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Bohner F, Papp C, Takacs T, Varga M, Szekeres A, Nosanchuk JD, Vágvölgyi C, Tóth R, Gacser A. Acquired Triazole Resistance Alters Pathogenicity-Associated Features in Candida auris in an Isolate-Dependent Manner. J Fungi (Basel) 2023; 9:1148. [PMID: 38132749 PMCID: PMC10744493 DOI: 10.3390/jof9121148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
Fluconazole resistance is commonly encountered in Candida auris, and the yeast frequently displays resistance to other standard drugs, which severely limits the number of effective therapeutic agents against this emerging pathogen. In this study, we aimed to investigate the effect of acquired azole resistance on the viability, stress response, and virulence of this species. Fluconazole-, posaconazole-, and voriconazole- resistant strains were generated from two susceptible C. auris clinical isolates (0381, 0387) and compared under various conditions. Several evolved strains became pan-azole-resistant, as well as echinocandin-cross-resistant. While being pan-azole-resistant, the 0381-derived posaconazole-evolved strain colonized brain tissue more efficiently than any other strain, suggesting that fitness cost is not necessarily a consequence of resistance development in C. auris. All 0387-derived evolved strains carried a loss of function mutation (R160S) in BCY1, an inhibitor of the PKA pathway. Sequencing data also revealed that posaconazole treatment can result in ERG3 mutation in C. auris. Despite using the same mechanisms to generate the evolved strains, both genotype and phenotype analysis highlighted that the development of resistance was unique for each strain. Our data suggest that C. auris triazole resistance development is a highly complex process, initiated by several pleiotropic factors.
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Affiliation(s)
- Flora Bohner
- Department of Microbiology, University of Szeged, 6726 Szeged, Hungary; (F.B.); (C.P.); (T.T.); (M.V.); (A.S.); (C.V.)
| | - Csaba Papp
- Department of Microbiology, University of Szeged, 6726 Szeged, Hungary; (F.B.); (C.P.); (T.T.); (M.V.); (A.S.); (C.V.)
| | - Tamas Takacs
- Department of Microbiology, University of Szeged, 6726 Szeged, Hungary; (F.B.); (C.P.); (T.T.); (M.V.); (A.S.); (C.V.)
| | - Mónika Varga
- Department of Microbiology, University of Szeged, 6726 Szeged, Hungary; (F.B.); (C.P.); (T.T.); (M.V.); (A.S.); (C.V.)
| | - András Szekeres
- Department of Microbiology, University of Szeged, 6726 Szeged, Hungary; (F.B.); (C.P.); (T.T.); (M.V.); (A.S.); (C.V.)
| | - Joshua D. Nosanchuk
- Department of Medicine (Infectious Diseases), Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA;
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA
| | - Csaba Vágvölgyi
- Department of Microbiology, University of Szeged, 6726 Szeged, Hungary; (F.B.); (C.P.); (T.T.); (M.V.); (A.S.); (C.V.)
| | - Renáta Tóth
- Department of Microbiology, University of Szeged, 6726 Szeged, Hungary; (F.B.); (C.P.); (T.T.); (M.V.); (A.S.); (C.V.)
| | - Attila Gacser
- Department of Microbiology, University of Szeged, 6726 Szeged, Hungary; (F.B.); (C.P.); (T.T.); (M.V.); (A.S.); (C.V.)
- HCEMM-USZ Fungal Pathogens Research Group, Department of Microbiology, University of Szeged, 6726 Szeged, Hungary
- HUN-REN-USZ Pathomechanisms of Fungal Infections Research Group, University of Szeged, 6726 Szeged, Hungary
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Fungal Endophthalmitis: A Comprehensive Review. J Fungi (Basel) 2021; 7:jof7110996. [PMID: 34829283 PMCID: PMC8623405 DOI: 10.3390/jof7110996] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 12/27/2022] Open
Abstract
Endophthalmitis is a serious ophthalmologic condition involving purulent inflammation of the intraocular spaces. The underlying etiology of infectious endophthalmitis is typically bacterial or fungal. The mechanism of entry into the eye is either exogenous, involving seeding of an infectious source from outside the eye (e.g., trauma or surgical complications), or endogenous, involving transit of an infectious source to the eye via the bloodstream. The most common organism for fungal endophthalmitis is Candida albicans. The most common clinical manifestation of fungal endophthalmitis is vision loss, but other signs of inflammation and infection are frequently present. Fungal endophthalmitis is a clinical diagnosis, which can be supported by vitreous, aqueous, or blood cultures. Treatment involves systemic and intravitreal antifungal medications as well as possible pars plana vitrectomy. In this review, we examine these essential elements of understanding fungal endophthalmitis as a clinically relevant entity, which threatens patients’ vision.
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Kumar A, Khan F, Saikia D. Exploration of Medicinal Plants as Sources of Novel Anticandidal Drugs. Curr Top Med Chem 2019; 19:2579-2592. [PMID: 31654513 DOI: 10.2174/1568026619666191025155856] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/25/2019] [Accepted: 04/25/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Human infections associated with skin and mucosal surfaces, mainly in tropical and sub-tropical parts of the world. During the last decade, there have been an increasing numbers of cases of fungal infections in immunocompromised patients, coupled with an increase in the number of incidences of drug resistance and toxicity to anti fungal agents. Hence, there is a dire need for safe, potent and affordable new antifungal drugs for the efficient management of candidal infections with minimum or no side effects. INTRODUCTION Candidiasis represents a critical problem to human health and a serious concern worldwide. Due to the development of drug resistance, there is a need for new antifungal agents. Therefore, we reviewed the different medicinal plants as sources of novel anticandidal drugs. METHODS The comprehensive and detailed literature on medicinal plants was carried out using different databases, such as Google Scholar, PubMed, and Science Direct and all the relevant information from the articles were analyzed and included. RESULTS Relevant Publications up to the end of November 2018, reporting anticandidal activity of medicinal plants has been included in the present review. In the present study, we have reviewed in the light of SAR and mechanisms of action of those plants whose extracts or phytomolecules are active against candida strains. CONCLUSION This article reviewed natural anticandidal drugs of plant origin and also summarized the potent antifungal bioactivity against fungal strains. Besides, mechanism of action of these potent active plant molecules was also explored for a comparative study. We concluded that the studied active plant molecules exhibit potential antifungal activity against resistant fungal strains.
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Affiliation(s)
- Ajay Kumar
- Molecular Bioprospection Department, CSIR-Central Institute of Medicinal & Aromatic Plants, P.O.- CIMAP, Kukrail Picnic Spot Road, Lucknow -226015 (U.P.), India
| | - Feroz Khan
- Metabolic & Structural Biology Department, CSIR-Central Institute of Medicinal & Aromatic Plants, P.O.- CIMAP, Kukrail Picnic Spot Road, Lucknow -226015 (U.P.), India
| | - Dharmendra Saikia
- Molecular Bioprospection Department, CSIR-Central Institute of Medicinal & Aromatic Plants, P.O.- CIMAP, Kukrail Picnic Spot Road, Lucknow -226015 (U.P.), India
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Kim Y, Rhee SJ, Park WB, Yu KS, Jang IJ, Lee S. A Personalized CYP2C19 Phenotype-Guided Dosing Regimen of Voriconazole Using a Population Pharmacokinetic Analysis. J Clin Med 2019; 8:E227. [PMID: 30744151 PMCID: PMC6406770 DOI: 10.3390/jcm8020227] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 01/28/2019] [Accepted: 01/31/2019] [Indexed: 12/11/2022] Open
Abstract
Highly variable and non-linear pharmacokinetics of voriconazole are mainly caused by CYP2C19 polymorphisms. This study aimed to develop a mechanistic population pharmacokinetic model including the CYP2C19 phenotype, and to assess the appropriateness of various dosing regimens based on the therapeutic target. A total of 1,828 concentrations from 193 subjects were included in the population pharmacokinetic analysis. A three-compartment model with an inhibition compartment appropriately described the voriconazole pharmacokinetics reflecting auto-inhibition. Voriconazole clearance in the CYP2C19 intermediate metabolizers (IMs) and poor metabolizers (PMs) decreased by 17% and 53% compared to that in the extensive metabolizers (EMs). There was a time-dependent inhibition of clearance to 16.2% of its original value in the CYP2C19 EMs, and the extent of inhibition differed according to the CYP2C19 phenotypes. The proposed CYP2C19 phenotype-guided initial dosing regimens are 400 mg twice daily (bid) for EMs, 200 mg bid for IMs, and 100 mg bid for PMs. This CYP2C19 phenotype-guided initial dosing regimen will provide a rationale for individualizing the optimal voriconazole therapy.
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Affiliation(s)
- Yun Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea.
| | - Su-Jin Rhee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea.
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea.
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea.
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea.
| | - SeungHwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea.
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Abstract
Each month, subscribers to The Formulary Monograph Service receive five to six well-documented monographs on drugs that are newly released or are in late Phase III trials. The monographs are targeted to your Pharmacy and Therapeutics Committee. Subscribers also receive monthly one-page summary monographs on the agents that are useful for agendas and pharmacy/nursing in-ser-vices. A comprehensive target drug utilization evaluation (DUE) is also provided each month. The monographs are published in printed form and on diskettes that allow customization. Subscribers to the The Formulary Monograph Service also receive access to a pharmacy bulletin board, The Formulary Information Exchange (The F.I.X.). All topics pertinent to clinical and hospital pharmacy are discussed on The F.I.X. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. If you would like information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The September 2002 monograph topics are ziprasidone mesylate for injection; lanthanum carbonate, artesunate rectal capsules, ZD1839, and memantine. The DUE is on ziprasidone.
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Affiliation(s)
- Dennis J Cada
- The Formulary; College of Pharmacy, Washington State University Spokane, Health Sciences Building, Box S, 310 North Riverpoint Boulevard, Spokane, WA 99202-1675
| | - Terri Levien
- Drug Information Center, Washington State University Spokane, College of Pharmacy, Washington State University Spokane, Health Sciences Building, Box S, 310 North Riverpoint Boulevard, Spokane, WA 99202-1675
| | - Danial E. Baker
- Drug Information Center, College of Pharmacy, Washington State University Spokane, Health Sciences Building, Box S, 310 North Riverpoint Boulevard, Spokane, WA 99202-1675
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Kalaiarasan K, Singh R, Chaturvedula L. Fungal Profile of Vulvovaginal Candidiasis in a Tertiary Care Hospital. J Clin Diagn Res 2017; 11:DC06-DC09. [PMID: 28511380 DOI: 10.7860/jcdr/2017/23578.9475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 12/11/2016] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Vulvovaginal Candidiasis (VVC) is a common medical health problem of adult women. It is most commonly caused by Candida albicans. But there is a change in fungal profile. Sabouraud's Dextrose Agar (SDA) is the most common culture medium used where mixed fungal infection may be missed. It can be detected easily by using chromogenic culture medium. AIM To know the fungal profile of vulvovaginal candidiasis using Candida CHROMagar and antifungal susceptibility pattern in patients attending tertiary care hospital. MATERIALS AND METHODS Culture confirmed cases of VVC presented at Department of Obstetrics and Gynaecology of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, from July 2015 to December 2015 were included in the cross-sectional study. Two high vaginal swabs were collected and inoculated on SDA and Candida CHROMagar (Hi-Media, Mumbai, India). After overnight incubation the colonies were counted and colour of the colonies were recorded from Candida CHROMagar. Candida spp. were identified by sugar fermentation and assimilation tests and other conventional tests. Antifungal susceptibility tests were performed by the disc diffusion method using fluconazole (25 μg) and voriconazole (1μg) as per the Clinical and Laboratory Standards Institute (CLSI - M44-A2) guidelines. RESULTS A total of 50 culture confirmed (23.7%) cases were detected from 211 clinically suspected VVC cases. Candida glabrata (45.1%) was the most common isolate, followed by Candidatropicalis (23.5%), Candida albicans (17.6%), Candida krusei (9.8%) and Candida parapsilosis (3.9%). One mixed infection of C. glabrata and C. albicans was identified on Candida CHROMagar. Mixed fungal infection was observed in 2% of positive culture and 0.5% of VVC cases. The antifungal susceptibility testing revealed that 15.7% and 9.8% isolates of Candida spp. were resistant and Susceptible Dose Dependent (S-DD) respectively to fluconazole. The increase resistant against fluconazole was because of increased isolation of C. glabrata strains. All strains of Candida spp. were susceptible to voriconazole. CONCLUSION C. glabrata was the most common causative agent of VVC in a tertiary care hospital. Chromogenic culture medium facilitates detection of mixed fungal infection. In vitro susceptibility testing should be used to guide the treatment especially in cases of non-albicans Candidiasis.
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Affiliation(s)
- Krishnapriya Kalaiarasan
- M.Sc (MLT), Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Rakesh Singh
- Associate Professor, Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Latha Chaturvedula
- Professor, Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Faisal W, Soliman GM, Hamdan AM. Enhanced skin deposition and delivery of voriconazole using ethosomal preparations. J Liposome Res 2016; 28:14-21. [DOI: 10.1080/08982104.2016.1239636] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Waleed Faisal
- Department of Pharmaceutics, Faculty of Pharmacy, Minia University, Minia, Egypt,
| | - Ghareb M. Soliman
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut, Egypt, and
- Department of Pharmaceutics, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Ahmed M. Hamdan
- Department of Pharmaceutics, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
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Rabelo VW, Santos TF, Terra L, Santana MV, Castro HC, Rodrigues CR, Abreu PA. Targeting CYP51 for drug design by the contributions of molecular modeling. Fundam Clin Pharmacol 2016; 31:37-53. [PMID: 27487199 DOI: 10.1111/fcp.12230] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/15/2016] [Accepted: 08/01/2016] [Indexed: 11/28/2022]
Abstract
CYP51 is an enzyme of sterol biosynthesis pathway present in animals, plants, protozoa and fungi. This enzyme is described as an important drug target that is still of interest. Therefore, in this work, we reviewed the structure and function of CYP51 and explored the molecular modeling approaches for the development of new antifungal and antiprotozoans that target this enzyme. Crystallographic structures of CYP51 of some organisms have already been described in the literature, which enable the construction of homology models of other organisms' enzymes and molecular docking studies of new ligands. The binding mode and interactions of some new series of azoles with antifungal or antiprotozoan activities has been studied and showed important residues of the active site. Molecular modeling is an important tool to be explored for the discovery and optimization of CYP51 inhibitors with better activities, pharmacokinetics, and toxicological profiles.
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Affiliation(s)
- Vitor W Rabelo
- Laboratório de Modelagem Molecular e Pesquisa em Ciências Farmacêuticas (LAMCIFAR), Universidade Federal do Rio de Janeiro, Campus Macaé Professor Aloísio Teixeira, Avenida São José do Barreto 767, CEP 27965-045, Macaé, RJ, Brazil
| | - Taísa F Santos
- Laboratório de Modelagem Molecular e Pesquisa em Ciências Farmacêuticas (LAMCIFAR), Universidade Federal do Rio de Janeiro, Campus Macaé Professor Aloísio Teixeira, Avenida São José do Barreto 767, CEP 27965-045, Macaé, RJ, Brazil
| | - Luciana Terra
- Laboratório de Antibióticos, Bioquímica, Ensino e Modelagem Molecular (LabiEMol), Instituto de Biologia, Universidade Federal Fluminense, Campus Valonguinho Outeiro de São João Baptista s/n, Centro, CEP 24210130, Niterói, RJ, Brazil
| | - Marcos V Santana
- Laboratório de Antibióticos, Bioquímica, Ensino e Modelagem Molecular (LabiEMol), Instituto de Biologia, Universidade Federal Fluminense, Campus Valonguinho Outeiro de São João Baptista s/n, Centro, CEP 24210130, Niterói, RJ, Brazil
| | - Helena C Castro
- Laboratório de Antibióticos, Bioquímica, Ensino e Modelagem Molecular (LabiEMol), Instituto de Biologia, Universidade Federal Fluminense, Campus Valonguinho Outeiro de São João Baptista s/n, Centro, CEP 24210130, Niterói, RJ, Brazil
| | - Carlos R Rodrigues
- Laboratório de Modelagem Molecular e QSAR (ModMolQSAR), Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Av. Carlos Chagas Filho, 373, Cidade Universitária, CEP 21941-599, Rio de Janeiro, RJ, Brazil
| | - Paula A Abreu
- Laboratório de Modelagem Molecular e Pesquisa em Ciências Farmacêuticas (LAMCIFAR), Universidade Federal do Rio de Janeiro, Campus Macaé Professor Aloísio Teixeira, Avenida São José do Barreto 767, CEP 27965-045, Macaé, RJ, Brazil
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Yenisehirli G, Bulut N, Yenisehirli A, Bulut Y. In Vitro Susceptibilities of Candida albicans Isolates to Antifungal Agents in Tokat, Turkey. Jundishapur J Microbiol 2015; 8:e28057. [PMID: 26495115 PMCID: PMC4609313 DOI: 10.5812/jjm.28057] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 06/09/2015] [Accepted: 06/16/2015] [Indexed: 12/02/2022] Open
Abstract
Background: Candida albicans is the pathogenic species most commonly isolated from fungal infections. Management of these infections depends on the immune status of the host, severity of disease, and the choice of antifungal drug. In spite of the development of new antifungal drugs, epidemiological studies have shown that resistance to antifungal drugs in C. albicans strains is becoming a serious problem. Objectives: The aim of this study was to evaluate the in vitro susceptibility of C. albicans isolates to ketoconazole, fluconazole, itraconazole, voriconazole, posaconazole, amphotericin B, caspofungin, and anidulafungin. Materials and Methods: A total of 201 C. albicans isolates were collected from clinical specimens. Antifungal susceptibility tests were performed using the Etest. Results: All the tested C. albicans isolates were found to be susceptible to amphotericin B and anidulafungin. Although none of the isolates showed resistance to caspofungin, 15% of the isolates were classified as showing intermediate resistance. The resistance rates of C. albicans isolates to ketoconazole, fluconazole, itraconazole, voriconazole and posaconazole were 32%, 34%, 21%, 14% and 14%, respectively. Conclusions: Our findings indicate that resistance of C. albicans strains to azoles is more common in Tokat, Turkey. Therefore, a strategy to control the inappropriate and widespread use of antifungal drugs is urgently needed. Fungal culturing and antifungal susceptibility testing will be useful in patient management as well as resistance surveillance.
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Affiliation(s)
- Gulgun Yenisehirli
- Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
- Corresponding author: Gulgun Yenisehirli, Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey. Tel: +90-3562129500; +90-3562127209, Fax: +90-3562133176, E-mail:
| | - Nermin Bulut
- Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Aydan Yenisehirli
- Department of Pharmacology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - Yunus Bulut
- Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
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Wang T, Chen S, Sun J, Cai J, Cheng X, Dong H, Wang X, Xing J, Dong W, Yao H, Dong Y. Identification of factors influencing the pharmacokinetics of voriconazole and the optimization of dosage regimens based on Monte Carlo simulation in patients with invasive fungal infections. J Antimicrob Chemother 2014; 69:463-470. [DOI: 10.1093/jac/dkt369] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
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Deshpande A, Gaur S, Bal A. Candidaemia in the non-neutropenic patient: A critique of the guidelines. Int J Antimicrob Agents 2013; 42:294-300. [DOI: 10.1016/j.ijantimicag.2013.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 06/11/2013] [Indexed: 10/26/2022]
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Abstract
Echinocandins are commonly used as initial empiric therapy in cases of moderate to severe invasive candidiasis. The authors demonstrate that caution should be exercised in applying this approach in certain clinical situations. A case of Candida glabrata fungemia and associated chorioretinitis that was clinically resistant to therapy with micafungin but appeared to resolve with amphotericin B is presented. The authors then briefly review current issues regarding the diagnosis and treatment of C glabrata chorioretinitis.
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Abstract
Candida tropicalis is one of the more common Candida causing human disease in tropical countries; the frequency of invasive disease varies by geography causing 3--66% of candidaemia. C. tropicalis is taxonomically close to C. albicans and shares many pathogenic traits. C. tropicalis is particularly virulent in neutropenic hosts commonly with hematogenous seeding to peripheral organs. For candidaemia and invasive candidiasis amphotericin B or an echinocandin are recommended as first-line treatment, with extended-spectrum triazoles acceptable alternatives. Primary fluconazole resistance is uncommon but may be induced on exposure. Physicians in regions where C. tropicalis is common need to be mindful of this lesser-described pathogen.
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Abstract
This review provides a historical overview of the analog based drug discovery of miconazole and its congeners, and is focused on marketed azole antifungals bearing the generic suffix “conazole”. The antifungal activity of miconazole, one of the first broad-spectrum antimycotic agents has been mainly restricted to topical applications. The attractive in vitro antifungal spectrum was a starting point to design more potent and especially orally active antifungal agents such as ketoconazole, itraconazole, posaconazole, fluconazole and voriconazole. The chemistry, in vitro and in vivo antifungal activity, pharmacology, and clinical applications of these marketed conazoles has been described.
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Narimatsu H, Kami M. Management of fungal infections following allogeneic stem cell transplantation. Expert Rev Anti Infect Ther 2008; 6:373-84. [PMID: 18588501 DOI: 10.1586/14787210.6.3.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fungal infection remains an important complication in allogeneic stem cell transplantation (allo-SCT). Since the prognosis of fungal infection is poor, prophylaxis is critical for its management; owing to recent progression in allo-SCT management and widespread use of reduced-intensity regimens, the strategy of infectious prophylaxis has also changed. Various antifungals have recently been developed and applied to clinical use. A major change in antifungal management will probably occur in the next few years.
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Affiliation(s)
- Hiroto Narimatsu
- Division of The Strategic Outcome Research Program for Cancer Control MHLW-commission, Japan Cancer Society, Yurakucho Center Bldg. (Mullion) 13F, 2-5-1, Yurakucho Chiyoda-ku Tokyo, 100-0006, Japan.
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Quindós G, Sánchez-Vargas LO, Villar-Vidal M, Eraso E, Alkorta M, Hernández-Almaraz JL. Activities of fluconazole and voriconazole against bloodstream isolates of Candida glabrata and Candida krusei: a 14-year study in a Spanish tertiary medical centre. Int J Antimicrob Agents 2008; 31:266-71. [DOI: 10.1016/j.ijantimicag.2007.09.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 09/18/2007] [Accepted: 09/19/2007] [Indexed: 11/28/2022]
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Kanafani ZA, Perfect JR. Antimicrobial resistance: resistance to antifungal agents: mechanisms and clinical impact. Clin Infect Dis 2008; 46:120-8. [PMID: 18171227 DOI: 10.1086/524071] [Citation(s) in RCA: 378] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Despite advances in preventive, diagnostic, and therapeutic interventions, invasive fungal infections cause significant morbidity and mortality in immunocompromised patients. The burden of antifungal resistance in such high-risk patients is becoming a major concern. A better understanding of the mechanisms and clinical impact of antifungal resistance is essential to the prompt and efficient treatment of patients with invasive mycoses and to improving the outcome of such infections. Although recent guidelines have attempted to standardize antifungal susceptibility testing, limitations still exist as a result of the incomplete correlation between in vitro susceptibility and clinical response to treatment. Four major mechanisms of resistance to azoles have been identified, all of which rely on altered gene expression. Mechanisms responsible for polyene and echinocandin resistance are less well understood. In addition to discussing the molecular mechanisms of antifungal resistance, this article elaborates on the concept of clinical resistance, which is critical to the understanding of treatment failure in patients with invasive fungal infections.
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Abstract
This observational study of the use of voriconazole conducted in Spain has identified reasons, characteristics, and forms of use of voriconazole in critically ill patients admitted to the ICU. Voriconale was used for directed treatment (63%), by the intravenous route (75%), as rescue treatment (41%) in severely ill patients (APACHE 21) with high need of resources and therapeutic interventions. Satisfactory clinical response was obtained in 50% of cases, related adverse events were scarce (16%), and withdrawal of voriconazole was not necessary. Clinical indications included empirical, etiologic, and rescue treatment of infections caused by Aspergillus, Candida albicans and most species different than C. albicans. Voriconazole can be used for preemptive therapy in patients at risk of invasive candidasis. When selecting voriconazole, liver function, renal function (i.v. formulation) and history of azoles use should be considered, although none of these circumstances is an absolute contraindication for the prescription of voriconazole in critically ill patients.
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Khan FA, Slain D, Khakoo RA. Candida Endophthalmitis: Focus on Current and Future Antifungal Treatment Options. Pharmacotherapy 2007; 27:1711-21. [DOI: 10.1592/phco.27.12.1711] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Wakieć R, Prasad R, Morschhäuser J, Barchiesi F, Borowski E, Milewski S. Voriconazole and multidrug resistance in Candida albicans. Mycoses 2007; 50:109-15. [PMID: 17305773 DOI: 10.1111/j.1439-0507.2006.01327.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In vitro activity of voriconazole against fluconazole-resistant Candida albicans clinical isolates with identified molecular basis of multidrug resistance (MDR) and recombinant Saccharomyces cerevisiae expressing C. albicans genes coding for major multidrug transporters, CaCdr1p, CaCdr2p or CaMdr1p, was compared with that of fluconazole, ketoconazole and clotrimazole. It was found that overexpression of the MDR genes made the yeast cells less susceptible to voriconazole. The voriconazole resistance indexes, defined as a ratio of minimum inhibitory concentrations (MICs) determined for MDR and sensitive cells, were comparable with those determined for fluconazole. Voriconazole effectively competed with rhodamine 6G for the active efflux mediated by CaCdr1p and CaCdr2p.
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Affiliation(s)
- Roland Wakieć
- Department of Pharmaceutical Technology and Biochemistry, Gdańsk University of Technology, Gdańsk, Poland
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Salgado-Parreño FJ, Alcoba-Flórez J, Arias A, Moragues MD, Quindós G, Pontón J, Arévalo MP. In VitroActivities of Voriconazole and Five Licensed Antifungal Agents AgainstCandida dubliniensis:Comparison of CLSI M27-A2, Sensititre YeastOne, Disk Diffusion, and Etest Methods. Microb Drug Resist 2006; 12:246-51. [PMID: 17227209 DOI: 10.1089/mdr.2006.12.246] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We compared the in vitro activity of six antifungal agents against 62 isolates of Candida dubliniensis by the Clinical Laboratory Standards Institute (CLSI [formerly National Committee for the Clinical Laboratory Standards]) M27-A2, Sensititre YeastOne, disk diffusion, and Etest methods and we studied the effect of the time of reading. For the azoles, voriconazole was the most potent in vitro followed by fluconazole, ketoconazole, and itraconazole. All the isolates were susceptible to amphotericin B and flucytosine. The highest rate of resistance was obtained against itraconazole with a high number of isolates defined as susceptible dose-dependent. At 24 hr, 100% of the isolates were susceptible to ketoconazole, amphotericin B, and flucytosine, 98% susceptible to voriconazole and fluconazole, and 95% for itraconazole. At 48 hr, 100% of the isolates remained susceptible for flucytosine and amphotericin B, 95% for voriconazole, 93% for fluconazole, 90% for ketoconazole, and 82% for itraconazole. The agreement between the CLSI and the other methods was better at 24 than 48 hr.
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Affiliation(s)
- F J Salgado-Parreño
- Departamento de Medicina Preventiva y Salud Pública, Facultad de Medicina, Universidad de La Laguna, Tenerife, Spain
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Kami M, Murashige N, Tanaka Y, Narimatsu H. Antifungal prophylaxis following reduced-intensity stem cell transplantation. Transpl Infect Dis 2006; 8:190-202. [PMID: 17116132 DOI: 10.1111/j.1399-3062.2006.00152.x] [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: 11/30/2022]
Abstract
Reduced-intensity stem cell transplantation (RIST) has been developed to be a novel curative option for advanced hematologic diseases. Its minimal toxicity allows for transplantation in patients with advanced age or with organ dysfunction. Young patients without comorbidity can undergo RIST as outpatients. However, fungal infection remains an important complication in RIST. Given the poor prognosis of fungal infection, prophylaxis is critical in its management. The prophylactic strategy is recently changing with the development of RIST. Hospital equipment is important for fungal prophylaxis; however, the median day for the development of fungal infection is day 100, when most RIST patients are followed as outpatients. The focus of fungal management after RIST needs to shift from in-hospital equipment to oral antifungals. Various antifungals have recently been developed and introduced for clinical use. A major change in antifungal management will probably occur within several years.
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Affiliation(s)
- M Kami
- Division of Exploratory Research, Institute of Medical Science, University of Tokyo, Tokyo, Japan.
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Aperis G, Myriounis N, Spanakis EK, Mylonakis E. Developments in the treatment of candidiasis: more choices and new challenges. Expert Opin Investig Drugs 2006; 15:1319-36. [PMID: 17040194 DOI: 10.1517/13543784.15.11.1319] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The incidence of oesophageal candidiasis, candidaemia and disseminated candidiasis has increased dramatically. In addition to the amphotericin B formulations and fluconazole, the echinocandins anidulafungin, caspofungin and micafungin and the newer triazoles posaconazole and voriconazole are in the last stages of development and are becoming available for the management of candidiasis. This review presents these new agents and addresses their role in the treatment of candidiasis. All new antifungal agents exhibit potent activity against Candida spp. and echinocandins are fungicidal against most Candida spp. but appear to be less potent against certain species, such as Candida parapsilosis and C. guilliermondii. Systemic antifungal therapy can now be individualised based on the severity of the infection, comorbid conditions and the Candida spp. causing the infection. Studies are needed to investigate the possible development of resistance and the efficacy of these antifungal agents against the more resistant Candida spp.
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Affiliation(s)
- George Aperis
- Massachusetts General Hospital, Division of Infectious Diseases, Gray-Jackson 504, 55 Fruit Street, Boston, MA 02114, USA
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Kami M, Matsumura T. [Fungal infection following reduced-intensity stem cell transplantation (RIST)]. NIHON ISHINKIN GAKKAI ZASSHI = JAPANESE JOURNAL OF MEDICAL MYCOLOGY 2006; 47:143-53. [PMID: 16940947 DOI: 10.3314/jjmm.47.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hematopoietic stem cell transplantation has been established as a curative treatment for advanced hematologic malignancies. Transplantation with a reduced-intensity conditioning regimen has been developed, and the minimal toxicity of reduced-intensity stem cell transplantation (RIST) has made this procedure available for patients of advanced age or with organ dysfunction. The response of malignant lymphoma and some solid tumors to RIST has been observed. RIST with unrelated donors and umbilical cord blood has been studied. Fungal infection is an important complication of RIST. Since the prognosis of fungal infection is poor, the management has been focused on its prophylaxis. Given recent progression in RIST management, the strategy of infectious prophylaxis has also changed. Equipment in the hospital is important for fungal infection; however, the median day of the development of fungal infection is day 100, when most patients are followed as outpatients. The focus of fungal management after RIST is oral antifungal agents rather than in-hospital equipment. Various antifungal agents have recently been developed and applied for clinical use, and many of these have been developed simultaneously for the first time. A major change in antifungal management will probably occur in the next several years.
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Affiliation(s)
- Masahiro Kami
- Division of Exploratory Research, The Institute of Medical Science, The University of Tokyo, Japan
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Girish Kumar CP, Hanafy AM, Katsu M, Mikami Y, Menon T. Molecular analysis and susceptibility profiling of Candida albicans isolates from immunocompromised patients in South India. Mycopathologia 2006; 161:153-9. [PMID: 16482387 DOI: 10.1007/s11046-005-9210-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Accepted: 11/24/2005] [Indexed: 10/25/2022]
Abstract
The genetic diversity and in vitro antifungal susceptibility profiles of 55 Candida albicans from immunocompromised patients were studied. PCR based analysis of the transposable intron in the 25S rDNA revealed 39 genotype A, 4 genotype B and 12 genotype C isolates. Serotype analysis categorized 52 isolates as serotype A and 3 as serotype B. All strains were susceptible to micafungin, 5-flucytosine and miconazole, whereas resistance against amphotericin B (3.6%), fluconazole (3.6%), itraconazole (7.3%) and voriconazole (5.5%) was observed. No association was seen between antifungal resistance and genotype/serotype status.
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Affiliation(s)
- C P Girish Kumar
- Department of Microbiology, Dr. AL Mudaliar Post Graduate Institute of Basic Medical Sciences, University of Madras, Taramani, Chennai, TN, India
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Abstract
Systemic and superficial fungal infections have progressively emerged over the past few decades as an increasing cause of human disease, especially in the immunocompromised host. Control of fungal disease has proved difficult because few risk factors are potentially preventable; the population at highest risk for fungal disease, the immunocompromised patient, has been steadily increasing. There is a clear need for additional safe and effective therapeutic agents for the treatment of systemic fungal disease. A new generation of triazoles that includes voriconazole, posaconazole, ravuconazole and albaconazole has emerged and are presently in different phases of clinical investigation. These new triazoles have demonstrated a broad spectrum of activity, in particular against fungal pathogens previously resistant to previously available antifungals. This review highlights the emerging azole antifungals, both those available and in clinical development, and discusses their prospects for the future.
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Affiliation(s)
- Anne Chen
- Wayne State University, Detroit Medical Center, 3990 Harper Street, 5 Hudson, Detroit, MI 48201, USA
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Arikan S, Rex JH. New agents for the treatment of systemic fungal infections – current status. Expert Opin Emerg Drugs 2005; 7:3-32. [PMID: 15989533 DOI: 10.1517/14728214.7.1.3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Systemic antifungal chemotherapy is enjoying its most dynamic era. More antifungal agents are under development than ever before, including agents in entirely new classes. Major goals of current investigations are to identify compounds with a wide spectrum of activity, minimal toxicity and a high degree of target specificity. The antifungal drugs in development include new azoles {voriconazole, posaconazole (formerly SCH-56592), ravuconazole (formerly BMS-207147)}, lipid formulations of amphotericin B, a lipid formulation of nystatin, echinocandins {anidulafungin (formerly, LY-303366, VER-002), caspofungin (formerly MK-991), micafungin (formerly FK-463)}, antifungal peptides other than echinocandins, and sordarin derivatives. This discussion reviews the currently available antifungal agents and summarises the developmental issues that surround these new systemic antifungal drugs.
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Affiliation(s)
- Sevtap Arikan
- Department of Microbiology and Clinical Microbiology, Hacettepe University Medical School, 06100 Ankara, Turkey.
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Takahata S, Okutomi T, Ohtsuka K, Hoshiko S, Uchida K, Yamaguchi H. In vitroandin vivoantifungal activities of FX0685, a novel triazole antifungal agent with potent activity against fluconazole-resistantCandida albicans. Med Mycol 2005; 43:227-33. [PMID: 16010849 DOI: 10.1080/13693780410001731600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
To evaluate the therapeutic potential of FX0685, a new triazole antifungal agent, for the treatment of opportunistic fungal infections, particularly systemic candidiasis and aspergillosis, in vitro and in vivo studies were performed using fluconazole (FLC), itraconazole (ITC) and/or amphotericin B (AMB) as reference drugs. A preliminary in vitro study showed that the antifungal activity of FX0685 against FLC-susceptible Candida albicans, several non-C. albicans Candida species and Cryptococcus neoformans was superior to that of FLC and comparable or superior to those of ITC and AMB, while the anti-Aspergillus fumigatus activity of FX0685 was to varying degrees lower than that of ITC. FX0685 appeared to be comparable to FLC and ITC in the treatment of murine systemic C. albicans and pulmonary A. fumigatus infection, respectively. The biological property of FX0685 was characterized by its potent in vitro and in vivo activity against FLC-resistant C. albicans. Part of this unique property was explained by the finding that it retained potent inhibitory activity against those CYP51 molecules in which amino acid substitutions confer a phenotype of resistance to FLC and some other azole derivatives. All of these results lead to the possibility that FX0685 may be a potential antifungal drug candidate for the treatment of various clinical forms of systemic candidiasis, including those caused by FLC-resistant C. albicans, as well as for the treatment of pulmonary aspergillosis.
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Affiliation(s)
- Sho Takahata
- Pharmaceutical Research Department, Meiji Seika Kaisha Ltd, Kohoku-ku, Yokohama, Japan.
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Perea JRA, Díaz De Rada BS, Quetglas EG, Juarez MJM. Oral versus intravenous therapy in the treatment of systemic mycosis. Clin Microbiol Infect 2004; 10 Suppl 1:96-106. [PMID: 14748806 DOI: 10.1111/j.1470-9465.2004.00846.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The great majority of systemic fungal infections require long-term therapy that often extends 6-12 months, particularly in immunosuppressed patients. It can be difficult to comply with this requirement when the drug to be used is only available for intravenous administration, because problems related to maintaining a permeable venous pathway for long periods arise. The availability of an intravenously (IV) and orally (PO) administered drug can solve this problem by making sequential therapy possible. Voriconazole is a new antifungal agent that, apart from satisfying this requirement because it has a high oral bioavailability, presents a broad spectrum of antifungal activity that makes its use possible, a priori, in the initial and/or sequential IV/PO treatment of any systemic mycotic infection. Based on current costs there is potential for savings compared with liposomal amphotericin B.
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Affiliation(s)
- J R Azanza Perea
- Servicio de Farmacología Clínica, Clínica Universitaria, Universidad de Navarra, Avenida Pío XII sn Pamplona 31008, Spain.
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Abstract
Currently, use of standard antifungal therapies can be limited because of toxicity, low efficacy rates, and drug resistance. New formulations are being prepared to improve absorption and efficacy of some of these standard therapies. Various new antifungals have demonstrated therapeutic potential. These new agents may provide additional options for the treatment of superficial fungal infections and they may help to overcome the limitations of current treatments. Liposomal formulations of AmB have a broad spectrum of activity against invasive fungi, such as Candida spp., C. neoformans, and Aspergillus spp., but not dermatophyte fungi. The liposomal AmB is associated with significantly less toxicity and good rates of efficacy, which compare or exceed that of standard AmB. These factors may provide enough of an advantage to patients to overcome the increased costs of these formulations. Three new azole drugs have been developed, and may be of use in both systemic and superficial fungal infections. Voriconazole, ravuconazole, and posaconazole are triazoles, with broad-spectrum activity. Voriconazole has a high bioavailability, and has been used with success in immunocompromised patients with invasive fungal infections. Ravuconazole has shown efficacy in candidiasis in immunocompromised patients, and onychomycosis in healthy patients. Preliminary in vivo studies with posaconazole indicated potential use in a variety of invasive fungal infections including oropharyngeal candidiasis. Echinocandins and pneumocandins are a new class of antifungals, which act as fungal cell wall beta-(1,3)-D-glucan synthase enzyme complex inhibitors. Caspofungin (MK-0991) is the first of the echinocandins to receive Food and Drug Administration approval for patients with invasive aspergillosis not responding or intolerant to other antifungal therapies, and has been effective in patients with oropharyngeal and esophageal candidiasis. Standardization of MIC value determination has improved the ability of scientists to detect drug resistance in fungal species. Cross-resistance of fungal species to antifungal drugs must be considered as a potential problem to future antifungal treatment, and so determination of susceptibility of fungal species to antifungal agents is an important component of information in development of new antifungal agents. Heterogeneity in susceptibility of species to azole antifungals has been noted. This heterogeneity suggests that there are differences in activity of azoles, and different mechanisms of resistance to the azoles, which may explain the present lack of cross-resistance between some azoles despite apparent structural similarities. The mechanisms of azole action and resistance themselves are not well understood, and further studies into azole susceptibility patterns are required.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Science Center (Sunnybrook Site), University of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
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Abstract
BACKGROUND Reports of resistance and intolerance to currently available antifungal agents are increasing. Voriconazole is a broad-spectrum azole antifungal agent structurally derived from fluconazole. It is indicated for the treatment of invasive aspergillosis and serious fungal infections caused by Scedosporium apiospermum and Fusarium species in patients who are unable to tolerate or are refractory to other antifungal therapy. OBJECTIVE This article reviews the pharmacologic and pharmacokinetic properties and clinical usefulness of voriconazole. METHODS Relevant information was identified through a search of MEDLINE (1966-December 2002), Iowa Drug Information Service (1966-December 2002), International Pharmaceutical Abstracts (1970-December 2002), and meeting abstracts of the Infectious Diseases Society of America (1996-2002) and the Interscience Conference on Antimicrobial Agents and Chemotherapy (1996-2002) using the terms voriconazole and UK-109,495. RESULTS In head-to-head comparative trials, voriconazole appeared to be as efficacious as amphotericin B for the treatment of invasive aspergillosis and the empiric treatment of fungal infections in patients with febrile neutropenia. In clinical studies, it was as efficacious as fluconazole for the treatment of oropharyngeal and esophageal candidiasis. The results of in vitro susceptibility studies and case reports suggested that voriconazole may be useful against fluconazole- and/or itraconazole-resistant strains of Candida. Although voriconazole may be associated with a lower incidence of serious systemic adverse effects compared with amphotericin B (13.4% vs 24.3% in 1 pivotal clinical study; P = NS), major adverse effects associated with voriconazole include visual abnormalities ( approximately 30%), skin reactions ( approximately 20%), and elevations in hepatic enzymes (< or =20%). Voriconazole is available as oral and intravenous formulations. Pharmacokinetically, it has widespread distribution, including penetration into cerebral tissue. However, as 80% of voriconazole is hepatically eliminated, primarily via the cytochrome P450 (CYP) isozymes CYP2C19, CYP3A4, and CYP2C9, voriconazole has a high potential for drug interactions, and dose reduction is recommended in patients with mild to moderate hepatic dysfunction (Child-Pugh class A or B). Oral voriconazole may be preferred in patients with a creatinine clearance <50 mL/min due to the potential accumulation of the solubilizing excipient in the parenteral formulation of voriconazole. CONCLUSIONS Voriconazole appears to be a useful alternative to conventional antifungal agents in cases of resistance or intolerance to initial therapy. However, dose adjustment is recommended in patients with hepatic dysfunction, as well as in those receiving medications that may interact with voriconazole via hepatic metabolism.
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Affiliation(s)
- LilyAnn Jeu
- Pharmacy Service, Veterans Affairs Medical Center, Bronx, New York 10468, USA
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Fukuoka T, Johnston DA, Winslow CA, de Groot MJ, Burt C, Hitchcock CA, Filler SG. Genetic basis for differential activities of fluconazole and voriconazole against Candida krusei. Antimicrob Agents Chemother 2003; 47:1213-9. [PMID: 12654649 PMCID: PMC152512 DOI: 10.1128/aac.47.4.1213-1219.2003] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Invasive infections caused by Candida krusei are a significant concern because this organism is intrinsically resistant to fluconazole. Voriconazole is more active than fluconazole against C. krusei in vitro. One mechanism of fluconazole resistance in C. krusei is diminished sensitivity of the target enzyme, cytochrome P450 sterol 14alpha-demethylase (CYP51), to inhibition by this drug. We investigated the interactions of fluconazole and voriconazole with the CYP51s of C. krusei (ckCYP51) and fluconazole-susceptible Candida albicans (caCYP51). We found that voriconazole was a more potent inhibitor of both ckCYP51 and caCYP51 in cell extracts than was fluconazole. Also, the ckCYP51 was less sensitive to inhibition by both drugs than was caCYP51. These results were confirmed by expressing the CYP51 genes from C. krusei and C. albicans in Saccharomyces cerevisiae and determining the susceptibility of the transformants to voriconazole and fluconazole. We constructed homology models of the CYP51s of C. albicans and C. krusei based on the crystal structure of CYP51 from Mycobacterium tuberculosis. These models predicted that voriconazole is a more potent inhibitor of both caCYP51 and ckCYP51 than is fluconazole, because the extra methyl group of voriconazole results in a stronger hydrophobic interaction with the aromatic amino acids in the substrate binding site and more extensive filling of this site. Although there are multiple differences in the predicted amino acid sequence of caCYP51 and ckCYP51, the models of the two enzymes were quite similar and the mechanism for the relative resistance of ckCYP51 to the azoles was not apparent.
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Affiliation(s)
- Takashi Fukuoka
- Division of Infectious Diseases, Department of Medicine, Harbor-UCLA Research and Education Institute, Torrance, California 90502, USA
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Gunderson SM, Jain R, Danziger LH. Voriconazole: A Novel Antifungal. J Pharm Technol 2003. [DOI: 10.1177/875512250301900205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review the published in vitro, in vivo, and clinical data and FDA background documents that led to the approval of voriconazole. Data Sources: Articles were identified by the referenced package insert and by a MEDLINE search (1966–October 2002) using the terms voriconazole, azole antifungal, aspergillosis, and UK-109, 496. Additionally, journal Web sites and abstracts from major infectious disease meetings were researched to obtain newly published data. Study Selection: All animal and human data published in journals, abstracts, and FDA background documentation were used. The only in vitro susceptibility testing studies used were those that incorporated a large number of fungal isolates. Data Synthesis: Voriconazole is a novel monotriazole antifungal agent that inhibits the fungal cytochrome P450–mediated 14 α-lanosterol demethylation. In vitro susceptibility studies, in vivo clinical trials, and case reports have shown potent activity against various Aspergillus spp., Scedosporium, and Fusarium. Additionally, voriconazole has shown in vitro activity against dimorphic fungi and yeast, including Candida spp. and Cryptococcus neoformans. The efficacy of voriconazole has been evaluated in 4 clinical trials. The clinical studies indicate that it is at least as effective as amphotericin B for the treatment of acute invasive aspergillus infection. The most common adverse effects in clinical trials included visual disturbances, rash, and elevated liver function tests. Voriconazole is metabolized by CYP2C19, CYP2C9, and CYP3A4 and thus causes multiple serious drug–drug interactions. Conclusions: Voriconazole provides an advance in therapy for the treatment of acute invasive aspergillus infection.
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Affiliation(s)
- Shana M Gunderson
- SHANA M GUNDERSON PharmD, Infectious Disease Fellow and Clinical
Associate, College of Pharmacy, University of Illinois at Chicago, Chicago,
IL
| | - Rupali Jain
- RUPALI JAIN PharmD, Infectious Disease Fellow and Clinical Associate,
College of Pharmacy, University of Illinois at Chicago
| | - Larry H Danziger
- LARRY H DANZIGER PharmD, Professor, Department of Pharmacy Practice,
College of Pharmacy, University of Illinois at Chicago
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Mann PA, Parmegiani RM, Wei SQ, Mendrick CA, Li X, Loebenberg D, DiDomenico B, Hare RS, Walker SS, McNicholas PM. Mutations in Aspergillus fumigatus resulting in reduced susceptibility to posaconazole appear to be restricted to a single amino acid in the cytochrome P450 14alpha-demethylase. Antimicrob Agents Chemother 2003; 47:577-81. [PMID: 12543662 PMCID: PMC151774 DOI: 10.1128/aac.47.2.577-581.2003] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To better understand the molecular basis of posaconazole (POS) resistance in Aspergillus fumigatus, resistant laboratory isolates were selected. Spontaneous mutants arose at a frequency of 1 in 10(8) and fell into two susceptibility groups, moderately resistant and highly resistant. Azole resistance in A. fumigatus was previously associated with decreased drug accumulation. We therefore analyzed the mutants for changes in levels of transcripts of genes encoding efflux pumps (mdr1 and mdr2) and/or alterations in accumulation of [(14)C]POS. No changes in either pump expression or drug accumulation were detected. Similarly, there was no change in expression of cyp51A or cyp51B, which encode the presumed target site for POS, cytochrome P450 14alpha-demethylase. DNA sequencing revealed that each resistant isolate carried a single point mutation in residue 54 of cyp51A. Mutations at the same locus were identified in three clinical A. fumigatus isolates exhibiting reduced POS susceptibility but not in susceptible clinical strains. To verify that these mutations were responsible for the resistance phenotype, we introduced them into the chromosome of a POS-susceptible A. fumigatus strain under the control of the glyceraldehyde phosphate dehydrogenase promoter. The transformants exhibited reductions in susceptibility to POS comparable to those exhibited by the original mutants, confirming that point mutations in the cyp51A gene in A. fumigatus can confer reduced susceptibility to POS.
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Affiliation(s)
- Paul A Mann
- Schering-Plough Research Institute, Kenilworth, New Jersey 07033, USA.
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Pacetti SA, Gelone SP. Caspofungin acetate for treatment of invasive fungal infections. Ann Pharmacother 2003; 37:90-8. [PMID: 12503942 DOI: 10.1345/aph.1c114] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To briefly discuss the changing epidemiology of fungal infections and review currently available agents; provide a review of caspofungin; and discuss its pharmacology, pharmacokinetics, dosing guidelines, safety and efficacy, and role in the treatment of invasive fungal infections as it relates to current antifungal therapy. DATA SOURCES A MEDLINE (1966 to August 2002) database search using key words caspofungin, echino candins, fungal infections, and invasive aspergillosis, was completed to identify relevant articles including reviews, recent studies, treatment guidelines, and data from Merck and Company. STUDY SELECTION In vitro studies and all clinical trials were evaluated to summarize the clinical efficacy and safety of caspofungin. DATA SYNTHESIS The incidence of fungal infections is increasing as the population at risk expands. Cost, resistance, and morbidity and mortality are key issues. Adding to the antifungal armamentarium is necessary to address these therapeutic dilemmas. Caspofungin is the first member of a new class of antifungal agents, the echinocandins, to be approved for clinical use. Caspofungin is classified as a glucan synthase inhibitor and represents a class of agents with a novel mechanism of action. Unlike currently available agents (polyenes, pyrimidines, azoles) that exert their effect on the fungal cell membrane, the echinocandins are the first agents to inhibit fungal cell wall synthesis. Caspofungin exhibits activity against Aspergillus spp. and Candida spp., including non-albicans species. Data from clinical trials demonstrate that caspofungin is effective in patients with invasive aspergillosis as well as candida esophagitis. Its Food and Drug Administration-approved indication is limited to invasive aspergillosis refractory to or intolerant of current therapy. CONCLUSIONS Caspofungin has activity against Aspergillus spp. as well as a variety of Candida spp. Clinical data support its usefulness in the treatment of invasive aspergillosis and select candida infections. As additional clinical data become available, it seems likely that the therapeutic role of caspofungin will expand.
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Affiliation(s)
- Staci A Pacetti
- School of Pharmacy, Temple University, Philadelphia, PA 19140-5101, USA.
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Abstract
The incidence of invasive candidiasis is on the rise because of increasing numbers of immunocompromised hosts and more invasive medical technology. Recovery of Candida spp from several body sites in a critically ill or immunocompromised patient should raise the question of disseminated disease. Although identification to the species level and antifungal susceptibility testing should guide therapy, at this time amphotericin B preparations are the usual initial therapy for severe life-threatening disease. Azole therapy has an expanding body of evidence that proves it is as effective as and safer than amphotericin B therapy. Some forms of candidiasis (e.g., those with ocular, bone, or heart involvement) require a combined medical and surgical approach.
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Affiliation(s)
- Luis Ostrosky-Zeichner
- Division of Infectious Diseases, University of Texas-Houston Medical School, 6431 Fannin, JFB 1.728, Houston, TX 77030, USA.
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Biancofiore G, Bindi ML, Baldassarri R, Romanelli AM, Catalano G, Filipponi F, Vagelli A, Mosca F. Antifungal prophylaxis in liver transplant recipients: a randomized placebo-controlled study. Transpl Int 2002. [DOI: 10.1111/j.1432-2277.2002.tb00176.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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41
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Abstract
Voriconazole is a new triazole antifungal agent structurally related to fluconazole, but with improved potency and spectrum of activity. Voriconazole has good in vitro activity against Candida species, Cryptococcus neoformans, Aspergillus spp. and other mould spp. Initial clinical studies and case reports demonstrate efficacy with voriconazole against invasive aspergillosis and infections caused by C. neoformans, Scedosporium apiospermum, Blastomyces dermatitidis, Coccidioides immitis and Histoplasma capsulatum. Voriconazole is available both as oral and iv. preparations and exhibits complex pharmacokinetics. This drug is metabolised by the cytochrome (CYP) P450 enzyme system and therefore, has potential drug interactions. This review evaluates the current literature regarding the safety and efficacy of voriconazole.
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Affiliation(s)
- Holly L Hoffman
- University of Oklahoma Health Sciences Center, College of Pharmacy, 1110 N. Stonewall Avenue, PO BOX 26901, Oklahoma City, OK 73190-5040, USA.
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Espinel-Ingroff A, Boyle K, Sheehan DJ. In vitro antifungal activities of voriconazole and reference agents as determined by NCCLS methods: review of the literature. Mycopathologia 2002; 150:101-15. [PMID: 11469757 DOI: 10.1023/a:1010954803886] [Citation(s) in RCA: 194] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Voriconazole (VfendTM) is a new triazole that currently is undergoing phase III clinical trials. This review summarizes the published data obtained by NCCLS methods on the in vitro antifungal activity of voriconazole in comparison to itraconazole, amphotericin B, fluconazole, ketoconazole and flucytosine. Voriconazole had fungistatic activity against most yeasts and yeastlike species (minimum inhibitory concentrations [MICs] < 2 microg/ml) that was similar or superior to those of fluconazole, amphotericin B, and itraconazole. Against Candida glabrata and C. krusei, voriconazole MIC ranges were 0.03 to 8 and 0.01 to > 4 microg/ml, respectively. For four of the six Aspergillus spp. evaluated, voriconazole MICs (< 0.03 to 2 microg/ml) were lower than amphotericin B (0.25 to 4 microg/ml) and similar to itraconazole MICs. Voriconazole fungistatic activity against Fusarium spp. has been variable. Against E oxysporum and F. solani, most studies showed MICs ranging from 0.25 to 8 microg/ml. Voriconazole had excellent fungistatic activity against five of the six species of dimorphic fungi evaluated (MIC90s < 1.0 microg/ml). The exception was Sporothrix schenckii (MIC90s and geometric mean MICs > or = 8 microg/ml). Only amphotericin B had good fungistatic activity against the Zygomycetes species (voriconazole MICs ranged from 2 to > 32 microg/ml). Voriconazole showed excellent in vitro activity (MICs < 0.03 to 1.0 microg/ml) against most of the 50 species of dematiaceous fungi tested, but the activity of all the agents was poor against most isolates of Scedosporium prolificans and Phaeoacremonium parasiticum (Phialophora parasitica). Voriconazole had fungicidal activity against most Aspergillus spp., B. dermatitidis, and some dematiaceous fungi. In vitro/in vivo correlations should aid in the interpretation of these results.
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Affiliation(s)
- A Espinel-Ingroff
- Division of Infectious Diseases, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298-0049, USA.
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Sylvester SL, Lipsett P. The Prevention of Invasive Candida Infection in Critically Ill Surgical Patients. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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44
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Abstract
Incidences of infections due to Candida have increased over the last 15-20 y. This increase in the incidence and the high associated mortality rate despite therapy has focused the attention on this disease and prompted investigators to undertake research aimed at understanding the pathogenesis of this disease as well as methods to treat it. This paper discusses recent developments in the Candida field and the impact they have on patient management.
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Affiliation(s)
- M A Ghannoum
- Center for Medical Mycology, University Hospitals of Cleveland, Case Western Reserve University, Ohio 44106-5028, USA.
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Lopez J, Pernot C, Aho S, Caillot D, Vagner O, Dalle F, Durnet-Archeray MJ, Chavanet P, Bonnin A. Decrease in Candida albicans strains with reduced susceptibility to fluconazole following changes in prescribing policies. J Hosp Infect 2001; 48:122-8. [PMID: 11428879 DOI: 10.1053/jhin.2001.0982] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study was undertaken to identify prescribing policies likely to favour or limit fluconazole resistance within a clinical department. Fluconazole exposure within the infectious diseases and clinical haematology units was investigated, and data were compared with in vitro susceptibility of Candida albicans isolates obtained in these units. Fluconazole utilization was determined by the number of fluconazole treatment-days per 100 hospitalization days (penetration index). In the infectious diseases unit, separate evaluations for low-dose fluconazole (50 mg) prescribed as intermittent or prolonged treatment, and for higher-dosing schedules (fluconazole 200 mg) were made. Susceptibility of C. albicans isolates was surveyed in a broth microdilution assay by measuring the inhibitory concentration 50% (IC50). The penetration index (PI) for fluconazole 50mg declined from 1992 to 1977 in infectious diseases (P= 0.0048). In the meantime, total usage of fluconazole increased, due to increased prescribing of fluconazole 200 mg (P = 0.0724). The IC50 of C. albicans isolates tested in infectious diseases decreased between 1994 and 1996 from 7.33 mg/ml to 1.64 mg/ml (P = 0.0075). In clinical haematology, declines in C. albicans IC50 and fluconazole PI were not significant (P = 0.35 and P = 0.07, respectively). These data suggest that prolonged or repeated exposure to low-dose fluconazole, rather than total cumulative use, was associated with fluconazole resistance in the infectious diseases unit. Moreover, restoration of a normal ecology was observed when low-dose prolonged or intermittent prescriptions were reduced.
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Affiliation(s)
- J Lopez
- Department of Parasitology and Mycology, University Hospital and School of Medicine, Dijon, France
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46
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Manavathu EK, Abraham OC, Chandrasekar PH. Isolation and in vitro susceptibility to amphotericin B, itraconazole and posaconazole of voriconazole-resistant laboratory isolates of Aspergillus fumigatus. Clin Microbiol Infect 2001; 7:130-7. [PMID: 11318811 DOI: 10.1046/j.1469-0691.2001.00220.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To select voriconazole-resistant mutants of Aspergillus fumigatus in the laboratory from drug-susceptible clinical isolates and examine their in vitro susceptibility to amphotericin B and investigational azoles, and to compare the intramycelial accumulation of voriconazole in the resistant isolates with that in the susceptible parent. METHODS Voriconazole-resistant Aspergillus fumigatus isolates were selected in the laboratory from three highly susceptible (MIC < or = 0.5 mg/L) clinical isolates by stepwise selection on peptone yeast extract glucose (PYG) agar containing 0.5 mg and 4 mg voriconazole/L. Twenty-three colonies that grew in the presence of 4 mg voriconazole/L on PYG agar (frequency 1.9 x 10(-8)) were tested for their in vitro susceptibility to amphotericin B, itraconazole, voriconazole and posaconazole by a broth macrodilution technique. The accumulation of voriconazole in the mycelia of two representative resistant isolates (VCZ-W42 and VCZ-W45) was determined by a previously described bioassay. RESULTS The geometric mean MICs (mg/L) of amphotericin B, itraconazole, voriconazole and posaconazole for these isolates were 0.45 +/- 0.19, 0.69 +/- 0.45, 5.24 +/- 3.74 and 0.27 +/- 0.18, respectively. A comparison of the geometric mean MICs of the antifungals obtained for the resistant isolates to those of the susceptible parents showed 1.15-, 2.76-, 16.90- and 1.42-fold increases, respectively, for amphotericin B, itraconazole, voriconazole and posaconazole, suggesting that low-level cross-resistance exists between the azole antifungals. The susceptible parent and the resistant isolates accumulated similar amounts of voriconazole. CONCLUSIONS These results suggest that spontaneous mutants of Aspergillus fumigatus resistant to voriconazole could emerge among clinical isolates under selection pressure and that the observed reduced in vitro susceptibility to voriconazole may not be due to reduced accumulation of the drug in the mycelia.
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Affiliation(s)
- E K Manavathu
- Division of Infectious Diseases, Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan 48201, USA.
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Uzun O, Arikan S, Kocagöz S, Sancak B, Unal S. Susceptibility testing of voriconazole, fluconazole, itraconazole and amphotericin B against yeast isolates in a Turkish University Hospital and effect of time of reading. Diagn Microbiol Infect Dis 2000; 38:101-7. [PMID: 11035241 DOI: 10.1016/s0732-8893(00)00177-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Voriconazole is a promising azole effective against a variety of fungi, including yeasts. In this study, we tested in vitro activities of voriconazole, fluconazole, itraconazole and amphotericin B against some ATCC and reference strains and 250 clinical yeast isolates. We also evaluated the effect of time of reading on MIC results. Voriconazole was the most active agent against Candida and Trichosporon isolates, including the putatively fluconazole-resistant C. krusei (MIC(90) 0.25 microg/ml) and C. glabrata (MIC(90) 0.5 microg/ml). Amphotericin B MICs were scattered in a considerably narrow range in both RPMI 1640 and Antibiotic Medium 3. MICs at 24 hours and 48 hours were similar in general for all antifungals tested. The highest percentage of strains that showed 24-hour and 48-hour MICs within +/-1-log(2) dilution was observed for amphotericin B tested in RPMI (99%), and the lowest for amphotericin B tested in Antibiotic Medium 3 (80%). In conclusion, voriconazole is very effective against a wide spectrum of Candida species and 24-hour readings could substitute 48-hour MIC evaluation.
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Affiliation(s)
- O Uzun
- Section of Infectious Diseases, Department of MedicineHacettepe University School of Medicine, 06100, Ankara, Turkey.
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48
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Hossain MA, Ghannoum MA. New investigational antifungal agents for treating invasive fungal infections. Expert Opin Investig Drugs 2000; 9:1797-813. [PMID: 11060778 DOI: 10.1517/13543784.9.8.1797] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Systemic fungal infections have been recognised as a major cause of morbidity and mortality during the last two decades. There are only a few therapeutic options for these infections. Severe toxicity, such as impairment of renal function, limits the use of amphotericin B. Flucytosine is associated with side effects and drug resistance. Fluconazole and itraconazole are safer, though emergence of resistance and innate resistance in some fungal pathogens is a concern in their use. Therefore, there is a need for developing novel drugs and/or treatment strategies to combat these infections. In recent years, increased efforts by the pharmaceutical industry and academia have led to the discovery of new re-engineered or reconsidered antifungal agents that are more efficacious, safer and have a broad spectrum of activity. Lipid formulations of polyene antifungal agents, amphotericin B and nystatin, have the advantage of improved therapeutic index. Activity against resistant fungi, high bioavailability, safety and longer half-life are the properties that encourage development of the newer triazoles (e.g., voriconazole, ravuconazole and posaconazole). Echinocandin-like lipopeptide antibiotics are among the antifungal agents with a novel mode of action. In addition to these lead investigational compounds, development of newer antifungal agents is underway.
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Affiliation(s)
- M A Hossain
- Center for Medical Mycology, Department of Dermatology, Case Western Reserve University and University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio, OH 44106-5028, USA
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49
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Chiou CC, Groll AH, Walsh TJ. New drugs and novel targets for treatment of invasive fungal infections in patients with cancer. Oncologist 2000; 5:120-35. [PMID: 10794803 DOI: 10.1634/theoncologist.5-2-120] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Invasive fungal infections have emerged as important causes of morbidity and mortality in profoundly immunocompromised patients with cancer. Current treatment strategies for these infections are limited by antifungal resistance, toxicity, drug interactions, and expense. In order to overcome these limitations, new antifungal compounds are being developed, which may improve our therapeutic armamentarium for prevention and treatment of invasive mycoses in high-risk patients with neoplastic diseases.
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Affiliation(s)
- C C Chiou
- National Cancer Institute, Bethesda, Maryland, USA
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50
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Perea S, Pennick GJ, Modak A, Fothergill AW, Sutton DA, Sheehan DJ, Rinaldi MG. Comparison of high-performance liquid chromatographic and microbiological methods for determination of voriconazole levels in plasma. Antimicrob Agents Chemother 2000; 44:1209-13. [PMID: 10770753 PMCID: PMC89846 DOI: 10.1128/aac.44.5.1209-1213.2000] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A new selective high-performance liquid chromatography (HPLC) method with UV detection for the determination of the investigational triazole voriconazole in human plasma by using acetonitrile precipitation followed by reverse-phase HPLC on a C(18) column was compared with a simple agar well diffusion bioassay method with Candida kefyr ATCC 46764 as the assay organism. Pooled plasma was used to prepare standard and control samples for both methods. The results of analyses with spiked serum samples (run as unknowns) were concordant by the bioassay and HPLC methods, with expected values being obtained. HPLC demonstrated an improved precision (3.47 versus 12.12%) and accuracy (0.81 versus 1.28%) compared to those of the bioassay method. The range of linearity obtained by both methods (from 0.2 to 10 microg/ml for HPLC and from 0.25 to 20 microg/ml for the bioassay) includes the range of concentrations of voriconazole (from 1.2 to 4.7 microg/ml) which are considered clinically relevant. Although either methodology could be used for the monitoring of patient therapy, the smaller variability observed with HPLC compared to that observed with the bioassay favors the use of HPLC for pharmacokinetic studies.
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Affiliation(s)
- S Perea
- Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
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