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Roy M, Karhana S, Shamsuzzaman M, Khan MA. Recent drug development and treatments for fungal infections. Braz J Microbiol 2023; 54:1695-1716. [PMID: 37219748 PMCID: PMC10484882 DOI: 10.1007/s42770-023-00999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/27/2023] [Indexed: 05/24/2023] Open
Abstract
Fungal infections are now becoming a hazard to individuals which has paved the way for research to expand the therapeutic options available. Recent advances in drug design and compound screening have also increased the pace of the development of antifungal drugs. Although several novel potential molecules are reported, those discoveries have yet to be translated from bench to bedside. Polyenes, azoles, echinocandins, and flucytosine are among the few antifungal agents that are available for the treatment of fungal infections, but such conventional therapies show certain limitations like toxicity, drug interactions, and the development of resistance which limits the utility of existing antifungals, contributing to significant mortality and morbidity. This review article focuses on the existing therapies, the challenges associated with them, and the development of new therapies, including the ongoing and recent clinical trials, for the treatment of fungal infections. Advancements in antifungal treatment: a graphical overview of drug development, adverse effects, and future prospects.
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Affiliation(s)
- Madhura Roy
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Sonali Karhana
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India
| | - Md Shamsuzzaman
- Department of Pharmaceutical Sciences, College of Pharmacy, Shaqra University, Sahqra, Kingdom of Saudi Arabia
| | - Mohd Ashif Khan
- Centre for Translational & Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi, 110062, India.
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2
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Modeling Invasive Aspergillosis: How Close Are Predicted Antifungal Targets? J Fungi (Basel) 2020; 6:jof6040198. [PMID: 33007839 PMCID: PMC7712059 DOI: 10.3390/jof6040198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
Animal model systems are a critical component of the process of discovery and development of new antifungal agents for treatment and prevention of invasive aspergillosis. The persistently neutropenic rabbit model of invasive pulmonary aspergillosis (IPA) has been a highly predictive system in identifying new antifungal agents for treatment and prevention of this frequently lethal infection. Since its initial development, the persistently neutropenic rabbit model of IPA has established a strong preclinical foundation for dosages, drug disposition, pharmacokinetics, safety, tolerability, and efficacy for deoxycholate amphotericin B, liposomal amphotericin B, amphotericin B lipid complex, amphotericin B colloidal dispersion, caspofungin, micafungin, anidulafungin, voriconazole, posaconazole, isavuconazole, and ibrexafungerp in treatment of patients with invasive aspergillosis. The findings of combination therapy with a mould-active triazole and an echinocandin in this rabbit model also predicted the outcome of the clinical trial for voriconazole plus anidulafungin for treatment of IPA. The plasma pharmacokinetic parameters and tissue disposition for most antifungal agents approximate those of humans in persistently neutropenic rabbits. Safety, particularly nephrotoxicity, has also been highly predictive in the rabbit model, as exemplified by the differential glomerular filtration rates observed in animals treated with deoxycholate amphotericin B, liposomal amphotericin B, amphotericin B lipid complex, and amphotericin B colloidal dispersion. A panel of validated outcome variables measures therapeutic outcome in the rabbit model: residual fungal burden, markers of organism-mediated pulmonary injury (lung weights and infarct scores), survival, and serum biomarkers. In selected antifungal studies, thoracic computerized tomography (CT) is also used with diagnostic imaging algorithms to measure therapeutic response of pulmonary infiltrates, which exhibit characteristic radiographic patterns, including nodules and halo signs. Further strengthening the predictive properties of the model, therapeutic response to successfully developed antifungal agents for treatment of IPA has been demonstrated over the past two decades by biomarkers of serum galactomannan and (1→3)-β-D-glucan with patterns of resolution, that closely mirror those documented responses in patients with IPA. The decision to move from laboratory to clinical trials should be predicated upon a portfolio of complementary and mutually validating preclinical laboratory animal models studies. Other model systems, including those in mice, rats, and guinea pigs, are also valuable tools in developing clinical protocols. Meticulous preclinical investigation of a candidate antifungal compound in a robust series of complementary laboratory animal models will optimize study design, de-risk clinical trials, and ensure tangible benefit to our most vulnerable immunocompromised patients with invasive aspergillosis.
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Otto WR, Pahud BA, Yin DE. Pediatric Mucormycosis: A 10-Year Systematic Review of Reported Cases and Review of the Literature. J Pediatric Infect Dis Soc 2019; 8:342-350. [PMID: 31181136 DOI: 10.1093/jpids/piz007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 05/28/2019] [Indexed: 12/29/2022]
Abstract
Mucormycosis is a severe infection that affects a variety of patients, including immunocompromised children and neonates. Given improved survival rates from advances in the treatment of malignancies, the population at risk for mucormycosis is increasing. We conducted a systematic review of cases of mucormycosis in children in the English-language literature reported between August 2008 and June 2017 and analyzed the clinical characteristics, diagnosis, management, and outcome of those infections. The most common underlying diagnoses included neutropenia (41%), hematologic malignancy (39%), prematurity (13%), and hematopoietic stem cell transplant (11%). Sinus disease (28%) and disseminated disease (24%) were the most common presentations. Rhizopus spp were the most common organisms isolated (22%). Amphotericin B remains the backbone of treatment and was prescribed in 86% of these cases. The resulting mortality rate remains high (32%). We provide here the results of a literature review of mucormycosis in children, including its epidemiology and clinical manifestations, and describe current advances in its diagnosis and treatment.
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Affiliation(s)
- William R Otto
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
| | - Barbara A Pahud
- Department of Pediatrics, Division of Infectious Diseases, Children's Mercy, Kansas City, Missouri.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Missouri
| | - Dwight E Yin
- Department of Pediatrics, Division of Infectious Diseases, Children's Mercy, Kansas City, Missouri.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Missouri
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Warris A, Lehrnbecher T, Roilides E, Castagnola E, Brüggemann RJM, Groll AH. ESCMID-ECMM guideline: diagnosis and management of invasive aspergillosis in neonates and children. Clin Microbiol Infect 2019; 25:1096-1113. [PMID: 31158517 DOI: 10.1016/j.cmi.2019.05.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 01/01/2023]
Abstract
SCOPE Presenting symptoms, distributions and patterns of diseases and vulnerability to invasive aspergillosis (IA) are similar between children and adults. However, differences exist in the epidemiology and underlying conditions, the usefulness of newer diagnostic tools, the pharmacology of antifungal agents and in the evidence from interventional phase 3 clinical trials. Therefore, the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and the European Confederation of Medical Mycology (ECMM) have developed a paediatric-specific guideline for the diagnosis and management of IA in neonates and children. METHODS Review and discussion of the scientific literature and grading of the available quality of evidence was performed by the paediatric subgroup of the ESCMID-ECMM-European Respiratory Society (ERS) Aspergillus disease guideline working group, which was assigned the mandate for the development of neonatal- and paediatric-specific recommendations. QUESTIONS Questions addressed by the guideline included the epidemiology of IA in neonates and children; which paediatric patients may benefit from antifungal prophylaxis; how to diagnose IA in neonates and children; which antifungal agents are available for use in neonates and children; which antifungal agents are suitable for prophylaxis and treatment of IA in neonates and children; what is the role of therapeutic drug monitoring of azole antifungals; and which management strategies are suitable to be used in paediatric patients. This guideline provides recommendations for the diagnosis, prevention and treatment of IA in the paediatric population, including neonates. The aim of this guideline is to facilitate optimal management of neonates and children at risk for or diagnosed with IA.
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Affiliation(s)
- A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands.
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University 96 School of Health Sciences, Thessaloniki, Greece; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
| | - E Castagnola
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - R J M Brüggemann
- Radboud Center for Infectious Diseases, Radboud University Medical Centre, Center of Expertise in Mycology Radboudumc/CWZ, European Confederation of Medical Mycology (ECMM) Excellence Center of Medical Mycology, Nijmegen, the Netherlands; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG)
| | - A H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Paediatric Hematology/Oncology, University Children's Hospital Münster, Münster, Germany; European Society of Clinical Microbiology and Infectious Diseases Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology, the Netherlands
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Katragkou A, Fisher BT, Groll AH, Roilides E, Walsh TJ. Diagnostic Imaging and Invasive Fungal Diseases in Children. J Pediatric Infect Dis Soc 2017; 6:S22-S31. [PMID: 28927203 DOI: 10.1093/jpids/pix055] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Invasive fungal disease (IFD) is a life-threatening condition, especially in immunocompromised children. The role of diagnostic imaging in children at risk for an IFD is multifactorial, including initially detecting it, evaluating for dissemination of infection beyond the primary site of disease, monitoring the response to antifungal therapy, and assessing for potential relapse. The objective of this review was to synthesize the published literature relevant to the use of various imaging modalities for the diagnosis and management of IFD in children.
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Affiliation(s)
- Aspasia Katragkou
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Nationwide Children's Hospital and Ohio State University, Columbus
| | - Brian T Fisher
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness Research, Children's Hospital of Philadelphia, Pennsylvania.,Departments of Pediatrics and Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology and Oncology and Center for Bone Marrow Transplantation, University Children's Hospital Muenster, Germany
| | - Emmanuel Roilides
- Infectious Diseases Section, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program and Departments of Medicine, Pediatrics, Microbiology and Immunology, Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital
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Wattier RL, Ramirez-Avila L. Pediatric Invasive Aspergillosis. J Fungi (Basel) 2016; 2:jof2020019. [PMID: 29376936 PMCID: PMC5753081 DOI: 10.3390/jof2020019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 06/06/2016] [Accepted: 06/08/2016] [Indexed: 02/06/2023] Open
Abstract
Invasive aspergillosis (IA) is a disease of increasing importance in pediatrics due to growth of the immunocompromised populations at risk and improvements in long-term survival for many of these groups. While general principles of diagnosis and therapy apply similarly across the age spectrum, there are unique considerations for clinicians who care for children and adolescents with IA. This review will highlight important differences in the epidemiology, clinical manifestations, diagnosis, and therapy of pediatric IA.
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Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California-San Francisco, 550 16th St, 4th Floor, Box 0434, San Francisco, CA 94143, USA.
| | - Lynn Ramirez-Avila
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California-San Francisco, 550 16th St, 4th Floor, Box 0434, San Francisco, CA 94143, USA.
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Pediatric Invasive Candidiasis: Epidemiology and Diagnosis in Children. J Fungi (Basel) 2016; 2:jof2010005. [PMID: 29376923 PMCID: PMC5753086 DOI: 10.3390/jof2010005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 12/31/2022] Open
Abstract
Pediatric patients present with differing underlying conditions and cytotoxic therapeutic protocols, so the differing epidemiology of invasive candidiasis in children versus adults is not surprising. Understanding the Candida species epidemiology is critical, as we often begin empiric therapy or therapy before antifungal susceptibilities are known. Reports with newer molecular diagnostic assays for invasive candidiasis are rare and require more study to develop firm pediatric-specific guidance. Antifungal treatment of pediatric candidiasis is reviewed in the context of larger epidemiologic studies and the few trials completed to date.
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Stergiopoulou T, Walsh TJ. Clinical pharmacology of antifungal agents to overcome drug resistance in pediatric patients. Expert Opin Pharmacother 2015; 16:213-26. [PMID: 25579070 DOI: 10.1517/14656566.2015.1000302] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Antifungal resistance is an emerging problem that increases morbidity and mortality in immunosuppressed pediatric patients, who suffer from invasive fungal diseases. Optimal pharmacological management is critical for the successful treatment of invasive fungal infections by resistant strains. AREAS COVERED This paper reviews the mechanisms of resistance of different classes of antifungal agents and the current understanding of pediatric antifungal pharmacology for overcoming antifungal resistance in children based on laboratory and clinical studies in the English literature. The therapeutic choices against fungal pathogens with intrinsic or acquired resistance are further reviewed. EXPERT OPINION There is a paucity of data in the pediatric population regarding the epidemiology of the resistant organisms to different antifungal agents. It is also unknown if there are more prevalent molecular mechanisms that promote antifungal resistance. Selection and dosages of the most effective antifungal agent for overcoming the antifungal resistance is crucial. However, there are limited studies guiding the optimal dosage and duration of treatment for management of emergent antifungal resistance. Further studies are warranted to elucidate the optimal pharmacology of the current antifungal agents against resistant organisms and to advance the development of new antifungal agents.
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Botero-Calderon L, Benjamin DK, Cohen-Wolkowiez M. Advances in the treatment of invasive neonatal candidiasis. Expert Opin Pharmacother 2015; 16:1035-48. [PMID: 25842986 PMCID: PMC4402277 DOI: 10.1517/14656566.2015.1031108] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Invasive candidiasis is responsible for ∼ 10% of nosocomial sepsis in very-low-birth-weight infants and is associated with substantial morbidity and mortality. Over the last two decades, the antifungal armamentarium against Candida spp. has increased; however, efficacy and safety studies in this population are lacking. AREAS COVERED We reviewed the medical literature and extracted information on clinical and observational studies evaluating the use of antifungal agents in neonates with invasive candidiasis. EXPERT OPINION Efficacy and safety data for antifungals in neonates are lacking, and the majority of studies conducted to date have concentrated on pharmacokinetic/pharmacodynamic evaluations. Unlike other anti-infective agents, efficacy data in the setting of neonatal candidiasis cannot be extrapolated from adult studies due to differences in the pathophysiology of the disease in this population relative to older children and adults. Data for amphotericin B deoxycholate, fluconazole, and micafungin suggest that these are the current agents of choice for this disease in neonates until data for newer antifungal agents become available. For prophylaxis, data from fluconazole randomized controlled trials will be submitted to the regulatory agencies for labeling. Ultimately, the field of therapeutics for neonatal candidiasis will require multidisciplinary collaboration given the numerous challenges associated with conducting clinical trials in neonates.
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Autmizguine J, Guptill JT, Cohen-Wolkowiez M, Benjamin DK, Capparelli EV. Pharmacokinetics and pharmacodynamics of antifungals in children: clinical implications. Drugs 2014; 74:891-909. [PMID: 24872147 PMCID: PMC4073603 DOI: 10.1007/s40265-014-0227-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Invasive fungal disease (IFD) remains life threatening in premature infants and immunocompromised children despite the recent development of new antifungal agents. Optimal dosing of antifungals is one of the few factors clinicians can control to improve outcomes of IFD. However, dosing in children cannot be extrapolated from adult data because IFD pathophysiology, immune response, and drug disposition differ from adults. We critically examined the literature on pharmacokinetics (PK) and pharmacodynamics (PD) of antifungal agents and highlight recent developments in treating pediatric IFD. To match adult exposure in pediatric patients, dosing adjustment is necessary for almost all antifungals. In young infants, the maturation of renal and metabolic functions occurs rapidly and can significantly influence drug exposure. Fluconazole clearance doubles from birth to 28 days of life and, beyond the neonatal period, agents such as fluconazole, voriconazole, and micafungin require higher dosing than in adults because of faster clearance in children. As a result, dosing recommendations are specific to bracketed ranges of age. PD principles of antifungals mostly rely on in vitro and in vivo models but very few PD studies specifically address IFD in children. The exposure-response relationship may differ in younger children compared with adults, especially in infants with invasive candidiasis who are at higher risk of disseminated disease and meningoencephalitis, and by extension severe neurodevelopmental impairment. Micafungin is the only antifungal agent for which a specific target of exposure was proposed based on a neonatal hematogenous Candida meningoencephalitis animal model. In this review, we found that pediatric data on drug disposition of newer triazoles and echinocandins are lacking, dosing of older antifungals such as fluconazole and amphotericin B products still need optimization in young infants, and that target PK/PD indices need to be clinically validated for almost all antifungals in children. A better understanding of age-specific PK and PD of new antifungals in infants and children will help improve clinical outcomes of IFD by informing dosing and identifying future research areas.
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Affiliation(s)
- Julie Autmizguine
- Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705, USA
| | | | | | | | - Edmund V. Capparelli
- Department of Pediatric Pharmacology, University of California, 9500 Gilman Drive, La Jolla, CA 92093-0831, USA
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Cornely O, Arikan-Akdagli S, Dannaoui E, Groll A, Lagrou K, Chakrabarti A, Lanternier F, Pagano L, Skiada A, Akova M, Arendrup M, Boekhout T, Chowdhary A, Cuenca-Estrella M, Freiberger T, Guinea J, Guarro J, de Hoog S, Hope W, Johnson E, Kathuria S, Lackner M, Lass-Flörl C, Lortholary O, Meis J, Meletiadis J, Muñoz P, Richardson M, Roilides E, Tortorano A, Ullmann A, van Diepeningen A, Verweij P, Petrikkos G. ESCMID† and ECMM‡ joint clinical guidelines for the diagnosis and management of mucormycosis 2013. Clin Microbiol Infect 2014; 20 Suppl 3:5-26. [DOI: 10.1111/1469-0691.12371] [Citation(s) in RCA: 465] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/09/2013] [Accepted: 08/12/2013] [Indexed: 12/22/2022]
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Thomas L, Baggen L, Chisholm J, Sharland M. Diagnosis and treatment of aspergillosis in children. Expert Rev Anti Infect Ther 2014; 7:461-72. [DOI: 10.1586/eri.09.19] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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13
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Kuyucu N. Amphotericin B use in children: conventional and lipid-based formulations. Expert Rev Anti Infect Ther 2014; 9:357-67. [DOI: 10.1586/eri.11.5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Hundalani S, Pammi M. Invasive fungal infections in newborns and current management strategies. Expert Rev Anti Infect Ther 2014; 11:709-21. [DOI: 10.1586/14787210.2013.811925] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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[Recommendations for the management of candidemia in children in Latin America. Grupo Proyecto Épico]. Rev Iberoam Micol 2013; 30:171-8. [PMID: 23764558 DOI: 10.1016/j.riam.2013.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 05/16/2013] [Indexed: 11/22/2022] Open
Abstract
Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. 'Recommendations for the diagnosis and management of candidemia' are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, 'Recommendations for the management of candidemia in children in Latin America', was written to provide guidance to healthcare professionals on the management of children who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. 'Recommendations for the management of candidemia in children in Latin America' includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, duration of candidemia treatment, and central venous catheter management in children with candidemia. This manuscript is the third of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: 'Recommendations for the diagnosis of candidemia in Latin America', 'Recommendations for the management of candidemia in adults in Latin America', and 'Recommendations for the management of candidemia in neonates in Latin America'.
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Santolaya ME, de Queiroz Telles F, Alvarado Matute T, Colombo AL, Zurita J, Tiraboschi IN, Cortes JA, Thompson-Moya L, Guzman-Blanco M, Sifuentes J, Echevarría J, Nucci M. Recommendations for the management of candidemia in children in Latin America. Latin America Invasive Mycosis Network. Rev Iberoam Micol 2013; 30:171-8. [PMID: 23764557 DOI: 10.1016/j.riam.2013.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/09/2013] [Accepted: 05/16/2013] [Indexed: 11/25/2022] Open
Abstract
Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. 'Recommendations for the diagnosis and management of candidemia' are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, 'Recommendations for the management of candidemia in children in Latin America', was written to provide guidance to healthcare professionals on the management of children who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. 'Recommendations for the management of candidemia in children in Latin America' includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, duration of candidemia treatment, and central venous catheter management in children with candidemia. This manuscript is the third of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: 'Recommendations for the diagnosis of candidemia in Latin America', 'Recommendations for the management of candidemia in adults in Latin America', and 'Recommendations for the management of candidemia in neonates in Latin America'.
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Affiliation(s)
- María E Santolaya
- Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; Latin America Invasive Mycosis Network.
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Hope W, Castagnola E, Groll A, Roilides E, Akova M, Arendrup M, Arikan-Akdagli S, Bassetti M, Bille J, Cornely O, Cuenca-Estrella M, Donnelly J, Garbino J, Herbrecht R, Jensen H, Kullberg B, Lass-Flörl C, Lortholary O, Meersseman W, Petrikkos G, Richardson M, Verweij P, Viscoli C, Ullmann A. ESCMID* *This guideline was presented in part at ECCMID 2011. European Society for Clinical Microbiology and Infectious Diseases. guideline for the diagnosis and management of Candida diseases 2012: prevention and management of invasive infections in neonates and children caused by Candida spp. Clin Microbiol Infect 2012; 18 Suppl 7:38-52. [DOI: 10.1111/1469-0691.12040] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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18
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Results from a prospective, international, epidemiologic study of invasive candidiasis in children and neonates. Pediatr Infect Dis J 2012; 31:1252-7. [PMID: 22982980 DOI: 10.1097/inf.0b013e3182737427] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Candida species are the third most common cause of pediatric health care-associated bloodstream infection in the United States and Europe. To our knowledge, this report from the International Pediatric Fungal Network is the largest prospective, multicenter observational study dedicated to pediatric and neonatal invasive candidiasis. METHODS From 2007 to 2011, we enrolled 196 pediatric and 25 neonatal patients with invasive candidiasis. RESULTS Non-albicans Candida species predominated in pediatric (56%) and neonatal (52%) age groups, yet Candida albicans was the most common species in both groups. Successful treatment responses were observed in pediatric (76%) and neonatal patients (92%). Infection with Candida parapsilosis led to successful responses in pediatric (92%) and neonatal (100%) patients, whereas infection with Candida glabrata was associated with a lower successful outcome in pediatric patients (55%). The most commonly used primary antifungal therapies for pediatric invasive candidiasis were fluconazole (21%), liposomal amphotericin B (20%) and micafungin (18%). Outcome of pediatric invasive candidiasis was similar in response to polyenes (73%), triazoles (67%) and echinocandins (73%). The most commonly used primary antifungal therapies for neonatal invasive candidiasis were fluconazole (32%), caspofungin (24%) and liposomal amphotericin B (16%) and micafungin (8%). Outcomes of neonatal candidiasis by antifungal class again revealed similar response rates among the classes. CONCLUSIONS We found a predominance of non-albicans Candida infection in children and similar outcomes based on antifungal class used. This international collaborative study sets the foundation for large epidemiologic studies focusing on the unique features of neonatal and pediatric candidiasis and comparative studies of therapeutic interventions in these populations.
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Antifungal agents for the treatment of systemic fungal infections in children. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2012; 21:e116-21. [PMID: 22132005 DOI: 10.1155/2010/784549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traditionally, the mainstay of systemic antifungal therapy has been amphotericin B deoxycholate (conventional amphotericin B). Newer agents have been developed to fulfill special niches and to compete with conventional amphotericin B by virtue of having more favourable toxicity profiles. Some agents have displaced conventional amphotericin B for the treatment of specific fungal diseases. For example, voriconazole has emerged as the preferred treatment for invasive pulmonary aspergillosis. This notwithstanding, conventional amphotericin B remains a useful agent for the treatment of paediatric fungal infections. Knowledge of the characteristics of the newer agents is important, given the increasing numbers of patients who are being treated with these drugs. Efforts need to be directed at research aimed at generating paediatric data where these are lacking. The antifungal agents herein described are most often used as monotherapy regimens because there is no uniform consensus on the value of combination therapy, except for specific scenarios.
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Manzoni P, Galletto P, Rizzollo S, Franco C, Gallo E, Antonucci R, Fanos V, Farina D. Liposomal amphotericin B does not induce nephrotoxicity or renal function impairment in premature neonates. Early Hum Dev 2012; 88 Suppl 2:S86-91. [PMID: 22633524 DOI: 10.1016/s0378-3782(12)70024-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Liposomal amphotericin B (LAMB) is frequently administered in NICU to preterm infants <1500 g at birth (VLBW) for treatment of systemic fungal infections (SFI). Concerns exist on safety and tolerability of such drug in patients who are at risk for renal function impairment due to their prematurity. AIM To assess the occurrence of renal function impairment related to LAMB in a 10-year cohort of VLBW neonates treated with this drug. METHODS Through database search of clinical charts, all VLBW neonates admitted to a 3(rd) level NICU in the years 1998-2007 and undergoing treatment with LAMB were identified. The occurrence of LAMB-attributable renal toxicity was investigated; infants withdrawn from treatment for development of adverse effects or toxicity were identified. RESULTS In the study period, 71 of 792 admitted VLBW neonates (8.9%) underwent antifungal treatment with LAMB administered at the recommended dosages (3-to-5 mg/kg/day). Mean duration of treatment was 14 (±9) days, mean cumulative dose given was 58 (±25) mg/kg per infant. Renal compromise, defined as hypokalaemia, and/or elevated creatinine serum levels, and/or decreased urine output, occurred in 2 of 71 (2.8%) treated patients, by 5 (±3) mean days after treatment initiation. In both patients LAMB was withdrawn; renal function impairment was only mild and transient, and normal renal function was restored at discharge. No other significant adverse effects were recorded in any treated neonate. CONCLUSIONS LAMB is generally safe and well tolerated in VLBW neonates. The occurrence of LAMB-related nephrotoxicity appears to be uncommon, mild and transient.
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Affiliation(s)
- P Manzoni
- Neonatology and NICU, Sant'Anna Hospital, Azienda Ospedaliera OIRM - S Anna, Torino, Italy.
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Pana ZD, Ioannidou M, Roilides E. Is There Still a Place for Conventional Amphotericin B in the Treatment of Neonatal Fungal Infections? CURRENT FUNGAL INFECTION REPORTS 2012. [DOI: 10.1007/s12281-011-0074-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lewis RE, Lortholary O, Spellberg B, Roilides E, Kontoyiannis DP, Walsh TJ. How Does Antifungal Pharmacology Differ for Mucormycosis Versus Aspergillosis? Clin Infect Dis 2012; 54 Suppl 1:S67-72. [DOI: 10.1093/cid/cir884] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Tragiannidis A, Roilides E, Walsh TJ, Groll AH. Invasive Aspergillosis in Children With Acquired Immunodeficiencies. Clin Infect Dis 2011; 54:258-67. [DOI: 10.1093/cid/cir786] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Bassetti M, Aversa F, Ballerini F, Benedetti F, Busca A, Cascavilla N, Concia E, Tendas A, Di Raimondo F, Mazza P, Nosari AM, Rossi G. Amphotericin B Lipid Complex in the Management of Invasive Fungal Infections in Immunocompromised Patients. Clin Drug Investig 2011; 31:745-58. [DOI: 10.2165/11593760-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Ruhnke M, Rickerts V, Cornely OA, Buchheidt D, Glöckner A, Heinz W, Höhl R, Horré R, Karthaus M, Kujath P, Willinger B, Presterl E, Rath P, Ritter J, Glasmacher A, Lass-Flörl C, Groll AH. Diagnosis and therapy of Candida infections: joint recommendations of the German Speaking Mycological Society and the Paul-Ehrlich-Society for Chemotherapy. Mycoses 2011; 54:279-310. [PMID: 21672038 DOI: 10.1111/j.1439-0507.2011.02040.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Invasive Candida infections are important causes of morbidity and mortality in immunocompromised and hospitalised patients. This article provides the joint recommendations of the German-speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMyKG) and the Paul-Ehrlich-Society for Chemotherapy (PEG) for diagnosis and treatment of invasive and superficial Candida infections. The recommendations are based on published results of clinical trials, case-series and expert opinion using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA). Key recommendations are summarised here: The cornerstone of diagnosis remains the detection of the organism by culture with identification of the isolate at the species level; in vitro susceptibility testing is mandatory for invasive isolates. Options for initial therapy of candidaemia and other invasive Candida infections in non-granulocytopenic patients include fluconazole or one of the three approved echinocandin compounds; liposomal amphotericin B and voriconazole are secondary alternatives because of their less favourable pharmacological properties. In granulocytopenic patients, an echinocandin or liposomal amphotericin B is recommended as initial therapy based on the fungicidal mode of action. Indwelling central venous catheters serve as a main source of infection independent of the pathogenesis of candidaemia in the individual patients and should be removed whenever feasible. Pre-existing immunosuppressive treatment, particularly by glucocorticosteroids, ought to be discontinued, if feasible, or reduced. The duration of treatment for uncomplicated candidaemia is 14 days following the first negative blood culture and resolution of all associated symptoms and findings. Ophthalmoscopy is recommended prior to the discontinuation of antifungal chemotherapy to rule out endophthalmitis or chorioretinitis. Beyond these key recommendations, this article provides detailed recommendations for specific disease entities, for antifungal treatment in paediatric patients as well as a comprehensive discussion of epidemiology, clinical presentation and emerging diagnostic options of invasive and superficial Candida infections.
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Affiliation(s)
- Markus Ruhnke
- Medizinische Klinik m S Onkologie u Hämatologie, Charité Universitätsmedizin, Charité, Campus Mitte, Berlin, Germany.
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Lehrnbecher T, Bochennek K, Schrey D, Groll AH. Antifungal Therapy in Pediatric Patients. CURRENT FUNGAL INFECTION REPORTS 2011. [DOI: 10.1007/s12281-011-0046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Aguado JM, Ruiz-Camps I, Muñoz P, Mensa J, Almirante B, Vázquez L, Rovira M, Martín-Dávila P, Moreno A, Alvarez-Lerma F, León C, Madero L, Ruiz-Contreras J, Fortún J, Cuenca-Estrella M. [Guidelines for the treatment of Invasive Candidiasis and other yeasts. Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). 2010 Update]. Enferm Infecc Microbiol Clin 2011; 29:345-61. [PMID: 21459489 DOI: 10.1016/j.eimc.2011.01.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 01/17/2011] [Indexed: 12/29/2022]
Abstract
These guidelines are an update of the recommendations of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) that were issued in 2004 (Enferm Infecc Microbiol Clin. 2004, 22:32-9) on the treatment of Invasive Candidiasis and infections produced by other yeasts. This 2010 update includes a comprehensive review of the new drugs that have appeared in recent years, as well as the levels of evidence for recommending them. These guidelines have been developed following the rules of the SEIMC by a working group composed of specialists in infectious diseases, clinical microbiology, critical care medicine, paediatrics and oncology-haematology. It provides a series of general recommendations regarding the management of invasive candidiasis and other yeast infections, as well as specific guidelines for prophylaxis and treatment, which have been divided into four sections: oncology-haematology, solid organ transplantation recipients, critical patients, and paediatric patients.
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Affiliation(s)
- José María Aguado
- Servicio de Enfermedades Infecciosas, Hospital Universitario 12 de Octubre, Madrid, España. Red Española de Investigación en Patología Infecciosa (REIPI RD06/0008)
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Les antifongiques pour le traitement des infections fongiques systémiques chez les enfants. Paediatr Child Health 2010. [DOI: 10.1093/pch/15.9.609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Maschmeyer G, Calandra T, Singh N, Wiley J, Perfect J. Invasive mould infections: a multi-disciplinary update. Med Mycol 2010; 47:571-83. [PMID: 19444698 DOI: 10.1080/13693780902946559] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Systemic fungal infections remain a significant cause of mortality in neutropenic and immunocompromised patients, despite advances in their diagnosis and treatment. The incidence of such infections is rising due to the use of intensive chemotherapy regimens in patients with solid tumours or haematological cancers, the increasing numbers of allogeneic haematopoietic stem cell and solid organ transplants, and the use of potent immunosuppressive therapy in patients with autoimmune disorders. In addition, the epidemiology of systemic fungal infections is changing, with atypical species such as Aspergillus terreus and zygomycetes becoming more common. Treatment has traditionally focused on empirical therapy, but targeted pre-emptive therapy in high-risk patients and prophylactic antifungal treatment are increasingly being adopted. New treatments, including lipid formulations of amphotericin B, second-generation broad-spectrum azoles, and echinocandins, offer effective antifungal activity with improved tolerability compared with older agents; the potential impact of these treatments is reflected in their inclusion in current treatment and prophylaxis guidelines. New treatment strategies, such as aerosolized lipid formulations of amphotericin B, may also reduce the burden of mortality associated with systemic fungal infections. The challenge is to identify ways of coupling potentially effective treatments with early and reliable identification of patients at highest risk of infection.
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Affiliation(s)
- Georg Maschmeyer
- Department of Haematology and Oncology, Center for Haematology, Oncology and Radiotherapy, Klinikum Ernst von Bergmann, Potsdam, Germany.
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Abstract
BACKGROUND An increase in the number of immunocompromised patients has led to a rising burden of systemic fungal infections. Historically, conventional amphotericin B has been used to treat these infections due to its broad spectrum of activity. The development of lipid-based amphotericin B agents, such as Abelcet * (ABLC), has allowed clinicians to take advantage of the broad spectrum of activity of amphotericin B while reducing adverse events. As well as this, a number of new antifungal agents have been developed in recent years which have significantly added to the treating physician's antifungal armamentarium. * Abelcet is a registered trade name of Cephalon Ltd, Herts, UK. OBJECTIVES Review the clinical data that support the use of ABLC and discuss the evidence for its continuing role in the treatment of invasive fungal infections in light of the introduction of newer antifungal agents. METHODS Published studies were identified by searching the MEDLINE database and the Cochrane Centre for Reviews up to August 2009. The search was conducted using the following key words: Amphotericin, Lipid, Abelcet, AmBisome, Efficacy, Nephrotoxicity, Renal, Toxicity. FINDINGS ABLC is effective and well-tolerated in the treatment of systemic fungal infections and remains a valuable therapeutic option in a variety of immunocompromised patients due to its broad antifungal spectrum and rarity of resistance. LIMITATIONS Data from randomised controlled trials of lipid-based amphotericin B formulations, as well as head-to-head comparison studies between ABLC and other antifungal agents are limited. In addition, the review uses a narrative approach and relies to a great extent on the authors' personal views and experiences.
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Abstract
Aspergillus spp produce a wide range of saprophytic and invasive syndromes in the lungs, including allergic bronchopulmonary aspergillosis (ABPA), aspergilloma and invasive pulmonary aspergillosis (IPA). ABPA results from hypersensitivity to the fungus, and mainly affects patients with asthma or cystic fibrosis (CF). The treatment of choice consists of systemic corticosteroids and itraconazole. Aspergilloma is managed by observation or surgery. IPA is predominantly seen in patients with haematological malignancies, chronic granulomatous disease or immunosuppressive treatment. With the use of aggressive therapies for end-stage CF, such as heart-lung transplantation, the potential for a patient to convert from colonization or ABPA to IPA has increased. Suggestive clinical and radiological findings, supplemented with mycological data using serology and molecular biology, have enhanced the capacity to diagnose IPA in paediatric patients. While voriconazole is considered the first-line therapy in IPA, several other antifungal agents may be appropriate alternatives.
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Affiliation(s)
- Elpis Hatziagorou
- 3rd Department of Paediatrics, Aristotle University, Hippokration Hospital, Konstantinoupoleos 49, GR-54642 Thessaloniki, Greece
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Arendrup MC, Fisher BT, Zaoutis TE. Invasive fungal infections in the paediatric and neonatal population: diagnostics and management issues. Clin Microbiol Infect 2009; 15:613-24. [PMID: 19673972 DOI: 10.1111/j.1469-0691.2009.02909.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Invasive fungal infections in children appear to have increased over the past few decades. Especially neonates and children with primary and secondary immunodeficiencies are at risk. Candida and Aspergillus spp. are the most commonly isolated organisms. In addition, Malassezia may cause systemic infections in newborns and zygomycosis is important because of its rising incidence and high case fatality rate. Timely diagnosis and initiation of appropriate antifungal therapy is imperative for improving outcomes. However, traditional techniques are time-consuming and representative sample material, using invasive procedures, may be difficult to obtain in the paediatric setting. This review provides an overview of the advances in detection and rapid species identification, with a focus on issues relevant in these settings. Subsequently, the current antifungal treatment options for neonates and children are discussed in light of the antifungal spectrum of the available agents and the specific pharmacokinetic properties in different age groups. Although a multitude of newer antifungal compounds have become available within the last decade, further studies are necessary to clearly establish the role for each of these agents among neonates and children.
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Affiliation(s)
- M C Arendrup
- Unit of Mycology and Parasitology, Statens Serum Institut, Copenhagen, Denmark
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Meckler G, Lindemulder S. Fever and Neutropenia in Pediatric Patients with Cancer. Emerg Med Clin North Am 2009; 27:525-44. [DOI: 10.1016/j.emc.2009.04.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zaoutis TE, Jafri HS, Huang LM, Locatelli F, Barzilai A, Ebell W, Steinbach WJ, Bradley J, Lieberman JM, Hsiao CC, Seibel N, Laws HJ, Gamba M, Petrecz M, Taylor AF, Strohmaier KM, Chow JW, Kartsonis NA, Ngai AL. A prospective, multicenter study of caspofungin for the treatment of documented Candida or Aspergillus infections in pediatric patients. Pediatrics 2009; 123:877-84. [PMID: 19255017 DOI: 10.1542/peds.2008-1158] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We evaluated the safety, tolerability, and efficacy of caspofungin in pediatric patients with invasive aspergillosis, invasive candidiasis, or esophageal candidiasis. METHODS This was a multicenter, prospective, open-label study in children 3 months to 17 years of age with proven or probable invasive aspergillosis, proven invasive candidiasis, or proven esophageal candidiasis. All of the patients received caspofungin 70 mg/m(2) on day 1, followed by 50 mg/m(2) per day (maximum: 70 mg/day), as primary or salvage monotherapy. Favorable response was defined as complete resolution of clinical findings and microbiologic (or radiographic/endoscopic) eradication (complete response) or significant improvement in these parameters (partial response). Efficacy was assessed at the end of caspofungin therapy in patients with a confirmed diagnosis who received >/=1 dose of caspofungin. The primary safety evaluation was the proportion of patients with clinical or laboratory drug-related adverse events. RESULTS Of the 49 patients enrolled, 3 were <2 years of age, 30 were 2 to 11 years of age, and 16 were 12 to 17 years of age. Forty-eight patients had confirmed disease: invasive aspergillosis (10), invasive candidiasis (37), and esophageal candidiasis (1). Eight of 10 patients with invasive aspergillosis had pulmonary involvement; 34 of 37 patients with invasive candidiasis had candidemia. Caspofungin was given for 2 to 87 days. Success at end of therapy was achieved in 5 of 10 patients with invasive aspergillosis, 30 of 37 with invasive candidiasis, and 1 of 1 with esophageal candidiasis. One patient (invasive candidiasis) relapsed during the 28-day follow-up period. Drug-related clinical or laboratory adverse events occurred in 27% and 35% of patients, respectively. There were no serious drug-related adverse events or discontinuations of caspofungin because of toxicity. CONCLUSIONS Caspofungin was generally well tolerated in pediatric patients aged 6 months through 17 years. Efficacy outcomes in patients with invasive aspergillosis or invasive candidiasis were consistent with previous adult studies in these indications.
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Affiliation(s)
- Theoklis E Zaoutis
- Children's Hospital of Philadelphia, Division of Infectious Diseases, 34th Street and Civic Center Boulevard, CHOP North, Suite 1527, Philadelphia, PA 19104, USA.
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Influence of sodium intake on Amphotericin B-induced nephrotoxicity among extremely premature infants. Pediatr Nephrol 2009; 24:497-505. [PMID: 19082636 DOI: 10.1007/s00467-008-1050-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Revised: 10/16/2008] [Accepted: 10/21/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED Amphotericin B (AmphoB) remains the preferred therapy for invasive fungal infections despite many side effects, such as nephrotoxicity and electrolyte imbalance. Our previous study suggested that high sodium (Na) intake >4 mEq/kg per day may be associated with lower nephrotoxicity in extremely premature infants treated with AmphoB. Subsequently, it became a standard of care in our unit to administer Na >4 mEq/kg per day to extremely premature infants treated with AmphoB. The purpose of this study was to evaluate the effect of high Na intake > 4 mEq/kg per day on the incidence of AmphoB-induced nephrotoxicity among extremely premature infants with birth weight <1250 gm. All extremely premature infants with birth weight <1250 gm born between 1992 and 2004 and treated with AmphoB for systemic fungal infections were included in the study. The study infants were divided into two groups: a control (CL) group (1/1992-12/1999, n = 21) consisting of extremely premature infants given a maintenance Na intake during AmphoB therapy, and a high sodium intake (High Na) group (1/2000-12/2004, n = 16) consisting of extremely premature infants given a high Na intake >4 mEq/kg per day during AmphoB therapy. Nephrotoxicity was defined as serum creatinine levels >1 mg/dl, urinary output (UOP) < 1 ml/kg per hour or a decrease in UOP of 50%, compared with the previous 2 days, and persisting for at least 2 days. Invasive fungal infection was diagnosed in 5.7% of the infants (44/763 infants). Thirty-seven infants were eligible for the study and seven were excluded. There were no differences between the two groups in gestational age, birth weight, age at fungal infection diagnosis, length of AmphoB therapy, daily fluid intake or hyponatremia. Nephrotoxicity was significantly higher in the CL group than in the High Na group (13/21 vs. 3/16; P = 0.02). In the CL group, nephrotoxicity occurred at (mean +/- SD) 1.9 +/- 3.2 days after the initiation of AmphoB treatment and lasted for 5.5 +/- 4.7 days. In this group, nephrotoxicity occurred in two of the 13 infants before the initiation of AmphoB therapy. In the High Na group, nephrotoxicity occurred before the start of AmphoB therapy in two of the three infants. In the third infant, nephrotoxicity lasted for 1 day. Mean Na intake was not different between the two groups during the 4-day period prior to AmphoB therapy. Mean Na intake during the first 10-day period of AmphoB therapy was significantly lower in the CL group (3.7 vs 6.2; P < 0.001). CONCLUSION High Na intake was associated with a reduction in the incidence of AmphoB-induced nephrotoxicity in extremely premature infants with birth weight <1250 gm. We recommend the use of a high Na intake of >4 mEq/kg per day for extremely premature infants during Amphotericin B therapy.
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Auron A, Auron-Gomez M, Raina R, Viswanathan S, Mhanna MJ. Effect of amphotericin B lipid complex (ABLC) in very low birth weight infants. Pediatr Nephrol 2009; 24:295-9. [PMID: 18846390 DOI: 10.1007/s00467-008-1017-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 09/11/2008] [Accepted: 09/12/2008] [Indexed: 10/21/2022]
Abstract
The aim of this retrospective, case-control study was to determine the effect of the amphotericin B lipid complex (ABLC) on serum creatinine (SCr), blood urea nitrogen (BUN), sodium (Na), and potassium (K) in very low birth weight (VLBW) infants. Medical records of all VLBW infants who were admitted to our Neonatal Intensive Care Unit between May 1998 and May 2006 and had received ABLC for at least 2 weeks were reviewed for patient demographics, use of medications (ABLC, diuretics, xanthines, indomethacin, vancomycin, gentamicin, pressors, and inotropes), fluid intake, urinary output, and serum electrolytes. Thirty-five patients who received ABLC were identified and matched by gestational age (GA) to 35 patients who served as controls. Infants who received ABLC had an average GA of 25.7 +/- 2.1 weeks and a birth weight of 764 +/- 196 g. Between day 1 and 14 of ABLC treatment, the BUN decreased from 17.5 +/- 11.5 to 10.5 +/- 6.8 mg/dl (p = 0.01), the SCr varied between 0.78 +/- 0.32 and 0.69 +/- 0.32 mg/dl, Na varied between 136.6 +/- 5.8 and 137.8 +/- 3.6 mEq/l, and K varied between 4.8 +/- 0.9 and 4.9 +/- 0.6 mEq/l, respectively. Based on these results, we conclude that treatment with ABLC for 2 weeks did not increase BUN or SCr, nor decrease Na or K in VLBW infants.
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Affiliation(s)
- Ari Auron
- Section of Pediatric Nephrology, Blank Children's Hospital, Iowa Health System, Des Moines, IA, USA
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Groll AH, McNeil Grist L. Current challenges in the diagnosis and management of invasive fungal infections: report from the 15th International Symposium on Infections in the Immunocompromised Host: Thessaloniki, Greece, 22–25 June 2008. Int J Antimicrob Agents 2009; 33:101-4. [DOI: 10.1016/j.ijantimicag.2008.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Accepted: 08/19/2008] [Indexed: 10/21/2022]
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Post-traumatic Lethal Form of Primary Cutaneous Zygomycosis in a Healthy Young Patient and Review of the Literature. J Taibah Univ Med Sci 2009. [DOI: 10.1016/s1658-3612(09)70105-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Abstract
BACKGROUND Diagnosing invasive aspergillosis is difficult but might be improved by detection of circulating galactomannan. Although galactomannan antigenemia has been well studied in the detection of invasive aspergillosis in adult patients, little is known about the expression of circulating galactomannan in immunocompromised children with invasive aspergillosis. METHODS We studied the expression of galactomannan antigen by enzyme immunoassay (EIA) in 990 serum samples from 56 pediatric oncology patients (ages 3 months to 18 years) of whom 17 had proven or probable invasive aspergillosis defined by the European Organization for Research and Treatment of Cancer-Mycoses Study Group criteria. Any sample with a galactomannan EIA Galactomannan index value of > or = 0.5 was considered positive. RESULTS At least 1 serum sample was positive for 11 of 17 pediatric oncology patients (65.7% sensitivity, 95% confidence interval: 38.3-85.7) with invasive aspergillosis. Galactomannan EIA was positive in 99 of 304 samples from patients with proven or probable invasive aspergillosis, and 7 of 686 (1.0%) samples from 39 control subjects resulted in a positive galactomannan EIA result. At least 1 sample tested positive in 5 of the 39 controls (12.8%, 95% confidence interval: 4.3-27.4). No significant association between accuracy and patient age was observed. Among the 7 evaluable galactomannan-positive patients with IA, the galactomannan EIA produced a positive result before clinical or radiographic evidence of infection in 6 cases, with a lead-time to diagnosis ranging from 1 day to 34 days (median: 10 days). In the remaining case, a positive galactomannan was observed on the same day as diagnosis by non-EIA methods. CONCLUSIONS The presence of circulating galactomannan is predictive of invasive aspergillosis in most pediatric oncology patients. Galactomannan antigenemia may precede clinical, microbiologic, or radiographic evidence of invasive aspergillosis.
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42
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Pediatric pharmacology of antifungal agents. CURRENT FUNGAL INFECTION REPORTS 2008. [DOI: 10.1007/s12281-008-0008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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43
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Ostrosky-Zeichner L, Rex JH. Antifungal and Antiviral Therapy. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50055-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Cutaneous zygomycosis is a rare but severe fungal infection with high risk of dissemination. Early recognition, deep surgical biopsy for diagnosis, aggressive treatment with repeated surgical debridement, and targeted pharmacotherapy are essential and can prevent dissemination and fatal outcome. We present case reports of 2 patients.
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Chiou CC, Walsh TJ, Groll AH. Clinical pharmacology of antifungal agents in pediatric patients. Expert Opin Pharmacother 2007; 8:2465-89. [DOI: 10.1517/14656566.8.15.2465] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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46
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Kontny U, Walsh TJ, Rossler J, Uhl M, Niemeyer CM. Successful treatment of refractory chronic disseminated candidiasis after prolonged administration of caspofungin in a child with acute myeloid leukemia. Pediatr Blood Cancer 2007; 49:360-2. [PMID: 16444677 DOI: 10.1002/pbc.20751] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This report documents the clinical activity of caspofungin in a 13-year-old girl with acute myeloid leukemia (AML) and chronic disseminated candidiasis (CDC), refractory to amphotericin B and fluconazole. Caspofungin was started at 50 mg/d resulting in a temporary response. With no further clinical improvement and radiological progress after 2 months of therapy, the dose of caspofungin was increased to 100 mg/d, leading to a sustained clinical response. Therapy was given for a total of 12 months and had no attributable adverse effects. This approach resulted in successful treatment of refractory CDC with caspofungin.
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Affiliation(s)
- Udo Kontny
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, University of Freiburg, Freiburg, Germany.
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Blyth CC, Palasanthiran P, O'Brien TA. Antifungal therapy in children with invasive fungal infections: a systematic review. Pediatrics 2007; 119:772-84. [PMID: 17403849 DOI: 10.1542/peds.2006-2931] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Invasive fungal infections are associated with significant morbidity and mortality. Differences between children and adults are reported, yet few trials of antifungal agents have been performed in pediatric populations. We performed a systematic review of the literature to guide appropriate pediatric treatment recommendations. From available trials that compared antifungal agents in either prolonged febrile neutropenia or invasive candidal or Aspergillus infection, no clear difference in treatment efficacy was demonstrated, although few trials were adequately powered. Differing antifungal pharmacokinetics between children and adults were demonstrated, requiring dose modification. Significant differences in toxicity, particularly nephrotoxicity, were identified between classes of antifungal agents. Therapy needs to be guided by the pathogen or suspected pathogens, the degree of immunosuppression, comorbidities (particularly renal dysfunction), concurrent nephrotoxins, and the expected length of therapy.
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Affiliation(s)
- Christopher C Blyth
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, High Street, Randwick, New South Wales 2130, Australia
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48
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Abstract
Invasive Candia infections have become the third most common cause of late-onset infection among very low birth weight infants in most neonatal intensive care units. Significant risk factors include birth weight less than 1000 g, exposure to more than two antibiotics, third generation cephalosporin exposure, parenteral nutrition including lipid emulsion, central venous catheter, and abdominal surgery. The majority of neonatal Candida infections are caused by C. albicans and C. parapsilosis, although other nonalbicans species are being reported more frequently. Standard therapy has been amphotericin B; however, successful use of fluconazole as a single agent has also been reported and a small comparison trial demonstrated similar efficacy. The addition of new antifungal agents, including voriconazole and the echinocandins may further improve our ability to effectively treat these infections and possibly reduce the development of complications. Antifungal chemoprophylaxis has been studied in single-center and cohort studies, primarily using fluconazole. Although it is clear that fluconazole prophylaxis decreases the risk of fungal colonization and infection, identification of potential harm, particularly the development of or selection for resistant strains, requires further investigation with multicenter trials before widespread use is recommended outside of the clinical trial setting.
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Affiliation(s)
- Rachel L Chapman
- Yale University School of Medicine, New Haven, CT 06520-8064, USA.
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Almyroudis NG, Kontoyiannis DP, Sepkowitz KA, DePauw BE, Walsh TJ, Segal BH. Issues Related to the Design and Interpretation of Clinical Trials of Salvage Therapy for Invasive Mold Infection. Clin Infect Dis 2006; 43:1449-55. [PMID: 17083020 DOI: 10.1086/508455] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2006] [Accepted: 06/08/2006] [Indexed: 11/03/2022] Open
Abstract
Invasive mold infection is a major cause of morbidity and mortality among severely immunocompromised individuals. We discuss the challenges involved in the design and interpretation of salvage antifungal trials, focusing on mold infection. We suggest that patients with refractory fungal infection be analyzed separately from those with intolerance to standard regimens because of the poorer prognosis of the former group. We propose a composite outcome assessment in which refractory infection is defined as infection associated with the worsening of at least 2 of the following 3 types of criteria: clinical, radiologic, and mycologic. Confounding variables, including heterogeneity in host factors, initial antifungal therapy, and selection bias, are discussed. Although randomized studies would provide the most credible results, the lack of an adequate number of patients to meet prespecified stratification criteria for all confounding variables makes such studies impractical. Given that randomized studies are unrealistic, studies involving carefully selected, matched, contemporaneous control subjects are likely to be the most useful alternative.
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50
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Abstract
For more than 40 years, there has been limited progress in the treatment of invasive fungal infections. There are now numerous nuances to choosing the appropriate antifungal agent. Important advantages have been achieved in understanding the safety, tolerability, and pharmacokinetics of these agents. One of the most important aspects for successful management of pediatric invasive fungal infections is an understanding of the differences in the pharmacokinetics of the drugs in children and adults to offer optimal dosing strategies. Unfortunately there have been few antifungal studies conducted in children. Consequently most information for the pediatrician has been extrapolated from adult data. The breadth of antifungal data in children is expanding, however, with newer studies underway. Through the efforts of dedicated clinicians and collaboration, pediatric indications and dosing strategies will eventually be discovered that directly benefit pediatric patients.
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Affiliation(s)
- William J Steinbach
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC 27710, USA.
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