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Barrs VR, Hobi S, Wong A, Sandy J, Shubitz LF, Bęczkowski PM. Invasive fungal infections and oomycoses in cats 2. Antifungal therapy. J Feline Med Surg 2024; 26:1098612X231220047. [PMID: 38189264 PMCID: PMC10949877 DOI: 10.1177/1098612x231220047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
CLINICAL RELEVANCE Invasive fungal infections (IFIs) and oomycoses (hereafter termed invasive fungal-like infections [IFLIs]) are characterised by penetration of tissues by fungal elements. The environment is the most common reservoir of infection. IFIs and IFLIs can be frustrating to treat because long treatment times are usually required and, even after attaining clinical cure, there may be a risk of relapse. Owner compliance with medication administration and recheck examinations can also decline over time. In addition, some antifungal drugs are expensive, have variable interpatient pharmacokinetic properties, can only be administered parenterally and/or have common adverse effects (AEs). Despite these limitations, treatment can be very rewarding, especially when an otherwise progressive and fatal disease is cured. AIM In the second of a two-part article series, the spectrum of activity, mechanisms of action, pharmacokinetic and pharmacodynamic properties, and AEs of antifungal drugs are reviewed, and the treatment and prognosis of specific IFIs/IFLIs - dermatophytic pseudomycetoma, cryptococcosis, sino-orbital aspergillosis, coccidioidomycosis, histoplasmosis, sporotrichosis, phaeohyphomycosis, mucormycosis and oomycosis - are discussed. Part 1 reviewed the diagnostic approach to IFIs and IFLIs. EVIDENCE BASE Information on antifungal drugs is drawn from pharmacokinetic studies in cats. Where such studies have not been performed, data from 'preclinical' animals (non-human studies) and human studies are reviewed. The review also draws on the wider published evidence and the authors' combined expertise in feline medicine, mycology, dermatology, clinical pathology and anatomical pathology. ABBREVIATIONS FOR ANTIFUNGAL DRUGS AMB (amphotericin B); FC (flucytosine); FCZ (fluconazole); ISA (isavuconazole); ITZ (itraconazole); KCZ (ketoconazole); PCZ (posaconazole); TRB (terbinafine); VCZ (voriconazole).
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Affiliation(s)
- Vanessa R Barrs
- Department of Veterinary Clinical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong, SAR China
- Centre for Animal Health and Welfare, City University of Hong Kong, Kowloon Tong, Hong Kong, SAR China
| | - Stefan Hobi
- Department of Veterinary Clinical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong, SAR China
| | - Angeline Wong
- Shatin Animal Hospital, Tai Wai, New Territories, Hong Kong, SAR China
| | - Jeanine Sandy
- Department of Veterinary Clinical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong, SAR China
| | - Lisa F Shubitz
- Valley Fever Center for Excellence, The University of Arizona, AZ, USA
| | - Paweł M Bęczkowski
- Department of Veterinary Clinical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong, SAR China
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2
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Hanzlicek AS, KuKanich KS, Cook AK, Hodges S, Thomason JM, DeSilva R, Ramachandran A, Durkin MM. Clinical utility of fungal culture and antifungal susceptibility in cats and dogs with histoplasmosis. J Vet Intern Med 2023; 37:998-1006. [PMID: 37092675 DOI: 10.1111/jvim.16725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/08/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Culture can be used for diagnosis and antifungal susceptibility testing in animals with fungal infections. Limited information is available regarding the diagnostic performance of culture and the susceptibility patterns of Histoplasma spp. isolates. HYPOTHESIS/OBJECTIVES Describe the clinical utility of culture and the susceptibility patterns of Histoplasma spp. isolates causing histoplasmosis in cats and dogs. ANIMALS Seventy-one client-owned animals, including 33 cats and 19 dogs with proven or probable histoplasmosis. METHODS Culture was attempted from tissue or fluid samples. Diagnostic performance of culture, cytopathology, and antigen detection were compared with final diagnosis. Susceptibility to antifungal agents was determined for a subset (11 from dogs, 9 from cats) of culture isolates. RESULTS Culture had a diagnostic sensitivity of 17/33 (52%; 95% confidence interval [CI], 34%-69%) and 15/19 (79%; 95% CI, 61%-97%) and specificity of 6/6 (100%; 95% CI, 54%-100%) and 10/10 (100%; 95% CI, 69%-100%) in cats and dogs, respectively. Culture was not positive in any animal in which cytopathology and antigen testing were negative. Target drug exposure (area under the concentration curve [AUC]/minimum inhibitory concentration [MIC] >25) should be easily achieved for all isolates for itraconazole, voriconazole, or posaconazole. Five of 20 (25%) isolates had fluconazole MIC ≥32 μg/mL and achieving target drug exposure is unlikely. CONCLUSIONS AND CLINICAL IMPORTANCE Fungal culture did not improve diagnostic sensitivity when used with cytopathology and antigen detection. Susceptibility testing might help identify isolates for which fluconazole is less likely to be effective.
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Affiliation(s)
- Andrew S Hanzlicek
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, Oklahoma, USA
- MiraVista Diagnostics, Indianapolis, Indiana, USA
| | - Kate S KuKanich
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas, USA
| | - Audrey K Cook
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Steven Hodges
- Oklahoma Veterinary Specialists, Tulsa, Oklahoma, USA
| | - John M Thomason
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA
| | - Rupika DeSilva
- Oklahoma Animal Disease Diagnostic Laboratory, Department of Veterinary Pathobiology, College of Veterinary Medicine, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Akhilesh Ramachandran
- Oklahoma Animal Disease Diagnostic Laboratory, Department of Veterinary Pathobiology, College of Veterinary Medicine, Oklahoma State University, Stillwater, Oklahoma, USA
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3
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Lautz LS, Jeddi MZ, Girolami F, Nebbia C, Dorne JLCM. Metabolism and pharmacokinetics of pharmaceuticals in cats (Felix sylvestris catus) and implications for the risk assessment of feed additives and contaminants. Toxicol Lett 2020; 338:114-127. [PMID: 33253781 DOI: 10.1016/j.toxlet.2020.11.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 01/25/2023]
Abstract
In animal health risk assessment, hazard characterisation of feed additives has been often using the default uncertainty factor (UF) of 100 to translate a no-observed-adverse-effect level in test species (rat, mouse, dog, rabbit) to a 'safe' level of chronic exposure in farm and companion animal species. Historically, both 10-fold factors have been further divided to include chemical-specific data in both dimensions when available. For cats (Felis Sylvestris catus), an extra default UF of 5 is applied due to the species' deficiency in particularly glucuronidation and glycine conjugation. This paper aims to assess the scientific basis and validity of the UF for inter-species differences in kinetics (4.0) and the extra UF applied for cats through a comparison of kinetic parameters between rats and cats for 30 substrates of phase I and phase II metabolism. When the parent compound undergoes glucuronidation the default factor of 4.0 is exceeded, with exceptions for zidovudine and S-carprofen. Compounds that were mainly renally excreted did not exceed the 4.0-fold default. Mixed results were obtained for chemicals which are metabolised by CYP3A in rats. When chemicals were administered intravenously the 4.0-fold default was not exceeded with the exception of clomipramine, lidocaine and alfentanil. The differences seen after oral administration might be due to differences in first-pass metabolism and bioavailability. Further work is needed to further characterise phase I, phase II enzymes and transporters in cats to support the development of databases and in silico models to support hazard characterisation of chemicals particularly for feed additives.
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Affiliation(s)
- L S Lautz
- Radboud University Nijmegen, Houtlaan 4, 6525 XZ Nijmegen, the Netherlands
| | - M Z Jeddi
- European Food Safety Authority, Scientific Committee and Emerging Risks Unit, Via Carlo Magno, 1A, 43126 Parma, Italy
| | - F Girolami
- University of Torino, Department of Veterinary Sciences, Largo P. Braccini 2, 10095 Grugliasco, Italy
| | - C Nebbia
- University of Torino, Department of Veterinary Sciences, Largo P. Braccini 2, 10095 Grugliasco, Italy
| | - J L C M Dorne
- European Food Safety Authority, Scientific Committee and Emerging Risks Unit, Via Carlo Magno, 1A, 43126 Parma, Italy.
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4
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KuKanich K, KuKanich B, Lin Z, Rankin AJ, Hanzlicek AS, Palerme JS, Bach J, Cook AK, Juracek A, Joo H. Clinical pharmacokinetics and outcomes of oral fluconazole therapy in dogs and cats with naturally occurring fungal disease. J Vet Pharmacol Ther 2020; 43:547-556. [PMID: 32656792 DOI: 10.1111/jvp.12888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/28/2020] [Accepted: 06/07/2020] [Indexed: 11/30/2022]
Abstract
This multi-institutional study was designed to determine the clinical pharmacokinetics of fluconazole and outcomes in client-owned dogs (n = 37) and cats (n = 35) with fungal disease. Fluconazole serum concentrations were measured. Pharmacokinetic analysis was limited to animals at steady state (≥72 hr of treatment). The mean (range) body weight in 31 dogs was 25.6 (2.8-58.2) kg and in 31 cats was 3.9 (2.4-6.1) kg included in pharmacokinetic analyses. The dose, average steady-state serum concentrations (CSS ), and oral clearance in dogs were 14.2 (4.5-21.3) mg/kg/d, 26.8 (3.8-61.5) µg/mL, and 0.63 ml min-1 kg-1 , respectively, and in cats were 18.6 (8.2-40.0) mg/kg/d, 32.1 (1.9-103.5) µg/mL, and 0.61 ml min-1 kg-1 , respectively. Random inter-animal pharmacokinetic variability was high in both species. Two dogs had near twofold increases in serum fluconazole when generic formulations were changed, suggesting lack of bioequivalence. Median CSS for dogs and cats achieving clinical remission was 19.4 and 35.8 µg/ml, respectively. Starting oral doses of 10 mg/kg q12h in dogs and 50-100 mg total daily dose in cats are recommended to achieve median CSS associated with clinical remission. Due to the large pharmacokinetic variability, individualized dose adjustments based on CSS (therapeutic drug monitoring) and treatment failure should be considered.
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Affiliation(s)
- Kate KuKanich
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Butch KuKanich
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Zhoumeng Lin
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Amy J Rankin
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Andrew S Hanzlicek
- Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK, USA
| | - Jean-Sebastien Palerme
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, IA, USA
| | - Jonathan Bach
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Audrey K Cook
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, TX, USA
| | - Amy Juracek
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Hyun Joo
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
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5
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Volk HA, O'Reilly A, Bodley K, McCracken H. Keratomycosis in captive red pandas (Ailurus fulgens): 2 cases. Open Vet J 2018; 8:200-203. [PMID: 29911025 PMCID: PMC5987353 DOI: 10.4314/ovj.v8i2.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 05/14/2018] [Indexed: 11/25/2022] Open
Abstract
Two cases of keratomycosis in captive red pandas (Ailurus fulgens) were diagnosed and treated at a zoo in Melbourne, Australia across a 9-year period. Both cases presented with severe unilateral ocular pain and stromal abscessation of the cornea. A superficial keratectomy was performed in both cases and the diagnosis was confirmed with either cytology or histopathology. Following surgery, a combination of oral, topical and subconjunctival medical therapy contributed to a successful outcome.
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Affiliation(s)
| | - Anu O'Reilly
- Melbourne EyeVet, 9-11 Miles Street, Mulgrave, VIC 3170, Australia
| | - Kate Bodley
- The Royal Melbourne Zoo, Elliot Ave, Parkville, VIC 3052, Australia
| | - Helen McCracken
- The Royal Melbourne Zoo, Elliot Ave, Parkville, VIC 3052, Australia
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6
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Momper JD, Capparelli EV, Wade KC, Kantak A, Dhanireddy R, Cummings JJ, Nedrelow JH, Hudak ML, Mundakel GT, Natarajan G, Gao J, Laughon M, Smith PB, Benjamin DK. Population Pharmacokinetics of Fluconazole in Premature Infants with Birth Weights Less than 750 Grams. Antimicrob Agents Chemother 2016; 60:5539-45. [PMID: 27401564 PMCID: PMC4997840 DOI: 10.1128/aac.00963-16] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 06/28/2016] [Indexed: 11/20/2022] Open
Abstract
Fluconazole is an effective agent for prophylaxis of invasive candidiasis in premature infants. The objective of this study was to characterize the population pharmacokinetics (PK) and dosing requirements of fluconazole in infants with birth weights of <750 g. As part of a randomized clinical trial, infants born at <750 g birth weight received intravenous (i.v.) or oral fluconazole at 6 mg/kg of body weight twice weekly. Fluconazole plasma concentrations from samples obtained by either scheduled or scavenged sampling were measured using a liquid chromatography-tandem mass spectrometry assay. Population PK analysis was conducted using NONMEM 7.2. Population PK parameters were allometrically scaled by body weight. Covariates were evaluated by univariable screening followed by multivariable assessment. Fluconazole exposures were simulated in premature infants using the final PK model. A population PK model was developed from 141 infants using 604 plasma samples. Plasma fluconazole PK were best described by a one-compartment model with first-order elimination. Only serum creatinine was an independent predictor for clearance in the final model. The typical population parameter estimate for oral bioavailability in the final model was 99.5%. Scavenged samples did not bias the parameter estimates and were as informative as scheduled samples. Simulations indicated that the study dose maintained fluconazole troughs of >2,000 ng/ml in 80% of simulated infants at week 1 and 59% at week 4 of treatment. Developmental changes in fluconazole clearance are best predicted by serum creatinine in this population. A twice-weekly dose of 6 mg/kg achieves appropriate levels for prevention of invasive candidiasis in extremely premature infants.
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Affiliation(s)
| | | | - Kelly C Wade
- Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Anand Kantak
- Children's Hospital Medical Center of Akron, Akron, Ohio, USA
| | | | - James J Cummings
- East Carolina University, Brody School of Medicine, Greenville, North Carolina, USA
| | | | - Mark L Hudak
- University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | | | - Jamie Gao
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Matt Laughon
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - P Brian Smith
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
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7
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Talbot JJ, Kidd SE, Martin P, Beatty JA, Barrs VR. Azole resistance in canine and feline isolates of Aspergillus fumigatus. Comp Immunol Microbiol Infect Dis 2015; 42:37-41. [PMID: 26387063 DOI: 10.1016/j.cimid.2015.08.002] [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] [Received: 01/30/2015] [Revised: 08/13/2015] [Accepted: 08/18/2015] [Indexed: 10/23/2022]
Abstract
Azole resistance is an emerging cause of treatment failure in humans with aspergillosis. The aim of this study was to determine if azole resistance is emerging in Aspergillus fumigatus isolates from canine and feline sino-nasal aspergillosis cases. Susceptibilities of isolates collected between 1988 and 2014 from 46 dogs and 4 cats to itraconazole, posaconazole, voriconazole, fluconazole and ketoconazole were assessed using Sensititre YeastOne microdilution trays; and to enilconazole and clotrimazole, following the CLSI M38-A2 standard. For the majority of isolates MICs were high for ketoconazole, low for enilconazole and clotrimazole, and less than established epidemiological cut-off values for itraconazole, posaconazole and voriconazole. One canine isolate from 1992 had multiazole resistance and on Cyp51A gene sequencing a mutation associated with azole resistance (F46Y) was detected. There is no evidence of emerging azole resistance among A. fumigatus isolates from dogs and cats and topical azole therapy should be effective against most isolates.
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Affiliation(s)
- Jessica J Talbot
- Valentine Charlton Cat Centre, Faculty of Veterinary Science, University of Sydney, Camperdown 2006, NSW, Australia
| | - Sarah E Kidd
- National Mycology Reference Centre, Microbiology and Infectious Diseases, SA Pathology, Frome Road, Adelaide 5000, SA, Australia
| | - Patricia Martin
- Veterinary Pathology Diagnostic Services, Faculty of Veterinary Science, University of Sydney, Camperdown 2006, NSW, Australia
| | - Julia A Beatty
- Valentine Charlton Cat Centre, Faculty of Veterinary Science, University of Sydney, Camperdown 2006, NSW, Australia
| | - Vanessa R Barrs
- Valentine Charlton Cat Centre, Faculty of Veterinary Science, University of Sydney, Camperdown 2006, NSW, Australia.
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8
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Lemetayer JD, Dowling PM, Taylor SM, Papich MG. Pharmacokinetics and distribution of voriconazole in body fluids of dogs after repeated oral dosing. J Vet Pharmacol Ther 2015; 38:451-6. [DOI: 10.1111/jvp.12208] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 01/16/2015] [Indexed: 01/21/2023]
Affiliation(s)
- J. D. Lemetayer
- Small Animal Clinical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - P. M. Dowling
- Veterinary Biomedical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - S. M. Taylor
- Small Animal Clinical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - M. G. Papich
- Department of Molecular Biomedical Sciences; College of Veterinary Medicine; North Carolina State University; Raleigh NC USA
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9
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Abstract
Understanding the tissue penetration of systemically administered antifungal agents is critical for a proper appreciation of their antifungal efficacy in animals and humans. Both the time course of an antifungal drug and its absolute concentrations within tissues may differ significantly from those observed in the bloodstream. In addition, tissue concentrations must also be interpreted within the context of the pathogenesis of the various invasive fungal infections, which differ significantly. There are major technical obstacles to the estimation of concentrations of antifungal agents in various tissue subcompartments, yet these agents, even those within the same class, may exhibit markedly different tissue distributions. This review explores these issues and provides a summary of tissue concentrations of 11 currently licensed systemic antifungal agents. It also explores the therapeutic implications of their distribution at various sites of infection.
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10
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Antifungal drug susceptibility and phylogenetic diversity among Cryptococcus isolates from dogs and cats in North America. J Clin Microbiol 2014; 52:2061-70. [PMID: 24696030 DOI: 10.1128/jcm.03392-13] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Molecular types of the Cryptococcus neoformans/Cryptococcus gattii species complex that infect dogs and cats differ regionally and with host species. Antifungal drug susceptibility can vary with molecular type, but the susceptibility of Cryptococcus isolates from dogs and cats is largely unknown. Cryptococcus isolates from 15 dogs and 27 cats were typed using URA5 restriction fragment length polymorphism analysis (RFLP), PCR fingerprinting, and multilocus sequence typing (MLST). Susceptibility was determined using a microdilution assay (Sensititre YeastOne; Trek Diagnostic Systems). MICs were compared among groups. The 42 isolates studied comprised molecular types VGI (7%), VGIIa (7%), VGIIb (5%), VGIIc (5%), VGIII (38%), VGIV (2%), VNI (33%), and VNII (2%), as determined by URA5 RFLP. The VGIV isolate was more closely related to VGIII according to MLST. All VGIII isolates were from cats. All sequence types identified from veterinary isolates clustered with isolates from humans. VGIII isolates showed considerable genetic diversity compared with other Cryptococcus molecular types and could be divided into two major subgroups. Compared with C. neoformans MICs, C. gattii MICs were lower for flucytosine, and VGIII MICs were lower for flucytosine and itraconazole. For all drugs except itraconazole, C. gattii isolates exhibited a wider range of MICs than C. neoformans. MICs varied with Cryptococcus species and molecular type in dogs and cats, and MICs of VGIII isolates were most variable and may reflect phylogenetic diversity in this group. Because sequence types of dogs and cats reflect those infecting humans, these observations may also have implications for treatment of human cryptococcosis.
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11
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Pharmacokinetics of fluconazole following intravenous and oral administration to koalas (Phascolarctos cinereus
). J Vet Pharmacol Ther 2013; 37:90-8. [DOI: 10.1111/jvp.12072] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 07/05/2013] [Indexed: 11/26/2022]
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12
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Leibovitz E. Strategies for the prevention of neonatal candidiasis. Pediatr Neonatol 2012; 53:83-9. [PMID: 22503254 DOI: 10.1016/j.pedneo.2012.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Revised: 11/19/2011] [Accepted: 11/29/2011] [Indexed: 11/17/2022] Open
Abstract
Invasive fungal infections represent the third-leading cause of late-onset sepsis in very-low-birth-weight infants (VLBWI) and have a high rate of infection-associated mortality. The infants at high risk for fungal sepsis are VLBWI with presence of additional risk factors that contribute to increased colonization and concentration of fungal organisms. Colonization with Candida spp. in neonates is secondary to either maternal vertical transmission or nosocomial acquisition in the nursery. Multiple sites may become colonized and a direct correlation between fungal colonization and subsequent progression to invasive candidemia was determined. Randomized, single and multiple-center, placebo-controlled trials found intravenous fluconazole prophylaxis to be effective in decreasing fungal colonization and sepsis for at-risk preterm infants <1500 g birth weight. The prophylactic use of fluconazole was found to be safe with no significant development of fungal resistance. Fluconazole prophylaxis administered to preterm neonates with birth weight <1000 g and/or 27 weeks' gestation or less has the potential of reducing and potentially eliminating invasive fungal infections and Candida-related mortality.
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Affiliation(s)
- Eugene Leibovitz
- Pediatric Emergency Medicine Department, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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13
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Corrêa JCR, Salgado HRN. Review of Fluconazole Properties and Analytical Methods for Its Determination. Crit Rev Anal Chem 2011. [DOI: 10.1080/10408347.2011.588924] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Corrêa JCR, Salgado HRN. Review of Fluconazole Properties and Analytical Methods for Its Determination. Crit Rev Anal Chem 2011. [DOI: 10.1080/10408347.2011.557980] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Ratzlaff K, Papich MG, Flammer K. Plasma Concentrations of Fluconazole After a Single Oral Dose and Administration in Drinking Water in Cockatiels (Nymphicus hollandicus). J Avian Med Surg 2011; 25:23-31. [DOI: 10.1647/2009-044.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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16
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Foy DS, Trepanier LA. Antifungal treatment of small animal veterinary patients. Vet Clin North Am Small Anim Pract 2011; 40:1171-88. [PMID: 20933143 DOI: 10.1016/j.cvsm.2010.07.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Antifungal therapy has progressed significantly with the development of new drugs directed at various processes in fungal cell metabolism. Within veterinary medicine, treatment options for systemic mycoses remain limited to amphotericin B, ketoconazole, fluconazole, and itraconazole. However, newer triazoles, echinocandins, and lipid-based formulations of amphotericin B are now approved for use in humans. This article provides a comprehensive review of the antifungal medications available for veterinary patients, and includes a brief discussion of the newer, presently cost-prohibitive, antifungal therapies used for systemic mycoses in humans.
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Affiliation(s)
- Daniel S Foy
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, USA.
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17
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Lohani M, Ahmad AH, Singh KP, Verma S. Pharmacokinetics and Residual Studies of Florfenicol Following Multiple Dose Oral Administration in Poultry. JOURNAL OF APPLIED ANIMAL RESEARCH 2010. [DOI: 10.1080/09712119.2010.9707145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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18
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Sharman MJ, Stayt J, McGill SE, Mansfield CS. Clinical resolution of a nasal granuloma caused by Trichosporon loubieri. J Feline Med Surg 2010; 12:345-50. [PMID: 20227317 PMCID: PMC11135600 DOI: 10.1016/j.jfms.2009.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2009] [Indexed: 11/25/2022]
Abstract
The current report describes the diagnosis of a nasopharyngeal granuloma due to a fungal infection by Trichosporon loubieri. This is the first report of successful treatment of nasal granuloma formation caused by Trichosporon species infection in a cat.
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Affiliation(s)
- Mellora J Sharman
- Department of Veterinary Clinical Sciences, School of Veterinary and Biomedical Sciences, Faculty of Health Sciences, Murdoch University, Murdoch Drive, Murdoch, Western Australia 6150, Australia.
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19
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Ong RKC, Raisis AL, Swindells KL. Candida albicansperitonitis in a dog. J Vet Emerg Crit Care (San Antonio) 2010; 20:143-7. [DOI: 10.1111/j.1476-4431.2009.00481.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kaufman DA. Epidemiology and Prevention of Neonatal Candidiasis: Fluconazole for All Neonates? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2010; 659:99-119. [DOI: 10.1007/978-1-4419-0981-7_9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
PURPOSE OF REVIEW Owing to the high mortality, risk of neurodevelopmental impairment and end-organ involvement with fungal infections in the neonate, prevention of invasive Candida infections in extremely preterm infants should be a priority for each neonatal ICU. RECENT FINDINGS Even with prompt or empiric treatment, mortality and neurodevelopmental impairment is high (57%) in infants <1000 g. Multiple studies have been performed with fluconazole prophylaxis, including a recent multicenter randomized controlled trial. All of the studies have demonstrated efficacy and safety with no increase or emergence of fungal resistance. Analysis of these studies demonstrates that fluconazole prophylaxis decreased the incidence of invasive Candida infections in high-risk infants <1000 g by 91% (P = 0.0004) and all infants <1500 g by 85% (P < 0.0001). The mortality rate from all causes was 25% lower (P = 0.029). Furthermore, studies have demonstrated that all Candida-related mortality can be eliminated in an entire neonatal ICU by targeting fluconazole prophylaxis in infants <1000 g. SUMMARY Targeting fluconazole prophylaxis to infants who are either <1000 g or < or =27 weeks is highly effective, safe and inexpensive, and can eliminate these infections as a cause of neurodevelopmental impairment and mortality.
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Finn MJ, Stiles J, Krohne SG. Visual outcome in a group of dogs with ocular blastomycosis treated with systemic antifungals and systemic corticosteroids. Vet Ophthalmol 2007; 10:299-303. [PMID: 17760709 DOI: 10.1111/j.1463-5224.2007.00554.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the success of the use of systemic corticosteroids and antifungal medications in the treatment of dogs with ocular lesions associated with systemic blastomycosis. DESIGN Retrospective study. ANIMALS STUDIED Medical records of 25 dogs diagnosed with blastomycosis, via either cytology or histopathology, at the Purdue University Veterinary Teaching Hospital between 1 January 2000 and 1 January 2005, were reviewed. PROCEDURE Data collected from the medical records included signalment, presence and progression of ocular lesions, antifungal drugs administered, oral and topical corticosteroid administration, length of follow-up, response to treatment, and visual outcome. RESULTS Of the 25 cases reviewed, 12 dogs (19 eyes) with follow-up information were found to have lesions consistent with ocular blastomycosis. Length of follow-up in the 12 cases ranged from 1 month to 31 months with a mean of 9 months. Antifungal therapy for all cases consisted of oral itraconazole (5 mg/kg every 24 h) initially. In seven cases, the antifungal drug administered was changed from itraconazole to oral fluconazole. Two of these also received intravenous amphotericin B, and two received additional treatment with itraconazole. All 12 dogs also received oral prednisone. The dose of oral prednisone utilized ranged from 0.2 mg/kg/day to 1.4 mg/kg/day with a mean of 0.7 mg/kg/day; the duration of oral prednisone administration ranged from 2 weeks to 8.5 months with a mean of 3 months. Topical prednisolone was a component of the treatment of 16 of the 19 eyes. Duration of topical prednisolone treatment ranged from 1 month to 30 months with a mean of 5 months. Lesions not located in the eyes exhibited a positive response to treatment in 11 (92%) of the 12 dogs. Overall, 14/19 (74%) affected eyes were visual at the time of their final recheck. All eyes with mild or moderate lesions and 5/10 (50%) severely affected eyes were visual at their last recorded recheck examination. CONCLUSIONS The administration of systemic corticosteroids did not appear to adversely affect the survival rate and might have played a role in preservation of vision in a majority of dogs in this group with ocular blastomycosis.
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Affiliation(s)
- Michael J Finn
- Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK, USA.
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Flammer K, Papich M. Pharmacokinetics of fluconazole after oral administration of single and multiple doses in African grey parrots. Am J Vet Res 2006; 67:417-22. [PMID: 16506902 DOI: 10.2460/ajvr.67.3.417] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the pharmacokinetics and effects of orally administered fluconazole in African grey parrots. ANIMALS 40 clinically normal Timneh African grey parrots (Psittacus erithacus timneh). PROCEDURE In single-dose trials, parrots were placed into groups of 4 to 5 birds each and fluconazole was administered orally at 10 and 20 mg/kg. Blood samples for determination of plasma fluconazole concentrations were collected from each group at 2 or 3 of the following time points: 1, 3, 6, 9, 12, 24, 31, 48, and 72 hours. In multiple-dose trials, fluconazole was administered orally to groups of 5 birds each at doses of 10 and 20 mg/kg every 48 hours for 12 days. Trough plasma concentrations were measured 3 times during treatment. Groups receiving 20 mg/kg were monitored for changes in plasma biochemical analytes, and blood samples were collected on days 1 and 13 of treatment to allow comparison of terminal half-life. RESULTS Peak plasma concentrations of fluconazole were 7.45 and 18.59 microg/mL, and elimination half-lives were 9.22 and 10.19 hours for oral administration of 10 and 20 mg/kg, respectively. Oral administration of fluconazole for 12 days at 10 or 20 mg/kg every 48 hours did not cause identifiable adverse effects or change the disposition of fluconazole. CONCLUSIONS AND CLINICAL RELEVANCE Oral administration of fluconazole to parrots at 10 to 20 mg/kg every 24 to 48 hours maintains plasma concentrations above the minimum inhibitory concentration for several common yeast species. The prolonged dosing interval is an advantage of this treatment regimen.
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Affiliation(s)
- Keven Flammer
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, 27606, USA
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24
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Abstract
In neonates born weighing less than 750 g, invasive candidates is common and often fatal. This situation provides an opportunity to study antifungal prophylaxis and treatment in this patient population, in which the pharmacokinetics, safety, and efficacy of antifungal products are unknown. The disease is less prevalent in larger, more mature, infants. Although some pharmacokinetic data for some products are available for term and near-term infants, optimal product choice, closing, and other treatment strategies also are unknown in this older age group.
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Affiliation(s)
- P Brian Smith
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA
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Hector RF. An Overview of Antifungal Drugs and Their Use for Treatment of Deep and Superficial Mycoses in Animals. ACTA ACUST UNITED AC 2005; 20:240-9. [PMID: 16317914 DOI: 10.1053/j.ctsap.2005.07.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fungal infections are often challenging to manage, given the limited numbers of therapeutics and a general lack of applicable clinical literature for their use in a given animal species. This article reviews some of the underlying principles that can affect the therapeutic outcome for a given antifungal, and provides specific information from the literature that is intended to highlight the distinctive properties of the most commonly used antifungals in veterinary medicine to better facilitate their successful application in clinical practice.
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Affiliation(s)
- Richard F Hector
- Institute for Global Health, University of California San Francisco, San Francisco, CA 94105, USA.
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Kaufman D, Boyle R, Hazen KC, Patrie JT, Robinson M, Grossman LB. Twice weekly fluconazole prophylaxis for prevention of invasive Candida infection in high-risk infants of <1000 grams birth weight. J Pediatr 2005; 147:172-9. [PMID: 16126045 DOI: 10.1016/j.jpeds.2005.03.036] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2004] [Revised: 12/16/2004] [Accepted: 03/14/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We tested the hypothesis that twice weekly prophylactic dosing of fluconazole prevents invasive candidiasis without promoting resistant Candida species in high-risk, preterm infants. STUDY DESIGN We compared our previous dosing schedule (Group A) to a less frequent dosing schedule of twice a week (Group B) of fluconazole prophylaxis for up to 6 weeks in a prospective, randomized, double-blind clinical trial in preterm infants weighing <1000 grams at birth and with an endotracheal tube and/or central vascular catheter over a 24-month period. Weekly surveillance cultures were obtained on study patients. RESULTS Candida colonization was documented in 5 (12%) of 41 Group A and in 4 (10%) of 40 Group B infants. Candida sepsis developed in two (5%) of Group A and one (3%) of Group B infants (risk difference, -0.02; 95% confidence interval, -0.14-0.10; P=.68). All fungal isolates remained sensitive to fluconazole, and no drug side effects were documented. CONCLUSIONS Twice weekly dosing of prophylactic fluconazole can decrease Candida colonization and invasive infection, cost, and patient exposure in high-risk, preterm infants weighing <1000 grams at birth. We speculate that lower and less frequent dosing may delay or prevent the emergence of antifungal resistance.
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Affiliation(s)
- David Kaufman
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA.
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Abstract
Fungal pathogens are becoming increasingly important for human and small animal medicine. This article highlights many standards-of-care and new agents for treatment of these pathogens for small animals and people.
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Affiliation(s)
- Amy M Grooters
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Skip Bertman Drive, Louisiana State University, Baton Rouge, LA 70803, USA.
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Malik R, Krockenberger MB, Cross G, Doneley R, Madill DN, Black D, McWhirter P, Rozenwax A, Rose K, Alley M, Forshaw D, Russell-Brown I, Johnstone AC, Martin P, O'Brien CR, Love DN. Avian cryptococcosis. Med Mycol 2003; 41:115-24. [PMID: 12964843 DOI: 10.1080/mmy.41.2.115.124] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Clinical and laboratory findings in 15 unreported cases of avian cryptococcosis from Australia were collated and contrasted with 11 cases recorded in the literature. Cryptococcus species produced localized invasive disease of the upper respiratory tract of captive parrots living in Australia. This resulted in signs referable to mycotic rhinitis or to involvement of structures contiguous with the nasal cavity, such as the beak, sinuses, choana, retrobulbar space and palate. Parrots of widely differing ages were affected and of the seven birds for which sex was determinable, six were male. Cryptococcus bacillisporus (formerly C. neoformans var. gattii) accounted for four of five infections in which the species or variety was determinable, suggesting that exposure to eucalyptus material may be a predisposing factor. In these cases, Cryptococcus appeared to behave as a primary pathogen of immunocompetent hosts. One tissue specimen was available from an Australian racing pigeon with minimally invasive subcutaneous disease; immunohistology demonstrated a C. neoformans var. grubii (formerly C. neoformans var. neoformans serotype A) infection, presumably subsequent to traumatic inoculation of yeast cells into the subcutis. Two similar cases had been reported previously in pigeons domiciled in America. Data for parrots, one pigeon and other birds studied principally in America and Europe (and likely infected with C. neoformans) suggested a different pattern of disease, more suggestive of opportunistic infection of immunodeficient hosts. In this cohort of patients, the organism was not restricted to cool superficial sites such as the upper respiratory tract or subcutis. Instead, infections typically penetrated the lower respiratory tract or disseminated widely to a variety of internal organs. Finally, three captive North Island brown kiwis, one residing in Australia, the other two in New Zealand, died as a result of severe diffuse cryptococcal pneumonia (two cases) or widely disseminated disease (one case). C. bacillisporus strains were isolated from all three cases, as reported previously for another kiwi with disseminated disease in New Zealand.
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Affiliation(s)
- R Malik
- University Veterinary Centre and Diagnostic Services Laboratory, Faculty of Veterinary Science, The University of Sydney, NSW 2006, Australia.
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Vanden Bossche H, Engelen M, Rochette F. Antifungal agents of use in animal health--chemical, biochemical and pharmacological aspects. J Vet Pharmacol Ther 2003; 26:5-29. [PMID: 12603774 DOI: 10.1046/j.1365-2885.2003.00456.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A limited number of antifungal agents is licensed for use in animals, however, many of those available for the treatment of mycoses in humans are used by veterinary practitioners. This review includes chemical aspects, spectra of activity, mechanisms of action and resistance, adverse reactions and drug interactions of the antifungals in current use.
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Kaufman D, Boyle R, Hazen KC, Patrie JT, Robinson M, Donowitz LG. Fluconazole prophylaxis against fungal colonization and infection in preterm infants. N Engl J Med 2001; 345:1660-6. [PMID: 11759644 DOI: 10.1056/nejmoa010494] [Citation(s) in RCA: 326] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Invasive fungal infection is associated with substantial morbidity and mortality in preterm infants. We evaluated the efficacy of prophylactic fluconazole in preventing fungal colonization and invasive infection in extremely-low-birth-weight infants. METHODS We conducted a prospective, randomized, double-blind clinical trial over a 30-month period in 100 preterm infants with birth weights of less than 1000 g. The infants were randomly assigned during the first five days of life to receive either intravenous fluconazole or placebo for six weeks. We obtained weekly surveillance cultures from all patients. RESULTS The 50 infants randomly assigned to fluconazole and the 50 control infants were similar in terms of birth weight, gestational age at birth, and base-line risk factors for fungal infection. During the six-week treatment period, fungal colonization was documented in 30 infants in the placebo group (60 percent) and 11 infants in the fluconazole group (22 percent; difference in risk, 0.38; 95 percent confidence interval, 0.18 to 0.56; P=0.002). Invasive fungal infection with positive growth of fungal isolates from the blood, urine, or cerebrospinal fluid developed in 10 infants in the placebo group (20 percent) and none of the infants in the fluconazole group (difference in risk, 0.20; 95 percent confidence interval, 0.04 to 0.36; P=0.008). The sensitivities of the fungal isolates to fluconazole did not change during the study, and no adverse effects of the fluconazole therapy were documented. CONCLUSIONS Prophylactic administration of fluconazole during the first six weeks of life is effective in preventing fungal colonization and invasive fungal infection in infants with birth weights of less than 1000 g.
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Affiliation(s)
- D Kaufman
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, USA.
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Hennig-Pauka I, Ganter M, Gerlach GF, Rothkötter HJ. Enzyme activities, protein content and cellular variables in the pulmonary epithelial lining fluid in selected healthy pigs. JOURNAL OF VETERINARY MEDICINE. A, PHYSIOLOGY, PATHOLOGY, CLINICAL MEDICINE 2001; 48:631-9. [PMID: 11848256 DOI: 10.1046/j.1439-0442.2001.00396.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Reference values of cellular and non-cellular components in the bronchoalveolar lavage fluid (BALF) were established from the BALF specimens obtained from 52 healthy pigs. Using urea as an endogenous marker of dilution, the reference values in the epithelial lining fluid (ELF) were calculated: total cell count 2.71 x 10(9) - 56.49 x 10(9) litre(-1) ELF, alveolar macrophages 2.02 x 10(9) - 49.91 x 10(9) litre(-1) ELF, lymphocytes 0.10 x 10(9) - 4.74 x 10(9) litre(-1) ELF, polymorphonuclear neutrophils 0.01 x 10(9) - 3.48 x 10(9) litre(-1) ELF, protein 0.10 - 13.13 g litre(-1) ELF, lactate dehydrogenase 127-1843 Units litre(-1) ELF, and alkaline phosphatase 86-994 Units litre(-1) ELF. The problems of quantification of BALF components are discussed and a standardized lavage protocol in swine is described, which is essential for the interpretation of diagnostic findings and for the comparison of different BALF specimens.
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Affiliation(s)
- I Hennig-Pauka
- Clinic for Swine and Small Ruminants, School of Veterinary Medicine, Hannover, Germany
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Abstract
OBJECTIVE To identify areas of consensus and controversy in the management of neonatal candidiasis. METHODS A questionnaire was distributed to US-based members of the Pediatric Infectious Diseases Society and a sampling of US neonatologists. RESULTS Three hundred eighty evaluable questionnaires were returned (42% of those mailed). Ninety-five percent of respondents have cared for an infant with systemic candidiasis in the past 2 years. Fluconazole and liposomal amphotericin are used to some extent by 90 and 69% of respondents, respectively. A single blood culture positive for Candida led to a recommendation for immediate treatment by 99%; amphotericin B was the preferred therapy for candidemia (88%). More than 80% of respondents would request cerebrospinal fluid, urine and repeat blood cultures and ophthalmologic examination in the evaluation of candidemia. If a cerebrospinal fluid culture is positive, 25% would use amphotericin B alone whereas 62% would add flucytosine. For candiduria Society members chose fluconazole therapy more often than did neonatologists, 23% vs. 3.4% (P<0.001). There was no consensus concerning duration of therapy, use of an amphotericin B test dose or management of a central catheter in place during candidemia. CONCLUSIONS Systemic candidiasis in neonates is a frequently encountered clinical problem. There is agreement that prompt therapy with amphotericin B is required if a blood culture is positive for Candida and that such infants require additional evaluations. Other antifungals (fluconazole, liposomal amphotericin B) are used to some extent in this population. Many issues in management have no clear consensus and warrant further research.
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Affiliation(s)
- J L Rowen
- Department of Pediatrics, University of Texas Medical Branch, Galveston 77555-0371, USA.
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