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Vergidis P, Sendi P, Alkhateeb HB, Nguyen MH. How do I manage refractory invasive pulmonary aspergillosis. Clin Microbiol Infect 2024; 30:755-761. [PMID: 38286175 DOI: 10.1016/j.cmi.2024.01.015] [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: 08/11/2023] [Revised: 11/06/2023] [Accepted: 01/20/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Invasive aspergillosis is associated with significant morbidity and mortality in patients with haematologic malignancies and haematopoietic cell transplant recipients. The prognosis is worse among patients who have failed primary antifungal treatment. OBJECTIVES We aim to provide guidance on the diagnosis and management of refractory invasive pulmonary aspergillosis. SOURCES Using PubMed, we performed a review of original articles, meta-analyses, and systematic reviews. CONTENT We discuss the diagnostic criteria for invasive pulmonary aspergillosis and the evidence on the treatment of primary infection. We outline our diagnostic approach to refractory disease. We propose a treatment algorithm for refractory disease and discuss the role of experimental antifungal agents. IMPLICATIONS For patients with worsening disease while on antifungal therapy, a thorough diagnostic evaluation is required to confirm the diagnosis of aspergillosis and exclude another concomitant infection. Treatment should be individualized. Current options include switching to another triazole, transitioning to a lipid formulation of amphotericin B, or using combination antifungal therapy.
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Affiliation(s)
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | | | - M Hong Nguyen
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
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Portillo V, Ragozzino S, Stavropoulou E, El-Khoury C, Bochud PY, Lamoth F, Khanna N, Neofytos D. Antifungal Treatment Duration in Hematology Patients With Invasive Mold Infections: A Real-life Update. Open Forum Infect Dis 2024; 11:ofae201. [PMID: 38756760 PMCID: PMC11097115 DOI: 10.1093/ofid/ofae201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024] Open
Abstract
Background Limited data exist on when and how to stop antifungal treatment (AFT) in patients with invasive mold infections (IMIs) who are immunocompromised. Methods This retrospective multicenter study included adult patients with acute myelogenous leukemia and proven/probable IMI (1 January 2010-31 December 2022) in 3 university hospitals. The primary objective was to describe AFT duration and adaptation. Secondary objectives were to investigate the reasons for AFT adjustments and prolongation. Results In total 71 patients with 73 IMIs were identified; 51 (71.8%) had an allogeneic hematopoietic cell transplant. Most infections were invasive aspergillosis (IA; 49/71, 69%), followed by mucormycosis (12, 16.9%) and other (12, 16.9%); there were 2 mixed infections. Median treatment duration was 227 days (IQR, 115.5-348.5). There was no difference in AFT duration between patients with IA and non-IA IMI (P = .85) or by center (P = .92). Treatment was longer in patients with an allogeneic hematopoietic cell transplant vs not (P = .004). Sixteen patients (22.5%) had no therapy modifications. In 55 patients (77.5%), a median 2 changes (IQR, 1-3; range, 1-8) were observed. There were 182 reasons leading to 165 changes, associated with clinical efficacy (82/182, 44.5%), toxicity (47, 25.8%), and logistical reasons (22, 12.1%); no reason was documented in 32 changes (18.8%). AFT was continued beyond days 90 and 180 in 59 (83%) and 39 (54.9%) patients, respectively, mostly due to persistence of immunosuppression. Conclusions AFT in patients with acute myelogenous leukemia and IMI is longer than that recommended by guidelines and is frequently associated with treatment adjustments due to variable reasons. More data and better guidance are required to optimize AFT duration and secondary prophylaxis administration according to immunosuppression.
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Affiliation(s)
- Vera Portillo
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Silvio Ragozzino
- Division of Infectious Diseases, University Hospital of Basel, Basel, Switzerland
| | - Elisavet Stavropoulou
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Celine El-Khoury
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre-Yves Bochud
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Frederic Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Microbiology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases, University Hospital of Basel, Basel, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
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Lai T, Yeo CY, Rockliff B, Stokes M, Kim HY, Marais BJ, McLachlan AJ, Alffenaar JWC. Therapeutic drug monitoring of liposomal amphotericin B in children. Are we there yet? A systematic review. J Antimicrob Chemother 2024; 79:703-711. [PMID: 38252921 PMCID: PMC10984953 DOI: 10.1093/jac/dkae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) is a tool that supports personalized dosing, but its role for liposomal amphotericin B (L-amb) is unclear. This systematic review assessed the evidence for L-amb TDM in children. OBJECTIVES To evaluate the concentration-efficacy relationship, concentration-toxicity relationship and pharmacokinetic/pharmacodynamic (PK/PD) variability of L-amb in children. METHODS We systematically reviewed PubMed and Embase databases following PRISMA guidelines. Eligible studies included L-amb PK/PD studies in children aged 0-18 years. Review articles, case series of RESULTS In total, 4220 studies were screened; 6 were included, presenting data on 195 children. Invasive candidiasis and aspergillosis were the two most common infections treated with L-amb. Studies showed significant PK variability due to age (mean age ranged from 14 days to 17 years), body weight, non-linear PK and changes in the volume of distribution. Limited evidence supported a peak concentration/MIC (Cmax/MIC) of 25-50 for optimal efficacy and an AUC24 of >600 mg·h/L for nephrotoxicity. L-amb doses of 2.5-10 mg/kg/day were reported to achieve Cmax/MIC > 25 using an MIC of 1 mg/L. CONCLUSIONS While significant PK variability was observed in children, evidence to support routine L-amb TDM was limited. Further studies on efficacy and toxicity benefits are required before routine TDM of L-amb can be recommended.
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Affiliation(s)
- Tony Lai
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Chin-Yen Yeo
- Pharmacy Department, Concord Hospital, Sydney, Australia
| | - Bradley Rockliff
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
| | - Michael Stokes
- Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Westmead Hospital, Sydney, Australia
| | - Ben J Marais
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jan-Willem C Alffenaar
- The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Westmead Hospital, Sydney, Australia
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Boyer J, Hoenigl M, Kriegl L. Therapeutic drug monitoring of antifungal therapies: do we really need it and what are the best practices? Expert Rev Clin Pharmacol 2024; 17:309-321. [PMID: 38379525 DOI: 10.1080/17512433.2024.2317293] [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: 10/26/2023] [Accepted: 02/07/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Despite advancements, invasive fungal infections (IFI) still carry high mortality rates, often exceeding 30%. The challenges in diagnosis, coupled with limited effective antifungal options, make managing IFIs complex. Antifungal drugs are essential for IFI management, but their efficacy can be diminished by drug-drug interactions and pharmacokinetic variability. Therapeutic Drug Monitoring (TDM), especially in the context of triazole use, has emerged as a valuable strategy to optimize antifungal therapy. AREAS COVERED This review provides current evidence regarding the potential benefits of TDM in IFI management. It discusses how TDM can enhance treatment response, safety, and address altered pharmacokinetics in specific patient populations. EXPERT OPINION TDM plays a crucial role in achieving optimal therapeutic outcomes in IFI management, particularly for certain antifungal agents. Preclinical studies consistently show a link between therapeutic drug levels and antifungal efficacy. However, clinical research in mycology faces challenges due to patient heterogeneity and the diversity of fungal infections. TDM's potential advantages in guiding Echinocandin therapy for critically ill patients warrant further investigation. Additionally, for drugs like Posaconazole, assessing whether serum levels or alternative markers like saliva offer the best measure of efficacy is an intriguing question.
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Affiliation(s)
- Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
- Translational Mycology Working Group, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria
| | - Lisa Kriegl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Cavassin FB, Magri MMC, Vidal JE, de Moraes Costa Carlesse FA, Falci DR, Baú-Carneiro JL, Breda GL, de Araújo Motta F, de Miranda Godoy CS, de Bastos Ascenço Soares R, De Oliveira CS, Mendes AVA, Morales HP, Montes PS, Taborda M, Rego CM, Félix MA, Katopodis PP, da Silva do Ó JR, Abrão MPL, Pereira TTT, Queiroz-Telles F. Effectiveness, Tolerability, and Safety of Different Amphotericin B Formulations in Invasive Fungal Infections: A Multicenter, Retrospective, Observational Study. Clin Ther 2024; 46:322-337. [PMID: 38403508 DOI: 10.1016/j.clinthera.2024.01.011] [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: 10/05/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE Data on the real-life use of amphotericin B lipid complex (ABLC) compared with other available formulations are limited. This study aimed to evaluate the effectiveness, tolerability, and safety of different amphotericin B (AMB) intravenously administered in the context of hospital practice for the treatment of invasive fungal infections (IFI) and to provide new insights into the profile of ABLC. METHODS This is a multicenter, retrospective, observational study conducted at 10 tertiary Brazilian hospitals. Patients first exposed to any formulation of AMB for treating endemic and opportunistic IFI who had received at least 2 intravenous doses were screened. Retrospective data (from January 2014 to December 2019) were extracted from the patients' medical records. Clinical parameters were examined pre- and post-treatment to determine effectiveness; acute infusion-related side effects (IRSE) and drug interruption to determine tolerability; and adverse events, toxicity, and treatment interruption were stated to analyze safety. FINDINGS Overall, 1879 medical records of patients were identified. The median (interquartile rate) duration of treatment was 14 (7-21) days. The overall success rate (95% confidence interval [CI]) was 65% (95% CI 60-65). ABLC proved to be effective among AMB formulations with 59% (95% CI 55.6-62.5) within complete response. This was significantly higher in patients who received the drug for a longer period, ≥4 weeks compared to <1 week treatment (P < 0.001). IRSE was observed in 446 (23.7%) patients. Eight cases (1.4%) of severe IRSE in pediatrics and 14 (1.1%) in adults resulted in treatment discontinuation. Regarding safety, 637 (33.9%) patients presented some alteration in creatinine levels during AMB exposure, and 89 (4.74%) had to interrupt or discontinue the drug within the first 14 days of therapy because of renal dysfunction. Overall mortality was 34%. IMPLICATIONS ABLC is an effective formulation for the treatment of invasive fungal infections, with few adverse events leading to drug discontinuation or lethal outcomes. Furthermore, this real-life study confirmed the comparative safety of AMB lipid formulations versus AMB deoxycholate.
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Affiliation(s)
| | | | | | | | | | | | - Giovanni Luís Breda
- Hospital de Clínicas da Universidade Federal do Paraná (HC/UFPR), Curitiba, Brazil
| | | | | | | | | | | | | | - Patrícia Silva Montes
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FAMUSP), São Paulo, Brazil
| | - Mariane Taborda
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FAMUSP), São Paulo, Brazil
| | | | | | | | | | | | | | - Flávio Queiroz-Telles
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas da Universidade Federal do Paraná (HC/UFPR), Curitiba, Brazil
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Heylen J, Vanbiervliet Y, Maertens J, Rijnders B, Wauters J. Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment. Semin Respir Crit Care Med 2024; 45:69-87. [PMID: 38211628 DOI: 10.1055/s-0043-1777769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Among all clinical manifestations of pulmonary aspergillosis, invasive pulmonary aspergillosis (IPA) is the most acute presentation. IPA is caused by Aspergillus hyphae invading the pulmonary tissue, causing either tracheobronchitis and/or bronchopneumonia. The degree of fungal invasion into the respiratory tissue can be seen as a spectrum, going from colonization to deep tissue penetration with angio-invasion, and largely depends on the host's immune status. Patients with prolonged, severe neutropenia and patients with graft-versus-host disease are at particularly high risk. However, IPA also occurs in other groups of immunocompromised and nonimmunocompromised patients, like solid organ transplant recipients or critically ill patients with severe viral disease. While a diagnosis of proven IPA is challenging and often warranted by safety and feasibility, physicians must rely on a combination of clinical, radiological, and mycological features to assess the likelihood for the presence of IPA. Triazoles are the first-choice regimen, and the choice of the drug should be made on an individual basis. Adjunctive therapy such as immunomodulatory treatment should also be taken into account. Despite an improving and evolving diagnostic and therapeutic armamentarium, the burden and mortality of IPA still remains high. This review aims to give a comprehensive and didactic overview of the current knowledge and best practices regarding the epidemiology, clinical presentation, diagnosis, and treatment of acute IPA.
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Affiliation(s)
- Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yuri Vanbiervliet
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Eschenauer GA. Antifungal Therapies for Aspergillus spp.: Present and Future. Semin Respir Crit Care Med 2024; 45:61-68. [PMID: 38151025 DOI: 10.1055/s-0043-1776776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Currently available and recommended options for the treatment of pulmonary aspergillosis include the triazoles, echinocandins, and amphotericin B products. These therapies have significant limitations. Only the azoles are available orally, but their use is often limited by toxicities, drug-drug interactions, pharmacokinetic variability, and emerging resistance. While the echinocandins are safe agents and may have a role in combination therapy, they are unproven as monotherapy. Amphotericin B preparations are toxic and require intensive monitoring. Finally, aspergillosis continues to be a disease conferring substantial morbidity and mortality, and clinical trials have not identified a therapeutic approach clearly associated with improved outcomes. As a result, there is a great need for new options in the treatment of invasive aspergillosis. Ideally, such options would be safe, have high oral bioavailability, have favorable pharmacokinetics to sequestered sites and retain activity against azole-resistant isolates. Reassuringly, there is a robust pipeline of novel therapies in development. Rezafungin (a once-weekly dosed echinocandin) and ibrexafungerp (oral agent with same mechanism of action as echinocandins) will likely be reserved for combination therapy or refractory/intolerance scenarios with no other options. Inhaled opelconazole is an attractive option for combination therapy and prophylaxis of pulmonary aspergillosis. Development of an oral form of amphotericin B that avoids nephrotoxicity and electrolyte disturbances is an exciting development. Finally, olorofim and fosmanogepix, two agents with novel mechanisms of action and oral formulations, hold significant potential to challenge the triazole antifungals place as preferred therapies. However, many questions remain regarding these novel agents, and at the time of this writing, none of these agents have been robustly studied in Phase III studies of aspergillosis, and so their promise remains investigational.
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Affiliation(s)
- Gregory A Eschenauer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan
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Stover KR, Jordan TE, Wagner JL, Barber KE. High-dose amphotericin: yay or nay? A case series and literature review. Drugs Context 2024; 13:2023-9-1. [PMID: 38264401 PMCID: PMC10803125 DOI: 10.7573/dic.2023-9-1] [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: 09/01/2023] [Accepted: 11/29/2023] [Indexed: 01/25/2024] Open
Abstract
Invasive fungal infections pose significant morbidity and mortality risks, particularly those caused by moulds. Available antifungal classes are limited by toxicities and are increasingly susceptible to resistance, particularly amongst challenging fungal pathogens. The purpose of this case series and literature review was to characterize the use of a high-dose lipid formulation of amphotericin B. A case series is presented including patients who received high-dose lipid formulation amphotericin B (≥7.5 mg/kg/day) between June 2012 and August 2021. Additionally, a systematic literature review was conducted by searching the PubMed database for English-language studies involving individuals who received high-dose amphotericin B therapy (≥7.5 mg/kg) using lipid formulations. Nine patients were included in the case series, receiving an average of 8.9 ± 1.3 mg/kg liposomal amphotericin B over a mean of 11.0 ± 10.8 days predominantly for mould infections including Mucorales, aspergillosis and Fusarium. The patients were primarily cared for in intensive care units, with varying treatment histories and outcomes. A total of 11 studies (n=260 patients) met inclusion criteria for the literature review. Responses to high-dose liposomal amphotericin B ranged from 8% to 100%, often showing favourable outcomes. High doses of liposomal amphotericin B were well tolerated both in the case series and in published literature, with serum creatinine changes being the most commonly reported adverse event. However, multi-patient studies continue to report less than favourable (range 8-62%) response rates. High-dose liposomal amphotericin B, either alone or in combination with other antifungal agents, might be a viable strategy for managing invasive fungal infections when few treatment choices exist. This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.
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Affiliation(s)
- Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Taylor E Jordan
- Department of Pharmacy, Mississippi Baptist Medical Center, Jackson, MS, USA
| | - Jamie L Wagner
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Katie E Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
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Boutin CA, Luong ML. Update on therapeutic approaches for invasive fungal infections in adults. Ther Adv Infect Dis 2024; 11:20499361231224980. [PMID: 38249542 PMCID: PMC10799587 DOI: 10.1177/20499361231224980] [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: 07/23/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Invasive fungal infections are increasingly encountered with the expansion of iatrogenic immunosuppression, including not only solid organ and hematopoietic stem cell transplant recipients but also patients with malignancies or autoimmune diseases receiving immunomodulatory therapies, such as Bruton Tyrosine Kinase (BTK) inhibitor. Their attributable mortality remains elevated, part of which is a contribution from globally emerging resistance in both molds and yeasts. Because antifungal susceptibility test results are often unavailable or delayed, empiric and tailored antifungal approaches including choice of agent(s) and use of combination therapy are heterogeneous and often based on clinician experience with knowledge of host's net state of immunosuppression, prior antifungal exposure, antifungal side effects and interaction profile, clinical severity of disease including site(s) of infection and local resistance data. In this review, we aim to summarize previous recommendations and most recent literature on treatment of invasive mold and yeast infections in adults to guide optimal evidence-based therapeutic approaches. We review the recent data that support use of available antifungal agents, including the different triazoles that have now been studied in comparison to previously preferred agents. We discuss management of complex infections with specific emerging fungi such as Scedosporium spp., Fusarium spp., Trichosporon asahii, and Candida auris. We briefly explore newer antifungal agents or formulations that are now being investigated to overcome therapeutic pitfalls, including but not limited to olorofim, rezafungin, fosmanogepix, and encochleated Amphotericin B. We discuss the role of surgical resection or debridement, duration of treatment, follow-up modalities, and need for secondary prophylaxis, all of which remain challenging, especially in patients chronically immunocompromised or awaiting more immunosuppressive therapies.
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Affiliation(s)
- Catherine-Audrey Boutin
- Division of Infectious Diseases, Department of Medicine, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
| | - Me-Linh Luong
- Department of Medicine, Division of Infectious Diseases, Université de Montréal, Centre Hospitalier de l’Université de Montréal (CHUM), F Building, 6th Floor, Room F06.1102F, 1051 Sanguinet, Montreal, QC, H2X 0C1, Canada
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Rinaldi M, Bartoletti M, Bonazzetti C, Caroccia N, Gatti M, Tazza B, Horna CS, Giannella M, Viale P. Tolerability of pulsed high-dose L-AmB as pre-emptive therapy in patients at high risk for intra-abdominal candidiasis: A phase 2 study (LAMBDA study). Int J Antimicrob Agents 2023; 62:106998. [PMID: 37838147 DOI: 10.1016/j.ijantimicag.2023.106998] [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: 06/04/2023] [Revised: 09/27/2023] [Accepted: 10/04/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Intra-abdominal candidiasis (IAC) has a high mortality rate. However, the correct management of a critically ill patient with suspected IAC remains unclear. The aim of this study was to evaluate the safety of pulsed high-dose liposomal amphotericin B (L-AmB) in patients with suspected IAC managed with a beta-D-glucan (BDG)-guided strategy. METHODS This phase 2 prospective study enrolled adult patients with intra-abdominal sepsis following surgery. Patients received a single dose of L-AmB 5 mg/kg on day 1. On day 3, L-AmB was discontinued in patients with a negative basal BDG result, and continued (3 mg/kg/daily) in patients with a positive basal BDG result or microbiologically confirmed IAC. The primary endpoint was the occurrence of adverse events, defined using the Common Toxicity Criteria classification. RESULTS In total, 40 patients were enrolled from January 2019 to August 2022. Fifteen (37.5%) patients were male, and the median age was 65 [interquartile range (IQR) 49-76] years. Thirty-one (77.5%) patients underwent urgent surgery, and the principal indication was secondary/tertiary peritonitis (n=22, 55%); half of the patients had undergone a previous surgical operation within the preceding 30 days. Five (12.5%) patients met the criteria for septic shock at enrolment. The median APACHE II score on admission to the intensive care unit was 12 (IQR 10-15). IAC was excluded in 33 (85%) patients, but IAC was probable and proven in five (12.5%) and two (5%) patients, respectively. The single dose of L-AmB 5 mg/kg was well tolerated in all patients, and no early or late severe adverse events related to the drug were reported. L-AmB was discontinued in 65% of patients following a negative basal BDG result. The all-cause 30-day mortality rate was 15%, and no deaths were related to L-AmB administration or uncontrolled IAC. The mortality rates for patients with and without proven IAC were 0% and 15.8%, respectively (P=0.99). CONCLUSIONS The rate of proven IAC among critically ill high-risk patients was low (5%). A single dose of L-AmB 5 mg/kg, with prompt withdrawal in the case of a basal negative BDG result, seems to be a safe and effective approach in this population.
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Affiliation(s)
- Matteo Rinaldi
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Michele Bartoletti
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Cecilia Bonazzetti
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Natascia Caroccia
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Beatrice Tazza
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Clara Solera Horna
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Portillo V, Neofytos D. Duration of antifungal treatment in mold infection: when is enough? Curr Opin Infect Dis 2023; 36:443-449. [PMID: 37729658 DOI: 10.1097/qco.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
PURPOSE OF REVIEW Although invasive mold infections (IMI) are a major complication in high-risk populations, treatment duration has not yet been well defined. RECENT FINDINGS Guidelines suggest documenting clinical/radiological resolution and immunological recovery before stopping antifungal treatment, after a minimum duration of treatment of 3 months for invasive pulmonary aspergillosis, while longer (up to 6 months) duration is proposed for the treatment of invasive mucormycosis. However, data on and definitions of clinical/radiological resolution and immune recovery remain scarce. Limited real-life data suggest that often much longer courses of treatment are given, generally in the context of continuous immunosuppression, occasionally defined as secondary prophylaxis. However, clearcut definition and distinction of secondary prophylaxis from antifungal treatment remain to be defined. SUMMARY Decisions to stop antifungal treatment are based on poorly defined treatment responses and immune reconstitution and experts' opinions. More evidence is needed to determine the optimal duration of treatment of IMI. Well designed, easy to use, and realistic algorithms to help clinicians decide when to stop antifungal treatment are urgently needed.
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Affiliation(s)
- Vera Portillo
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
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12
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Tiwari R, Gupta RP, Singh VK, Kumar A, Rajneesh, Madhukar P, Sundar S, Gautam V, Kumar R. Nanotechnology-Based Strategies in Parasitic Disease Management: From Prevention to Diagnosis and Treatment. ACS OMEGA 2023; 8:42014-42027. [PMID: 38024747 PMCID: PMC10655914 DOI: 10.1021/acsomega.3c04587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023]
Abstract
Parasitic infections are a major global health issue causing significant mortality and morbidity. Despite substantial advances in the diagnostics and treatment of these diseases, the currently available options fall far short of expectations. From diagnosis and treatment to prevention and control, nanotechnology-based techniques show promise as an alternative approach. Nanoparticles can be designed with specific properties to target parasites and deliver antiparasitic medications and vaccines. Nanoparticles such as liposomes, nanosuspensions, polymer-based nanoparticles, and solid lipid nanoparticles have been shown to overcome limitations such as limited bioavailability, poor cellular permeability, nonspecific distribution, and rapid drug elimination from the body. These nanoparticles also serve as nanobiosensors for the early detection and treatment of these diseases. This review aims to summarize the potential applications of nanoparticles in the prevention, diagnosis, and treatment of parasitic diseases such as leishmaniasis, malaria, and trypanosomiasis. It also discusses the advantages and disadvantages of these applications and their market values and highlights the need for further research in this field.
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Affiliation(s)
- Rahul Tiwari
- Centre
of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
| | - Rohit P. Gupta
- Centre
of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
- Applied
Microbiology, Department of Botany, Institute of Science, Banaras Hindu University, Varanasi 221 005, India
| | - Vishal K. Singh
- Centre
of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
| | - Awnish Kumar
- Centre
of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
| | - Rajneesh
- Centre
of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
| | - Prasoon Madhukar
- Department
of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
| | - Shyam Sundar
- Department
of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
| | - Vibhav Gautam
- Centre
of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
| | - Rajiv Kumar
- Centre
of Experimental Medicine & Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India
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13
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Porta G, JohnBritto JS, Bonfrate L. Editorial to 'A score for predicting invasive pulmonary aspergillosis in immunocompetent critically ill patients'. Eur J Clin Invest 2023; 53:e14080. [PMID: 37606368 DOI: 10.1111/eci.14080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/04/2023] [Accepted: 08/04/2023] [Indexed: 08/23/2023]
Affiliation(s)
- G Porta
- Department of Emergency Medicine, Santa Maria Delle Grazie Hospital, Naples, Italy
| | - J S JohnBritto
- Clinica Medica 'A. Murri', Internal Medicine, Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University 'Aldo Moro', Policlinico Hospital, Bari, Italy
| | - L Bonfrate
- Clinica Medica 'A. Murri', Internal Medicine, Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University 'Aldo Moro', Policlinico Hospital, Bari, Italy
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14
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Gaffney S, Kelly DM, Rameli PM, Kelleher E, Martin-Loeches I. Invasive pulmonary aspergillosis in the intensive care unit: current challenges and best practices. APMIS 2023; 131:654-667. [PMID: 37022291 DOI: 10.1111/apm.13316] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/02/2023] [Indexed: 04/07/2023]
Abstract
The prevalence of invasive pulmonary aspergillosis (IPA) is growing in critically ill patients in the intensive care unit (ICU). It is increasingly recognized in immunocompetent hosts and immunocompromised ones. IPA frequently complicates both severe influenza and severe coronavirus disease 2019 (COVID-19) infection. It continues to represent both a diagnostic and therapeutic challenge and can be associated with significant morbidity and mortality. In this narrative review, we describe the epidemiology, risk factors and disease manifestations of IPA. We discuss the latest evidence and current published guidelines for the diagnosis and management of IPA in the context of the critically ill within the ICU. Finally, we review influenza-associated pulmonary aspergillosis (IAPA), COVID-19-associated pulmonary aspergillosis (CAPA) as well as ongoing and future areas of research.
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Affiliation(s)
- Sarah Gaffney
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Dearbhla M Kelly
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Puteri Maisarah Rameli
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Eoin Kelleher
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Hospital Clinic, Institut D'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
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15
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Tverdek F, Escobar ZK, Liu C, Jain R, Lindsay J. Antimicrobials in patients with hematologic malignancies and recipients of hematopoietic cell transplantation and other cellular therapies. Transpl Infect Dis 2023; 25 Suppl 1:e14129. [PMID: 37594221 DOI: 10.1111/tid.14129] [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: 06/15/2023] [Revised: 07/28/2023] [Accepted: 08/07/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Appropriate use of antimicrobials for hematologic malignancy, hematopoietic stem cell transplant recipients, and other cellular therapies is vital, with infection causing significant morbidity and mortality in this unique population of immunocompromised hosts. However, often in this population the choice and management of antimicrobial therapy is complex. When selecting an antimicrobial agent, key considerations include the need for dose adjustments due to renal or hepatic impairment, managing drug interactions, the potential for additive drug toxicity among those receiving polypharmacy and therapeutic drug monitoring. Other factors include leveraging pharmacodynamic principles to enable optimization of directed therapy against challenging pathogens, as well as judicious use of antimicrobials to limit drug resistance and adverse drug reactions. SUMMARY This review summarizes the clinical considerations for commonly used antimicrobials in this setting, including antibacterial, antiviral, and antifungal agents.
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Affiliation(s)
- Frank Tverdek
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pharmacy, University of Washington Medicine, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Zahra Kassamali Escobar
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pharmacy, University of Washington Medicine, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Catherine Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Rupali Jain
- Department of Pharmacy, University of Washington Medicine, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Julian Lindsay
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- National Centre for Infection in Cancer and Transplantation (NCICT), Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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16
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Munzen ME, Goncalves Garcia AD, Martinez LR. An update on the global treatment of invasive fungal infections. Future Microbiol 2023; 18:1095-1117. [PMID: 37750748 DOI: 10.2217/fmb-2022-0269] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023] Open
Abstract
Fungal infections are a serious problem affecting many people worldwide, creating critical economic and medical consequences. Fungi are ubiquitous and can cause invasive diseases in individuals mostly living in developing countries or with weakened immune systems, and antifungal drugs currently available have important limitations in tolerability and efficacy. In an effort to counteract the high morbidity and mortality rates associated with invasive fungal infections, various approaches are being utilized to discover and develop new antifungal agents. This review discusses the challenges posed by fungal infections, outlines different methods for developing antifungal drugs and reports on the status of drugs currently in clinical trials, which offer hope for combating this serious global problem.
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Affiliation(s)
- Melissa E Munzen
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL 32610, USA
| | | | - Luis R Martinez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
- Center for Immunology and Transplantation, University of Florida, Gainesville, FL 32610, USA
- Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL 32610, USA
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17
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Tashiro M, Namie H, Ito Y, Takazono T, Kakeya H, Miyazaki Y, Mukae H, Mikamo H, Tomoo F, Shibuya K, Izumikawa K. Prognostic Association of Liposomal Amphotericin B Doses Above 5 mg/kg/d in Mucormycosis: A Nationwide Epidemiologic and Treatment Analysis in Japan. Open Forum Infect Dis 2023; 10:ofad480. [PMID: 37808895 PMCID: PMC10552064 DOI: 10.1093/ofid/ofad480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023] Open
Abstract
Background Mucormycosis is a potentially fatal fungal infection, and there is limited information on its precise epidemiology and treatment practices, including the optimal dosage of liposomal amphotericin B. Methods A retrospective, multicenter, nationwide analysis of 82 proven and probable cases of mucormycosis was performed. Cases between 2015 and 2022 were collected from 51 hospitals in Japan by hematologists and infectious disease specialists. The study included the epidemiology, treatment details, and association between the dose of liposomal amphotericin B and the outcome. Results The lungs were the most commonly involved organ (70.7% of cases), and 35.4% of patients had disseminated disease. Rhizopus spp., Cunninghamella spp., and Mucor spp. were the most common organisms. Mortality at 4 weeks was 41.5%. The survivors had a shorter duration of neutropenia (P = .006) and less persistent hyperglycemia (P = .023). The site of infection and species of Mucorales had no detectable effect on survival. Survival did not differ between patients receiving liposomal amphotericin B at 5 mg/kg/d relative to those receiving >5 mg/kg/d (P = .625). Using Cox proportional hazards models and adjusting for confounders, the hazard ratio for the influence of >5 mg/kg/d liposomal amphotericin B on 4-week survival was 0.86 (95% CI, 0.28-2.68; P = .796) compared with 5 mg/kg/d. Conclusions This study provides important insights into the precise epidemiology and treatment practices of mucormycosis. Treatment with liposomal amphotericin B at doses higher than 5 mg/kg/d did not improve outcomes relative to 5 mg/kg/d.
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Affiliation(s)
- Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Hotaka Namie
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yuya Ito
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Takahiro Takazono
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yoshitsugu Miyazaki
- Department of Fungal Infection, National Institute of Infectious Disease, Tokyo, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University Hospital, Aichi, Japan
| | - Fukuda Tomoo
- Department of Dermatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Kazutoshi Shibuya
- Department of Pathology, Toho University Omori Medical Center, Tokyo, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
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18
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Boyer J, Feys S, Zsifkovits I, Hoenigl M, Egger M. Treatment of Invasive Aspergillosis: How It's Going, Where It's Heading. Mycopathologia 2023; 188:667-681. [PMID: 37100963 PMCID: PMC10132806 DOI: 10.1007/s11046-023-00727-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/17/2023] [Indexed: 04/28/2023]
Abstract
Despite improvements in treatment and diagnostics over the last two decades, invasive aspergillosis (IA) remains a devastating fungal disease. The number of immunocompromised patients and hence vulnerable hosts increases, which is paralleled by the emergence of a rise in IA cases. Increased frequencies of azole-resistant strains are reported from six continents, presenting a new challenge for the therapeutic management. Treatment options for IA currently consist of three classes of antifungals (azoles, polyenes, echinocandins) with distinctive advantages and shortcomings. Especially in settings of difficult to treat IA, comprising drug tolerance/resistance, limiting drug-drug interactions, and/or severe underlying organ dysfunction, novel approaches are urgently needed. Promising new drugs for the treatment of IA are in late-stage clinical development, including olorofim (a dihydroorotate dehydrogenase inhibitor), fosmanogepix (a Gwt1 enzyme inhibitor), ibrexafungerp (a triterpenoid), opelconazole (an azole optimized for inhalation) and rezafungin (an echinocandin with long half-life time). Further, new insights in the pathophysiology of IA yielding immunotherapy as a potential add-on therapy. Current investigations show encouraging results, so far mostly in preclinical settings. In this review we discuss current treatment strategies, give an outlook on possible new pharmaceutical therapeutic options, and, lastly, provide an overview of the ongoing research in immunotherapy for IA.
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Affiliation(s)
- Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Simon Feys
- Medical Intensive Care Unit, University Hospitals Leuven, Louvain, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Louvain, Belgium
| | - Isabella Zsifkovits
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- BioTechMed, Graz, Austria
| | - Matthias Egger
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
- BioTechMed, Graz, Austria.
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19
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O'Grady N, Davis M, McManus D, Topal J, Azar MM, Briggs N. Response to comment on "Dosing implications for liposomal amphotericin B in pregnancy". Pharmacotherapy 2023; 43:992. [PMID: 37701938 DOI: 10.1002/phar.2864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Niamh O'Grady
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew Davis
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Dayna McManus
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Jeffrey Topal
- Infectious Disease Section, Department of Internal Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Marwan M Azar
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Neima Briggs
- Infectious Disease Section, Department of Internal Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
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20
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Barros N, Rosenblatt RE, Phipps MM, Fomin V, Mansour MK. Invasive fungal infections in liver diseases. Hepatol Commun 2023; 7:e0216. [PMID: 37639701 PMCID: PMC10462082 DOI: 10.1097/hc9.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/07/2023] [Indexed: 08/31/2023] Open
Abstract
Patients with liver diseases, including decompensated cirrhosis, alcohol-associated hepatitis, and liver transplant recipients are at increased risk of acquiring invasive fungal infections (IFIs). These infections carry high morbidity and mortality. Multiple factors, including host immune dysfunction, barrier failures, malnutrition, and microbiome alterations, increase the risk of developing IFI. Candida remains the most common fungal pathogen causing IFI. However, other pathogens, including Aspergillus, Cryptococcus, Pneumocystis, and endemic mycoses, are being increasingly recognized. The diagnosis of IFIs can be ascertained by the direct observation or isolation of the pathogen (culture, histopathology, and cytopathology) or by detecting antigens, antibodies, or nucleic acid. Here, we provide an update on the epidemiology, pathogenesis, diagnosis, and management of IFI in patients with liver disease and liver transplantation.
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Affiliation(s)
- Nicolas Barros
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Division of Infectious Diseases, Department of Medicine, Indiana University Health, Indianapolis, Indiana, USA
| | - Russell E. Rosenblatt
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Meaghan M. Phipps
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Vladislav Fomin
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Michael K. Mansour
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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21
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Roland LT, Humphreys IM, Le CH, Babik JM, Bailey CE, Ediriwickrema LS, Fung M, Lieberman JA, Magliocca KR, Nam HH, Teo NW, Thomas PC, Winegar BA, Birkenbeuel JL, David AP, Goshtasbi K, Johnson PG, Martin EC, Nguyen TV, Patel NN, Qureshi HA, Tay K, Vasudev M, Abuzeid WM, Hwang PH, Jafari A, Russell MS, Turner JH, Wise SK, Kuan EC. Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations. Int Forum Allergy Rhinol 2023; 13:1615-1714. [PMID: 36680469 DOI: 10.1002/alr.23132] [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: 08/23/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.
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Affiliation(s)
- Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ian M Humphreys
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Christopher H Le
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Jennifer M Babik
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christopher E Bailey
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Lilangi S Ediriwickrema
- Gavin Herbert Eye Institute, Department of Ophthalmology, University of California, Irvine, Irvine, California, USA
| | - Monica Fung
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joshua A Lieberman
- Department of Pathology and Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University Medical Center, Atlanta, Georgia, USA
| | - Hannah H Nam
- Division of Infectious Diseases, Department of Medicine, University of California, Irvine, Orange, California, USA
| | - Neville W Teo
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Penelope C Thomas
- Department of Radiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Blair A Winegar
- Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Abel P David
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Patricia G Johnson
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Elaine C Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Theodore V Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Neil N Patel
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hannan A Qureshi
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Kaijun Tay
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Waleed M Abuzeid
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Aria Jafari
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew S Russell
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University Medical Center, Atlanta, Georgia, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
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22
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Lyster H, Shekar K, Watt K, Reed A, Roberts JA, Abdul-Aziz MH. Antifungal Dosing in Critically Ill Patients on Extracorporeal Membrane Oxygenation. Clin Pharmacokinet 2023; 62:931-942. [PMID: 37300631 PMCID: PMC10338597 DOI: 10.1007/s40262-023-01264-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 06/12/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an established advanced life support system, providing temporary cardiac and/or respiratory support in critically ill patients. Fungal infections are associated with increased mortality in patients on ECMO. Antifungal drug dosing for critically ill patients is highly challenging because of altered pharmacokinetics (PK). PK changes during critical illness; in particular, the drug volume of distribution (Vd) and clearance can be exacerbated by ECMO. This article discusses the available literature to inform adequate dosing of antifungals in this patient population. The number of antifungal PK studies in critically ill patients on ECMO is growing; currently available literature consists of case reports and studies with small sample sizes providing inconsistent findings, with scant or no data for some antifungals. Current data are insufficient to provide definitive empirical drug dosing guidance and use of dosing strategies derived from critically patients not on ECMO is reasonable. However, due to high PK variability, therapeutic drug monitoring should be considered where available in critically ill patients receiving ECMO to prevent subtherapeutic or toxic antifungal exposures.
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Affiliation(s)
- Haifa Lyster
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- University of Portsmouth, Portsmouth, UK
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Kevin Watt
- School of Pharmacy, University of Waterloo, 10 Victoria St S. Kitchener, Waterloo, ON, N2G 1C5, Canada
- Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Anna Reed
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- Imperial College London, London, SW3 6NP, UK
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
- Herston Infectious Diseases (HeIDI), Metro North Health, Brisbane, QLD, Australia.
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
| | - Mohd-Hafiz Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
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Weiss ZF, Little J, Hammond S. Evolution of antifungals for invasive mold infections in immunocompromised hosts, then and now. Expert Rev Anti Infect Ther 2023; 21:535-549. [PMID: 37104686 DOI: 10.1080/14787210.2023.2207821] [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: 04/29/2023]
Abstract
INTRODUCTION The current armamentarium of antifungal agents for invasive mold infections (IMI) has dramatically improved over the last 50 years. Existing therapies are, however, associated with toxicities, drug interactions, and in some cases, therapeutic failures. Novel antifungals are needed to address the increasing prevalence of IMI and the growing threat of antifungal resistance. AREAS COVERED We review the history and development of the most commonly used antifungals. We discuss the current consensus guidelines and supporting data for treatment of invasive mold infection (IMI), the role of susceptibility testing, and the niche that novel antifungals could fill. We review the current data for aspergillosis, mucormycosis, and hyalohyphomycosis. EXPERT OPINION Robust clinical trial data demonstrating the relative effectiveness of our current antifungal agents for treating IMI outside of A. fumigatus remains limited. Clinical trials are urgently needed to delineate the relationship between MICs and clinical outcomes for existing agents and to better evaluate the invitro and in-vivo aspects of antifungal synergy. Continued international multicenter collaboration and standardized clinical endpoints for trials evaluating both existing and new agents is necessary to advance the field.
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Affiliation(s)
- Zoe Freeman Weiss
- Tufts Medical Center, Division of Infectious Diseases and Geographic Medicine, Boston MA, USA
- Tufts Medical Center, Division of Pathology, Boston MA, USA
| | - Jessica Little
- Brigham and Women's Hospital, Division of Infectious Diseases, Boston MA, USA
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Sarah Hammond
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
- Massachusetts General Hospital, Divisions of Infectious Diseases and Hematology Oncology, Boston MA, USA
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Muthu V, Gogineni RR, Agarwal R, Prasad KT, Sehgal IS, Dhooria S, Aggarwal AN, Rudramurthy SM, Singh H, Garg M, Chakrabarti A. Treatment of pulmonary mucormycosis with adjunctive nebulized amphotericin B (MUCONAB trial): Results of an open-label randomized controlled trial. Mycoses 2023. [PMID: 37095064 DOI: 10.1111/myc.13591] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The role of nebulized amphotericin B (NAB) in managing pulmonary mucormycosis (PM) is unknown. METHODS In this open-label trial, we randomized PM subjects to receive either intravenous liposomal amphotericin B (control arm, 3-5 mg/kg/day) alone or along with nebulized amphotericin B deoxycholate (NAB, 10 mg twice a day, every alternate day). The primary outcomes were: (1) overall response ('success' [complete or partial response] or 'failure' [stable disease, progressive disease, or death]) at 6 weeks; and (2) the proportion of subjects with adverse events (AE). The key secondary outcome was 90-day mortality. We performed a modified intention-to-treat (mITT) analysis where we included only subjects receiving at least a single dose of NAB. RESULTS Fifteen and 17 subjects were randomized to the control and NAB arms; two died before the first dose of NAB. Finally, we included 30 subjects (15 in each arm; mean age 49.8 years; 80% men) for the mITT analysis. Diabetes mellitus (n = 27; 16/27 were COVID-19-associated PM) was the most common predisposing factor. The overall treatment success was not significantly different between the control and the NAB arms (71.4% vs. 53.3%; p = .45). Twenty-nine subjects experienced any AE, but none discontinued treatment. The 90-day mortality was not significantly different between the control (28.6%) and NAB arm (53.3%; p = .26). CONCLUSION Adjunctive NAB was safe but did not improve overall response at 6 weeks. A different dosing schedule or nebulized liposomal amphotericin B may still need evaluation. More research is needed to explore other treatment options for PM.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ratnakara Rao Gogineni
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Harkant Singh
- Department of Cardiovascular and thoracic surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Kitayama T, Tone K, Makimura K, Takagi M, Kuwano K. COVID-19-Associated Pulmonary Aspergillosis Complicated by Severe Coronavirus Disease: Is Detection of Aspergillus in Airway Specimens Before Disease Onset an Indicator of Antifungal Prophylaxis? Cureus 2023; 15:e36212. [PMID: 37069870 PMCID: PMC10105287 DOI: 10.7759/cureus.36212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
A 55-year-old man was admitted for coronavirus disease 2019 (COVID-19)-related respiratory failure. He was treated with corticosteroids and tocilizumab in the intensive care unit. Aspergillus fumigatus (A. fumigatus) was isolated from his sputum on admission. However, no radiological findings suggesting pulmonary aspergillosis were seen on chest computed tomography (CT). Since the fungus had merely colonized in airways, antifungal drugs were not administered immediately. On day 19 of hospitalization, a high (1→3)-β-D-glucan (BDG) level was noted. A CT scan on day 22 revealed consolidations with a cavity in the right lung. A. fumigatus was isolated from his sputum again. Thus, we diagnosed the patient with COVID-19-associated pulmonary aspergillosis (CAPA) and started voriconazole. After the treatment, BDG levels and radiological findings were noted to improve. In this case, tocilizumab probably had a critical role in developing the disease. Although antifungal prophylaxis therapy for CAPA is not well established, this case shows that detecting Aspergillus in airway specimens before the disease onset possibly implies a high risk of developing CAPA and is an indicator of antifungal prophylaxis.
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Ji X, Shi C, Guo D, Yang X, Suo L, Luo J. Engineering Telodendrimer Nanocarriers for Monomeric Amphotericin B Delivery. Mol Pharm 2023; 20:2138-2149. [PMID: 36877183 DOI: 10.1021/acs.molpharmaceut.2c01087] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Systemic fungal infections are an increasingly prevalent health problem. Amphotericin B (AmB), a hydrophobic polyene antibiotic, remains the drug of choice for life-threatening invasive fungal infections. However, it has dose-limiting side effects, including nephrotoxicity. The efficacy and toxicity of AmB are directly related to its aggregation state. Here, we report the preparation of a series of telodendrimer (TD) nanocarriers with the freely engineered core structures for AmB encapsulation to fine-tune AmB aggregation status. The reduced aggregation status correlates well with the optimized antifungal activity, attenuated hemolytic properties, and reduced cytotoxicity to mammalian cells. The optimized TD nanocarrier for monomeric AmB encapsulation significantly increases the therapeutic index, reduces the in vivo toxicity, and enhances antifungal effects in mouse models with Candida albicans infection in comparison to two common clinical formulations, i.e., Fungizone and AmBisome.
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Affiliation(s)
- Xiaotian Ji
- Department of Pharmacology, State University of New York Upstate Medical University, Syracuse, New York 13210, United States
| | - Changying Shi
- Department of Pharmacology, State University of New York Upstate Medical University, Syracuse, New York 13210, United States
| | - Dandan Guo
- Department of Pharmacology, State University of New York Upstate Medical University, Syracuse, New York 13210, United States
| | - Xiguang Yang
- Department of Pharmacology, State University of New York Upstate Medical University, Syracuse, New York 13210, United States
| | - Liye Suo
- Department of Pathology, State University of New York Upstate Medical University, Syracuse, New York 13210, United States
| | - Juntao Luo
- Department of Pharmacology, Department of Surgery, Department of Microbiology and Immunology, Upstate Cancer Center, Upstate Sepsis Interdisciplinary Research Center, State University of New York Upstate Medical University, Syracuse, New York 13210, United States
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27
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Systemic Antifungal Therapy for Invasive Pulmonary Infections. J Fungi (Basel) 2023; 9:jof9020144. [PMID: 36836260 PMCID: PMC9966409 DOI: 10.3390/jof9020144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Antifungal therapy for pulmonary fungal diseases is in a state of flux. Amphotericin B, the time-honored standard of care for many years, has been replaced by agents demonstrating superior efficacy and safety, including extended-spectrum triazoles and liposomal amphotericin B. Voriconazole, which became the treatment of choice for most pulmonary mold diseases, has been compared with posaconazole and itraconazole, both of which have shown clinical efficacy similar to that of voriconazole, with fewer adverse events. With the worldwide expansion of azole-resistant Aspergillus fumigatus and infections with intrinsically resistant non-Aspergillus molds, the need for newer antifungals with novel mechanisms of action becomes ever more pressing.
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28
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Ledoux MP, Herbrecht R. Invasive Pulmonary Aspergillosis. J Fungi (Basel) 2023; 9:jof9020131. [PMID: 36836246 PMCID: PMC9962768 DOI: 10.3390/jof9020131] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 01/19/2023] Open
Abstract
Invasive pulmonary aspergillosis is growing in incidence, as patients at risk are growing in diversity. Outside the classical context of neutropenia, new risk factors are emerging or newly identified, such as new anticancer drugs, viral pneumonias and hepatic dysfunctions. Clinical signs remain unspecific in these populations and the diagnostic work-up has considerably expanded. Computed tomography is key to assess the pulmonary lesions of aspergillosis, whose various features must be acknowledged. Positron-emission tomography can bring additional information for diagnosis and follow-up. The mycological argument for diagnosis is rarely fully conclusive, as biopsy from a sterile site is challenging in most clinical contexts. In patients with a risk and suggestive radiological findings, probable invasive aspergillosis is diagnosed through blood and bronchoalveolar lavage fluid samples by detecting galactomannan or DNA, or by direct microscopy and culture for the latter. Diagnosis is considered possible with mold infection in lack of mycological criterion. Nevertheless, the therapeutic decision should not be hindered by these research-oriented categories, that have been completed by better adapted ones in specific settings. Survival has been improved over the past decades with the development of relevant antifungals, including lipid formulations of amphotericin B and new azoles. New antifungals, including first-in-class molecules, are awaited.
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Lamoth F, Calandra T. Pulmonary aspergillosis: diagnosis and treatment. Eur Respir Rev 2022; 31:31/166/220114. [DOI: 10.1183/16000617.0114-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/18/2022] [Indexed: 12/05/2022] Open
Abstract
Aspergillusspecies are the most frequent cause of fungal infections of the lungs with a broad spectrum of clinical presentations including invasive pulmonary aspergillosis (IPA) and chronic pulmonary aspergillosis (CPA). IPA affects immunocompromised populations, which are increasing in number and diversity with the advent of novel anti-cancer therapies. Moreover, IPA has emerged as a complication of severe influenza and coronavirus disease 2019 in apparently immunocompetent hosts. CPA mainly affects patients with pre-existing lung lesions and is recognised increasingly frequently among patients with long-term survival following cure of tuberculosis or lung cancer. The diagnosis of pulmonary aspergillosis is complex as it relies on the presence of clinical, radiological and microbiological criteria, which differ according to the type of pulmonary aspergillosis (IPA or CPA) and the type of patient population. The management of pulmonary aspergillosis is complicated by the limited number of treatment options, drug interactions, adverse events and the emergence of antifungal resistance.
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30
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Stott KE, Moyo M, Ahmadu A, Kajanga C, Gondwe E, Chimang’anga W, Chasweka M, Leeme TB, Molefi M, Chofle A, Bidwell G, Changalucha J, Unsworth J, Jimenez-Valverde A, Lawrence DS, Mwandumba HC, Lalloo DG, Harrison TS, Jarvis JN, Hope W, Märtson AG. Population pharmacokinetics of liposomal amphotericin B in adults with HIV-associated cryptococcal meningoencephalitis. J Antimicrob Chemother 2022; 78:276-283. [PMID: 36411251 PMCID: PMC9780527 DOI: 10.1093/jac/dkac389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/18/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Single, high-dose liposomal amphotericin B (LAmB; AmBisome, Gilead Sciences) has demonstrated non-inferiority to amphotericin B deoxycholate in combination with other antifungals for averting all-cause mortality from HIV-associated cryptococcal meningitis. There are limited data on the pharmacokinetics (PK) of AmBisome. The aim of this study was to describe population PK of AmBisome and conduct a meta-analysis of the available studies to suggest the optimal dosing for cryptococcal meningoencephalitis. METHODS Data from a Phase II and Phase III trial of high-dose, short-course AmBisome for cryptococcal meningoencephalitis were combined to develop a population PK model. A search was conducted for trials of AmBisome monotherapy and meta-analysis of clinical outcome data was performed. RESULTS A two-compartment model with first-order clearance of drug from the central compartment fitted the data best and enabled the extent of inter-individual variability in PK to be quantified. Mean (SD) population PK parameter estimates were: clearance 0.416 (0.363) L/h; volume of distribution 4.566 (4.518) L; first-order transfer of drug from central to peripheral compartments 2.222 (3.351) h-1, and from peripheral to central compartment 2.951 (4.070) h-1. Data for the meta-analysis were insufficient to suggest optimal dosing of AmBisome for cryptococcal meningoencephalitis. CONCLUSIONS This study provides novel insight into the PK of AmBisome at the population level and the variability therein. Our analysis also serves to highlight the paucity of data available on the pharmacodynamics (PD) of AmBisome and underscores the importance of thorough and detailed PK/PD analysis in the development of novel antifungals, by demonstrating the challenges associated with post hoc PK/PD analysis.
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Affiliation(s)
- Katharine E Stott
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, UK
- Malawi Liverpool Wellcome Programme, Kamuzu University of Health Sciences, Malawi
| | - Melanie Moyo
- Malawi Liverpool Wellcome Programme, Kamuzu University of Health Sciences, Malawi
- Department of Medicine, Kamuzu University of Health Sciences, Malawi
| | - Ajisa Ahmadu
- Malawi Liverpool Wellcome Programme, Kamuzu University of Health Sciences, Malawi
| | - Cheusisime Kajanga
- Malawi Liverpool Wellcome Programme, Kamuzu University of Health Sciences, Malawi
| | - Ebbie Gondwe
- Malawi Liverpool Wellcome Programme, Kamuzu University of Health Sciences, Malawi
| | - Wezzie Chimang’anga
- Malawi Liverpool Wellcome Programme, Kamuzu University of Health Sciences, Malawi
| | - Madalitso Chasweka
- Malawi Liverpool Wellcome Programme, Kamuzu University of Health Sciences, Malawi
| | - Tshepo B Leeme
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | | | - Awilly Chofle
- National Institute of Medical Research, Mwanza, Tanzania
| | | | | | - Jenny Unsworth
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, UK
| | - Ana Jimenez-Valverde
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, UK
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Henry C Mwandumba
- Malawi Liverpool Wellcome Programme, Kamuzu University of Health Sciences, Malawi
- Department of Medicine, Kamuzu University of Health Sciences, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Thomas S Harrison
- Institute of Infection and Immunity, St George’s University Hospital, London, UK
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, UK
| | - Anne-Grete Märtson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, UK
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Punia A, Choudhary P, Sharma N, Dahiya S, Gulia P, Chhillar AK. Therapeutic Approaches for Combating Aspergillus Associated Infection. Curr Drug Targets 2022; 23:1465-1488. [PMID: 35748549 DOI: 10.2174/1389450123666220623164548] [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: 09/28/2021] [Revised: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 01/25/2023]
Abstract
Now-a-days fungal infection emerges as a significant problem to healthcare management systems due to high frequency of associated morbidity, mortality toxicity, drug-drug interactions, and resistance of the antifungal agents. Aspergillus is the most common mold that cause infection in immunocompromised hosts. It's a hyaline mold that is cosmopolitan and ubiquitous in nature. Aspergillus infects around 10 million population each year with a mortality rate of 30-90%. Clinically available antifungal formulations are restricted to four classes (i.e., polyene, triazole, echinocandin, and allylamine), and each of them have their own limitations associated with the activity spectrum, the emergence of resistance, and toxicity. Consequently, novel antifungal agents with modified and altered chemical structures are required to combat these invasive fungal infections. To overcome these limitations, there is an urgent need for new antifungal agents that can act as potent drugs in near future. Currently, some compounds have shown effective antifungal activity. In this review article, we have discussed all potential antifungal therapies that contain old antifungal drugs, combination therapies, and recent novel antifungal formulations, with a focus on the Aspergillus associated infections.
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Affiliation(s)
- Aruna Punia
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Pooja Choudhary
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Namita Sharma
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Sweety Dahiya
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Prity Gulia
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Anil K Chhillar
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
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32
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Lee SO. Diagnosis and Treatment of Invasive Mold Diseases. Infect Chemother 2022; 55:10-21. [PMID: 36603818 PMCID: PMC10079437 DOI: 10.3947/ic.2022.0151] [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: 10/18/2022] [Accepted: 11/09/2022] [Indexed: 12/05/2022] Open
Abstract
Although invasive fungal diseases are relatively less common than superficial diseases, there has been an overall increase in their incidence. Here, I review the epidemiology, diagnosis, and treatment of invasive mold diseases (IMDs) such as aspergillosis, mucormycosis, hyalohyphomycosis, and phaeohyphomycosis. Histopathologic demonstration of tissue invasion by hyphae or recovery of mold by the culture of a specimen obtained by a sterile procedure provides definitive evidence of IMD. If IMD cannot be confirmed through invasive procedures, IMD can be diagnosed through clinical criteria such as the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Instituteof Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) definitions. For initial primary therapy of invasive aspergillosis, voriconazole or isavuconazole is recommended and lipid formulations of amphotericin B are useful primary alternatives. Echinocandins are representative antifungal agents for salvage therapy. Treatment of invasive mucormycosis involves a combination of urgent surgical debridement of involved tissues and antifungal therapy. Lipid formulations of amphotericin B are the drug of choice for initial therapy. Isavuconazole or posaconazole can be used as salvage or step-down therapy. IMDs other than aspergillosis and mucormycosis include hyalohyphomycosis and phaeohyphomycosis, for which there is no standard therapy and the treatment depends on the clinical disease and status of the patient.
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Affiliation(s)
- Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Abstract
The discovery of amphotericin B, a polyene antifungal compound, in the 1950s, and the formulation of this compound in a liposomal drug delivery system, has resulted in decades of use in systemic fungal infections. The use of liposomal amphotericin B formulation is referenced in many international guidelines for the treatment of fungal infections such as Aspergillus and cryptococcal disease and Candida infections, as well as other less common infections such as visceral leishmaniasis. With the development of liposomal amphotericin B, an improved therapeutic index could be achieved that allowed the attainment of higher drug concentrations in both the plasma and tissue while simultaneously lowering the toxicity compared with amphotericin B deoxycholate. In over 30 years of experience with this drug, a vast amount of information has been collected on preclinical and clinical efficacy against a wide variety of pathogens, as well as evidence on its toxicity. This article explores the history and nature of the liposomal formulation, the key clinical studies that developed the pharmacokinetic, safety and efficacy profile of the liposomal formulation, and the available microbiological data.
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Affiliation(s)
- R J Brüggemann
- Department of Pharmacy, and Radboudumc Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Center, Nijmegen, The Netherlands
| | - G M Jensen
- Pharmaceutical Development and Manufacturing, Gilead Sciences Inc., La Verne, CA, USA
| | - C Lass-Flörl
- Department of Hygiene, Medical Microbiology and Public Health, Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
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Muacevic A, Adler JR, Loutfi S, Alqahatani HY, Bosaeed M, Ahmed A, Alahmari B, Alsadi H, Ahmed M, Al Dhoayan M. Comparing Invasive Pulmonary Aspergillosis Mortality Between Liposomal Amphotericin B and Voriconazole in Patients With Hematological Malignancy or Hematopoietic Stem Cell Transplantation. Cureus 2022; 14:e31762. [PMID: 36569688 PMCID: PMC9771842 DOI: 10.7759/cureus.31762] [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] [Accepted: 11/20/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives We evaluated liposomal amphotericin B versus voriconazole for the treatment of invasive pulmonary aspergillosis (IPA) in patients with hematological malignancy or hematopoietic stem cell transplantation (HSCT). Methods This retrospective cohort, single-center study included patients with compatible radiological diagnosis of IPA between 2016 and 2021. Results Forty-six patients with hematological malignancy or HSCT were diagnosed with IPA. Thirty-nine of them fulfilled the criteria for comparing liposomal amphotericin B (n=15) with voriconazole (n=24). Their median age was 48.5 years. Stem cell transplant recipients were 45.65%, and nearly half of the patients (47.83%) had acute myeloid leukemia. Twenty-six (56.52%) of the patients did not require oxygen therapy. The 12-week mortality was 13.33% (two out of 15) in patients who received liposomal amphotericin B compared to 25% (six out of 24) in patients who received voriconazole. There was no mortality judged to be related to IPA. Success or global clinical response was not different between the two drugs: 80% for liposomal amphotericin B versus 83.33% for voriconazole. However, the safety profile favored liposomal amphotericin B. Conclusion In this small cohort, there was an equipoise in the mortality and clinical and radiological outcomes obtained using liposomal amphotericin B or voriconazole for the treatment of IPA in hematological malignancy or HSCT.
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Roth RS, Masouridi‐Levrat S, Giannotti F, Mamez A, Morin S, van Delden C, Chalandon Y, Neofytos D. When and how do we stop antifungal treatment for an invasive mould infection in allogeneic haematopoietic cell transplant recipients? Mycoses 2022; 65:1061-1067. [PMID: 35815918 PMCID: PMC9796773 DOI: 10.1111/myc.13496] [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: 04/01/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limited data exist to describe end-of-treatment (EOT) parameters of antifungal therapy for invasive mould infections (IMI). METHODS In a 10-year cohort of consecutive adult allogeneic haematopoietic cell transplant recipients with proven/probable IMI, we describe treatment duration and patient profile at EOT. RESULTS There were 61 patients with 66 proven/probable IMI identified: 47/66 (71%) invasive aspergillosis (IA), 11/66 (17%) mucormycosis, and 8/66 (12%) other-IMI. Excluding 5 (8%) patients lost to follow-up, treatment was prematurely discontinued due to death or palliative care in 29/56 (51.8%) patients. Antifungal treatment was completed in 27 (48.2%) patients, for a median duration of 280 days (IQR: 110, 809): 258 (IQR: 110, 1905) and 307.5 (99, 809) days in IA and non-IA IMI, respectively. Treatment was continued after 90 and 180 days in 43/56 (76.8%) and 30/56 (53.6%) patients, respectively. At EOT, most patients were not neutropenic (ANC: 2.12 G/L, IQR: 0.04, 5.3), with CD4+ counts at 99 cells/μl (IQR: 0, 759) and immunoglobulins at 5.6 g/L (IQR: 2.3, 10.6). Most patients (16/27, 59.3%) were not receiving steroids at EOT, while 14/27 (53.9%) were on another type of immunosuppression. Amongst 15 patients with imaging at EOT, 12 (80%) had complete/partial radiologic response. Any chart documentation or an infectious disease consultation on treatment discontinuation was observed in 12/56 (21%) and 11/56 (20%) patients, respectively. CONCLUSIONS Long treatment courses are observed in patients with IMI, due to prolonged immunosuppression. Although immune reconstitution and radiological response were frequently observed at EOT, consistent documentation of treatment discontinuation based on well-defined parameters is lacking.
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Affiliation(s)
- Romain Samuel Roth
- Division of Infectious DiseasesUniversity Hospital of GenevaGenevaSwitzerland
| | - Stavroula Masouridi‐Levrat
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva and Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Federica Giannotti
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva and Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Anne‐Claire Mamez
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva and Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Sarah Morin
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva and Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | | | - Yves Chalandon
- Bone Marrow Transplant Unit, Division of Hematology, University Hospital of Geneva and Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Dionysios Neofytos
- Division of Infectious DiseasesUniversity Hospital of GenevaGenevaSwitzerland
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Mehta R, Rao KN, Nagarkar NM, Sharma A, Kumar B, Karthik P. Outcomes of Open Fronto-Facial Resection for Fungal Osteomyelitis of Frontal Bone. Rambam Maimonides Med J 2022; 13:RMMJ.10484. [PMID: 36394502 PMCID: PMC9622391 DOI: 10.5041/rmmj.10484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The second wave of coronavirus disease 2019 (COVID-19) led to the resurgence of opportunistic infections due to the injudicious use of steroids. Sinonasal mucormycosis was declared an epidemic in India during the pandemic. Mucormycosis was managed effectively by surgical debridement along with systemic amphotericin B. Currently, a resurgence of mucormycosis following initial treatment, in the form of fungal osteomyelitis of the frontal bone, is being seen in India. METHODS This prospective study included 10 patients with fungal osteomyelitis of the frontal bone due to mucormycosis. All patients underwent surgical debridement of the sequestrum and involucrum, with systemic antifungal pharmacotherapy. RESULTS The average duration of time until mucormycosis recurrence was 22 days following initial treatment (range 10-33 days). Patients presented with extracranial bossing following outer frontal cortex erosion (n=3), bicortical erosion (n=3), bifrontal involvement (n=2), dural involvement (n=3), and involvement of the brain parenchyma and prefrontal cortex (n=2). All cases underwent debridement of the entire sequestrous bone and involucrum until normal bone could be identified. The mean admission duration was 4 weeks (range 3-6 weeks). All treated patients are currently alive and without disease, confirmed by contrast-enhanced computed tomography. CONCLUSION Based on our experience, the successful treatment of fungal osteomyelitis due to mucormycosis requires a four-pronged approach: early detection, multidisciplinary management of comorbidities, surgical debridement of necrotic bone, and adequate systemic antifungal therapy.
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Affiliation(s)
- Rupa Mehta
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
| | - Karthik Nagaraga Rao
- Department of Head and Neck Oncology, All India Institute of Medical Sciences, Raipur, India
| | - Nitin M Nagarkar
- Director and CEO, All India Institute of Medical Sciences, Raipur, India
| | - Anil Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, Raipur, India
| | - Badal Kumar
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
| | - P Karthik
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
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Novel Insights into Fungal Infections Prophylaxis and Treatment in Pediatric Patients with Cancer. Antibiotics (Basel) 2022; 11:antibiotics11101316. [PMID: 36289974 PMCID: PMC9598217 DOI: 10.3390/antibiotics11101316] [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: 08/19/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/23/2022] Open
Abstract
Invasive fungal diseases (IFDs) are a relevant cause of morbidity and mortality in children with cancer. Their correct prevention and management impact patients’ outcomes. The aim of this review is to highlight the rationale and novel insights into antifungal prophylaxis and treatment in pediatric patients with oncological and hematological diseases. The literature analysis showed that IFDs represent a minority of cases in comparison to bacterial and viral infections, but their impact might be far more serious, especially when prolonged antifungal therapy or invasive surgical treatments are required to eradicate colonization. A personalized approach is recommended since pediatric patients with cancer often present with different complications and require tailored therapy. Moreover, while the Aspergillus infection rate does not seem to increase, in the near future, new therapeutic recommendations should be required in light of new epidemiological data on Candidemia due to resistant species. Finally, further studies on CAR-T treatment and other immunotherapies are needed in patients with unique needs and the risk of complications. Definitive guidelines on IFD treatment considering the evolving epidemiology of antifungal resistance, new therapeutic approaches in pediatric cancer, novel antifungal drugs and the importance of an appropriate antifungal stewardship are urgently needed.
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Zhang B, Gui R, Wang Q, Jiao X, Li Z, Wang J, Han L, Zhou L, Wang H, Wang X, Fan X, Lyu X, Song Y, Zhou J. Comparing the application of mNGS after combined pneumonia in hematologic patients receiving hematopoietic stem cell transplantation and chemotherapy: A retrospective analysis. Front Cell Infect Microbiol 2022; 12:969126. [PMID: 36211959 PMCID: PMC9532739 DOI: 10.3389/fcimb.2022.969126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
Rapid and accurate pathogen identification is essential for timely and effective treatment of pneumonia. Here, we describe the use of metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage (BALF) fluid to identify pathogens in patients with hematologic comorbid respiratory symptoms in a retrospective study with 84 patients. In the transplantation group, 8 cases (19.5%) and 47 cases (97.9%) were positive for BALF by conventional method detection and mNGS detection, respectively, and 6 cases (14.0%) and 41 cases (91.1%) in chemotherapy group, respectively. The detection rate of mNGS in both groups was significantly higher than that of conventional detection methods (all P<0.05). Pseudomonas aeruginosa and Streptococcus pneumoniae were the most common bacterial infections in the transplantation and chemotherapy groups, respectively. Aspergillus was the most common fungal infection in both groups. Human betaherpesvirus 5 (HHV-5), torque teno virus and human betaherpesvirus 7 (HHV-7) were the most common pathogen species in both groups. The most common type of infection in patients in the transplantation and chemotherapy groups was the mixed infection of bacteria-virus. Most patients in the transplantation group had mixed infections based on multiple viruses, with 42 cases of viral infections in the transplantation group and 30 cases of viral infections in the chemotherapy group, which were significantly higher in the transplantation group than in the chemotherapy group (χ2 = 5.766, P=0.016). and the mixed infection of virus-virus in the transplantation group was significantly higher than that in the chemotherapy group (27.1% vs 4.4%, P=0.003). The proportion of death due to pulmonary infection was significantly higher in the transplantation group than in the chemotherapy group (76.9% vs 16.7%, χ2 = 9.077, P=0.003). This study demonstrated the value of mNGS of BALF in improving the diagnosis and prognosis of hematologic comorbid pneumonia, helping patients to obtain timely and effective treatment, and giving guidance on the overall treatment plan for patients, with particular benefit for patients with hematologic chemotherapy comorbid pneumonia.
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Affiliation(s)
- Binglei Zhang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
- School of Basic Medical Sciences, Academy of Medical Sciences, Henan Academy of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Ruirui Gui
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Qian Wang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Xueli Jiao
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Zhen Li
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Juan Wang
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Lu Han
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Ling Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Huili Wang
- Department of Hematology, The Third People’s Hospital of Zhengzhou, Zhengzhou, China
| | - Xianjing Wang
- Department of Hematology, The Third People’s Hospital of Zhengzhou, Zhengzhou, China
| | - Xinxin Fan
- Department of Hematology, The Third People’s Hospital of Zhengzhou, Zhengzhou, China
| | - Xiaodong Lyu
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
- *Correspondence: Xiaodong Lyu, ; Yongping Song, ; Jian Zhou,
| | - Yongping Song
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
- *Correspondence: Xiaodong Lyu, ; Yongping Song, ; Jian Zhou,
| | - Jian Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
- *Correspondence: Xiaodong Lyu, ; Yongping Song, ; Jian Zhou,
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Potential Original Drug for Aspergillosis: In Vitro and In Vivo Effects of 1-N,N-Dimethylamino-5-Isocyanonaphthalene (DIMICAN) on Aspergillus fumigatus. J Fungi (Basel) 2022; 8:jof8100985. [PMID: 36294550 PMCID: PMC9605569 DOI: 10.3390/jof8100985] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 12/03/2022] Open
Abstract
As the recent outbreak of coronavirus disease 2019 (COVID-19) has shown, viral infections are prone to secondary complications like invasive aspergillosis with a high mortality rate, and therefore the development of novel, effective antifungals is of paramount importance. We have previously demonstrated that 1-amino-5-isocyanonaphthalene (ICAN) derivatives are promising original drug candidates against Candida strains (Patent pending), even against fluconazole resistant C. albicans. Consequently, in this study ICANs were tested on Aspergillus fumigatus, an opportunistic pathogen, which is the leading cause of invasive and systematic pulmonary aspergillosis in immunosuppressed, transplanted and cancer- or COVID-19 treated patients. We have tested several N-alkylated ICANs, a well as 1,5-naphthalene-diisocyanide (DIN) with the microdilution method against Aspergillus fumigatus strains. The results revealed that the diisocyanide (DIN) was the most effective with a minimum inhibitory concentration (MIC) value as low as 0.6 µg mL−1 (3.4 µM); however, its practical applicability is limited by its poor water solubility, which needs to be overcome by proper formulation. The other alkylated derivatives also have in vitro and in vivo anti-Aspergillus fumigatus effects. For animal experiments the second most effective derivative 1-N, N-dimethylamino-5-isocyanonaphthalene (DIMICAN, MIC: 7–8 µg mL−1, 36–41 µM) was selected, toxicity tests were made with mice, and then the antifungal effect of DIMICAN was tested in a neutropenic aspergillosis murine model. Compared to amphotericin B (AMB), a well-known antifungal, the antifungal effect of DIMICAN in vivo turned out to be much better (40% vs. 90% survival after eight days), indicating its potential as a clinical drug candidate.
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Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
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Posaconazole oral suspension for secondary antifungal prophylaxis in allogeneic stem cell transplantation recipients: a retrospective study. BMC Infect Dis 2022; 22:465. [PMID: 35570276 PMCID: PMC9107735 DOI: 10.1186/s12879-022-07442-y] [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: 02/10/2022] [Accepted: 04/29/2022] [Indexed: 11/24/2022] Open
Abstract
Background There is no consensus on the optimal secondary antifungal prophylaxis (SAP) regimen in patients receiving allogeneic hematopoietic stem cell transplantation (allo-HSCT). The purpose of this study was to evaluate the efficacy and safety of posaconazole oral suspension as secondary prophylaxis of invasive fungal disease (IFD) for allo-HSCT patients. Methods We retrospectively reviewed clinical data from prior IFD patients who received posaconazole oral suspension as systemic antifungal prophylaxis between June 2016 and January 2021 and have a follow-up period of 1 year after HSCT. The clinical outcomes of patients with a prior history of IFD (n = 30) and those without (n = 93) were compared. Results The 1-year cumulative incidence of prophylaxis failure was 58.3% in the group with prior history of IFD and 41.6% in the group without a prior history of IFD (p = 0.459). The cumulative incidence of proven, probable or possible IFD within 1 year after allo-HSCT was 23.1% in the group with prior history of IFD and 14.1% in the group without prior history of IFD (p = 0.230). There was no significant difference between the cumulative incidence of proven or probable IFD within 1-year after allo-HSCT in the group with a prior history of IFD and the group without (p = 0.807). Multivariate logistic regression revealed cytomegalovirus disease as risk factor for post-transplantation IFD occurrence in posaconazole oral suspension prophylaxis. There was not a significant difference in overall survival between the patients with IFD history and those without (P = 0.559). Conclusions Our study support that allo-HSCT recipients with a prior history of IFD and normal GI absorption can choose posaconazole oral suspension as a safe and effective SAP option.
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Mrig S, Sardana K, Arora P, Narula V, Arora S, Kapoor A, Baruah RR, Sen P, Agarwal S, Sachdeva S, Dewan A, Panesar S. Adjunctive use of saturated solution of potassium iodide (SSKI) with liposomal amphotericin B (L-AMB) in mucormycosis achieves favorable response, shortened dose and duration of amphotericin: A retrospective study from a COVID-19 tertiary care center. Am J Otolaryngol 2022; 43:103465. [PMID: 35429848 PMCID: PMC8990439 DOI: 10.1016/j.amjoto.2022.103465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/04/2022] [Indexed: 12/12/2022]
Abstract
Purpose Second wave of COVID-19 pandemic was associated with an unprecedented rise in cases of mucormycosis, treatment of which has been challenging owing to the availability and side effects associated with amphotericin. Methods All patients presenting with rhino-orbital cerebral mucormycosis (ROCM) following COVID-19 infection between April 2021 to June 2021 were included in this retrospective interventional study. Primary objective was to assess the clinical response with combination of intravenous liposomal amphotericin B (4–5 mg/kg/day) and saturated solution of potassium iodide (SSKI) given orally along with surgical debridement. Results Twenty-five patients of ROCM were treated with the regimen. Mean age and fasting blood sugar levels were 53.48 years and 239.64 mg/dL respectively. All patients had history of intake of steroids with a mean daily dose of 86.39 mg of prednisolone equivalent. 88% of patients had a “proven” diagnosis of mucormycosis. Cultures were positive in 52% of patients with Rhizopus arrhizus as the predominant species. The mean daily dose of amphotericin received was 268 mg/day with a mean duration of 9.52 days. Mean daily dose of SSKI was 2.57 g. 21 patients (84%) had stabilization of disease at week 8 and achieved cure at the end of treatment whereas the mortality rate was 16%. Factors that significantly affected outcome were eye and central nervous system (CNS) involvement on presentation. Conclusion SSKI, with its remarkably low cost and safety profile, makes it a potential adjuvant drug that may help achieve the twin benefits of shortened duration and dose of LAMB.
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Affiliation(s)
- Sumit Mrig
- Department of ENT, Max Smart Superspeciality Hospital, Saket, New Delhi, India
| | - Kabir Sardana
- Dermatology, Dr RML Hospital & ABVIMS, New Delhi, India
| | - Pooja Arora
- Dermatology, Dr RML Hospital & ABVIMS, New Delhi, India.
| | - Vineet Narula
- Department of ENT, Max Smart Superspeciality Hospital, Saket, New Delhi, India
| | - Sandeep Arora
- Department of ENT, Max Smart Superspeciality Hospital, Saket, New Delhi, India
| | - Amrit Kapoor
- Department of ENT, Max Smart Superspeciality Hospital, Saket, New Delhi, India
| | - Ritu Raj Baruah
- Ophthalmology, Max Smart Superspeciality Hospital, Saket, New Delhi, India
| | - Poornima Sen
- Max Superspeciality Hospital, Saket, New Delhi, India
| | | | | | - Arun Dewan
- Critical Care & Internal Medicine, Max Smart Superspeciality Hospital, Saket, New Delhi, India
| | - Sanjeet Panesar
- Department of Community Medicine, Dr RML Hospital & ABVIMS, New Delhi, India
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Xie Y, Papadopoulou P, de Wit B, d’Engelbronner JC, van Hage P, Kros A, Schaaf MJM. Two Types of Liposomal Formulations Improve the Therapeutic Ratio of Prednisolone Phosphate in a Zebrafish Model for Inflammation. Cells 2022; 11:cells11040671. [PMID: 35203318 PMCID: PMC8870436 DOI: 10.3390/cells11040671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/31/2022] [Accepted: 02/12/2022] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids (GCs) are effective anti-inflammatory drugs, but their clinical use is limited by their side effects. Using liposomes to target GCs to inflammatory sites is a promising approach to improve their therapeutic ratio. We used zebrafish embryos to visualize the biodistribution of liposomes and to determine the anti-inflammatory and adverse effects of the GC prednisolone phosphate (PLP) encapsulated in these liposomes. Our results showed that PEGylated liposomes remained in circulation for long periods of time, whereas a novel type of liposomes (which we named AmbiMACs) selectively targeted macrophages. Upon laser wounding of the tail, both types of liposomes were shown to accumulate near the wounding site. Encapsulation of PLP in the PEGylated liposomes and AmbiMACs increased its potency to inhibit the inflammatory response. However, encapsulation of PLP in either type of liposome reduced its inhibitory effect on tissue regeneration, and encapsulation in PEGylated liposomes attenuated the activation of glucocorticoid-responsive gene expression throughout the body. Thus, by exploiting the unique possibilities of the zebrafish animal model to study the biodistribution as well as the anti-inflammatory and adverse effects of liposomal formulations of PLP, we showed that PEGylated liposomes and AmbiMACs increase the therapeutic ratio of this GC drug.
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Affiliation(s)
- Yufei Xie
- Institute of Biology, Leiden University, 2333 CC Leiden, The Netherlands; (Y.X.); (B.d.W.); (J.C.d.); (P.v.H.)
| | - Panagiota Papadopoulou
- Institute of Chemistry, Leiden University, 2333 CC Leiden, The Netherlands; (P.P.); (A.K.)
| | - Björn de Wit
- Institute of Biology, Leiden University, 2333 CC Leiden, The Netherlands; (Y.X.); (B.d.W.); (J.C.d.); (P.v.H.)
| | - Jan C. d’Engelbronner
- Institute of Biology, Leiden University, 2333 CC Leiden, The Netherlands; (Y.X.); (B.d.W.); (J.C.d.); (P.v.H.)
| | - Patrick van Hage
- Institute of Biology, Leiden University, 2333 CC Leiden, The Netherlands; (Y.X.); (B.d.W.); (J.C.d.); (P.v.H.)
| | - Alexander Kros
- Institute of Chemistry, Leiden University, 2333 CC Leiden, The Netherlands; (P.P.); (A.K.)
| | - Marcel J. M. Schaaf
- Institute of Biology, Leiden University, 2333 CC Leiden, The Netherlands; (Y.X.); (B.d.W.); (J.C.d.); (P.v.H.)
- Correspondence: ; Tel.: +31-715274975; Fax: +31-715275088
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Darwish RM, AlMasri M, Al‐Masri MM. Mucormycosis: The Hidden and Forgotten Disease. J Appl Microbiol 2022; 132:4042-4057. [DOI: 10.1111/jam.15487] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/14/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Rula M. Darwish
- Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy The University of Jordan Amman Jordan
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Roth RS, Masouridi-Levrat S, Giannotti F, Mamez AC, Glambedakis E, Lamoth F, Bochud PY, Erard V, Emonet S, Van Delden C, Kaiser L, Chalandon Y, Neofytos D. Frequency and causes of antifungal treatment changes in allogeneic haematopoïetic cell transplant recipients with invasive mould infections. Mycoses 2021; 65:199-210. [PMID: 34936143 PMCID: PMC9303791 DOI: 10.1111/myc.13416] [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] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 12/21/2022]
Abstract
Background Antifungal treatment duration and changes for invasive mould infections (IMI) have been poorly described. Methods We performed a 10‐year cohort study of adult (≥18‐year‐old) allogeneic haematopoietic cell transplant recipients with proven/probable IMI to describe the duration and changes of antifungal treatment. All‐cause‐12‐week mortality was described. Results Sixty‐one patients with 66 IMI were identified. Overall treatment duration was 157 days (IQR: 14–675) and 213 (IQR: 90–675) days for patients still alive by Day 84 post‐IMI diagnosis. There was at least one treatment change in 57/66 (86.4%) cases: median 2, (IQR: 0–6, range:0–8). There were 179 antifungal treatment changes due to 193 reasons: clinical efficacy (104/193, 53.9%), toxicity (55/193, 28.5%), toxicity or drug interactions resolution (15/193, 7.8%) and logistical reasons (11/193, 5.7%) and 15/193 (7.8%) changes due to unknown reasons. Clinical efficacy reasons included lack of improvement (34/104, 32.7%), targeted treatment (30/104, 28.8%), subtherapeutic drug levels (14/104, 13.5%) and other (26/104, 25%). Toxicity reasons included hepatotoxicity, nephrotoxicity, drug interactions, neurotoxicity and other in 24 (43.6%), 12 (21.8%), 12 (21.8%), 4 (7.4%) and 3 (5.5%) cases respectively. All‐cause 12‐week mortality was 31% (19/61), higher in patients whose antifungal treatment (logrank 0.04) or appropriate antifungal treatment (logrank 0.01) was started >7 days post‐IMI diagnosis. All‐cause 1‐year mortality was higher in patients with ≥2 changes of treatment during the first 6 weeks post‐IMI diagnosis (logrank 0.008) with an OR: 4.00 (p = .04). Conclusions Patients with IMI require long treatment courses with multiple changes for variable reasons and potential effects on clinical outcomes, demonstrating the need more effective and safer treatment options. Early initiation of appropriate antifungal treatment is associated with improved outcomes.
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Affiliation(s)
- Romain Samuel Roth
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Stavroula Masouridi-Levrat
- Division of Hematology, Bone Marrow Transplant Unit, University Hospital of Geneva and faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Federica Giannotti
- Division of Hematology, Bone Marrow Transplant Unit, University Hospital of Geneva and faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Anne-Claire Mamez
- Division of Hematology, Bone Marrow Transplant Unit, University Hospital of Geneva and faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Emmanouil Glambedakis
- Division of Infectious Diseases, University Hospital of Lausanne, Lausanne, Switzerland
| | - Frederic Lamoth
- Division of Infectious Diseases, University Hospital of Lausanne, Lausanne, Switzerland
| | - Pierre-Yves Bochud
- Division of Infectious Diseases, University Hospital of Lausanne, Lausanne, Switzerland
| | - Veronique Erard
- Division of Infectious Diseases, Cantonal Hospital of Fribourg, Fribourg, Switzerland
| | - Stephane Emonet
- Division of Infectious Diseases, Cantonal Hospital of Sion and Institut Central des Hôpitaux (ICH), Sion, Switzerland
| | - Christian Van Delden
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Laurent Kaiser
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Division of Hematology, Bone Marrow Transplant Unit, University Hospital of Geneva and faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
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Douglas AP, Smibert OC, Bajel A, Halliday CL, Lavee O, McMullan B, Yong MK, Hal SJ, Chen SC. Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021. Intern Med J 2021; 51 Suppl 7:143-176. [DOI: 10.1111/imj.15591] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Abby P. Douglas
- 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 Austin Health Melbourne Victoria Australia
| | - Olivia. C. Smibert
- 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 Austin Health Melbourne Victoria Australia
| | - Ashish Bajel
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- Department of Clinical Haematology Peter MacCallum Cancer Centre and The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Catriona L. Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital Sydney New South Wales Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity The University of Sydney Sydney New South Wales Australia
| | - Orly Lavee
- Department of Haematology St Vincent's Hospital Sydney New South Wales Australia
| | - Brendan McMullan
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Immunology and Infectious Diseases Sydney Children's Hospital Sydney New South Wales Australia
- School of Women's and Children's Health University of New South Wales Sydney New South Wales Australia
| | - Michelle K. Yong
- 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
- Victorian Infectious Diseases Service Royal Melbourne Hospital Melbourne Victoria Australia
| | - Sebastiaan J. Hal
- Sydney Medical School University of Sydney Sydney New South Wales Australia
- Department of Microbiology and Infectious Diseases Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Sharon C.‐A. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital Sydney New South Wales Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity The University of Sydney Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
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van de Peppel RJ, van Grootveld R, Hendriks BJC, van Paassen J, Bernards S, Jolink H, Koopmans JG, von dem Borne PA, van der Beek MT, de Boer MGJ. Implementation of a clinical decision rule for selecting empiric treatment for invasive aspergillosis in a setting with high triazole resistance. Med Mycol 2021; 60:6433628. [PMID: 34878121 PMCID: PMC8653343 DOI: 10.1093/mmy/myab060] [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: 05/18/2021] [Revised: 08/17/2021] [Indexed: 11/14/2022] Open
Abstract
World-wide, emerging triazole resistance increasingly complicates treatment of invasive aspergillosis (IA). In settings with substantial (>10%) prevalence of triazole resistance, empiric combination therapy with both a triazole and liposomal amphotericin B (LAmB) can be considered because of the low yields of susceptibility testing. To avoid toxicity while optimizing outcome, a strategy with monotherapy would be preferable. A newly designed treatment algorithm based on literature and expert consensus provided guidance for empiric monotherapy with either voriconazole or LAmB. Over a four and a half year period, all adult patients in our hospital treated for IA were included and patient data were collected. An independent committee reviewed the attributability of death to IA for each patient. Primary outcomes were 30- and 100-day crude mortality and attributable mortality. In total, 110 patients were treated according to the treatment algorithm. Fifty-six patients (51%) were initially treated with voriconazole and 54 patients (49%) with LAmB. Combined attributable and contributable mortality was 13% within 30 days and 20% within 100 days. Treatment switch to LAmB was made in 24/56 (43%) of patients who were initially treated with voriconazole. Combined contributable and attributable 100-day mortality in this subgroup was 21% and was not increased when compared with patients initially treated with LAmB (P = 0.38). By applying a comprehensive clinical decision algorithm, an antifungal-sparing regime was successfully introduced. Further research is warranted to explore antifungal treatment strategies that account for triazole-resistance. LAY SUMMARY Due to resistance of Aspergillus against triazoles, combination therapy with liposomal amphotericin B (LAmB) is applied more often as primary therapy against invasive aspergillosis. This study presents the results of a decision tool which differentiated between triazole or LAmB monotherapy.
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Affiliation(s)
- Robert J van de Peppel
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Rebecca van Grootveld
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Bart J C Hendriks
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Sandra Bernards
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Hetty Jolink
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Julia G Koopmans
- Department of Pulmonology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Peter A von dem Borne
- Department of Haematology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Martha T van der Beek
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
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48
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Maher KR, Bouligny IM, Yeager AM. Prevention and management of infections after exposure to ionising radiation. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:R176-R188. [PMID: 34265748 DOI: 10.1088/1361-6498/ac14d3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/15/2021] [Indexed: 06/13/2023]
Abstract
Ionising radiation impacts many organ systems, each of which comprises a level of immunity to infectious disease. Bone marrow toxicity after radiation results in a predisposition to leukopenia and subsequent susceptibility to bacterial, viral, and fungal infections. Radiation-induced damage to mucosal, integumentary, and solid organ structures disrupts additional lines of innate defense. Over the past three decades, much progress has been made in effective antimicrobial prophylaxis, resulting in decreased infectious complications and improved survival. Vaccination schedules following myeloablative radiation have become highly regimented and treatment of overt infectious complications is largely standardised. In this article, we discuss consequences, prevention, and management of infections following exposure to ionising radiation.
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Affiliation(s)
- Keri R Maher
- Department of Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA 23298, United States of America
- Virginia Commonwealth University Massey Cancer Center, Richmond, VA 23298, United States of America
| | - Ian M Bouligny
- Department of Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA 23298, United States of America
| | - Andrew M Yeager
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, United States of America
- Blood and Marrow Transplantation Program, University of Arizona Cancer Center, Tucson, AZ 85724, United States of America
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Affiliation(s)
- George R Thompson
- From the Department of Medicine, Division of Infectious Diseases, and the Department of Medical Microbiology and Immunology, University of California, Davis, Sacramento (G.R.T.); and the Department of Medicine, Division of Infectious Disease and International Medicine, Program in Adult Transplant Infectious Disease, University of Minnesota, Minneapolis (J.-A.H.Y.)
| | - Jo-Anne H Young
- From the Department of Medicine, Division of Infectious Diseases, and the Department of Medical Microbiology and Immunology, University of California, Davis, Sacramento (G.R.T.); and the Department of Medicine, Division of Infectious Disease and International Medicine, Program in Adult Transplant Infectious Disease, University of Minnesota, Minneapolis (J.-A.H.Y.)
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50
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Mehta R, Nagarkar NM, Jindal A, Rao KN, Nidhin SB, Arora RD, Sharma A, Wankhede A, Satpute S, Chakravarty S, Agrawal NK, Pranita, Kannauje P, Behera A, Thangaraju P. Multidisciplinary Management of COVID-Associated Mucormycosis Syndemic in India. Indian J Surg 2021; 84:934-942. [PMID: 34642558 PMCID: PMC8493768 DOI: 10.1007/s12262-021-03134-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/25/2021] [Indexed: 11/30/2022] Open
Abstract
The study aimed to determine clinical presentation, contributing factors, medical and surgical management, and outcome of patients with coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM). A cross-sectional, single-center study was conducted on patients receiving multidisciplinary treatment for mucormycosis following the second wave of COVID-19 pandemic from April to June 2021 in India. Clinicoepidemiological factors were analyzed, 30-day overall survival and disease-specific survival were determined, and t-test was used to determine the statistical significance. A total of 215 patients were included in the study, the cases were stratified into sino-nasal 95 (44.2%), sino-naso-orbital 32 (14.9%), sino-naso-palatal 55 (25.6%), sino-naso-cerebral 12 (5.6%), sino-naso-orbito-cerebral 16 (7.4%), and sino-naso-orbito-palato-cerebral 5 (2.3%) based on their presentation. A multidisciplinary team treated patients by surgical wound debridement and medical therapy with broad-spectrum antibiotics and amphotericin B. Across all disease stages, cumulative 30-day disease-specific survival is 94% (p < 0.001, intergroup comparison, Breslow (generalized Wilcoxon) CI 95%) and overall 30-day survival is 87.9% (p < 0.001, intergroup comparison, Breslow (generalized Wilcoxon) CI 95%) (censored). Early identification, triaging, and proper multidisciplinary team management with systemic antifungals, surgical debridement, and control of comorbidities lead to desirable outcomes in COVID-associated mucormycosis. The patients with intracranial involvement have a higher chance of mortality compared to the other group.
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Affiliation(s)
- Rupa Mehta
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
| | - Nitin M Nagarkar
- Director and CEO, All India Institute of Medical Sciences, Raipur, India
| | - Atul Jindal
- DM Pediatric Critical care, All India Institute of Medical Sciences, Raipur, India
| | - Karthik Nagaraja Rao
- MCh Head Neck Surgery and Oncology, Department of Head and Neck Oncology, All India Institute of Medical Sciences, Raipur, India
| | - S B Nidhin
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
| | - Ripu Daman Arora
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
| | - Anil Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, Raipur, India
| | - Archana Wankhede
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, India
| | - Satish Satpute
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
| | - Sharmistha Chakravarty
- Department of Otolaryngology and Head Neck Surgery, All India Institute of Medical Sciences, Raipur, India
| | - N K Agrawal
- Department of Anaesthesiology, All India Institute of Medical Sciences, Raipur, India
| | - Pranita
- Department of General Medicine, All India Institute of Medical Sciences, Raipur, India
| | - Pankaj Kannauje
- Department of General Medicine, All India Institute of Medical Sciences, Raipur, India
| | - Ajoy Behera
- Department of Pulmonology, All India Institute of Medical Sciences, Raipur, India
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