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Zhu P, Li Y, Guo T, Liu S, Tancer RJ, Hu C, Zhao C, Xue C, Liao G. New antifungal strategies: drug combination and co-delivery. Adv Drug Deliv Rev 2023; 198:114874. [PMID: 37211279 DOI: 10.1016/j.addr.2023.114874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 05/23/2023]
Abstract
The growing occurrence of invasive fungal infections and the mounting rates of drug resistance constitute a significant menace to human health. Antifungal drug combinations have garnered substantial interest for their potential to improve therapeutic efficacy, reduce drug doses, reverse, or ameliorate drug resistance. A thorough understanding of the molecular mechanisms underlying antifungal drug resistance and drug combination is key to developing new drug combinations. Here we discuss the mechanisms of antifungal drug resistance and elucidate how to discover potent drug combinations to surmount resistance. We also examine the challenges encountered in developing such combinations and discuss prospects, including advanced drug delivery strategies.
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Affiliation(s)
- Ping Zhu
- State Key Laboratory of Silkworm Genome Biology, College of Pharmaceutical Sciences, Southwest University, Chongqing, 400700, China
| | - Yan Li
- Beijing Key Laboratory of Antimicrobial Agents, Institute of Medicinal Biotechnology, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100050, China
| | - Ting Guo
- State Key Laboratory of Silkworm Genome Biology, College of Pharmaceutical Sciences, Southwest University, Chongqing, 400700, China
| | - Simei Liu
- Department of Traditional Chinese Medicine, Chongqing College of Traditional Chinese Medicine, Chongqing 402760, China; Institute of Pharmacology and Toxicology, Chongqing Academy of Chinese Materia Medica, Chongqing 400065, China
| | - Robert J Tancer
- Public Health Research Institute and Department of Microbiology, Biochemistry and Molecular Genetics, New Jersey Medical School, Rutgers University, Newark, NJ, 07103, USA
| | - Changhua Hu
- State Key Laboratory of Silkworm Genome Biology, College of Pharmaceutical Sciences, Southwest University, Chongqing, 400700, China
| | - Chengzhi Zhao
- Chongqing Health Center for Women and Children, Chongqing, 400700, PR China.
| | - Chaoyang Xue
- Public Health Research Institute and Department of Microbiology, Biochemistry and Molecular Genetics, New Jersey Medical School, Rutgers University, Newark, NJ, 07103, USA
| | - Guojian Liao
- State Key Laboratory of Silkworm Genome Biology, College of Pharmaceutical Sciences, Southwest University, Chongqing, 400700, China.
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Sattarzadeh Badkoubeh R, Farajpour M, Salehi M, Sherafati A, Zamani Z, Rezahosseini O, Mansouri P, Sardari A. Caspofungin-Induced Cardiotoxicity in Patients Treating for Candidemia. TOXICS 2022; 10:521. [PMID: 36136486 PMCID: PMC9506447 DOI: 10.3390/toxics10090521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 06/16/2023]
Abstract
Echinocandins selectively inhibit fungal cell wall synthesis and, therefore, have few side effects. However, there are reports of hemodynamic and cardiac complications. We conducted this study to investigate the effects of caspofungin both on the noninvasive echocardiographic indices of myocardial function and myocardial injury based on serum high-sensitivity cardiac troponin I (hs-cTnI) levels. This study was conducted on patients treated for candidemia. The hs-cTnI level and echocardiographic parameters were measured before and 1 h after the infusion of the induction dose of caspofungin. Data were compared between central and peripheral venous drug administration routes. Fifteen patients were enrolled in the study. There were no significant differences in the echocardiographic parameters between the baseline and post-treatment period. The mean hs-cTnI level exhibited a significant rise following drug administration (0.24 ± 0.2 ng/mL vs 0.32 ± 0.3 ng/mL; p = 0.006). There was also a significant difference concerning the hs-cTnI level between central and peripheral venous drug administration routes (p = 0.034). Due to differences in the hs-cTnI level, it appears that the administration of caspofungin may be associated with myocardial injury. Our findings also showed a higher possibility of cardiotoxicity via the central venous administration route.
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Affiliation(s)
- Roya Sattarzadeh Badkoubeh
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran P.O. Box 14197-33141, Iran
| | - Mostafa Farajpour
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran P.O. Box 14197-33141, Iran
| | - Mohammadreza Salehi
- Department of Infectious diseases and Tropical Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran P.O. Box 14197-33141, Iran
| | - Alborz Sherafati
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran P.O. Box 14197-33141, Iran
| | - Zahra Zamani
- Department of Community Medicine, Tehran University of Medical Sciences, Tehran P.O. Box 14155-6559, Iran
| | - Omid Rezahosseini
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Pejman Mansouri
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran P.O. Box 14155-6559, Iran
| | - Akram Sardari
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran P.O. Box 14197-33141, Iran
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Chaves AFA, Xander P, Romera LMD, Fonseca FLA, Batista WL. What is the elephant in the room when considering new therapies for fungal diseases? Crit Rev Microbiol 2021; 47:275-289. [PMID: 33513315 DOI: 10.1080/1040841x.2021.1876632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The global scenario of antimicrobial resistance is alarming, and the development of new drugs has not appeared to make substantial progress. The constraints on drug discovery are due to difficulties in finding new targets for therapy, the high cost of development, and the mismatch between the time of drug introduction in a clinic and microorganism adaptation to a drug. Policies to address neglected diseases miss the broad spectrum of mycosis. Society is not aware of the actual threat represented by fungi to human health, food security, and biodiversity. The evidence discussed here is critical for warning governments to establish effective surveillance policies for fungi.HIGHLIGHTSFungal diseases are ignored even among neglected disease classifications.There are few options to treat mycoses, which is an increasing concern regarding fungal resistance to drugs, as evidenced by the spread of Candida auris.Fungal diseases represent a real threat to human health and food security.Investment in research to investigate the potential of repurposing drugs already in use could obtain results in the short term.
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Affiliation(s)
| | - Patricia Xander
- Department of Pharmaceutical Sciences, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Wagner Luiz Batista
- Department of Microbiology, Immunology and Parasitology, Federal University of São Paulo, São Paulo, Brazil.,Department of Pharmaceutical Sciences, Federal University of São Paulo, São Paulo, Brazil
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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Flanagan S, Goodman DB, Jandourek A, O'Reilly T, Sandison T. Lack of Effect of Rezafungin on QT/QTc Interval in Healthy Subjects. Clin Pharmacol Drug Dev 2019; 9:456-465. [PMID: 31793231 DOI: 10.1002/cpdd.757] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/05/2019] [Indexed: 11/12/2022]
Abstract
Rezafungin is a new echinocandin in development for treatment of candidemia and invasive candidiasis, and for prophylaxis of invasive fungal infections. Rezafungin is the first echinocandin to undergo definitive QT/QTc study. This phase 1, single-center, randomized, double-blind trial was conducted to assess effects of intravenous rezafungin vs intravenous placebo (with moxifloxacin as positive control) on the QT interval of the electrocardiogram, corrected for heart rate by Fridericia's formula (QTcF), in healthy adults. Therapeutic (600 mg) and supratherapeutic (1400 mg) rezafungin doses were selected to achieve exposures 2.5-fold higher than produced by the highest dose used in a phase 2 trial (400 mg once weekly). The primary end point was change in QTcF from baseline (ΔQTcF) as a function of plasma concentration, assessed by comparing upper bounds of the 2-sided 90% confidence interval. The estimated mean ΔΔQTcF at the mean plasma concentrations for the rezafungin doses had upper bounds <10 milliseconds, within the upper bound of the 2-sided 90% confidence interval. Intravenous rezafungin up to 1400 mg in a single dose did not prolong QT interval and had no apparent effect on repolarization or QRS duration. Electrocardiogram results showed no clinically significant effects of concern. These findings support the continued development of rezafungin.
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Koch C, Schneck E, Arens C, Markmann M, Sander M, Henrich M, Weigand MA, Lichtenstern C. Hemodynamic changes in surgical intensive care unit patients undergoing echinocandin treatment. Int J Clin Pharm 2019; 42:72-79. [DOI: 10.1007/s11096-019-00939-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 11/08/2019] [Indexed: 01/05/2023]
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Mourad A, Perfect JR. Tolerability profile of the current antifungal armoury. J Antimicrob Chemother 2019; 73:i26-i32. [PMID: 29304209 DOI: 10.1093/jac/dkx446] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The tolerability of available antifungal agents is essential to the final outcome of the management of invasive mycoses. There are limited classes of antifungal agents for use, and they can have serious direct toxicities and/or drug-drug interactions. In this review, we examine the common toxicities noted for antifungal agents and attempt to both identify the issues around the adverse events and provide clinical context for their occurrence in these fragile patients.
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Affiliation(s)
- Ahmad Mourad
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Caspofungin Modulates Ryanodine Receptor-Mediated Calcium Release in Human Cardiac Myocytes. Antimicrob Agents Chemother 2018; 62:AAC.01114-18. [PMID: 30150463 DOI: 10.1128/aac.01114-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/18/2018] [Indexed: 01/21/2023] Open
Abstract
Recent studies showed that critically ill patients might be at risk for hemodynamic impairment during caspofungin (CAS) therapy. The aim of our present study was to examine the mechanisms behind CAS-induced cardiac alterations. We revealed a dose-dependent increase in intracellular Ca2+ concentration ([Ca2+]i) after CAS treatment. Ca2+ ions were found to be released from intracellular caffeine-sensitive stores, most probably via the activation of ryanodine receptors.
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Epstein DJ, Seo SK, Brown JM, Papanicolaou GA. Echinocandin prophylaxis in patients undergoing haematopoietic cell transplantation and other treatments for haematological malignancies. J Antimicrob Chemother 2018; 73:i60-i72. [PMID: 29304213 PMCID: PMC7189969 DOI: 10.1093/jac/dkx450] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Antifungal prophylaxis is the standard of care for patients undergoing intensive chemotherapy for haematological malignancy or haematopoietic cell transplantation (HCT). Prophylaxis with azoles reduces invasive fungal infections and may reduce mortality. However, breakthrough infections still occur, and the use of azoles is sometimes complicated by pharmacokinetic variability, drug interactions, adverse events and other issues. Echinocandins are highly active against Candida species, including some organisms resistant to azoles, and have some clinical activity against Aspergillus species as well. Although currently approved echinocandins require daily intravenous administration, the drugs have a favourable safety profile and more predictable pharmacokinetics than mould-active azoles. Clinical data support the efficacy and safety of echinocandins for antifungal prophylaxis in haematology and HCT patients, though data are less robust than for azoles. Notably, sparse evidence exists supporting the use of echinocandins as antifungal prophylaxis for patients with significant graft-versus-host disease (GvHD) after HCT. Two drugs that target (1,3)-β-d-glucan are in development, including an oral glucan synthase inhibitor and an echinocandin with unique pharmacokinetics permitting subcutaneous and weekly administration. Echinocandins are a reasonable alternative to azoles and other agents for antifungal prophylaxis in patients undergoing intensive chemotherapy for haematological malignancy or those receiving HCT, excluding those with significant GvHD.
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Affiliation(s)
- David J Epstein
- Division of Infectious Diseases, Stanford University, Palo Alto, CA, USA
| | - Susan K Seo
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Janice M Brown
- Division of Infectious Diseases, Stanford University, Palo Alto, CA, USA
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Chang CC, Slavin MA, Chen SCA. New developments and directions in the clinical application of the echinocandins. Arch Toxicol 2017; 91:1613-1621. [DOI: 10.1007/s00204-016-1916-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/13/2016] [Indexed: 01/05/2023]
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