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Pham D, Howard-Jones AR, Sparks R, Stefani M, Sivalingam V, Halliday CL, Beardsley J, Chen SCA. Epidemiology, Modern Diagnostics, and the Management of Mucorales Infections. J Fungi (Basel) 2023; 9:659. [PMID: 37367595 DOI: 10.3390/jof9060659] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023] Open
Abstract
Mucormycosis is an uncommon, yet deadly invasive fungal infection caused by the Mucorales moulds. These pathogens are a WHO-assigned high-priority pathogen group, as mucormycosis incidence is increasing, and there is unacceptably high mortality with current antifungal therapies. Current diagnostic methods have inadequate sensitivity and specificity and may have issues with accessibility or turnaround time. Patients with diabetes mellitus and immune compromise are predisposed to infection with these environmental fungi, but COVID-19 has established itself as a new risk factor. Mucorales also cause healthcare-associated outbreaks, and clusters associated with natural disasters have also been identified. Robust epidemiological surveillance into burden of disease, at-risk populations, and emerging pathogens is required. Emerging serological and molecular techniques may offer a faster route to diagnosis, while newly developed antifungal agents show promise in preliminary studies. Equitable access to these emerging diagnostic techniques and antifungal therapies will be key in identifying and treating mucormycosis, as delayed initiation of therapy is associated with higher mortality.
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Affiliation(s)
- David Pham
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Annaleise R Howard-Jones
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
| | - Rebecca Sparks
- Douglass Hanly Moir Pathology, Sydney, NSW 2113, Australia
| | - Maurizio Stefani
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Varsha Sivalingam
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Catriona L Halliday
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Justin Beardsley
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Sydney, NSW 2145, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
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Zhang T, Shen Y, Feng S. Clinical research advances of isavuconazole in the treatment of invasive fungal diseases. Front Cell Infect Microbiol 2022; 12:1049959. [PMID: 36530445 PMCID: PMC9751058 DOI: 10.3389/fcimb.2022.1049959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/16/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose Invasive fungal diseases (IFD) are a major global public health concern. The incidence of IFD has increased the demand for antifungal agents. Isavuconazole (ISA) is a new triazole antifungal agent that has shown promising efficacy in the prophylaxis and treatment of invasive fungal diseases. The aim of this review is to summarize the recent real-world experiences of using ISA for the treatment and prevention of IFD. Methods We performed a comprehensive literature search of the MEDLINE, PubMed, Embase, and Cochrane databases for clinical applications of ISA in the real world. Tables and reference lists are presented for this systematic review. Results IFD poses a major threat to public health and causes high mortality rates. ISA may provide a good treatment. For example, the efficacy of ISA in the treatment of invasive aspergillosis (IA) is comparable to that of voriconazole, and its efficacy in the treatment of invasive mucormycosis (IM) is similar to that of liposomal amphotericin B (L-AmB); therefore, ISA is recommended as the first-line treatment for IA and IM. ISA can also achieve good efficacy in the treatment of invasive candidiasis (IC) and can be used as an alternative to de-escalation therapy after first-line drug therapy. In addition, most studies have shown the efficacy and safety of ISA for the prophylaxis of IFD. Conclusion Taken together, ISA are expected to become a new choice for the treatment and prevention of IFD because of their good tolerability, high bioavailability, and few drug interactions.
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Affiliation(s)
- Tingting Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China,Hematopoietic Stem Cell Transplantation Center, Tianjin Institutes of Health Science, Tianjin, China
| | - Yuyan Shen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China,Hematopoietic Stem Cell Transplantation Center, Tianjin Institutes of Health Science, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China,Hematopoietic Stem Cell Transplantation Center, Tianjin Institutes of Health Science, Tianjin, China,*Correspondence: Sizhou Feng,
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COVID-19-Associated Mucormycosis: A Matter of Concern Amid the SARS-CoV-2 Pandemic. Vaccines (Basel) 2022; 10:vaccines10081266. [PMID: 36016154 PMCID: PMC9415927 DOI: 10.3390/vaccines10081266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 12/16/2022] Open
Abstract
Mucormycosis is an invasive fungal infection caused by fungi belonging to order Mucorales. Recently, with the increase in COVID-19 infections, mucormycosis infections have become a matter of concern globally, because of the high morbidity and mortality rates associated with them. Due to the association of mucormycosis with COVID-19 disease, it has been termed COVID-19-associated mucormycosis (CAM). In the present review, we focus on mucormycosis incidence, pathophysiology, risk factors, immune dysfunction, interactions of Mucorales with endothelial cells, and the possible role of iron in Mucorales growth. We review the limitations associated with current diagnostic procedures and the requirement for more specific, cost-effective, convenient, and sensitive assays, such as PCR-based assays and monoclonal antibody-based assays for the effective diagnosis of mucormycosis. We discuss the current treatment options involving antifungal drug therapies, adjunctive therapy, surgical treatment, and their limitations. We also review the importance of nutraceuticals-based therapy for the prevention as well as treatment of mucormycosis. Our review also highlights the need to explore the potential of novel immunotherapeutics, which include antibody-based therapy, cytokine-based therapy, and combination/synergistic antifungal therapy, as treatment options for mucormycosis. In summary, this review provides a complete overview of COVID-19-associated mucormycosis, addressing the current research gaps and future developments required in the field.
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Jampilek J. Novel avenues for identification of new antifungal drugs and current challenges. Expert Opin Drug Discov 2022; 17:949-968. [PMID: 35787715 DOI: 10.1080/17460441.2022.2097659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Some of otherwise useful fungi are pathogenic to humans, and unfortunately, the number of these pathogens is increasing. In addition to common skin infections, these opportunistic pathogens are able to cause severe, often incurable, systemic mycoses. AREAS COVERED : The number of antifungal drugs is limited, especially drugs that can be used for systemic administration, and resistance to these drugs is very common. This review summarizes various approaches to the discovery and development of new antifungal drugs, provides an overview of the most important molecules in terms of basic (laboratory) research and compounds currently in clinical trials, and focuses on drug repurposing strategy, while providing an overview of drugs of other indications that have been tested in vitro for their antifungal activity for possible expansion of antifungal drugs and/or support of existing antimycotics. EXPERT OPINION : Despite the limitations of the research of new antifungal drugs by pharmaceutical manufacturers, in addition to innovated molecules based on clinically used drugs, several completely new small entities with unique mechanisms of actions have been identified. The identification of new molecular targets that offer alternatives for the development of new unique selective antifungal highly effective agents has been an important outcome of repurposing of non-antifungal drugs to antifungal drug. Also, given the advances in monoclonal antibodies and their application to immunosuppressed patients, it may seem possible to predict a more optimistic future for antifungal therapy than has been the case in recent decades.
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Affiliation(s)
- Josef Jampilek
- Department of Analytical Chemistry, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, 842 15 Bratislava, Slovakia.,Institute of Neuroimmunology, Slovak Academy of Sciences, Dubravska Cesta 9, 845 10 Bratislava, Slovakia
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Synergistic In Vitro Interaction of Isavuconazole and Isoquercitrin against Candida glabrata. J Fungi (Basel) 2022; 8:jof8050525. [PMID: 35628780 PMCID: PMC9147185 DOI: 10.3390/jof8050525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/14/2022] [Accepted: 05/19/2022] [Indexed: 02/05/2023] Open
Abstract
In vitro interactions of broad-spectrum azole isavuconazole with flavonoid isoquercitrin were evaluated by a broth microdilution checkerboard technique based on the European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference methodology for antifungal susceptibility testing against 60 Candida strains belonging to the species Candida albicans (n = 10), Candida glabrata (n = 30), Candida kefyr (n = 6), Candida krusei (n = 5), Candida parapsilosis (n = 4), and Candida tropicalis (n = 5). The results were analyzed with the fractional inhibitory concentration index and by response surface analysis based on the Bliss model. Synergy was found for all C. glabrata strains, when the results were interpreted by the fractional inhibitory concentration index, and for 60% of the strains when response surface analysis was used. Interaction for all other species was indifferent for all strains tested, whatever interpretation model used. Importantly, antagonistic interaction was never observed.
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Drug repurposing strategies in the development of potential antifungal agents. Appl Microbiol Biotechnol 2021; 105:5259-5279. [PMID: 34151414 PMCID: PMC8214983 DOI: 10.1007/s00253-021-11407-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/01/2021] [Accepted: 06/08/2021] [Indexed: 12/15/2022]
Abstract
Abstract The morbidity and mortality caused by invasive fungal infections are increasing across the globe due to developments in transplant surgery, the use of immunosuppressive agents, and the emergence of drug-resistant fungal strains, which has led to a challenge in terms of treatment due to the limitations of three classes of drugs. Hence, it is imperative to establish effective strategies to identify and design new antifungal drugs. Drug repurposing is a potential way of expanding the application of existing drugs. Recently, various existing drugs have been shown to be useful in the prevention and treatment of invasive fungi. In this review, we summarize the currently used antifungal agents. In addition, the most up-to-date information on the effectiveness of existing drugs with antifungal activity is discussed. Moreover, the antifungal mechanisms of existing drugs are highlighted. These data will provide valuable knowledge to stimulate further investigation and clinical application in this field. Key points • Conventional antifungal agents have limitations due to the occurrence of drug-resistant strains. • Non-antifungal drugs act as antifungal agents in various ways toward different targets. • Non-antifungal drugs with antifungal activity are demonstrated as effective antifungal strategies.
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Bidaud AL, Schwarz P, Herbreteau G, Dannaoui E. Techniques for the Assessment of In Vitro and In Vivo Antifungal Combinations. J Fungi (Basel) 2021; 7:jof7020113. [PMID: 33557026 PMCID: PMC7913650 DOI: 10.3390/jof7020113] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 12/18/2022] Open
Abstract
Systemic fungal infections are associated with high mortality rates despite adequate treatment. Moreover, acquired resistance to antifungals is increasing, which further complicates the therapeutic management. One strategy to overcome antifungal resistance is to use antifungal combinations. In vitro, several techniques are used to assess drug interactions, such as the broth microdilution checkerboard, agar-diffusion methods, and time-kill curves. Currently, the most widely used technique is the checkerboard method. The aim of all these techniques is to determine if the interaction between antifungal agents is synergistic, indifferent, or antagonistic. However, the interpretation of the results remains difficult. Several methods of analysis can be used, based on different theories. The most commonly used method is the calculation of the fractional inhibitory concentration index. Determination of the usefulness of combination treatments in patients needs well-conducted clinical trials, which are difficult. It is therefore important to study antifungal combinations in vivo, in experimental animal models of fungal infections. Although mammalian models have mostly been used, new alternative animal models in invertebrates look promising. To evaluate the antifungal efficacy, the most commonly used criteria are the mortality rate and the fungal load in the target organs.
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Affiliation(s)
- Anne-Laure Bidaud
- Parasitology-Mycology Unit, Microbiology Department, APHP, European Georges Pompidou Hospital, Paris-Descartes University, F-75015 Paris, France;
| | - Patrick Schwarz
- Department of Internal Medicine, Respiratory and Critical Care Medicine, University Hospital Marburg, Baldingerstraße, D-35043 Marburg, Germany;
- Center for Invasive Mycoses and Antifungals, Philipps University Marburg, D-35037 Marburg, Germany
| | | | - Eric Dannaoui
- Parasitology-Mycology Unit, Microbiology Department, APHP, European Georges Pompidou Hospital, Paris-Descartes University, F-75015 Paris, France;
- Dynamyc Research Group, Paris Est Créteil University (UPEC, EnvA), F-94010 Paris, France
- Correspondence: ; Tel.: +33-1-56-09-39-48; Fax: +33-1-56-09-24-46
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Papon N, Nevez G, Le Gal S, Vigneau C, Robert-Gangneux F, Bouchara JP, Cornely OA, Denning DW, Gangneux JP. Fungal infections in transplant recipients: pros and cons of immunosuppressive and antimicrobial treatment. THE LANCET MICROBE 2021; 2:e6-e8. [DOI: 10.1016/s2666-5247(20)30199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 11/17/2022] Open
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Schwarz P, Bidaud AL, Dannaoui E. In vitro synergy of isavuconazole in combination with colistin against Candida auris. Sci Rep 2020; 10:21448. [PMID: 33293607 PMCID: PMC7722718 DOI: 10.1038/s41598-020-78588-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022] Open
Abstract
The in vitro interactions of isavuconazole with colistin were evaluated against 15 clinical Candida auris isolates by a microdilution checkerboard technique based on the EUCAST reference method for antifungal susceptibility testing and by agar diffusion using isavuconazole gradient concentration strips with or without colistin incorporated RPMI agar. Interpretation of the checkerboard results was done by the fractional inhibitory concentration index and by response surface analysis based on the Bliss model. By checkerboard, combination was synergistic for 93% of the isolates when interpretation of the data was done by fractional inhibitory concentration index, and for 80% of the isolates by response surface analysis interpretation. By agar diffusion test, although all MICs in combination decreased compared to isavuconazole alone, only 13% of the isolates met the definition of synergy. Essential agreement of EUCAST and gradient concentration strip MICs at +/− 2 log2 dilutions was 93.3%. Antagonistic interactions were never observed for any technique or interpretation model used.
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Affiliation(s)
- Patrick Schwarz
- Department of Internal Medicine, Respiratory and Critical Care Medicine, University Hospital Marburg, Baldingerstraße, 35043, Marburg, Germany. .,Center for Invasive Mycoses and Antifungals, Philipps University Marburg, 35037, Marburg, Germany.
| | - Anne-Laure Bidaud
- Unité de Parasitologie-Mycologie, Hôpital Européen Georges Pompidou, AP-HP, Faculté de Médecine, Université de Paris, 75015, Paris, France
| | - Eric Dannaoui
- Unité de Parasitologie-Mycologie, Hôpital Européen Georges Pompidou, AP-HP, Faculté de Médecine, Université de Paris, 75015, Paris, France.,EA 7380 Dynamyc, Université Paris-Est Créteil, Ecole Nationale Vétérinaire D'Alfort, USC Anses, 94010, Maisons-Alfort, France
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10
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Kim JH, Cheng LW, Chan KL, Tam CC, Mahoney N, Friedman M, Shilman MM, Land KM. Antifungal Drug Repurposing. Antibiotics (Basel) 2020; 9:antibiotics9110812. [PMID: 33203147 PMCID: PMC7697925 DOI: 10.3390/antibiotics9110812] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/30/2020] [Accepted: 11/13/2020] [Indexed: 12/19/2022] Open
Abstract
Control of fungal pathogens is increasingly problematic due to the limited number of effective drugs available for antifungal therapy. Conventional antifungal drugs could also trigger human cytotoxicity associated with the kidneys and liver, including the generation of reactive oxygen species. Moreover, increased incidences of fungal resistance to the classes of azoles, such as fluconazole, itraconazole, voriconazole, or posaconazole, or echinocandins, including caspofungin, anidulafungin, or micafungin, have been documented. Of note, certain azole fungicides such as propiconazole or tebuconazole that are applied to agricultural fields have the same mechanism of antifungal action as clinical azole drugs. Such long-term application of azole fungicides to crop fields provides environmental selection pressure for the emergence of pan-azole-resistant fungal strains such as Aspergillus fumigatus having TR34/L98H mutations, specifically, a 34 bp insertion into the cytochrome P450 51A (CYP51A) gene promoter region and a leucine-to-histidine substitution at codon 98 of CYP51A. Altogether, the emerging resistance of pathogens to currently available antifungal drugs and insufficiency in the discovery of new therapeutics engender the urgent need for the development of new antifungals and/or alternative therapies for effective control of fungal pathogens. We discuss the current needs for the discovery of new clinical antifungal drugs and the recent drug repurposing endeavors as alternative methods for fungal pathogen control.
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Affiliation(s)
- Jong H. Kim
- Foodborne Toxin Detection and Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, USA; (L.W.C.); (K.L.C.); (C.C.T.); (N.M.)
- Correspondence: ; Tel.: +1-510-559-5841
| | - Luisa W. Cheng
- Foodborne Toxin Detection and Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, USA; (L.W.C.); (K.L.C.); (C.C.T.); (N.M.)
| | - Kathleen L. Chan
- Foodborne Toxin Detection and Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, USA; (L.W.C.); (K.L.C.); (C.C.T.); (N.M.)
| | - Christina C. Tam
- Foodborne Toxin Detection and Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, USA; (L.W.C.); (K.L.C.); (C.C.T.); (N.M.)
| | - Noreen Mahoney
- Foodborne Toxin Detection and Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, USA; (L.W.C.); (K.L.C.); (C.C.T.); (N.M.)
| | - Mendel Friedman
- Healthy Processed Foods Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, USA;
| | | | - Kirkwood M. Land
- Department of Biological Sciences, University of the Pacific, Stockton, CA 95211, USA;
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Abstract
Mucormycosis is one of the most complicated to diagnose and treat invasive fungal diseases. Diagnostic techniques have not significantly advanced in years, and recent international consensus treatment guidelines offer some insight into the current best approaches to treating this deadly invasive mold.
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Affiliation(s)
- William J Steinbach
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA.,Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Pediatric Immunocompromised Host Program, Durham, North Carolina, USA.,International Pediatric Fungal Network, Duke University Medical Center, Durham, North Carolina, USA
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In Vitro Interaction between Isavuconazole and Tacrolimus, Cyclosporin A, or Sirolimus against Aspergillus Species. J Fungi (Basel) 2020; 6:jof6030103. [PMID: 32650564 PMCID: PMC7560155 DOI: 10.3390/jof6030103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/07/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022] Open
Abstract
The interaction of isavuconazole with immunosuppressors (tacrolimus, cyclosporin A, or sirolimus) against 30 Aspergillus isolates belonging to the most common species responsible for invasive aspergillosis in humans (Aspergillus flavus, Aspergillus fumigatus, Aspergillus nidulans, Aspergillus niger, and Aspergillus terreus) was evaluated in vitro by a microdilution checkerboard technique based on the EUCAST reference method for antifungal susceptibility testing. The interpretation of the results was performed based on the fractional inhibitory concentration index. The combination of isavuconazole with tacrolimus, cyclosporin A, or sirolimus, was synergistic for 56, 20, or 10% of the isolates, respectively. Interestingly synergy of the combination of isavuconazole with tacrolimus was also achieved for the majority of azole-resistant isolates of A. fumigatus, and for all A. niger isolates with isavuconazole minimal inhibitory concentrations ≥ 8 µg/mL. Antagonistic interactions were never observed for any combination tested.
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Brunet K, Rammaert B. Mucormycosis treatment: Recommendations, latest advances, and perspectives. J Mycol Med 2020; 30:101007. [PMID: 32718789 DOI: 10.1016/j.mycmed.2020.101007] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/09/2020] [Accepted: 06/15/2020] [Indexed: 12/21/2022]
Abstract
Mucormycosis are life-threatening fungal infections especially affecting immunocompromised or diabetic patients. Despite treatment, mortality remains high (from 32 to 70% according to organ involvement). This review provides an update on mucormycosis management. The latest recommendations strongly recommend as first-line therapy the use of liposomal amphotericin B (≥5mg/kg) combined with surgery whenever possible. Isavuconazole and intravenous or delayed-release tablet forms of posaconazole have remained second-line. Many molecules are currently in development to fight against invasive fungal diseases but few have demonstrated efficacy against Mucorales. Despite in vitro efficacy, combinations of treatment have failed to demonstrate superiority versus monotherapy. Adjuvant therapies are particularly complex to evaluate without prospective randomized controlled studies, which are complex to perform due to low incidence rate and high mortality of mucormycosis. Perspectives are nonetheless encouraging. New approaches assessing relationships between host, fungi, and antifungal drugs, and new routes of administration such as aerosols could improve mucormycosis treatment.
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Affiliation(s)
- K Brunet
- INSERM U1070, Poitiers, France; Faculté de médecine et pharmacie, université de Poitiers, Poitiers, France; Service de mycologie-parasitologie, département des agents infectieux, CHU de Poitiers, Poitiers, France.
| | - B Rammaert
- INSERM U1070, Poitiers, France; Faculté de médecine et pharmacie, université de Poitiers, Poitiers, France; Service de maladies infectieuses et tropicales, CHU de Poitiers, Poitiers, France
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Bidaud A, Djenontin E, Botterel F, Chowdhary A, Dannaoui E. Colistin interacts synergistically with echinocandins against Candida auris. Int J Antimicrob Agents 2020; 55:105901. [DOI: 10.1016/j.ijantimicag.2020.105901] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/02/2020] [Accepted: 01/11/2020] [Indexed: 02/06/2023]
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Schmidt S, Hogardt M, Demir A, Röger F, Lehrnbecher T. Immunosuppressive Compounds Affect the Fungal Growth and Viability of Defined Aspergillus Species. Pathogens 2019; 8:pathogens8040273. [PMID: 31795350 PMCID: PMC6963520 DOI: 10.3390/pathogens8040273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 12/14/2022] Open
Abstract
Immunosuppressive drugs are administered to a number of patients; e.g., to allogeneic hematopoietic stem cell transplant recipients. Immunosuppressive drugs impair the immune system and thus increase the risk of invasive fungal disease, but may exhibit antifungal activity at the same time. We investigated the impact of various concentrations of three commonly used immunosuppressive compounds—cyclosporin A (CsA), methylprednisolone (mPRED), and mycophenolic acid (MPA)—on the growth and viability of five clinically important Aspergillus species. Methods included disc diffusion, optical density of mycelium, and viability assays such as XTT. MPA and CsA had a species-specific and dose-dependent inhibitory effect on the growth of all Aspergillus spp. tested, although growth inhibition by MPA was highest in A. niger,A. flavus and A. brasiliensis. Both agents exhibited species-specific hyphal damage, which was higher when the immunosuppressants were added to growing conidia than to mycelium. In contrast, mPRED increased the growth of A. niger, but had no major impact on the growth and viability of any of the other Aspergillus species tested. Our findings may help to better understand the interaction of drugs with Aspergillus species and ultimately may have an impact on individualizing immunosuppressive therapy.
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Affiliation(s)
- Stanislaw Schmidt
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (S.S.); (A.D.); (F.R.)
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany;
| | - Asuman Demir
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (S.S.); (A.D.); (F.R.)
| | - Frauke Röger
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (S.S.); (A.D.); (F.R.)
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (S.S.); (A.D.); (F.R.)
- Correspondence:
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16
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In vitro antifungal combination of flucytosine with amphotericin B, voriconazole, or micafungin against Candida auris shows no antagonism. Antimicrob Agents Chemother 2019:AAC.01393-19. [PMID: 31591129 DOI: 10.1128/aac.01393-19] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Candida auris is an emerging, multidrug resistant pathogen, responsible for invasive hospital-acquired infections. Flucytosine is an effective anti-Candida drug, but which cannot be used as a monotherapy because of the risk of development of resistant mutants during treatment. It is therefore noteworthy to test possible combinations with flucytosine that may have a synergistic interaction. In this study, we determined the in vitro interaction between flucytosine and amphotericin B, micafungin, or voriconazole. These combinations have been tested against 15 C. auris isolates. The MIC range (Gmean) of flucytosine, amphotericin B, micafungin and voriconazole were 0.125 to 1 μg/mL (0.42 μg/ml), 0.25 to 1 μg/ml (0.66 μg/ml), 0.125 to 0.5 μg/ml (0.3 μg/ml) and 0.03 to 4 μg/ml (1.05 μg/ml), respectively. When tested in combination, indifferent interactions were mostly observed with fractional inhibitory concentration index values from 0.5 to 1, 0.31 to 1.01 and 0.5 to 1.06 for the combination of flucytosine with amphotericin B, micafungin and voriconazole, respectively. A synergy was observed for the strain CBS 10913 from Japan. No antagonism was observed for any combination. Combination of flucytosine with amphotericin B or micafungin may be relevant for the treatment of C. auris infections.
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17
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Schwarz P, Cornely OA, Dannaoui E. Antifungal combinations in Mucorales: A microbiological perspective. Mycoses 2019; 62:746-760. [PMID: 30830980 DOI: 10.1111/myc.12909] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 12/24/2022]
Abstract
Mucormycosis mostly affects immunocompromised patients and is associated with a high morbidity and mortality despite currently available treatments. In that context, combination therapy might be the key to a better outcome for these patients. Purpose of this review is to summarise and to discuss the current combination data obtained in vitro, in vivo in animal models of mucormycosis, and in patients. In vitro combination studies showed that most of the interactions between antifungal drugs were indifferent, even though that some synergistic interactions were achieved for the combination of echinocandins with either azoles or amphotericin B. Importantly, antagonism was never observed. Animal models of mucormycosis focused on infections caused by Rhizopus arrhizus, neglecting most other species responsible for human disease. In these experimental animal models, no strong interactions have been demonstrated, although a certain degree of synergism has been reported in some instances. Combinations of antifungals with non-antifungal drugs have also been largely explored in vitro and in animal models and yielded interesting results. In patients with ketoacidosis and rhino-orbito-cerebral infection, combination of polyene with caspofungin was effective. In contrast, despite promising experimental data, adjunctive therapy with the iron chelator deferasirox was unfavourable and was associated with a higher mortality than monotherapy with liposomal amphotericin B. More combinations have to be tested in vitro and a much larger panel of Mucorales species has to be tested in vivo to give a valuable statement if antifungal combination therapy could be an effective treatment strategy in patients with mucormycosis.
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Affiliation(s)
- Patrick Schwarz
- Department of Internal Medicine, Respiratory and Critical Care Medicine, University Hospital Marburg, Marburg, Germany.,Center for Invasive Mycoses and Antifungals, Philipps University Marburg, Marburg, Germany
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), ZKS Köln, University of Cologne, Cologne, Germany.,Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Eric Dannaoui
- Université Paris Descartes, Faculté de Médecine, AP-HP, Hôpital Européen Georges Pompidou, Unité de Parasitologie-Mycologie, Paris, France.,Dynamyc Research Group (EA 7380), Paris Est Créteil University, Créteil, France
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