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Wang H, Li D, Jiang Y, Liang J, Yu Q, Kuang L, Huang Y, Qin D, Li P, He J, Xu F, Li X, Wang F, Wei Y, Li X. Population pharmacokinetics of fluconazole for prevention or treatment of invasive candidiasis in Chinese young infants. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03184-7. [PMID: 38850301 DOI: 10.1007/s00210-024-03184-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/24/2024] [Indexed: 06/10/2024]
Abstract
The dosing of fluconazole for young infants remains empirical because of the limited pharmacokinetic (PK) data. We aimed to establish a population PK model and assess the systematic exposure-response of commonly used regimens of fluconazole in Chinese infants. We included infants with a postnatal age of less than 120 days and received intravenous fluconazole. Both scheduled and scavenged plasma samples were collected, and fluconzaole concentration was determined by a validated ultra-performance liquid chromatography-tandem mass spectrometry assay. Population PK analysis was conducted using Phoenix NLME, and then Monte Carlo simulation was conducted to predict the probability of target attainment (PTA) of empirically used regimens of both prophylactic and therapeutic purposes. Based on 304 plasma samples from 183 young infants, fluconazole concentration data was best described by a one-compartment model with first-order elimination. Gestational Age (GA), postnatal age (PNA), and body weight (BW) were included in the final model as CL = 0.02*(GA/214)2.77*(PNA/13)0.24*exp(nCL); V = 1.56*(BW/1435)0.90*exp(nV). Model validation revealed the final model had qualified stability and acceptable predictive properties. Monte Carlo simulation indicated that under the same minimum inhibitory concentration (MIC) value and administration regimen, PTA decreased with GA and PNA. The commonly used prophylactic regimens can meet the clinical need, while higher doses might be needed for treatment of invasive candidiasis. This population PK model of fluconazole discriminated the impact of GA and PNA on CL and BW on V. Dosing adjustment was needed according to the GA and PNA of infants to achieve targeted exposures.
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Affiliation(s)
- Honghong Wang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University,, Beijing, China
| | - Yongjiang Jiang
- Department of Neonatology, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Jing Liang
- Department of Neonatology, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Qiaoai Yu
- Department of Laboratory, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Linghong Kuang
- School of Computer Science and Mathematics, Fujian University of Technology, Fuzhou, Fujian, China
| | - Yuling Huang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Dongjie Qin
- Pharmaceutical Division, Liuzhou Quality Inspection and Testing Research Center, Liuzhou, Guangxi, China
| | - Ping Li
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Jing He
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Feng Xu
- Department of Pharmacy, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Xueli Li
- Department of Laboratory, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Fei Wang
- Department of Pharmacy, Fujian Provincial Geriatric Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yanfei Wei
- Department of Neonatology, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China.
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University,, Beijing, China.
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Novy E, Roger C, Roberts JA, Cotta MO. Pharmacokinetic and pharmacodynamic considerations for antifungal therapy optimisation in the treatment of intra-abdominal candidiasis. Crit Care 2023; 27:449. [PMID: 37981676 PMCID: PMC10659066 DOI: 10.1186/s13054-023-04742-w] [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: 09/13/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023] Open
Abstract
Intra-abdominal candidiasis (IAC) is one of the most common of invasive candidiasis observed in critically ill patients. It is associated with high mortality, with up to 50% of deaths attributable to delays in source control and/or the introduction of antifungal therapy. Currently, there is no comprehensive guidance on optimising antifungal dosing in the treatment of IAC among the critically ill. However, this form of abdominal sepsis presents specific pharmacokinetic (PK) alterations and pharmacodynamic (PD) challenges that risk suboptimal antifungal exposure at the site of infection in critically ill patients. This review aims to describe the peculiarities of IAC from both PK and PD perspectives, advocating an individualized approach to antifungal dosing. Additionally, all current PK/PD studies relating to IAC are reviewed in terms of strength and limitations, so that core elements for the basis of future research can be provided.
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Affiliation(s)
- Emmanuel Novy
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia
- Department of Anaesthesiology, Critical Care and Peri-Operative Medicine, University Hospital of Nancy, Nancy, France
- Université de Lorraine, SIMPA, 54500, Nancy, France
| | - Claire Roger
- Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nimes University Hospital, Place du Professeur Robert Debré, 30029, Nîmes Cedex 9, France
- UR UM103 IMAGINE, Univ Montpellier, Montpellier, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia.
- Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nimes University Hospital, Place du Professeur Robert Debré, 30029, Nîmes Cedex 9, France.
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia.
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia
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3
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Huang A, Luo X, Xu Z, Huang L, Wang X, Xie S, Pan Y, Fang S, Liu Z, Yuan Z, Hao H. Optimal Regimens and Clinical Breakpoint of Avilamycin Against Clostridium perfringens in Swine Based on PK-PD Study. Front Pharmacol 2022; 13:769539. [PMID: 35281904 PMCID: PMC8908370 DOI: 10.3389/fphar.2022.769539] [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: 09/02/2021] [Accepted: 01/14/2022] [Indexed: 11/21/2022] Open
Abstract
Clostridium perfringens causes significant morbidity and mortality in swine worldwide. Avilamycin showed no cross resistance and good activity for treatment of C. perfringens. The aim of this study was to formulate optimal regimens of avilamycin treatment for C. perfringens infection based on the clinical breakpoint (CBP). The wild-type cutoff value (COWT) was defined as 0.25 μg/ml, which was developed based on the minimum inhibitory concentration (MIC) distributions of 120 C. perfringens isolates and calculated using ECOFFinder. Pharmacokinetics–pharmacodynamics (PK-PD) of avilamycin in ileal content were analyzed based on the high-performance liquid chromatography method and WinNonlin software to set up the target of PK/PD index (AUC0–24h/MIC)ex based on sigmoid Emax modeling. The PK parameters of AUC0–24h, Cmax, and Tmax in the intestinal tract were 428.62 ± 14.23 h μg/mL, 146.30 ± 13.41 μg/ml,, and 4 h, respectively. The target of (AUC0–24h/MIC)ex for bactericidal activity in intestinal content was 36.15 h. The PK-PD cutoff value (COPD) was defined as 8 μg/ml and calculated by Monte Carlo simulation. The dose regimen designed from the PK-PD study was 5.2 mg/kg mixed feeding and administrated for the treatment of C. perfringens infection. Five respective strains with different MICs were selected as the infection pathogens, and the clinical cutoff value was defined as 0.125 μg/ml based on the relationship between MIC and the possibility of cure (POC) following nonlinear regression analysis, CART, and “Window” approach. The CBP was set to be 0.25 μg/ml and selected by the integrated decision tree recommended by the Clinical Laboratory of Standard Institute. The formulation of the optimal regimens and CBP is good for clinical treatment and to control drug resistance.
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Affiliation(s)
- Anxiong Huang
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Xun Luo
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Zihui Xu
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Lingli Huang
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Xu Wang
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Shuyu Xie
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Yuanhu Pan
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Shiwei Fang
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Zhenli Liu
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Zonghui Yuan
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
| | - Haihong Hao
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MOA (Ministry of Agriculture) Key Laboratory for Detection of Veterinary Drug Residues, Wuhan, China.,MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Wuhan, China
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4
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Durand C, Maubon D, Cornet M, Wang Y, Aldebert D, Garnaud C. Can We Improve Antifungal Susceptibility Testing? Front Cell Infect Microbiol 2021; 11:720609. [PMID: 34568095 PMCID: PMC8461061 DOI: 10.3389/fcimb.2021.720609] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022] Open
Abstract
Systemic antifungal agents are increasingly used for prevention or treatment of invasive fungal infections, whose prognosis remains poor. At the same time, emergence of resistant or even multi-resistant strains is of concern as the antifungal arsenal is limited. Antifungal susceptibility testing (AFST) is therefore of key importance for patient management and antifungal stewardship. Current AFST methods, including reference and commercial types, are based on growth inhibition in the presence of an antifungal, in liquid or solid media. They usually enable Minimal Inhibitory Concentrations (MIC) to be determined with direct clinical application. However, they are limited by a high turnaround time (TAT). Several innovative methods are currently under development to improve AFST. Techniques based on MALDI-TOF are promising with short TAT, but still need extensive clinical validation. Flow cytometry and computed imaging techniques detecting cellular responses to antifungal stress other than growth inhibition are also of interest. Finally, molecular detection of mutations associated with antifungal resistance is an intriguing alternative to standard AFST, already used in routine microbiology labs for detection of azole resistance in Aspergillus and even directly from samples. It is still restricted to known mutations. The development of Next Generation Sequencing (NGS) and whole-genome approaches may overcome this limitation in the near future. While promising approaches are under development, they are not perfect and the ideal AFST technique (user-friendly, reproducible, low-cost, fast and accurate) still needs to be set up routinely in clinical laboratories.
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Affiliation(s)
| | - Danièle Maubon
- TIMC, Univ Grenoble Alpes, CNRS, Grenoble INP, Grenoble, France.,Parasitology-Mycology, CHU Grenoble Alpes, Grenoble, France
| | - Muriel Cornet
- TIMC, Univ Grenoble Alpes, CNRS, Grenoble INP, Grenoble, France.,Parasitology-Mycology, CHU Grenoble Alpes, Grenoble, France
| | | | | | - Cécile Garnaud
- TIMC, Univ Grenoble Alpes, CNRS, Grenoble INP, Grenoble, France.,Parasitology-Mycology, CHU Grenoble Alpes, Grenoble, France
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5
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Pea F. From bench to bedside: Perspectives on the utility of pharmacokinetics/pharmacodynamics in predicting the efficacy of antifungals in invasive candidiasis. Mycoses 2020; 63:854-858. [PMID: 32472719 DOI: 10.1111/myc.13121] [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: 04/24/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 12/16/2022]
Abstract
The aim of this perspective is to give an overlook on the utility of pharmacokinetics/pharmacodynamics (PK/PD) in predicting the efficacy of antifungals in invasive candidiasis. Overall, from the available literature it appears that bridging data of PK/PD of antifungals from the laboratory to the clinic for the treatment of invasive candidiasis are feasible only partially. Fluconazole is the only antifungal agent having the pharmacodynamic threshold of efficacy identified in experimental animal models convincingly validated in the clinical setting of invasive candidiasis as well. Conversely, for voriconazole and posaconazole data on this topic are very limited. For the echinocandins, robust PK/PD identified in the laboratory represented the rationale for defining differential clinical breakpoints of echinocandins against different species of Candida by the regulatory agencies. However, translation of the findings in the clinical setting provided conflicting results. Data on PK/PD of amphotericin B and flucytosine in models of invasive candidiasis are quite limited, and clinical studies assessing the role of drug exposure on efficacy are currently lacking. The expectation is that prospective studies could test more and more frequently the validity of experimental PK/PD data of antifungals in the clinical setting of invasive candidiasis. The findings could represent a step forward in addressing adequate antifungal stewardship programmes.
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Affiliation(s)
- Federico Pea
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital of Udine, ASUFC, Udine, Italy
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6
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Pea F, Lewis RE. Overview of antifungal dosing in invasive candidiasis. J Antimicrob Chemother 2019; 73:i33-i43. [PMID: 29304210 DOI: 10.1093/jac/dkx447] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In the past, most antifungal therapy dosing recommendations for invasive candidiasis followed a 'one-size fits all' approach with recommendations for lowering maintenance dosages for some antifungals in the setting of renal or hepatic impairment. A growing body of pharmacokinetic/pharmacodynamic research, however now points to a widespread 'silent epidemic' of antifungal underdosing for invasive candidiasis, especially among critically ill patients or special populations who have altered volume of distribution, protein binding and drug clearance. In this review, we explore how current adult dosing recommendations for antifungal therapy in invasive candidiasis have evolved, and special populations where new approaches to dose optimization or therapeutic drug monitoring may be needed, especially in light of increasing antifungal resistance among Candida spp.
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Affiliation(s)
- Federico Pea
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Russell E Lewis
- Infectious Diseases Unit, S. Orsola-Malpighi Hospital; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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7
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Ebenhan T, Sathekge MM, Lengana T, Koole M, Gheysens O, Govender T, Zeevaart JR. 68Ga-NOTA-Functionalized Ubiquicidin: Cytotoxicity, Biodistribution, Radiation Dosimetry, and First-in-Human PET/CT Imaging of Infections. J Nucl Med 2017; 59:334-339. [PMID: 29051342 DOI: 10.2967/jnumed.117.200048] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/09/2017] [Indexed: 12/27/2022] Open
Abstract
Ubiquicidin is an antimicrobial peptide with great potential for nuclear imaging of infectious diseases, as its cationic-rich fragment TGRAKRRMQYNRR (UBI) has been functionalized with NOTA to allow complexation to 68Ga (68Ga-NOTA-UBI). We herein assess the cytotoxicity and radiation dosimetry for 68Ga-NOTA-UBI and a first-in-human evaluation to diagnose infectious processes. Methods: Cytotoxicity was evaluated in green monkey kidney epithelial (Vero) cells and MT-4 leukocytes. Tracer susceptibility was studied in vitro using different bacterial and fungal strains. PET/CT-based biodistribution, pharmacokinetics, and radiation dosimetry were performed on nonhuman primates. Two healthy volunteers and 3 patients with suspected infection underwent 68Ga-NOTA-UBI PET/CT imaging. Results: Negligible cytotoxicity was determined for NOTA-UBI. 68Ga-NOTA-UBI showed moderate blood clearance (29-min half-life) and predominant renal clearance in nonhuman primates. Human radiation dose estimates indicated the bladder wall as the dose-critical tissue (185 μSv/MBq), followed by the kidneys (23 μSv/MBq). The total absorbed body dose was low (<7 μSv/MBq); the effective dose was estimated at 17 μSv/MBq. 68Ga-NOTA-UBI could diagnose bone- and soft-tissue infection in 3 of 3 patients. Conclusion:68Ga-NOTA-UBI is considered a nontoxic, safe-to-administer radiopharmaceutical unlikely to cause adverse effects in humans. The favorable tracer biodistribution and the first-in-human results will make 68Ga-NOTA-UBI PET/CT an encouraging future diagnostic technique with auxiliary clinical relevance.
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Affiliation(s)
- Thomas Ebenhan
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
| | - Thabo Lengana
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
| | - Michel Koole
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Thavendran Govender
- Catalysis and Peptide Research Unit, University of KwaZulu-Natal, Durban, South Africa; and
| | - Jan R Zeevaart
- Department of Science and Technology, Preclinical Drug Development Platform, North West University, Potchefstroom, South Africa
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8
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Brosh-Nissimov T, Ben-Ami R. Differential association of fluconazole dose and dose/MIC ratio with mortality in patients with Candida albicans and non-albicans bloodstream infection. Clin Microbiol Infect 2015; 21:1011-7. [PMID: 26183300 DOI: 10.1016/j.cmi.2015.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 06/26/2015] [Accepted: 07/03/2015] [Indexed: 10/23/2022]
Abstract
Targeting fluconazole therapy to achieve predefined pharmacodynamic goals has been suggested as a means of optimizing the treatment of patients with candidaemia. However, data regarding species-specific dosing targets are inconclusive. We retrospectively analysed a cohort of 75 adult patients with Candida bloodstream infection (BSI) who received initial treatment with fluconazole for ≥48 h (36 Candida albicans and 39 non-albicans Candida (NAC)). Fluconazole dose, the dose/MIC ratio and the 24-h area under the concentration-time curve (AUC24)/MIC ratio were determined for each patient, and classification and regression tree analysis was used to determine breakpoints for significant interactions with 30-day survival. Both fluconazole exposure parameters and patient-related and disease-related variables were assessed in univariable and multivariable survival models. The crude 30-day mortality rate was 32% (44% and 21% for C. albicans and NAC, respectively). An average fluconazole dose of >200 mg/day, a dose/MIC ratio of >400 and an AUC24/MIC ratio of >400 were associated with a higher 30-day survival rate and better microbiological response in patients with C. albicans BSI but not in those with NAC BSI. Baseline chronic kidney disease was a risk factor for fluconazole underdosing and mortality. Severity of sepsis (Sequential Organ Failure Assessment score) was the only significant predictor of death in patients with NAC BSI. We conclude that, although pharmacodynamic target-directed fluconazole dosing may help to optimize outcomes for patients with C. albicans BSI, additional studies are needed to define the role of fluconazole in the treatment of NAC BSI.
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Affiliation(s)
- T Brosh-Nissimov
- Infectious Disease Unit, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - R Ben-Ami
- Infectious Disease Unit, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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9
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Efficacy of the clinical agent VT-1161 against fluconazole-sensitive and -resistant Candida albicans in a murine model of vaginal candidiasis. Antimicrob Agents Chemother 2015; 59:5567-73. [PMID: 26124165 DOI: 10.1128/aac.00185-15] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 06/22/2015] [Indexed: 01/01/2023] Open
Abstract
Vulvovaginal candidiasis (VVC) and recurrent VVC (RVVC) remain major health problems for women. VT-1161, a novel fungal CYP51 inhibitor which has potent antifungal activity against fluconazole-sensitive Candida albicans, retained its in vitro potency (MIC50 of ≤0.015 and MIC90 of 0.12 μg/ml) against 10 clinical isolates from VVC or RVVC patients resistant to fluconazole (MIC50 of 8 and MIC90 of 64 μg/ml). VT-1161 pharmacokinetics in mice displayed a high volume of distribution (1.4 liters/kg), high oral absorption (73%), and a long half-life (>48 h) and showed rapid penetration into vaginal tissue. In a murine model of vaginal candidiasis using fluconazole-sensitive yeast, oral doses as low as 4 mg/kg VT-1161 significantly reduced the fungal burden 1 and 4 days posttreatment (P < 0.0001). Similar VT-1161 efficacy was measured when an isolate highly resistant to fluconazole (MIC of 64 μg/ml) but fully sensitive in vitro to VT-1161 was used. When an isolate partially sensitive to VT-1161 (MIC of 0.12 μg/ml) and moderately resistant to fluconazole (MIC of 8 μg/ml) was used, VT-1161 remained efficacious, whereas fluconazole was efficacious on day 1 but did not sustain efficacy 4 days posttreatment. Both agents were inactive in treating an infection with an isolate that demonstrated weaker potency (MICs of 2 and 64 μg/ml for VT-1161 and fluconazole, respectively). Finally, the plasma concentrations of free VT-1161 were predictive of efficacy when in excess of the in vitro MIC values. These data support the clinical development of VT-1161 as a potentially more efficacious treatment for VVC and RVVC.
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10
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Cuenca-Estrella M, Rodriguez-Tudela JL. The current role of the reference procedures by CLSI and EUCAST in the detection of resistance to antifungal agentsin vitro. Expert Rev Anti Infect Ther 2014; 8:267-76. [DOI: 10.1586/eri.10.2] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Orasch C, Marchetti O, Garbino J, Schrenzel J, Zimmerli S, Mühlethaler K, Pfyffer G, Ruef C, Fehr J, Zbinden R, Calandra T, Bille J. Candida species distribution and antifungal susceptibility testing according to European Committee on Antimicrobial Susceptibility Testing and new vs. old Clinical and Laboratory Standards Institute clinical breakpoints: a 6-year prospective candidaemia survey from the fungal infection network of Switzerland. Clin Microbiol Infect 2013; 20:698-705. [PMID: 24188136 DOI: 10.1111/1469-0691.12440] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 10/28/2013] [Accepted: 10/29/2013] [Indexed: 12/01/2022]
Abstract
We analyzed the species distribution of Candida blood isolates (CBIs), prospectively collected between 2004 and 2009 within FUNGINOS, and compared their antifungal susceptibility according to clinical breakpoints defined by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in 2013, and the Clinical and Laboratory Standards Institute (CLSI) in 2008 (old CLSI breakpoints) and 2012 (new CLSI breakpoints). CBIs were tested for susceptiblity to fluconazole, voriconazole and caspofungin by microtitre broth dilution (Sensititre® YeastOne™ test panel). Of 1090 CBIs, 675 (61.9%) were C. albicans, 191 (17.5%) C. glabrata, 64 (5.9%) C. tropicalis, 59 (5.4%) C. parapsilosis, 33 (3%) C. dubliniensis, 22 (2%) C. krusei and 46 (4.2%) rare Candida species. Independently of the breakpoints applied, C. albicans was almost uniformly (>98%) susceptible to all three antifungal agents. In contrast, the proportions of fluconazole- and voriconazole-susceptible C. tropicalis and F-susceptible C. parapsilosis were lower according to EUCAST/new CLSI breakpoints than to the old CLSI breakpoints. For caspofungin, non-susceptibility occurred mainly in C. krusei (63.3%) and C. glabrata (9.4%). Nine isolates (five C. tropicalis, three C. albicans and one C. parapsilosis) were cross-resistant to azoles according to EUCAST breakpoints, compared with three isolates (two C. albicans and one C. tropicalis) according to new and two (2 C. albicans) according to old CLSI breakpoints. Four species (C. albicans, C. glabrata, C. tropicalis and C. parapsilosis) represented >90% of all CBIs. In vitro resistance to fluconazole, voriconazole and caspofungin was rare among C. albicans, but an increase of non-susceptibile isolates was observed among C. tropicalis/C. parapsilosis for the azoles and C. glabrata/C. krusei for caspofungin according to EUCAST and new CLSI breakpoints compared with old CLSI breakpoints.
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Affiliation(s)
- C Orasch
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
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Alastruey-Izquierdo A, Cuenca-Estrella M. EUCAST and CLSI: How to Assess in Vitro Susceptibility and Clinical Resistance. CURRENT FUNGAL INFECTION REPORTS 2012. [DOI: 10.1007/s12281-012-0100-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Candidiasis invasora en un receptor de trasplante hepático: tratamiento antifúngico de rescate precoz. Rev Iberoam Micol 2011; 28:124-8. [DOI: 10.1016/j.riam.2011.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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14
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Can We Achieve Clinical Breakpoints for the Triazoles in Aspergillosis? CURRENT FUNGAL INFECTION REPORTS 2011. [DOI: 10.1007/s12281-011-0058-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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15
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Diagnosis of Antifungal Drug Resistance Mechanisms in Fungal Pathogens: Transcriptional Gene Regulation. CURRENT FUNGAL INFECTION REPORTS 2011. [DOI: 10.1007/s12281-011-0055-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ayats J, Martín-Mazuelos E, Pemán J, Quindós G, Sánchez F, García-Rodríguez J, Guarro J, Guinea J, Linares MJ, Pontón J, Rodríguez-Tudela JL, Cuenca-Estrella M. Recomendaciones sobre el diagnóstico de la enfermedad fúngica invasora de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC). Actualización 2010. Enferm Infecc Microbiol Clin 2011; 29:39.e1-15. [DOI: 10.1016/j.eimc.2010.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 08/18/2010] [Indexed: 12/21/2022]
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Wild-type MIC distributions, epidemiological cutoff values and species-specific clinical breakpoints for fluconazole and Candida: Time for harmonization of CLSI and EUCAST broth microdilution methods. Drug Resist Updat 2010; 13:180-95. [PMID: 21050800 DOI: 10.1016/j.drup.2010.09.002] [Citation(s) in RCA: 225] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 09/21/2010] [Accepted: 09/22/2010] [Indexed: 11/22/2022]
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Pfaller MA, Diekema DJ. Wild-Type MIC Distributions and Epidemiologic Cutoff Values for Fluconazole and Candida: Time for New Clinical Breakpoints? CURRENT FUNGAL INFECTION REPORTS 2010. [DOI: 10.1007/s12281-010-0022-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Alburquenque C, Bucarey SA, Neira-Carrillo A, Urzúa B, Hermosilla G, Tapia CV. Antifungal activity of low molecular weight chitosan against clinical isolates of Candida spp. Med Mycol 2010; 48:1018-23. [PMID: 20482450 DOI: 10.3109/13693786.2010.486412] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Chitosan is a natural polymer derived from chitin, a structural component of fungi, insects and shrimp, which exerts antimicrobial effects against bacteria and fungi. The aim of this study was to investigate the in vitro antifungal activity of low molecular weight chitosan (LMWC), and the potential synergy between chitosan and a currently used antifungal drug, fluconazole. The in vitro minimal inhibitory concentrations (MICs) of chitosan and fluconazole against 105 clinical Candida isolates were measured by the broth microdilution method. LMWC exhibited a significant antifungal activity, inhibiting over 89.9% of the clinical isolates examined (68.6% of which was completely inhibited). The species included several fluconazole-resistant strains and less susceptible species such as C. glabrata, which was inhibited at a concentration of 4.8 mg/l LMWC. Although some strains were susceptible at pH 7.0, a greater antifungal activity of LMWC was observed at pH 4.0. There was no evidence of a synergistic effect of the combination of LMWC and fluconazole at pH 7.0. This is the first report in which the antifungal activity of LMWC was investigated with clinical Candida strains. The use of LMWC as an antifungal compound opens new therapeutic perspectives, as the low toxicity of LMWC in humans supports its use in new applications in an environment of pH 4.0-4.5, such as a topical agent for vulvovaginal candidiasis.
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Cuesta I, Bielza C, Cuenca-Estrella M, Larrañaga P, Rodríguez-Tudela JL. Evaluation by data mining techniques of fluconazole breakpoints established by the Clinical and Laboratory Standards Institute (CLSI) and comparison with those of the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Antimicrob Agents Chemother 2010; 54:1541-6. [PMID: 20124002 PMCID: PMC2849363 DOI: 10.1128/aac.01688-09] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 01/26/2010] [Indexed: 11/20/2022] Open
Abstract
The EUCAST and the CLSI have established different breakpoints for fluconazole and Candida spp. However, the reference methodologies employed to obtain the MICs provide similar results. The aim of this work was to apply supervised classification algorithms to analyze the clinical data used by the CLSI to establish fluconazole breakpoints for Candida infections and to compare these data with the results obtained with the data set used to set up EUCAST fluconazole breakpoints, where the MIC for detecting failures was >4 mg/liter, with a sensitivity of 87%, a false-positive rate of 8%, and an area under the receiver operating characteristic (ROC) curve of 0.89. Five supervised classifiers (J48 and CART decision trees, the OneR decision rule, the naïve Bayes classifier, and simple logistic regression) were used to analyze the original cohort of patients (Rex's data set), which was used to establish CLSI breakpoints, and a later cohort of candidemia (Clancy's data set), with which CLSI breakpoints were validated. The target variable was the outcome of the infections, and the predictor variable was the MIC or dose/MIC ratio. For Rex's data set, the MIC detecting failures was >8 mg/liter, and for Clancy's data set, the MIC detecting failures was >4 mg/liter, in close agreement with the EUCAST breakpoint (MIC > 4 mg/liter). The sensitivities, false-positive rates, and areas under the ROC curve obtained by means of CART, the algorithm with the best statistical results, were 52%, 18%, and 0.7, respectively, for Rex's data set and 65%, 6%, and 0.72, respectively, for Clancy's data set. In addition, the correlation between outcome and dose/MIC ratio was analyzed for Clancy's data set, where a dose/MIC ratio of >75 was associated with successes, with a sensitivity of 93%, a false-positive rate of 29%, and an area under the ROC curve of 0.83. This dose/MIC ratio of >75 was identical to that found for the cohorts used by EUCAST to establish their breakpoints (a dose/MIC ratio of >75, with a sensitivity of 91%, a false-positive rate of 10%, and an area under the ROC curve of 0.90).
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Affiliation(s)
- Isabel Cuesta
- Servicio de Micologia, Centro Nacional de Microbiologia, Instituto de Salud Carlos III, Majadahonda, Madrid, Departamento de Inteligencia Artificial, Facultad de Informática, Universidad Politécnica, Madrid, Spain
| | - Concha Bielza
- Servicio de Micologia, Centro Nacional de Microbiologia, Instituto de Salud Carlos III, Majadahonda, Madrid, Departamento de Inteligencia Artificial, Facultad de Informática, Universidad Politécnica, Madrid, Spain
| | - Manuel Cuenca-Estrella
- Servicio de Micologia, Centro Nacional de Microbiologia, Instituto de Salud Carlos III, Majadahonda, Madrid, Departamento de Inteligencia Artificial, Facultad de Informática, Universidad Politécnica, Madrid, Spain
| | - Pedro Larrañaga
- Servicio de Micologia, Centro Nacional de Microbiologia, Instituto de Salud Carlos III, Majadahonda, Madrid, Departamento de Inteligencia Artificial, Facultad de Informática, Universidad Politécnica, Madrid, Spain
| | - Juan L. Rodríguez-Tudela
- Servicio de Micologia, Centro Nacional de Microbiologia, Instituto de Salud Carlos III, Majadahonda, Madrid, Departamento de Inteligencia Artificial, Facultad de Informática, Universidad Politécnica, Madrid, Spain
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