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Groll AH, Körholz K, Holterhus M, Lehrnbecher T. New and emerging options for management of invasive fungal diseases in paediatric patients. Mycoses 2024; 67:e13654. [PMID: 37789721 DOI: 10.1111/myc.13654] [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: 07/10/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 10/05/2023]
Abstract
Invasive fungal diseases (IFDs) play an important role in the supportive care of paediatric patients with acute leukaemia and those undergoing allogeneic haematopoietic cell transplantation, and they are associated with significantly decreased overall survival rates in affected individuals. Relative to adults, children and adolescents are distinct in terms of host biology, predisposing conditions, presentation and epidemiology of fungal diseases, and in the pharmacology of antifungal agents. The paediatric development of antifungal agents has moved forward in a coordinated manner, and major advances have been made regarding concepts and recommendations for the prevention and treatment of IFDs. However, antifungal therapy is increasingly complex, and a solid knowledge of the available options is needed more than ever for successful management. This narrative review provides a summary of the paediatric development of agents that have been recently approved (anidulafungin, posaconazole) or are in advanced stages of development (isavuconazole). It also reviews the emerging evidence for the efficacy of echinocandins for prophylaxis of invasive aspergillosis, presents new data on alternative dosing regimens of echinocandins and voriconazole, and provides a brief overview of new antifungal agents in clinical development that are expected to be developed for paediatric patients.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Katharina Körholz
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Malcolm Holterhus
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt, Germany
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2
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Alali M, Balsara K, Khaitan A, Streicher DA, Barros KL, Budnick HC, Schulte RR. Successful isavuconazole salvage therapy for cerebral mucormycosis in a child with relapsed leukemia: A light in the dark tunnel. Pediatr Blood Cancer 2023; 70:e29807. [PMID: 35657144 DOI: 10.1002/pbc.29807] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Muayad Alali
- Department of Pediatrics, Ryan White Center for Pediatric, Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Karl Balsara
- Department of Neurosurgery, Goodman Campbell Brain and Spine, Riley Hospital for Children, Section of Pediatric Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alka Khaitan
- Department of Pediatrics, Ryan White Center for Pediatric, Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Drew A Streicher
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kathryn L Barros
- Department of Pediatrics, Ryan White Center for Pediatric, Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hailey C Budnick
- Department of Neurosurgery, Goodman Campbell Brain and Spine, Riley Hospital for Children, Section of Pediatric Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachael R Schulte
- Department of Pediatrics, Section of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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3
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Ding Q, Huang S, Sun Z, Chen K, Li X, Pei Q. A Review of Population Pharmacokinetic Models of Posaconazole. Drug Des Devel Ther 2022; 16:3691-3709. [PMID: 36277600 PMCID: PMC9584355 DOI: 10.2147/dddt.s384637] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022] Open
Abstract
Posaconazole is often used for the prophylaxis and treatment of invasive fungal infections (IFI). However, intra- and inter-individual differences and drug interactions affect the efficacy and safety of posaconazole. Precision dosing of posaconazole based on the population pharmacokinetic (PopPK) model may assist in making significant clinical decisions. This review aimed to comprehensively summarize the published PopPK models of posaconazole and analyze covariates that significantly influence posaconazole exposure. Articles published until May 2022 for PopPK analysis of posaconazole were searched in PubMed and EMBASE databases. Demographic characteristics, model characteristics, and results of PopPK analysis were extracted from the selected articles. In addition, the steady-state pharmacokinetic profiles of posaconazole were simulated at different covariate levels and dosing regimens. Out of the 13 studies included in our review, nine studies included adults, three included children, and one included both adults and children. All oral administration models were one-compartment models, and all intravenous administration models were two-compartment models. Body weight, proton pump inhibitors, and incidence of diarrhea were found to be important covariates. Clinically, the potential impact of factors such as patient physiopathologic characteristics and comorbid medications on posaconazole pharmacokinetics should be considered. Dose adjustment in combination with TDM or replacement with a tablet or intravenous formulation with higher exposure may be an effective way to ensure drug efficacy as well as to reduce fungal resistance. Meanwhile, published models require further external evaluation to examine extrapolation.
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Affiliation(s)
- Qin Ding
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Shuqi Huang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Zexu Sun
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, People’s Republic of China
| | - Kaifeng Chen
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xin Li
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China,Xin Li, Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013, People’s Republic of China, Email
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China,Correspondence: Qi Pei, Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, People’s Republic of China, Tel +86 1 317 041 9804, Email
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Lin D, Yu L, Shang D, Huang L, Wu L, Liao X, Zhang Y, Zi J, Zhang J, Zeng Y, Wang X, Yang L. Population pharmacokinetics of posaconazole in Chinese pediatric patients with acute leukaemia: effect of food on bioavailability and dose optimization. Eur J Pharm Sci 2022; 178:106289. [PMID: 36041707 DOI: 10.1016/j.ejps.2022.106289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/03/2022]
Abstract
This study aimed to investigate the effect of food on the pharmacokinetics of posaconazole suspension in pediatric patients with acute leukaemia and to recommend optimal dosing strategies. This single-site, prospective, open-label, observational study was conducted in 42 patients and included 186 plasma concentrations of posaconazole. Sparse data were analyzed using population pharmacokinetic modeling. Monte Carlo simulations were conducted to predict the morning trough concentrations at steady-state with the proposed dose of 2-7 mg/kg three times daily (tid) or four times daily (qid) for bodyweights of 10-36 kg. The target concentrations were 700 ng/mL for prophylaxis and 1000 ng/mL for treatment. Dosage regimens with percentage of target attainment (PTA) ≥70% were recommended. A one-compartment model with allometric scaling adequately described the pharmacokinetic profile. The apparent clearance was 9.05 L/h (95% confidence interval [CI] 7.14-11.09) and the apparent volume of distribution was 283 L (95% CI 168-491) for a typical individual of 17.5 kg. The relative bioavailability with high-fat diet was as high as 1.95-fold compared with regular food. Following the intake of regular meals, 4 mg/kg qid was adequate with a PTA ≥ 71.8% for prophylaxis. A dosage of 6 mg/kg qid under a regular diet reached a PTA ≥ 73.4% for treatment. The recommended dosage of posaconazole for prophylaxis and treatment could be predicted by the pharmacokinetic model based on bodyweight and diet type in pediatric patients.
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Affiliation(s)
- Danna Lin
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Lihua Yu
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Dewei Shang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Lulu Huang
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Li Wu
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Xu Liao
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Yajie Zhang
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Juan Zi
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Jingxin Zhang
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Yinghua Zeng
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
| | - Xipei Wang
- Medical Research Center, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China; Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Lihua Yang
- Department of Pediatric Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China..
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Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
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Jia M, Zhang Q, Qin Z, Wang D, Liu P, Yang J, Zhang X. Dose Optimisation of Posaconazole and Therapeutic Drug Monitoring in Pediatric Patients. Front Pharmacol 2022; 13:833303. [PMID: 35517786 PMCID: PMC9061949 DOI: 10.3389/fphar.2022.833303] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Experience in the clinical use of posaconazole (PCZ) in pediatric patients is limited, and no specific dose recommendations exist. This study aimed to investigate an appropriate dosing regimen, and assess the exposure-response relationships of PCZ in children. We reviewed the medical records of inpatients aged <18 years who subjected to PCZ concentrations monitoring. Clinical data, PCZ dosing and monitoring data were collected. A total of 375 PCZ trough concentrations (C min) from 105 pediatric patients were included. For children receiving PCZ for prophylaxis, the median doses required to achieve the therapeutic range at the ages of <6, 6-12 and >12 years were 14.80, 14.52 and 12.90 mg/kg/day, respectively (p = 0.001); and for those receiving PCZ for treatment, the median doses were 23.50, 20.96 and 15.38 mg/kg/day, respectively (p = 0.001). Among children taking PCZ for prophylaxis, 12% developed a proven or probable breakthrough IFIs; the median PCZ concentrations were significantly lower than those children with successful treatment response (0.43 versus 1.20 μg mL-1; p < 0.001). 79.2% patients taking PCZ for treatment had a positive clinical response, and the median PCZ concentrations were significantly higher than those children with disease progression (1.06 versus 0.53 μg mL-1; p = 0.024). No association between C min values and hepatotoxicity was observed. Factors such as age, CRP, ALT and co-administration with proton pump inhibitors exhibited significant effects on PCZ C min. It is necessary to adjust the dosing regimens based on PCZ C min to individualize antifungal therapy and provide guidelines for dose adjustment in children.
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Affiliation(s)
- Mengmeng Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Zifei Qin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Dao Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Liu
- Pediatric Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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Kably B, Launay M, Derobertmasure A, Lefeuvre S, Dannaoui E, Billaud EM. Antifungal Drugs TDM: Trends and Update. Ther Drug Monit 2022; 44:166-197. [PMID: 34923544 DOI: 10.1097/ftd.0000000000000952] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The increasing burden of invasive fungal infections results in growing challenges to antifungal (AF) therapeutic drug monitoring (TDM). This review aims to provide an overview of recent advances in AF TDM. METHODS We conducted a PubMed search for articles during 2016-2020 using "TDM" or "pharmacokinetics" or "drug-drug-interaction" with "antifungal," consolidated for each AF. Selection was limited to English language articles with human data on drug exposure. RESULTS More than 1000 articles matched the search terms. We selected 566 publications. The latest findings tend to confirm previous observations in real-life clinical settings. The pharmacokinetic variability related to special populations is not specific but must be considered. AF benefit-to-risk ratio, drug-drug interaction (DDI) profiles, and minimal inhibitory concentrations for pathogens must be known to manage at-risk situations and patients. Itraconazole has replaced ketoconazole in healthy volunteers DDI studies. Physiologically based pharmacokinetic modeling is widely used to assess metabolic azole DDI. AF prophylactic use was studied more for Aspergillus spp. and Mucorales in oncohematology and solid organ transplantation than for Candida (already studied). Emergence of central nervous system infection and severe infections in immunocompetent individuals both merit special attention. TDM is more challenging for azoles than amphotericin B and echinocandins. Fewer TDM requirements exist for fluconazole and isavuconazole (ISZ); however, ISZ is frequently used in clinical situations in which TDM is recommended. Voriconazole remains the most challenging of the AF, with toxicity limiting high-dose treatments. Moreover, alternative treatments (posaconazole tablets, ISZ) are now available. CONCLUSIONS TDM seems to be crucial for curative and/or long-term maintenance treatment in highly variable patients. TDM poses fewer cost issues than the drugs themselves or subsequent treatment issues. The integration of clinical pharmacology into multidisciplinary management is now increasingly seen as a part of patient care.
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Affiliation(s)
- Benjamin Kably
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
| | - Manon Launay
- Laboratoire de Pharmacologie-Toxicologie-Gaz du sang, Hôpital Nord-CHU Saint Etienne, Saint-Etienne
| | - Audrey Derobertmasure
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
| | - Sandrine Lefeuvre
- Laboratoire de Toxicologie et Pharmacocinétique, CHU de Poitiers, Poitiers; and
| | - Eric Dannaoui
- Faculté de Médecine, Université de Paris, Paris, France
- Unité de Parasitologie-Mycologie, Laboratoire de Microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Eliane M Billaud
- Laboratoire de Pharmacologie-Toxicologie, Hôpital Européen Georges Pompidou, AP-HP Centre
- Faculté de Médecine, Université de Paris, Paris, France
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8
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Maquera-Afaray J, Luna-Vilchez M, Salazar-Mesones B, Portillo-Alvarez D, Uribe-Ramirez L, Taipe-Sedano G, Santillán-Salas C, López JW. Antifungal Prophylaxis With Posaconazole in Immunocompromised Children Younger Than 13 Years. J Pediatr Pharmacol Ther 2022; 27:57-62. [PMID: 35002560 DOI: 10.5863/1551-6776-27.1.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Prophylaxis with posaconazole (PP) is effective in the prevention of invasive fungal infections in immunocompromised adult patients. However, evaluation of its effectiveness and safety in children is limited. The aim of the study was to describe the use of posaconazole as antifungal prophylaxis in children. METHODS We reviewed the medical records of immunocompromised patients younger than 13 years with hematologic diseases and post hematopoietic stem cell transplant (HSCT) who received antifungal PP at the Instituto Nacional de Salud del Niño San Borja (INSN-SB) in Lima, Peru, from January 2014 to December 2018. RESULTS Fifty-six courses of PP were identified in 47 patients with a median age of 7.5 years (IQR, 4-10), 51.6% (n = 24) of whom were female. The main underlying medical conditions were aplastic anemia (n = 19, 33.9%), acute lymphoblastic leukemia (n = 18, 32.1%), acute myeloid leukemia (n = 14, 25.0%), and 34.1% had undergone HSCT. The median dose of posaconazole was 13.62 mg/kg/day (IQR, 12.0-16.8), and the median duration of PP was 24 days (IQR, 16-82). Gastrointestinal symptoms included abdominal pain (17.9%), nausea (16.1%), diarrhea (7.1%), and vomiting (3.6%). Elevated alanine aminotransferase and aspartate aminotransferase levels were observed in 9/35 patients (25.7%) and 10/51 (19.6%) patients, respectively. Five cases of breakthrough fungal infection were identified (8.9%). CONCLUSIONS Patients younger than 13 years who received PP showed an increase in transaminase values, and the development of breakthrough fungal infections.
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Affiliation(s)
- Julio Maquera-Afaray
- Unidad de Atención Integral Especializada (JM-A, ML-V, BS-M, DP-A, LU-R, GT-S, CS-S, JWL), Instituto Nacional de Salud del Niño San Borja, Lima, Perú.,Facultad de Ciencias de la Salud (JM-A), Universidad Privada de Tacna, Tacna, Perú
| | - Medalit Luna-Vilchez
- Unidad de Atención Integral Especializada (JM-A, ML-V, BS-M, DP-A, LU-R, GT-S, CS-S, JWL), Instituto Nacional de Salud del Niño San Borja, Lima, Perú
| | - Blanca Salazar-Mesones
- Unidad de Atención Integral Especializada (JM-A, ML-V, BS-M, DP-A, LU-R, GT-S, CS-S, JWL), Instituto Nacional de Salud del Niño San Borja, Lima, Perú
| | - Diana Portillo-Alvarez
- Unidad de Atención Integral Especializada (JM-A, ML-V, BS-M, DP-A, LU-R, GT-S, CS-S, JWL), Instituto Nacional de Salud del Niño San Borja, Lima, Perú
| | - Luis Uribe-Ramirez
- Unidad de Atención Integral Especializada (JM-A, ML-V, BS-M, DP-A, LU-R, GT-S, CS-S, JWL), Instituto Nacional de Salud del Niño San Borja, Lima, Perú
| | - Graciela Taipe-Sedano
- Unidad de Atención Integral Especializada (JM-A, ML-V, BS-M, DP-A, LU-R, GT-S, CS-S, JWL), Instituto Nacional de Salud del Niño San Borja, Lima, Perú
| | - Carlos Santillán-Salas
- Unidad de Atención Integral Especializada (JM-A, ML-V, BS-M, DP-A, LU-R, GT-S, CS-S, JWL), Instituto Nacional de Salud del Niño San Borja, Lima, Perú
| | - José W López
- Unidad de Atención Integral Especializada (JM-A, ML-V, BS-M, DP-A, LU-R, GT-S, CS-S, JWL), Instituto Nacional de Salud del Niño San Borja, Lima, Perú.,Facultad de Ciencias de la Salud (JWL), Universidad Científica del Sur, Lima, Perú
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10
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Bupha-Intr O, Butters C, Reynolds G, Kennedy K, Meyer W, Patil S, Bryant P, Morrissey CO. Consensus guidelines for the diagnosis and management of invasive fungal disease due to moulds other than Aspergillus in the haematology/oncology setting, 2021. Intern Med J 2021; 51 Suppl 7:177-219. [PMID: 34937139 DOI: 10.1111/imj.15592] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Invasive fungal disease (IFD) due to moulds other than Aspergillus is a significant cause of mortality in patients with malignancies or post haemopoietic stem cell transplantation. The current guidelines focus on the diagnosis and management of the common non-Aspergillus moulds (NAM), such as Mucorales, Scedosporium species (spp.), Lomentospora prolificans and Fusarium spp. Rare but emerging NAM including Paecilomyces variotii, Purpureocillium lilacinum and Scopulariopsis spp. are also reviewed. Culture and histological examination of tissue biopsy specimens remain the mainstay of diagnosis, but molecular methods are increasingly being used. As NAM frequently disseminate, blood cultures and skin examination with biopsy of any suspicious lesions are critically important. Treatment requires a multidisciplinary approach with surgical debridement as a central component. Other management strategies include control of the underlying disease/predisposing factors, augmentation of the host response and the reduction of immunosuppression. Carefully selected antifungal therapy, guided by susceptibility testing, is critical to cure. We also outline novel antifungal agents still in clinical trial which offer substantial potential for improved outcomes in the future. Paediatric recommendations follow those of adults. Ongoing epidemiological research, improvement in diagnostics and the development of new antifungal agents will continue to improve the poor outcomes that have been traditionally associated with IFD due to NAM.
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Affiliation(s)
- Olivia Bupha-Intr
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
| | - Coen Butters
- Department of General Paediatric and Adolescent Medicine, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - Karina Kennedy
- Department of Infectious Diseases and Microbiology, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia.,ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Westmead Clinical School and Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, New South Wales, Australia
| | - Sushrut Patil
- Malignant Haematology and Stem Cell Transplantation Service, Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Penelope Bryant
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Catherine O Morrissey
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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11
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Teh BW, Yeoh DK, Haeusler GM, Yannakou CK, Fleming S, Lindsay J, Slavin MA. Consensus guidelines for antifungal prophylaxis in haematological malignancy and haemopoietic stem cell transplantation, 2021. Intern Med J 2021; 51 Suppl 7:67-88. [PMID: 34937140 DOI: 10.1111/imj.15588] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Antifungal prophylaxis can reduce morbidity and mortality from invasive fungal disease (IFD). However, its use needs to be optimised and appropriately targeted to patients at highest risk to derive the most benefit. In addition to established risks for IFD, considerable recent progress in the treatment of malignancies has resulted in the development of new 'at-risk' groups. The changing epidemiology of IFD and emergence of drug resistance continue to impact choice of prophylaxis, highlighting the importance of active surveillance and knowledge of local epidemiology. These guidelines aim to highlight emerging risk groups and review the evidence and limitations around new formulations of established agents and new antifungal drugs. It provides recommendations around use and choice of antifungal prophylaxis, discusses the potential impact of the changing epidemiology of IFD and emergence of drug resistance, and future directions for risk stratification to assist optimal management of highly vulnerable patients.
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Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Daniel K Yeoh
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Costas K Yannakou
- Department of Molecular Oncology and Cancer Immunology, Epworth Freemasons Hospital, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Shaun Fleming
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health, Melbourne, Victoria, Australia
| | - Julian Lindsay
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Immunocompromised Host Infection Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Garner LM, Ngo S, Kaplan JB, Wilson WS, McKinzie CJ. Evaluation of Posaconazole Dosing in Children and Young Adults: A Single-Center Review. J Pediatr Pharmacol Ther 2021; 26:834-840. [PMID: 34790074 DOI: 10.5863/1551-6776-26.8.834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/08/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Initial posaconazole dosing regimens in children often do not achieve target concentrations, and data continue to support the need for higher initial dosing regimens. The objective of this study is to contribute to the current data regarding suboptimal posaconazole dosing in pediatric patients by retrospectively observing dosing strategies and subsequent drug concentrations. METHODS This study was conducted at a single institution in 27 patients aged 1 to 21 years. Patients who were initiated on any formulation of posaconazole for prophylaxis or treatment while admitted to the hospital were included. The primary outcome was to determine the percentage of pediatric patients who achieved the targeted trough concentration using their initial posaconazole dosing regimen. Secondary outcomes included percentage of patients who experienced a breakthrough invasive fungal infection (IFI), percentage of patients with elevated liver function tests (LFTs), and discontinuation for any reason. RESULTS There were 15 patients (55.5%) who reached desired trough serum concentration after the initial dosing regimen. The number of dose modifications to achieve the desired trough ranged from 1 to 3. Most patients received delayed-release tablets (n = 17), and the average doses for reaching prophylactic and treatment trough concentrations were 6.1 mg/kg/day and 11 mg/kg/day, respectively. There were 2 patients (7.4%) who experienced breakthrough IFI. Overall, 5 patients developed elevated LFTs and 7 patients discontinued treatment early. CONCLUSIONS The results describe a single population of pediatric patients, of whom 55% were able to achieve target trough concentrations of posaconazole with the initial dosing strategy used.
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Panagopoulou P, Roilides E. Evaluating posaconazole, its pharmacology, efficacy and safety for the prophylaxis and treatment of fungal infections. Expert Opin Pharmacother 2021; 23:175-199. [PMID: 34758695 DOI: 10.1080/14656566.2021.1996562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFDs) are a significant cause of morbidity and mortality among immunocompromised patients. Safe and effective antifungal medications used for prophylaxis and treatment are pivotal in their management. Posaconazole is a promising triazole antifungal agent. AREAS COVERED The authors discuss the pharmacological properties of posaconazole, including pharmacokinetics/pharmacodynamics, safety and tolerability profile, together with efficacy data for prophylaxis and treatment as well as its use in special populations based on current literature. EXPERT OPINION Posaconazole has a favorable safety and tolerability profile; however, caution is advised when co-administered with agents that are CYP3A4 inhibitors, because their concentration may significantly increase, and their levels should be closely monitored. It has an extended spectrum of activity against yeasts and filamentous fungi. It is successfully used as prophylaxis for patients with acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) and post-hematopoietic cell transplantation (HCT) with graft-versus-host disease (GVHD). It is the first line treatment for oropharyngeal candidiasis and is also used as a salvage treatment for refractory IFDs. Currently available formulations include the oral suspension, delayed-release tablets and solution for intravenous infusion, all with different PK/PD properties and indications. Its use in children and adolescents is currently being examined in Phase-II clinical trials.
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Affiliation(s)
- Paraskevi Panagopoulou
- 4th Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Papageorgiou General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece.,Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Elkayal O, Spriet I, Uyttebroeck A, Colita A, Annaert P, Allegaert K, Smits A, Van Daele R, Dreesen E. A Population Pharmacokinetic Modeling and Simulation Study of Posaconazole Oral Suspension in Immunocompromised Pediatric Patients: A Short Communication. Ther Drug Monit 2021; 43:512-518. [PMID: 33560094 DOI: 10.1097/ftd.0000000000000877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Posaconazole oral suspension emerged as a promising candidate for prophylaxis of invasive fungal infections in immunocompromised children. Its pharmacodynamic advantages include a broad-spectrum activity and a favorable safety profile; however, they are overshadowed by its large pharmacokinetic (PK) variability, which might cause subtherapeutic exposure. The aim of this study was to develop a population (pop) PK model based on rich sampling data to better understand the PK of posaconazole oral suspension in pediatric patients. METHODS Data were obtained from a prospective interventional study involving hospitalized pediatric patients with a hematologic malignancy and prophylactically treated with posaconazole oral suspension. After constructing the popPK model, the probability of target attainment (PTA; 100% T ≥ 0.7 mg/L) for prophylaxis under fixed, body weight-based, and body surface area-based dosing was evaluated using Monte Carlo simulation. RESULTS Fourteen patients contributed 112 posaconazole plasma concentrations. The PK of posaconazole was adequately described by a 1-compartment model with lag time 2.71 hours [13%]; nonlinear bioavailability ED50 99.1 mg/m2 (fixed); first-order absorption rate constant 0.325 hour-1 [27%]; apparent volume of distribution 1150 L [34%]; and apparent clearance 15.4 L/h [24%] (∼70-kg individual). The bioavailability decreased in the presence of diarrhea and co-treatment with a proton pump inhibitor (PPI). The unexplained interindividual variability in posaconazole PK remained large. The PTA was <85%, irrespective of the simulated dosing strategy. Patients without diarrhea and not administered a PPI had the highest PTA (85% under the fixed 300-mg dosing 4 times per day). CONCLUSIONS Therapeutic drug monitoring is recommended during prophylactic posaconazole therapy in immunocompromised pediatric patients. Large-scale comparative studies are needed to characterize the PK variability between different posaconazole formulations in this cohort.
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Affiliation(s)
- Omar Elkayal
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacy Department, University Hospitals Leuven
| | - Anne Uyttebroeck
- Paediatric Oncology Unit, Department of Oncology, KU Leuven
- Pediatric Oncology and Hematology Department, University Hospitals Leuven, Leuven, Belgium
| | - Anca Colita
- Department of Pediatrics, Fundeni Clinical Institute
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Pieter Annaert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Woman and Child Unit, Department of Development and Regeneration, KU Leuven
| | - Anne Smits
- Woman and Child Unit, Department of Development and Regeneration, KU Leuven
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium ; and
| | - Ruth Van Daele
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacy Department, University Hospitals Leuven
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacometrics Research Group, Department of Pharmacy, Uppsala University, Uppsala, Sweden
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15
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Abstract
Posaconazole is typically used for preventing invasive yeast and mold infections such as invasive aspergillosis in high-risk immunocompromised patients. The oral suspension was the first released formulation and many pharmacokinetic and pharmacodynamic studies of this formulation have been published. Erratic absorption profiles associated with this formulation were widely reported. Posaconazole exposure was found to be significantly influenced by food and many gastrointestinal conditions, including pH and motility. As a result, low posaconazole plasma concentrations were obtained in large groups of patients. These issues of erratic absorption urged the development of the subsequently marketed delayed-release tablet, which proved to be associated with higher and more stable exposure profiles. Shortly thereafter, an intravenous formulation was released for patients who are not able to take oral formulations. Both new formulations require a loading dose on day 1 to achieve high posaconazole concentrations more quickly, which was not possible with the oral suspension. So far, there appears to be no evidence of increased toxicity correlated to the higher posaconazole exposure achieved with the regimen for these formulations. The higher systemic availability of posaconazole for the delayed-release tablet and intravenous formulation have resulted in these two formulations being preferable for both prophylaxis and treatment of invasive fungal disease. This review aimed to integrate the current knowledge on posaconazole pharmacokinetics, pharmacodynamics, major toxicity, existing resistance, clinical experience in special populations, and new therapeutic strategies in order to get a clear understanding of the clinical use of this drug.
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16
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Antachopoulos C, Roilides E. Pharmacokinetics and Pharmacodynamics of Antifungal Agents in Neonates and Children. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00402-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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17
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Mauro M, Colombini A, Perruccio K, Zama D, D'Amico MR, Calore E, Carraro F, Muggeo P, Tridello G, Baretta V, Cesaro S. Posaconazole delayed‐release tablets in paediatric haematology–oncology patients. Mycoses 2020; 63:604-609. [DOI: 10.1111/myc.13084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Margherita Mauro
- Pediatric Hematology Oncology Department of Mother and Child Azienda Ospedaliera Universitaria Integrata Verona Verona Italy
| | - Antonella Colombini
- Department of Pediatrics Ospedale San Gerardo University of Milano‐Bicocca, Fondazione MBBM Monza Italy
| | - Katia Perruccio
- Pediatric Oncology‐Hematology Santa Maria della Misericordia Hospital Perugia Italy
| | - Daniele Zama
- Department of Pediatrics Pediatric Oncology and Haematology Unit “Lalla Seràgnoli” Sant' Orsola Malpighi Hospital University of Bologna Bologna Italy
| | - Maria Rosaria D'Amico
- BMT Unit Department of Pediatric Hemato‐Oncology Santobono‐Pausilipon Hospital Napoli Italy
| | - Elisabetta Calore
- Clinic of Pediatric Hemato‐Oncology Department of Women's and Children's Health University Hospital of Padova Padova Italy
| | - Francesca Carraro
- Stem Cell Transplantation and Cellular Therapy Division Pediatric Onco‐Hematology AOU Città della Salute e della Scienza Regina Margherita Childrens Hospital Turin Italy
| | - Paola Muggeo
- Department of Pediatric Oncology and Hematology University Hospital of Policlinico, Bari Bari Italy
| | - Gloria Tridello
- Pediatric Hematology Oncology Department of Mother and Child Azienda Ospedaliera Universitaria Integrata Verona Verona Italy
| | - Valentina Baretta
- Pediatric Hematology Oncology Department of Mother and Child Azienda Ospedaliera Universitaria Integrata Verona Verona Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology Department of Mother and Child Azienda Ospedaliera Universitaria Integrata Verona Verona Italy
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Abstract
Neonates and immunosuppressed/immunocompromised pediatric patients are at high risk of invasive fungal diseases. Appropriate antifungal selection and optimized dosing are imperative to the successful prevention and treatment of these life-threatening infections. Conventional amphotericin B was the mainstay of antifungal therapy for many decades, but dose-limiting nephrotoxicity and infusion-related adverse events impeded its use. Despite the development of several new antifungal classes and agents in the past 20 years, and their now routine use in at-risk pediatric populations, data to guide the optimal dosing of antifungals in children are limited. This paper reviews the spectra of activity for approved antifungal agents and summarizes the current literature specific to pediatric patients regarding pharmacokinetic/pharmacodynamic data, dosing, and therapeutic drug monitoring.
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Affiliation(s)
- Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 2716 South Street, Suite 10360, Philadelphia, PA, 19146, USA.
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Brian T Fisher
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 2716 South Street, Suite 10360, Philadelphia, PA, 19146, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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19
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Ojeda-Diezbarroso K, Aguilar-Rascón J, Jiménez-Juárez RN, Moreno-Espinosa S, Reséndiz-Sánchez J, Romero-Zamora JL. Successful posaconazole salvage therapy for rhinocerebral mucormycosis in a child with leukemia. Review of the literature. Rev Iberoam Micol 2019; 36:160-164. [PMID: 31563327 DOI: 10.1016/j.riam.2018.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/20/2018] [Accepted: 07/30/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Mucormycosis is a fungal infection caused by species of the Mucorales order. These microorganisms are angioinvasive, with rapid disease progression and potentially lethal in its rhinocerebral form. CASE REPORT We present the case of a 12-year-old female with trisomy 21, acute lymphoblastic leukemia and diabetes, with fever and neutropenia who developed rhinocerebral mucormicosis. After treatment with amphotericin B lipid complex and extensive surgery, disease progressed and posaconazole was added as salvage treatment with full remission of the infection. Four years after diagnosis the patient continues without relapse of mucormycosis or leukemia. CONCLUSIONS This case highlights the use of posaconazole as either monotherapy or combined therapy. Although it is still debated, it can be considered an option for salvage treatment in children with non-responding mucormycosis, despite lack of standard dosage in pediatric patients.
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Affiliation(s)
- Karla Ojeda-Diezbarroso
- Pediatric Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico; Otorhinolaryngology Department, Hospital Infantil de México Federico Gómez, Mexico
| | - Juan Aguilar-Rascón
- Otorhinolaryngology Department, Hospital Infantil de México Federico Gómez, Mexico
| | - Rodolfo Norberto Jiménez-Juárez
- Pediatric Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico; Department of Pediatrics, Infectious Diseases Hospital, National Medical Center La Raza, Mexican Institute of Social Security, Mexico City, Mexico.
| | | | - Jesús Reséndiz-Sánchez
- Pediatric Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico
| | - José Luis Romero-Zamora
- Pediatric Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico
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20
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Athanasiadou KI, Athanasiadis DI, Constantinidis J, Anastasiou A, Roilides E, Papakonstantinou E. Successful treatment of rhinoorbital mucormycosis due to Rhizopus arrhizus with liposomal amphotericin B, posaconazole and surgical debridement in a child with neuroblastoma. Med Mycol Case Rep 2019; 25:10-14. [PMID: 31245270 PMCID: PMC6582074 DOI: 10.1016/j.mmcr.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/14/2019] [Accepted: 06/07/2019] [Indexed: 11/20/2022] Open
Abstract
Mucormycosis is a rare but potentially mortal opportunistic infection caused by Mucorales. We present a case of rhinoorbital mucormycosis in an 11-year old male with neuroblastoma successfully treated with aggressive surgical debridement and antifungal combination of liposomal amphotericin B and posaconazole. Our patient developed signs of paranasal sinus infection and culture of fine needle biopsy grew Rhizopus arrhizus. Prompt treatment and drastic surgical resection led to complete clinical and radiological recovery without evidence of mucormycosis relapse.
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Affiliation(s)
- Kleoniki I. Athanasiadou
- Pediatric Oncology Department, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Dimitrios I. Athanasiadis
- Department of Surgery, Papageorgiou University Hospital, Aristotle University of Thessaloniki, Region of Efkarpia, GR-564 03, Thessaloniki, Greece
| | - John Constantinidis
- Otorhinolaryngology Department, Papageorgiou University Hospital, Aristotle University of Thessaloniki, Region of Efkarpia, GR-564 03, Thessaloniki, Greece
| | - Athanasia Anastasiou
- Department of Radiology, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Hippokration Hospital, Aristotle University School of Medicine, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Evgenia Papakonstantinou
- Pediatric Oncology Department, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
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21
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Cornu M, Bruno B, Loridant S, Navarin P, François N, Lanternier F, Amzallag-Bellenger E, Dubos F, Mazingue F, Sendid B. Successful outcome of disseminated mucormycosis in a 3-year-old child suffering from acute leukaemia: the role of isavuconazole? A case report. BMC Pharmacol Toxicol 2018; 19:81. [PMID: 30522521 PMCID: PMC6282241 DOI: 10.1186/s40360-018-0273-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/21/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The use of isavuconazole is approved for the management of invasive aspergillosis and mucormycosis, only in adults, as no paediatric pharmacology studies have been reported to date. Very few paediatric cases have been published concerning the use of isavuconazole. Amphotericin B is the only antifungal agent recommended in paediatric mucormycosis, but adverse effects and especially nephrotoxicity, even with the liposomal formulation, could be problematic. In this context, the use of other antifungal molecules active on Mucorales becomes needful. CASE PRESENTATION We describe a case of mucormycosis with rapid onset dissemination in a 3-year-old girl recently diagnosed with acute lymphocytic leukaemia. She was successfully treated with isavuconazole alone and then in combination with liposomal amphotericin B. Isavuconazole therapy was guided by therapeutic drug monitoring. CONCLUSIONS This case offers new perspectives on the potential use of isavuconazole in children with mucormycosis, as an alternative or adjunct to liposomal amphotericin B.
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Affiliation(s)
- Marjorie Cornu
- Laboratoire de Parasitologie Mycologie, CHU Lille, Univ. Lille, INSERM U995 – LIRIC - Lille Inflammation Research International Centre, F-59000 Lille, France
| | - Bénédicte Bruno
- Service d’Onco-Hématologie Pédiatrique, CHU Lille, F-59000 Lille, France
| | - Séverine Loridant
- Laboratoire de Parasitologie Mycologie, CHU Lille, Univ. Lille, INSERM U995 – LIRIC - Lille Inflammation Research International Centre, F-59000 Lille, France
| | - Pauline Navarin
- Service d’Onco-Hématologie Pédiatrique, CHU Lille, F-59000 Lille, France
| | - Nadine François
- Laboratoire de Parasitologie Mycologie, CHU Lille, Univ. Lille, INSERM U995 – LIRIC - Lille Inflammation Research International Centre, F-59000 Lille, France
| | - Fanny Lanternier
- Paris Descartes University, Sorbonne Paris Cité, Infectious Diseases Unit, Necker-Enfants Malades University Hospital, AP-HP, Imagine Institute, Paris, France
- Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Paris, France
- Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | | | - François Dubos
- Service des urgences et maladies infectieuses pédiatriques, CHU Lille et Univ. Lille, F-59000 Lille, France
| | - Françoise Mazingue
- Service d’Onco-Hématologie Pédiatrique, CHU Lille, F-59000 Lille, France
| | - Boualem Sendid
- Laboratoire de Parasitologie Mycologie, CHU Lille, Univ. Lille, INSERM U995 – LIRIC - Lille Inflammation Research International Centre, F-59000 Lille, France
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Iosifidis E, Papachristou S, Roilides E. Advances in the Treatment of Mycoses in Pediatric Patients. J Fungi (Basel) 2018; 4:E115. [PMID: 30314389 PMCID: PMC6308938 DOI: 10.3390/jof4040115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/05/2018] [Accepted: 10/07/2018] [Indexed: 12/16/2022] Open
Abstract
The main indications for antifungal drug administration in pediatrics are reviewed as well as an update of the data of antifungal agents and antifungal policies performed. Specifically, antifungal therapy in three main areas is updated as follows: a) Prophylaxis of premature neonates against invasive candidiasis; b) management of candidemia and meningoencephalitis in neonates; and c) prophylaxis, empiric therapy, and targeted antifungal therapy in children with primary or secondary immunodeficiencies. Fluconazole remains the most frequent antifungal prophylactic agent given to high-risk neonates and children. However, the emergence of fluconazole resistance, particularly in non-albicans Candida species, should be considered during preventive or empiric therapy. In very-low birth-weight neonates, although fluconazole is used as antifungal prophylaxis in neonatal intensive care units (NICU's) with relatively high incidence of invasive candidiasis (IC), its role is under continuous debate. Amphotericin B, primarily in its liposomal formulation, remains the mainstay of therapy for treating neonatal and pediatric yeast and mold infections. Voriconazole is indicated for mold infections except for mucormycosis in children >2 years. Newer triazoles-such as posaconazole and isavuconazole-as well as echinocandins, are either licensed or under study for first-line or salvage therapy, whereas combination therapy is kept for refractory cases.
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Affiliation(s)
- Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
| | - Savvas Papachristou
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
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Abstract
PURPOSE OF REVIEW Chronic granulomatous disease (CGD) is a primary immunodeficiency, with a defect of phagocytes in killing specific pathogens. CGD is characterized by severe recurrent bacterial and fungal infections and dysregulated inflammatory response. Since its first description as fatal disease about 60 years ago, a significant improvement in outcome has been achieved in the last 20 years. The purpose of this review is to framework recent advances in CGD immunopathogenesis, management of disease manifestation and cure of CGD patients. RECENT FINDINGS For years, CGD is a known cause of life-threatening infections and excessive inflammation. The cause and the management of inflammatory reactions, however, have not been clarified, and the range of clinical presentation is growing with corresponding novel therapeutic interventions. Recent work focuses on the best outcome of hematopoietic stem cell transplantation (HSCT) and gene therapy for the cure of CGD patients, more specifically, those with X-linked and p47 mutations. SUMMARY The genetics and phenotype of CGD is well characterized; however, the underlying mechanisms, the treatment of its inflammatory manifestations and the cure of CGD is under further investigation.
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24
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Vicenzi EB, Cesaro S. Posaconazole in immunocompromised pediatric patients. Expert Rev Anti Infect Ther 2018; 16:543-553. [DOI: 10.1080/14787210.2018.1490177] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Edoardo Bruno Vicenzi
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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25
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Abstract
Invasive fungal infections are a significant cause of morbidity and mortality in infants and children. Early diagnosis is critical, and treatment with the appropriate drug and dose should be initiated promptly. Although an increasing number of studies have examined dosing of antifungals in this population, pediatric safety and efficacy data are lacking.
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Affiliation(s)
- Mihai Puia-Dumitrescu
- Department of Pediatrics, Division of Neonatal Medicine, Duke University Medical Center, 2424 Erwin Road, Suite 504, Durham, NC 27705, USA; Department of Pediatrics, Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715, USA
| | - P Brian Smith
- Department of Pediatrics, Division of Neonatal Medicine, Duke University Medical Center, 2424 Erwin Road, Suite 504, Durham, NC 27705, USA; Department of Pediatrics, Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715, USA.
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