Successful therapy of Candida albicans arthritis with a sequential intravenous amphotericin B and oral fluconazole regimen

Candidal arthritis in revision knee arthroplasty successfully treated with sequential parenteral-oral fluconazole and amphotericin B-loaded cement spacer

We present a case of a patient with preoperative cutaneous candidiasis, who developed candidal infection during stage revision knee arthroplasty. The patient received intravenous fluconazole for 6 weeks and resection arthroplasty with an amphotericin B-loaded cement spacer and continuous oral fluconazole therapy for 9 weeks. Revision surgery was successful.

Single-blind, randomized, prospective study of sequential itraconazole and terbinafine pulse compared with terbinafine pulse for the treatment of toenail onychomycosis

OBJECTIVE

Efficacy and safety of sequential pulse therapy with itraconazole and terbinafine were compared with pulse terbinafine alone in the treatment of toenail onychomycosis.

METHODS

This was a 72-week prospective, single-blind, randomized, multicenter, comparative, parallel group, nonindustry-sponsored trial. A total of 190 patients were recruited from 3 outpatient dermatology offices in North America. Patients were at least 18 years old and had a clinical and mycologic diagnosis of dermatophyte toenail onychomycosis. Patients were randomly assigned to receive sequential pulse therapy (IIT) with 2 pulses of itraconazole followed by 1 or 2 pulses of terbinafine (itraconazole pulse is 200 mg twice daily for 1 week and terbinafine pulse is 250 mg twice daily for 1 week) versus 3 or 4 pulses of terbinafine (TTT). Main outcome measures at week 72 evaluated mycologic cure rate (negative light microscopy and culture), clinical cure (nail appears completely or totally normal), complete cure (clinical and mycologic cure), and effective therapy (mycologic cure and clinical response with at least 5 mm of new, uninvolved nail growth).

RESULTS

At week 72, in the IIT versus TTT groups, the mycologic cure rate was 54 of 75 (72.0%) versus 44 of 90 (48.9%), clinical cure rate was 42 of 75 (56.0%) versus 35 of 90 (38.9%), effective therapy 49 of 75 (65.3%) versus 41 of 90 (45.6%), and complete cure 39 of 75 (52.0%) versus 29 of 90 (32.2%), respectively. Both regimens were well tolerated with no new adverse effects being identified. The rate of permanent discontinuation of therapy because of adverse effects was 2 of 81 (2.5%) with IIT and 2 of 95 (2.1%) with TTT. Each of the adverse effects normalized over time. The number of patients who reported an adverse effect in the 2 groups was 12 of 81 (14.8%) versus 22 of 95 (23.2%), respectively. All these adverse effects were reversible and mild to moderate in severity.

CONCLUSION

Sequential pulse therapy with itraconazole and terbinafine is effective and safe for the treatment of dermatophyte toenail onychomycosis.

[Fungal arthritis--a rare complication of systemic candidiasis or orthopedic intervention. Review of therapeutic experience with fluconazole]

The higher number of implanted artificial joints, the broader use of aggressive treatment regimen, e.g. high-dose chemotherapy and total parenteral nutrition, the increasing use of central venous catheters and a broader use of immunosuppressive drugs are likely to result in a higher incidence of fungal arthritis, especially caused by Candida spp. Therefore, a careful evaluation of the available therapeutic options is necessary. The published clinical data on the therapeutic use of fluconazole in the treatment of fungal arthritis were reviewed. A total of 24 publications report the use of fluconazole in fungal arthritis in 32 patients. The mean duration of therapy was 6 months (maximum duration: 2 years) with an average dosage of 200-400 mg/d (maximum dosage: 800 mg/d). Native arthritis was diagnosed in 27 patients, prosthetic arthritis in 5 patients. In all patients an isolated joint was infected, most frequently the knee joint. Fluconazole was effective and safe in acute therapy alone or in combination with surgery as well as in long term suppression therapy.