II, prospective, single-center, open-label, and single-arm study. From November 2011 to February 2017, 125 patients were screened from Seoul National University Children’s Hospital, Korea, and 112 were enrolled. Micafungin was administered intravenously at a dose of 1 mg/kg/day (maximum 50 mg/day) from day 8 of autologous HSCT until neutrophil engraftment. Treatment success was defined as the absence of proven, probable, or possible IFD up to 4 weeks after therapy. Results: The study protocol was achieved without premature interruption in 110 patients (98.2%). The reasons interrupting micafungin treatment included early death (n = 1) and patient refusal (n = 1). Treatment success was achieved in 109 patients (99.1%). Only one patient was diagnosed with probable IFD. No patients were diagnosed with possible or proven IFD. In the full analysis set, 21 patients (18.8%) experienced 22 adverse events (AEs); however, all AEs were classified as “unlikely” related to micafungin. No patient experienced grade IV AEs nor discontinued treatment, and none of the deaths were related to micafungin. Conclusions: Our study demonstrated that micafungin is a safe and effective option for antifungal prophylaxis in pediatric patients who underwent autologous HSCT, with promising efficacy without significant AEs.
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Affiliation(s)
- Bo-Kyung Kim
- Department of Pediatrics, College of Medicine, Seoul National University, Seoul 03080, Korea; (B.-K.K.); (J.-Y.C.); (K.-T.H.); (H.-Y.A.); (H.-Y.S.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
| | - Jung-Yoon Choi
- Department of Pediatrics, College of Medicine, Seoul National University, Seoul 03080, Korea; (B.-K.K.); (J.-Y.C.); (K.-T.H.); (H.-Y.A.); (H.-Y.S.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
| | - Kyung-Taek Hong
- Department of Pediatrics, College of Medicine, Seoul National University, Seoul 03080, Korea; (B.-K.K.); (J.-Y.C.); (K.-T.H.); (H.-Y.A.); (H.-Y.S.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
| | - Hong-Yul An
- Department of Pediatrics, College of Medicine, Seoul National University, Seoul 03080, Korea; (B.-K.K.); (J.-Y.C.); (K.-T.H.); (H.-Y.A.); (H.-Y.S.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
| | - Hee-Young Shin
- Department of Pediatrics, College of Medicine, Seoul National University, Seoul 03080, Korea; (B.-K.K.); (J.-Y.C.); (K.-T.H.); (H.-Y.A.); (H.-Y.S.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
| | - Hyoung-Jin Kang
- Department of Pediatrics, College of Medicine, Seoul National University, Seoul 03080, Korea; (B.-K.K.); (J.-Y.C.); (K.-T.H.); (H.-Y.A.); (H.-Y.S.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
- Correspondence:
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Teh BW, Yeoh DK, Haeusler GM, Yannakou CK, Fleming S, Lindsay J, Slavin MA. Consensus guidelines for antifungal prophylaxis in haematological malignancy and haemopoietic stem cell transplantation, 2021. Intern Med J 2021; 51 Suppl 7:67-88. [PMID: 34937140 DOI: 10.1111/imj.15588] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Antifungal prophylaxis can reduce morbidity and mortality from invasive fungal disease (IFD). However, its use needs to be optimised and appropriately targeted to patients at highest risk to derive the most benefit. In addition to established risks for IFD, considerable recent progress in the treatment of malignancies has resulted in the development of new 'at-risk' groups. The changing epidemiology of IFD and emergence of drug resistance continue to impact choice of prophylaxis, highlighting the importance of active surveillance and knowledge of local epidemiology. These guidelines aim to highlight emerging risk groups and review the evidence and limitations around new formulations of established agents and new antifungal drugs. It provides recommendations around use and choice of antifungal prophylaxis, discusses the potential impact of the changing epidemiology of IFD and emergence of drug resistance, and future directions for risk stratification to assist optimal management of highly vulnerable patients.
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Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Daniel K Yeoh
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Costas K Yannakou
- Department of Molecular Oncology and Cancer Immunology, Epworth Freemasons Hospital, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Shaun Fleming
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health, Melbourne, Victoria, Australia
| | - Julian Lindsay
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Immunocompromised Host Infection Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Villaescusa T, Vázquez L, Bergua JM, García J, Romero A, Olave MT, García Belmonte D, Queipo de Llano MP. Micafungin as antifungal prophylaxis in non-transplanted haemotological patients. REVISTA ESPANOLA DE QUIMIOTERAPIA 2019; 33:44-48. [PMID: 31865649 PMCID: PMC6987625 DOI: 10.37201/req/067.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Fungal infections are a major cause of morbidity and mortality in the haematological patients. These infections are mainly due to Candida spp. and Aspergillus spp. Mortality by these infections is high, but rates have descended in the latest series due to better antifungal agents. Echinocan-dins are, in vitro, very active against Candida and Aspergillus spp. The objective of the study is to analyse the efficacy and safety of micafungin in the antifungal prophylaxis of haema-tological patients on chemotherapy. METHODS A multicentre, observational retrospective study was performed in 7 Haematology Depart-ments in Spain. Patients admitted to these departments with chemotherapy or immunosuppressive treatment, and who had received antifungal prophylaxis with micafungin between 1 January 2009 and 31 December 2014 were included. RESULTS There were 5 cases of probable or proven fun-gal infection (4.8%) according to the 2008 EORTC criteria: 2 proven, 3 probable. The types of fungal infection were 3 as-pergillosis and 2 candidiasis. There were no drop-outs from the prophylaxis with micafungin due to toxicity. CONCLUSIONS Micafungin is an antifungal agent which, used in prophylaxis, has demonstrated good efficacy and an excellent toxicity profile, making it an apparently interesting option in patients requiring antifungal prophylaxis during their hospitalisation episode.
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Affiliation(s)
- T Villaescusa
- Teresa Villaescusa de la Rosa. Hospital Virgen de la Concha. Avda. Requejo nº 35. 49022. Zamora. Spain.
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El Cheikh J, Ceballos P, Dalle JH, Ducastelle-Leprêtre S, Dulon E, Herbrecht R. Micafungin prophylaxis in routine medical practice in adult and pediatric patients with hematological malignancy: a prospective, observational study in France. Diagn Microbiol Infect Dis 2019; 94:268-273. [DOI: 10.1016/j.diagmicrobio.2019.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
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Warris A, Lehrnbecher T, Roilides E, Castagnola E, Brüggemann RJM, Groll AH. ESCMID-ECMM guideline: diagnosis and management of invasive aspergillosis in neonates and children. Clin Microbiol Infect 2019; 25:1096-1113. [PMID: 31158517 DOI: 10.1016/j.cmi.2019.05.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 01/01/2023]
Abstract
SCOPE Presenting symptoms, distributions and patterns of diseases and vulnerability to invasive aspergillosis (IA) are similar between children and adults. However, differences exist in the epidemiology and underlying conditions, the usefulness of newer diagnostic tools, the pharmacology of antifungal agents and in the evidence from interventional phase 3 clinical trials. Therefore, the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the European Confederation of Medical Mycology (ECMM) have developed a paediatric-specific guideline for the diagnosis and management of IA in neonates and children. METHODS Review and discussion of the scientific literature and grading of the available quality of evidence was performed by the paediatric subgroup of the ESCMID-ECMM-European Respiratory Society (ERS) Aspergillus disease guideline working group, which was assigned the mandate for the development of neonatal- and paediatric-specific recommendations. QUESTIONS Questions addressed by the guideline included the epidemiology of IA in neonates and children; which paediatric patients may benefit from antifungal prophylaxis; how to diagnose IA in neonates and children; which antifungal agents are available for use in neonates and children; which antifungal agents are suitable for prophylaxis and treatment of IA in neonates and children; what is the role of therapeutic drug monitoring of azole antifungals; and which management strategies are suitable to be used in paediatric patients. This guideline provides recommendations for the diagnosis, prevention and treatment of IA in the paediatric population, including neonates. The aim of this guideline is to facilitate optimal management of neonates and children at risk for or diagnosed with IA.
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Affiliation(s)
- A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands.
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University 96 School of Health Sciences, Thessaloniki, Greece; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Castagnola
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - R J M Brüggemann
- Radboud Center for Infectious Diseases, Radboud University Medical Centre, Center of Expertise in Mycology Radboudumc/CWZ, European Confederation of Medical Mycology (ECMM) Excellence Center of Medical Mycology, Nijmegen, the Netherlands; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - A H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Paediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
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Micafungin prophylaxis for acute leukemia patients undergoing induction chemotherapy. BMC Cancer 2019; 19:358. [PMID: 30991992 PMCID: PMC6469030 DOI: 10.1186/s12885-019-5557-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/31/2019] [Indexed: 01/17/2023] Open
Abstract
Background Micafungin is a well-tolerated and effective prophylactic antifungal agent used in hematologic diseases. In this prospective trial, we evaluated the efficacy and safety of prophylactic micafungin during first induction chemotherapy in patients with acute leukemia. We also compared outcomes of prophylactic micafungin with those of prophylactic posaconazole in acute myeloid leukemia (AML). Methods Medically fit patients with newly diagnosed acute leukemia received 50 mg micafungin intravenously once daily from the initiation of first induction chemotherapy to recovery of neutrophil count, suspected fungal infection, or unacceptable drug-related toxicity (Clinicaltrials.gov number, NCT02440178). The primary end point was incidence of invasive fungal infection, and the secondary end points were adverse events of prophylactic micafungin and mortality during induction therapy. Results The 65 patients (median age = 51 years, male:female = 34:31) enrolled in this study had diagnoses of AML (33, 50.8%), acute lymphoblastic leukemia (31, 47.7%), and acute biphenotypic leukemia (1, 1.5%). Median duration of micafungin treatment was 24 days (range 1–68), with proven invasive fungal disease in one patient (1.5%) and possible fungal infection in two patients (3.1%). Three of the patients (4.6%) experienced the following adverse events, but all events were tolerable: liver function abnormality (Grade 2, n = 1; Grade 3, n = 1) and allergic reaction (Grade 2, n = 1). Three patients died during induction therapy, and invasive aspergillosis pneumonia was the cause of death for one of those patients. Overall, 19 patients (29.2%) discontinued prophylactic micafungin, and 18 (27.7%) patients switched to another antifungal agent. We observed no fungal infections caused by amphotericin B-resistant organisms. In AML patients, outcomes of prophylactic micafungin during induction chemotherapy did not differ significantly with those of prophylactic posaconazole with regard to incidence of fungal infections, rate of discontinuation, or safety. Conclusions Our study demonstrates that prophylactic micafungin is safe and effective in patients with acute leukemia undergoing induction chemotherapy. Outcomes in patients with AML were similar to those of prophylactic posaconazole, indicating the usefulness of micafungin as a prophylactic antifungal agent during induction chemotherapy for AML. Trial registration Clinicaltrials.gov NCT02440178, registered May 12th 2015.
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Efficacy and Safety of Echinocandins for the Treatment of Invasive Candidiasis in Children: A Meta-analysis. Pediatr Infect Dis J 2019; 38:42-49. [PMID: 29596219 DOI: 10.1097/inf.0000000000002032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Echinocandins are recommended for the treatment of suspected or confirmed invasive candidiasis (IC) in adults. Less is known about the use of echinocandins for the management of IC in children. The aim of this study was to investigate the overall efficacy and safety of echinocandin class in neonatal and pediatric patients with IC. METHODS PubMed, Cochrane Central, Scopus and Clinical trial registries were searched up to July 27, 2017. Eligible studies were randomized controlled trials that evaluated the efficacy and safety of any echinocandin versus agents of other antifungal classes for the treatment of IC in pediatric patients. The primary outcome was treatment success with resolution of symptoms and signs, and absence of IC. In the meta-analysis a random effects model was used, and the odds ratio (OR) and 95% confidence intervals (CIs) were calculated. RESULTS Four randomized clinical trials (324 patients), 2 confirmed IC (micafungin vs. liposomal amphotericin B (L-AmB) and caspofungin vs. L-AmB) and 2 empirical therapy trials (caspofungin vs. deoxycholate amphotericin B and caspofungin vs. L-AmB) were included. There was no significant difference between echinocandins and comparator in terms of treatment success (OR = 1.61, 95% CI: 0.74-3.50) and incidence of treatment-related adverse events (OR = 0.70, 95% CI: 0.39-1.26). However, fewer children treated with echinocandins discontinued treatment because of adverse events than amphotericin B formulations (OR = 0.26, 95% CI: 0.08-0.82, P = 0.02). CONCLUSIONS In the treatment of IC in children, echinocandins show non-inferior efficacy compared with amphotericin B formulations with fewer discontinuations than in comparator arm.
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Primary Fungal Prophylaxis in Hematological Malignancy: a Network Meta-Analysis of Randomized Controlled Trials. Antimicrob Agents Chemother 2018; 62:AAC.00355-18. [PMID: 29866872 DOI: 10.1128/aac.00355-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/19/2018] [Indexed: 12/19/2022] Open
Abstract
Several new antifungal agents have become available for primary fungal prophylaxis of neutropenia fever in hematological malignancy patients. Our aim was to synthesize all evidence on efficacy and enable an integrated comparison of all current treatments. We performed a systematic literature review to identify all publicly available evidence from randomized controlled trials (RCT). We searched Embase, PubMed, the Cochrane Central Register of Controlled Clinical Trials, and the www.ClinicalTrials.gov website. In total, 54 RCTs were identified, including 13 treatment options. The evidence was synthesized using a network meta-analysis. Relative risk (RR) was adopted. Posaconazole was ranked highest in effectiveness for primary prophylaxis, being the most favorable in terms of (i) the RR for reduction of invasive fungal infection (0.19; 95% confidence interval [CI], 0.11 to 0.36) and (ii) the probability of being the best option (94% of the cumulative ranking). Posaconazole also demonstrated its efficacy in preventing invasive aspergillosis and proven fungal infections, with RR of 0.13 (CI, 0.03 to 0.65) and 0.14 (CI, 0.05 to 0.38), respectively. However, there was no significant difference among all of the antifungal agents in all-cause mortality and overall adverse events. Our network meta-analysis provided an integrated overview of the relative efficacy of all available treatment options for primary fungal prophylaxis for neutropenic fever in hematological malignancy patients under myelosuppressive chemotherapy or hematopoietic cell transplantation. On the basis of this analysis, posaconazole seems to be the most effective prophylaxis option until additional data from head-to-head randomized controlled trials become available.
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Rubinstein SM, Culos KA, Savani B, Satyanarayana G. Foiling fungal disease post hematopoietic cell transplant: review of prophylactic strategies. Bone Marrow Transplant 2017; 53:123-128. [PMID: 29058698 DOI: 10.1038/bmt.2017.222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 08/12/2017] [Accepted: 08/29/2017] [Indexed: 11/10/2022]
Abstract
Hematopoietic cell transplantation (HCT) offers definitive management for a wide variety of malignant and nonmalignant diseases. Conditioning regimens and therapies used to prevent and treat GvHD are immune suppressive, often increasing the risk of developing fungal disease due to yeasts or molds. Antifungal prophylaxis may be useful in preventing morbidity and mortality during and after HCT. In this article, we review the epidemiology and current literature regarding strategies for prevention of invasive fungal disease (IFD) in the pre-engraftment and post-engraftment settings, and propose future direction for scientific discovery.
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Affiliation(s)
- S M Rubinstein
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K A Culos
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - B Savani
- Division of Hematology/Oncology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - G Satyanarayana
- Division of Infectious Diseases, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Patil A, Majumdar S. Echinocandins in antifungal pharmacotherapy. J Pharm Pharmacol 2017; 69:1635-1660. [DOI: 10.1111/jphp.12780] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 06/05/2017] [Indexed: 12/12/2022]
Abstract
Abstract
Objectives
Echinocandins are the newest addition of the last decade to the antifungal armamentarium, which, owing to their unique mechanism of action, selectively target the fungal cells without affecting mammalian cells. Since the time of their introduction, they have come to occupy an important niche in the antifungal pharmacotherapy, due to their efficacy, safety, tolerability and favourable pharmacokinetic profiles. This review deals with the varying facets of echinocandins such as their chemistry, in-vitro and in-vivo evaluations, clinical utility and indications, pharmacokinetic and pharmacodynamic profiles, and pharmacoeconomic considerations.
Key findings
Clinical studies have demonstrated that the echinocandins – caspofungin, micafungin and anidulafungin – are equivalent, if not superior, to the mainstay antifungal therapies involving amphotericin B and fluconazole. Moreover, echinocandin regimen has been shown to be more cost-effective and economical. Hence, the echinocandins have found favour in the management of invasive systemic fungal infections.
Conclusions
The subtle differences in echinocandins with respect to their pharmacology, clinical therapy and the mechanisms of resistance are emerging at a rapid pace from the current pool of research which could potentially aid in extending their utility in the fungal infections of the eye, heart and nervous system.
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Affiliation(s)
- Akash Patil
- Department of Pharmaceutics and Drug Delivery, School of Pharmacy, University of Mississippi, Oxford, MS, USA
| | - Soumyajit Majumdar
- Department of Pharmaceutics and Drug Delivery, School of Pharmacy, University of Mississippi, Oxford, MS, USA
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Maximova N, Schillani G, Simeone R, Maestro A, Zanon D. Comparison of Efficacy and Safety of Caspofungin Versus Micafungin in Pediatric Allogeneic Stem Cell Transplant Recipients: A Retrospective Analysis. Adv Ther 2017; 34:1184-1199. [PMID: 28429246 DOI: 10.1007/s12325-017-0534-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The high morbidity and mortality associated with invasive fungal infections (IFIs) provide the rationale for antifungal prophylaxis in immuno-compromised pediatric patients undergoing hematopoietic stem cell transplantation (HSCT). Caspofungin and micafungin are antifungal agents of interest for prophylaxis of IFIs because of their potency against Candida and minimal toxicity or interactions with other drugs. Few studies have demonstrated the safety and efficacy of such echinocandins as prophylaxis for IFIs in patients undergoing HSCT. METHODS This retrospective cohort study compared caspofungin and micafungin for prevention of IFIs in 93 pediatric patients undergoing HSCT for oncological or non-oncological disease. The observation began with the first dose of antifungal agent and ended 3 months after transplantation. RESULTS Patients in the micafungin group had a higher overall treatment success rate of 87.2 versus 84.8% in the caspofungin group, but the difference was not significant. There were no statistically significant differences in the incidence or type of proven/probable IFIs between the 2 groups. The low incidence of death did not differ statistically between the groups. Patients in the caspofungin group presented more frequently with fever, during and after neutropenia. In both groups, we observed an expected worsening of blood chemistry parameters. There were no adverse events definitely attributable to the two antifungal agents. CONCLUSION These results demonstrate good efficacy and tolerability for caspofungin and micafungin. However, better results with respect to the incidence and resolution of fever in the micafungin group may suggest its use in preference to that of caspofungin.
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Affiliation(s)
- Natalia Maximova
- Bone Marrow Transplantation Unit, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy.
| | - Giulia Schillani
- Bone Marrow Transplantation Unit, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - Roberto Simeone
- Department of Transfusion Medicine, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - Alessandra Maestro
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - Davide Zanon
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
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14
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Scott LJ. Micafungin: A Review in the Prophylaxis and Treatment of Invasive Candida Infections in Paediatric Patients. Paediatr Drugs 2017; 19:81-90. [PMID: 28083856 DOI: 10.1007/s40272-016-0211-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Intravenous micafungin (Mycamine®; Funguard®), an echinocandin, is approved in the EU for the treatment of invasive candidiasis in children (including neonates) and adolescents (<16 years of age) and as prophylaxis against Candida infections in patients undergoing haematopoietic stem cell transplantation (HSCT) or who are expected to have neutropenia for ≥10 days. This narrative review focuses on the use of micafungin in paediatric indications approved in the EU, which may vary from those approved elsewhere in the world. Micafungin has a broad spectrum of in vitro activity against clinically relevant isolates of Candida spp. (including fluconazole-resistant Candida glabrata isolates), a low propensity for emergence of resistant isolates and a convenient once-daily regimen. In paediatric substudies and a small multinational, phase 3 trial in neonates with proven invasive candidiasis, intravenous micafungin was effective and generally well tolerated in the treatment of candidaemia and other types of invasive candidiasis and as prophylaxis against fungal infections in patients undergoing HSCT. Hence, micafungin remains an important option for the prophylaxis and treatment of invasive Candida infections in paediatric and adult patients.
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Affiliation(s)
- Lesley J Scott
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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15
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de Almeida Júnior JN, Hennequin C. Invasive Trichosporon Infection: a Systematic Review on a Re-emerging Fungal Pathogen. Front Microbiol 2016; 7:1629. [PMID: 27799926 PMCID: PMC5065970 DOI: 10.3389/fmicb.2016.01629] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 09/29/2016] [Indexed: 12/11/2022] Open
Abstract
Objectives: This review aimed to better depict the clinical features and address the issue of therapeutic management of Trichosporon deep-seated infections. Methods: We comprehensively reviewed the cases of invasive Trichosporon infection reported in the literature from 1994 (date of taxonomic modification) to 2015. Data from antifungal susceptibility testing (AST) studies were also analyzed. Results: Two hundred and three cases were retained and split into four groups: homeopathy (n = 79), other immunodeficiency conditions (n = 41), miscellaneous (n = 58) and newborns (n = 25). Trichosporon asahii was the main causative species (46.7%) and may exhibit cross-resistance to different antifungal classes. The unfavorable outcome rate was at 44.3%. By multivariate analysis, breakthrough infection (OR 2.45) was associated with unfavorable outcome, whilst the use of an azole-based therapy improved the prognosis (OR 0.16). Voriconazole-based treatment was associated with favorable outcome in hematological patients (73.6 vs. 41.8%; p = 0.016). Compiled data from AST demonstrated that (i) T. asahii exhibits the highest MICs to amphotericin B and (ii) voriconazole has the best in vitro efficacy against clinical isolates of Trichosporon spp. Conclusions:Trichosporon infection is not only restricted to hematological patients. Analysis of compiled data from AST and clinical outcome support the use of voriconazole as first line therapy.
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Affiliation(s)
- João N de Almeida Júnior
- Central Laboratory Division-LIM03, Faculdade de Medicina da Universidade de São PauloSão Paulo, Brazil; Laboratory of Medical Mycology-LIM53, Instituto de Medicina Tropical da Universidade de São PauloSão Paulo, Brazil
| | - Christophe Hennequin
- Service de Parasitologie-Mycologie-AP-HP, Hôpital St AntoineParis, France; Institut National de la Santé et de la Recherche Médicale UMR 1135, Centre National de la Recherche Scientifique ERL 8255, Sorbonne Universités, University Pierre and Marie Curie (UPMC)Paris, France; Centre d'Immunologie et des Maladies Infectieuses, Bd de l'hôpitalParis, France
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