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Dong L, Zhuang X, Yang T, Yan K, Cai Y. A Physiologically Based Pharmacokinetic Model of Voriconazole in Human CNS -- Integrating Time-Dependent Inhibition of CYP3A4, Genetic Polymorphisms of CYP2C19 and Possible Transporter Mechanisms. Int J Antimicrob Agents 2024:107310. [PMID: 39168418 DOI: 10.1016/j.ijantimicag.2024.107310] [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: 03/04/2024] [Revised: 07/26/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
AIMS Voriconazole is a classical antifungal drug that is often used to treat CNS fungal infections due to its permeability through the BBB. However, its clinical use remains challenging because of its narrow therapeutic window and wide inter-individual variability. In this study, we proposed an optimized and validated PBPK model by integrating in vitro, in vivo and clinical data to simulate the distribution and PK process of voriconazole in the CNS, providing guidance for clinical individualized treatment. METHODS The model structure was optimized and tissue-to-plasma partition coefficients were obtained through animal experiments. Using the allometric relationships, the distribution of voriconazole in the human CNS was predicted. The model integrated factors affecting inter-individual variation and drug interactions of voriconazole-polymorphisms in the CYP2C19 gene and auto-inhibition and then was validated using real clinical data. RESULTS The overall AFE value showing model predicted differences was 1.1420 in the healthy population; and in the first prediction of plasma and CSF in actual clinical patients, 89.5% of the values were within the 2-fold error interval, indicating good predictive performance of the model. The bioavailability of voriconazole varied at different doses (39%-86%), and the optimized model conformed to this pattern (46%-83%). CONCLUSION Combined with the relevant pharmacodynamic indexes, the PBPK model provides a feasible way for precise medication in patients with CNS infection and improve the treatment effect and prognosis.
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Affiliation(s)
- Liuhan Dong
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing 100853, China; State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
| | - Xiaomei Zhuang
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
| | - Tianli Yang
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing 100853, China
| | - Kaicheng Yan
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing 100853, China
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, Beijing 100853, China.
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Fernández-Ruiz M. Pharmacological management of invasive mold infections in solid organ transplant recipients. Expert Opin Pharmacother 2024; 25:239-254. [PMID: 38436619 DOI: 10.1080/14656566.2024.2326507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Solid organ transplant (SOT) recipients face an increased susceptibility to invasive fungal infection (IFI) due to filamentous fungi. Post-transplant invasive aspergillosis (IA) and mucormycosis are related to exceedingly high mortality rates and graft loss risk, and its management involve a unique range of clinical challenges. AREAS COVERED First, the current treatment recommendations for IA and mucormycosis among SOT recipients are critically reviewed, including the supporting evidence. Next, we discussed particular concerns in this patient population, such as drug-drug interactions (DDIs) between triazoles and post-transplant immunosuppression or treatment-related toxicity. The role for immunomodulatory and host-targeted therapies is also considered, as well as the theoretical impact of the intrinsic antifungal activity of calcineurin inhibitors. Finally, a personal opinion is made on future directions in the pharmacological approach to post-transplant IFI. EXPERT OPINION Despite relevant advances in the treatment of mold IFIs in the SOT setting, such as the incorporation of isavuconazole (with lower incidence of DDIs and better tolerability than voriconazole), there remains a large room for improvement in areas such as the position of combination therapy or the optimal strategy for the reduction of baseline immunosuppression. Importantly, future studies should define the specific contribution of newer antifungal agents and classes.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Soriano A, Honore PM, Puerta-Alcalde P, Garcia-Vidal C, Pagotto A, Gonçalves-Bradley DC, Verweij PE. Invasive candidiasis: current clinical challenges and unmet needs in adult populations. J Antimicrob Chemother 2023:7176280. [PMID: 37220664 DOI: 10.1093/jac/dkad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Invasive candidiasis (IC) is a serious infection caused by several Candida species, and the most common fungal disease in hospitals in high-income countries. Despite overall improvements in health systems and ICU care in the last few decades, as well as the development of different antifungals and microbiological techniques, mortality rates in IC have not substantially improved. The aim of this review is to summarize the main issues underlying the management of adults affected by IC, focusing on specific forms of the infection: IC developed by ICU patients, IC observed in haematological patients, breakthrough candidaemia, sanctuary site candidiasis, intra-abdominal infections and other challenging infections. Several key challenges need to be tackled to improve the clinical management and outcomes of IC patients. These include the lack of global epidemiological data for IC, the limitations of the diagnostic tests and risk scoring tools currently available, the absence of standardized effectiveness outcomes and long-term data for IC, the timing for the initiation of antifungal therapy and the limited recommendations on the optimal step-down therapy from echinocandins to azoles or the total duration of therapy. The availability of new compounds may overcome some of the challenges identified and increase the existing options for management of chronic Candida infections and ambulant patient treatments. However, early identification of patients that require antifungal therapy and treatment of sanctuary site infections remain a challenge and will require further innovations.
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Affiliation(s)
- Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | - Patrick M Honore
- CHU UCL Godinne Namur, UCL Louvain Medical School, Namur, Belgium
| | - Pedro Puerta-Alcalde
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, CIBERINF, University of Barcelona, Barcelona, Spain
| | | | | | - Paul E Verweij
- Radboudumc-CWZ Center of Expertise for Mycology, Nijmegen, the Netherlands
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Therapeutic Drug Monitoring of Sputum Voriconazole in Pulmonary Aspergillosis. Pharmaceutics 2022; 14:pharmaceutics14081598. [PMID: 36015224 PMCID: PMC9414625 DOI: 10.3390/pharmaceutics14081598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023] Open
Abstract
Voriconazole is one of the most used antifungal azoles against pulmonary aspergillosis. Therapeutic drug monitoring (TDM) of the voriconazole concentration in plasma is recommended in clinical practice guidelines to prevent treatment failure and toxicity. The aim of this study was to evaluate the feasibility and utility of TDM of the voriconazole concentration in the sputum of patients treated for pulmonary aspergillosis. Fifty sputum and 31 plasma samples were analysed with high-performance tandem mass spectrometry (HPLC-MS/MS) in 24 patients included in the study. The voriconazole concentration was simultaneously assessed in the plasma and sputum in 22 samples. The correlation between the sputum and plasma levels was estimated with a univariate linear regression model, and the observed R2 was 0.86. We determined the following equation, Csputum = 0.45 (Cplasma) + 0.21, which could predict the voriconazole concentration in plasma from sputum. TDM of the voriconazole concentration in sputum is an easy, non-invasive and accurate method with which to evaluate voriconazole exposure in patients with pulmonary aspergillosis.
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Marx J, Reinstadler V, Gasperetti T, Welte R, Oberacher H, Moser P, Joannidis M, Bellmann R. Human Tissue Distribution of Caspofungin. Int J Antimicrob Agents 2022; 59:106553. [PMID: 35176477 DOI: 10.1016/j.ijantimicag.2022.106553] [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: 10/12/2021] [Revised: 01/24/2022] [Accepted: 02/07/2022] [Indexed: 11/26/2022]
Abstract
Tissue concentrations of caspofungin were determined in nine different tissues taken during autopsy of twenty patients who had deceased during treatment or within 23 days after cessation. The highest levels were achieved in liver with concentrations ranging from ≤0.50 to 91.5 µg/g (0.60 µg/g 21 days after the last administration), followed by spleen (<0.25 to 46.3 µg/g), kidney (<0.25 to 33.6 µg/g), and lung (<0.25 to 31.0 µg/g). Intermediate concentrations were found in pancreas, skeletal muscle, thyroid, and myocardium. The smallest amounts were recovered from brain where caspofungin could be measured in six out of seventeen samples only. Caspofungin concentrations exceeded the MIC values of pathogenic Candida species in most of the tissue samples taken from patients who had deceased during treatment, except in brain samples. Our findings warrant clinical outcome studies for establishment of optimal treatment of deep-seated candidiasis and support the current recommendations against echinocandins for treatment of fungal meningoencephalitis.
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Affiliation(s)
- Jana Marx
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Vera Reinstadler
- Institute of Legal Medicine and Core Facility Metabolomics, Medical University of Innsbruck, Innsbruck, Austria
| | - Tiziana Gasperetti
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - René Welte
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Herbert Oberacher
- Institute of Legal Medicine and Core Facility Metabolomics, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrizia Moser
- Department of Pathology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria.
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Chau MM, Daveson K, Alffenaar JWC, Gwee A, Ho SA, Marriott DJE, Trubiano JA, Zhao J, Roberts JA. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy and haemopoietic stem cell transplant recipients, 2021. Intern Med J 2021; 51 Suppl 7:37-66. [PMID: 34937141 DOI: 10.1111/imj.15587] [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: 01/09/2023]
Abstract
Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.
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Affiliation(s)
- Maggie M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases and Microbiology, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Jan-Willem C Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Camperdown, New South Wales, Australia.,Pharmacy Department, Westmead Hospital, Westmead, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Su Ann Ho
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Faculty of Science, University of Technology, Ultimo, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Zhao
- Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason A Roberts
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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O’Dowd TR, Mc Hugh JW, Theel ES, Wengenack NL, O’Horo JC, Enzler MJ, Vergidis P. Diagnostic Methods and Risk Factors for Severe Disease and Mortality in Blastomycosis: A Retrospective Cohort Study. J Fungi (Basel) 2021; 7:jof7110888. [PMID: 34829177 PMCID: PMC8619313 DOI: 10.3390/jof7110888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Blastomycosis can cause severe disease with progressive respiratory failure and dissemination even in immunocompetent individuals. We sought to evaluate risk factors for severe disease and mortality using clinical and laboratory data within a large health system in an endemic area. Methods: We performed a retrospective cohort study of patients diagnosed with blastomycosis at all Mayo Clinic sites from 1 January 2004 through 31 March 2020. Diagnosis was established by culture, histopathology/cytopathology, serology, antigen testing, or PCR. Disease was categorized as mild for patients treated in the outpatient setting, moderate for hospitalized patients who did not require intensive care, and severe for patients admitted to the intensive care unit. Logistic regression was used to evaluate risk factors for severe disease. A Cox proportional hazards model was constructed to evaluate mortality. Findings: We identified 210 patients diagnosed with blastomycosis. Mean age was 51 years (range, 6–84). Most subjects were male (71.0%). Extrapulmonary disease was confirmed in 24.8%. In this cohort, 40.5% of patients had mild disease, 37.6% had moderate disease, and 21.9% had severe disease. Independent risk factors for severe disease were neutrophilia (odds ratio (OR) 3.35 (95% CI 1.53–7.35), p = 0.002) and lymphopenia (OR 3.34 (95% CI 1.59–7.03), p = 0.001). Mortality at 90 days was 11.9%. Median time from diagnosis to death was 23 days (interquartile range 8–31 days). Independent risk factors for mortality were age (OR 1.04 (95% CI 1.01–1.08), p = 0.009), neutrophilia (OR 2.84 (95% CI 1.04–7.76), p = 0.041), and lymphopenia (OR 4.50 (95% CI 1.67–12.11), p = 0.003). Blastomyces immunodiffusion had an overall sensitivity of 39.6% (95% CI 30.1–49.8). Sensitivity was higher among those who were tested 4 weeks or longer after the onset of symptoms. Urine Blastomyces antigen had a significantly higher sensitivity of 80.8% (95% CI 68.1–89.2) compared to serology. There was a trend towards higher antigen concentration in patients with severe disease. The sensitivity of PCR from respiratory specimens was 67.6% (95% CI 50.1–85.5). Conclusion: In this cohort, we did not find an association between pharmacologic immunosuppression and disease severity. Lymphopenia at diagnosis was an independent risk factor for mortality. This simple marker may aid clinicians in determining disease prognosis.
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Affiliation(s)
- Timothy R. O’Dowd
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (T.R.O.); (J.W.M.H.)
| | - Jack W. Mc Hugh
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (T.R.O.); (J.W.M.H.)
| | - Elitza S. Theel
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic, Rochester, MN 55905, USA; (E.S.T.); (N.L.W.)
| | - Nancy L. Wengenack
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic, Rochester, MN 55905, USA; (E.S.T.); (N.L.W.)
| | - John C. O’Horo
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (J.C.O.); (M.J.E.)
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Mark J. Enzler
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (J.C.O.); (M.J.E.)
| | - Paschalis Vergidis
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (J.C.O.); (M.J.E.)
- Correspondence:
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Abstract
Concentrations of anidulafungin and micafungin were determined in eight different tissues obtained during autopsy of four deceased individuals who had been treated with anidulafungin and of seven who had received micafungin. The largest amounts were recovered from liver, with anidulafungin concentrations of 11.01 to 66.50 μg/g and micafungin levels of 0.36 to 5.53 μg/g (0.65 μg/g 30 days after the last administration). The lowest anidulafungin levels were measured in skeletal muscle, and the lowest micafungin concentrations were in kidneys.
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Back HM, Yun HY, Kim SK, Kim JK. Beyond the Michaelis-Menten: Accurate Prediction of In Vivo Hepatic Clearance for Drugs With Low K M. Clin Transl Sci 2020; 13:1199-1207. [PMID: 32324332 PMCID: PMC7719389 DOI: 10.1111/cts.12804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 04/12/2020] [Indexed: 02/03/2023] Open
Abstract
Clearance (CL) is the major pharmacokinetic parameter for evaluating systemic exposure of drugs in the body and, thus, for developing new drugs. To predict in vivo CL, the ratio between the maximal rate of metabolism and Michaelis‐Menten constant (Vmax/KM estimated from in vitro metabolism study has been widely used. This canonical approach is based on the Michaelis‐Menten equation, which is valid only when the KM value of a drug is much higher than the hepatic concentration of the enzymes, especially cytochrome P450, involved in its metabolism. Here, we find that such a condition does not hold for many drugs with low KM, and, thus, the canonical approach leads to considerable error. Importantly, we propose an alternative approach, which incorporates the saturation of drug metabolism when concentration of the enzymes is not sufficiently lower than KM. This new approach dramatically improves the accuracy of prediction for in vivo CL of high‐affinity drugs with low KM. This indicates that the proposed approach in this study, rather than the canonical approach, should be used to predict in vivo hepatic CL for high‐affinity drugs, such as midazolam and propafenone.
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Affiliation(s)
- Hyun-Moon Back
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Hwi-Yeol Yun
- College of Pharmacy, Chungnam National University, Daejeon, Republic of Korea
| | - Sang Kyum Kim
- College of Pharmacy, Chungnam National University, Daejeon, Republic of Korea
| | - Jae Kyoung Kim
- Department of Mathematical Sciences, Korean Advanced Institute of Science and Technology, Daejeon, Republic of Korea
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Mora-Pereira M, Abarca EM, Duran S, Ravis W, McMullen RJ, Fischer BM, Lee YHP, Wooldridge AA. Sustained-release voriconazole-thermogel for subconjunctival injection in horses: ocular toxicity and in-vivo studies. BMC Vet Res 2020; 16:115. [PMID: 32295599 PMCID: PMC7160932 DOI: 10.1186/s12917-020-02331-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 04/05/2020] [Indexed: 12/13/2022] Open
Abstract
Background Keratomycosis is a relatively common, sight threatening condition in horses, where treatment is often prolonged and costly. Subconjunctival (SCo) injections offer less resistance to drug diffusion than the topical route, resulting in better penetration to the ocular anterior segment. Voriconazole, a second generation triazole antifungal, is effective against common fungal organisms causing keratomycosis. If combined with a thermogel biomaterial, voriconazole can be easily injected in the SCo space to provide sustained drug release. The purpose of this study was to evaluate the drug concentrations in the anterior segment and clinical effects after SCo injections of voriconazole-containing thermogel: poly (DL-lactide-co-glycolide-b-ethylene glycol-b-DL-lactide-co-glycolide) (PLGA-PEG-PLGA) in healthy equine eyes. Results Voriconazole aqueous humor (AH) and tear concentrations were compared between 6 horses, receiving 1% voriconazole applied topically (0.2 mL, q4h) (Vori-Top) or 1.7% voriconazole-thermogel (0.3 mL) injected SCo (Vori-Gel). For the Vori-Gel group, voriconazole concentrations were measured in AH and tears at day 2 and then weekly for 23 days, and at day 2 only for the Vori-Top group. Ocular inflammation was assessed weekly (Vori-Gel) using the modified Hackett-McDonald scoring system. Ocular tissue concentrations of voriconazole following SCo 1.7% voriconazole-thermogel (0.3 mL) injections were evaluated post euthanasia in 6 additional horses at 3 different time points. Three horses received bilateral injections at 2 h (n = 3, right eye (OD)) and 48 h (n = 3, left eye (OS)) prior to euthanasia, and 3 horses were injected unilaterally (OS), 7 days prior to euthanasia. Voriconazole-thermogel was easily injected and well tolerated in all cases, with no major adverse effects. On day 2, drug concentrations in tears were higher in the Vori-Top, but not statistically different from Vori-Gel groups. For the Vori-Gel group, voriconazole was non-quantifiable in the AH at any time point. Total voriconazole concentrations in the cornea were above 0.5 μg/g (the target minimum inhibitory concentration (MIC) for Aspergillus sp.) for up to 48 h; however, concentrations were below this MIC at 7 days post treatment. Conclusions Voriconazole-thermogel was easily and safely administered to horses, and provided 48 h of sustained release of voriconazole into the cornea. This drug delivery system warrants further clinical evaluation.
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Affiliation(s)
- Mariano Mora-Pereira
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - Eva M Abarca
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA.
| | - Sue Duran
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - William Ravis
- Department of Drug Discovery and Development, Auburn University, Auburn, AL, USA
| | - Richard J McMullen
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - Britta M Fischer
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | | | - Anne A Wooldridge
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
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Ashley ED. Antifungal Drugs: Special Problems Treating Central Nervous System Infections. J Fungi (Basel) 2019; 5:E97. [PMID: 31614505 PMCID: PMC6958367 DOI: 10.3390/jof5040097] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 02/07/2023] Open
Abstract
Treating fungal infections in the central nervous system (CNS) remains a challenge despite the availability of new antifungal agents. Therapy is limited by poor understanding of the kinetic properties of antifungal drugs in the CNS compounded by lack of data for many agents. In some cases, clinical response rates do not correspond to data on drug concentrations in the cerebral spinal fluid and/or brain parenchyma. In order to better characterize the use of antifungal agents in treating CNS infections, a review of the essential principles of neuroPK are reviewed. Specific data regarding antifungal drug concentrations in the cerebral spinal fluid and brain tissue are described from human data where available. Alternative dosing regimens and the role of antifungal drug concentration monitoring in treating fungal infections in the CNS are also discussed. Having a better understanding of these key concepts will help guide clinicians in determining the best treatment courses for patients with these devastating infections.
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Affiliation(s)
- Elizabeth Dodds Ashley
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC 27710, USA.
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Tissue Distribution and Elimination of Isavuconazole following Single and Repeat Oral-Dose Administration of Isavuconazonium Sulfate to Rats. Antimicrob Agents Chemother 2017; 61:AAC.01292-17. [PMID: 28971866 PMCID: PMC5700325 DOI: 10.1128/aac.01292-17] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/23/2017] [Indexed: 12/18/2022] Open
Abstract
Quantitative whole-body autoradiography was used to assess the distribution and tissue penetration of isavuconazole in rats following single and repeated oral-dose administration of radiolabeled isavuconazonium sulfate, the prodrug of isavuconazole. Following a single-dose administration of radiolabeled isavuconazonium sulfate (labeled on the active moiety), radioactivity was detectable within 1 h postdose in 56 of 65 tissue/fluid specimens. The highest maximum concentrations (Cmax) were observed in bile and liver (66.6 and 24.7 μg eq/g, respectively). The lowest Cmax values were in bone and eye lens (0.070 and 0.077 μg eq/g, respectively). By 144 h postdose, radioactivity was undetectable in all tissues/fluids except liver (undetectable at 336 h) and adrenal gland tissues (undetectable at 672 h). Following daily administration for up to 21 days, 1-h-postdose Cmax values were the highest on or before day 14 in all except seven tissues/fluids, of which only rectum mucosa and small intestine mucosa had Cmax values >25% higher than all other 1-h-postdose values. For 24-h-postdose Cmax values, only large intestine, large intestine mucosa, and urine had the highest Cmax values at day 21. The penetration of single oral doses of unlabeled isavuconazole (25 mg/kg of body weight isavuconazonium sulfate) and voriconazole (50 mg/kg) into rat brain (assessed using liquid chromatography-tandem mass spectrometry) was also compared. Brain concentration/plasma concentration ratios reached approximately 1.8:1 and 2:1, respectively. These data suggest that isavuconazole penetrates most tissues rapidly, reaches a steady state in most or all tissues/fluids within 14 days, does not accumulate in tissues/fluids over time, and achieves potentially efficacious concentrations in the brain.
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Job KM, Olson J, Stockmann C, Constance JE, Enioutina EY, Rower JE, Linakis MW, Balch AH, Yu T, Liu X, Thorell EA, Sherwin CMT. Pharmacodynamic studies of voriconazole: informing the clinical management of invasive fungal infections. Expert Rev Anti Infect Ther 2017; 14:731-46. [PMID: 27355512 DOI: 10.1080/14787210.2016.1207526] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Voriconazole is a broad-spectrum antifungal agent commonly used to treat invasive fungal infections (IFI), including aspergillosis, candidiasis, Scedosporium infection, and Fusarium infection. IFI often occur in immunocompromised patients, leading to increased morbidity and mortality. AREAS COVERED The objective of this review is to summarize the pharmacodynamic properties of voriconazole and to provide considerations for potential optimal dosing strategies. Studies have demonstrated superior clinical response when an AUC/MIC >25 or Cmin/MIC >1 is attained in adult patients, correlating to a trough concentration range as narrow as 2-4.5 mg/L; however, these targets are poorly established in the pediatric population. Topics in this discussion include voriconazole use in multiple age groups, predisposing patient factors for IFI, and considerations for clinicians managing IFI. Expert commentary: The relationship between voriconazole dosing and exposure is not well defined due to the large inter- and intra-subject variability. Development of comprehensive decision support tools for individualizing dosing, particularly in children who require higher dosing, will help to increase the probability of achieving therapeutic efficacy and decrease sub-therapeutic dosing and adverse events.
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Affiliation(s)
- Kathleen M Job
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Jared Olson
- b Pharmacy, Primary Children's Hospital, Intermountain Healthcare , University of Utah , Salt Lake City , UT , USA
| | - Chris Stockmann
- c Division of Pediatric Infectious Diseases, Department of Pediatrics , University of Utah , Salt Lake City , UT , USA
| | - Jonathan E Constance
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Elena Y Enioutina
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA.,d Division of Microbiology and Immunology, Department of Pathology , University of Utah , Salt Lake City , UT , USA
| | - Joseph E Rower
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Matthew W Linakis
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Alfred H Balch
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Tian Yu
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Xiaoxi Liu
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA
| | - Emily A Thorell
- c Division of Pediatric Infectious Diseases, Department of Pediatrics , University of Utah , Salt Lake City , UT , USA
| | - Catherine M T Sherwin
- a Division of Clinical Pharmacology , University of Utah , Salt Lake City , UT , USA.,e Department of Pharmacology and Toxicology, College of Pharmacy , University of Utah , Salt Lake City , UT , USA
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Bellmann R, Smuszkiewicz P. Pharmacokinetics of antifungal drugs: practical implications for optimized treatment of patients. Infection 2017; 45:737-779. [PMID: 28702763 PMCID: PMC5696449 DOI: 10.1007/s15010-017-1042-z] [Citation(s) in RCA: 203] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/25/2017] [Indexed: 02/08/2023]
Abstract
Introduction Because of the high mortality of invasive fungal infections (IFIs), appropriate exposure to antifungals appears to be crucial for therapeutic efficacy and safety. Materials and methods This review summarises published pharmacokinetic data on systemically administered antifungals focusing on co-morbidities, target-site penetration, and combination antifungal therapy. Conclusions and discussion Amphotericin B is eliminated unchanged via urine and faeces. Flucytosine and fluconazole display low protein binding and are eliminated by the kidney. Itraconazole, voriconazole, posaconazole and isavuconazole are metabolised in the liver. Azoles are substrates and inhibitors of cytochrome P450 (CYP) isoenzymes and are therefore involved in numerous drug–drug interactions. Anidulafungin is spontaneously degraded in the plasma. Caspofungin and micafungin undergo enzymatic metabolism in the liver, which is independent of CYP. Although several drug–drug interactions occur during caspofungin and micafungin treatment, echinocandins display a lower potential for drug–drug interactions. Flucytosine and azoles penetrate into most of relevant tissues. Amphotericin B accumulates in the liver and in the spleen. Its concentrations in lung and kidney are intermediate and relatively low myocardium and brain. Tissue distribution of echinocandins is similar to that of amphotericin. Combination antifungal therapy is established for cryptococcosis but controversial in other IFIs such as invasive aspergillosis and mucormycosis.
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Affiliation(s)
- Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Treatment, University Hospital, Poznań, Poland
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16
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[Strategies for antifungal treatment failure in intensive care units]. Anaesthesist 2016; 64:643-58. [PMID: 26349425 DOI: 10.1007/s00101-015-0072-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Recent epidemiologic studies reveal both an increasing incidence and an escalation in resistance of invasive fungal infections in intensive care units. Primary therapy fails in 70 % of cases, depending on the underlying pathogens and diseases. The purpose of this review is to raise awareness for the topic of antifungal therapy failure, describe the clinical conditions in which it occurs, and suggest a possible algorithm for handling the situation of suspected primary therapy failure.
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Goldman JL, Abdel-Rahman SM. Pharmacokinetic considerations in treating invasive pediatric fungal infections. Expert Opin Drug Metab Toxicol 2016; 12:645-55. [PMID: 27111148 DOI: 10.1080/17425255.2016.1181752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Despite the increased availability of systemic antifungal agents in recent years, the management of invasive fungal disease is still associated with significant morbidity and mortality. Knowledge of a drug's pharmacokinetic behavior is critical for optimizing existing treatment strategies. AREAS COVERED This review examines the pharmacokinetics of the major drug classes used to treat invasive mycoses including the echinocandins, imidazoles, triazoles, nucleoside analogs, and polyenes. It examines the mechanisms behind dose-exposure profiles that differ in children as compared with adults and explores the utility of pharmacogenetic testing and therapeutic drug monitoring. EXPERT OPINION Lifesaving medical advances for oncologic and autoimmune conditions have resulted in a significant increase in the frequency of opportunistic fungal infections. Owing to the high rate of treatment failures observed when managing invasive fungal infections, strategies to optimize antifungal therapy are critical when caring for these complex patients. Opportunities to maximize positive outcomes include dose refinement based on age or genetic status, formulation selection, co-administration of interacting medications, and administration with regard to food. The application of therapeutic drug monitoring for dose individualization is a valuable strategy to achieve pharmacodynamic targets.
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Affiliation(s)
- Jennifer L Goldman
- a Department of Pediatrics , UMKC School of Medicine , Kansas City , MO , USA.,b Drug Safety Service Children's Mercy Hospital , Kansas City , MO , USA.,c Antimicrobial Stewardship Program Children's Mercy Hospital , Kansas City , MO , USA.,d Divisions Pediatric Infectious Diseases & Clinical Pharmacology , Toxicology, and Therapeutic Innovation Children's Mercy Hospital , Kansas City , MO , USA
| | - Susan M Abdel-Rahman
- a Department of Pediatrics , UMKC School of Medicine , Kansas City , MO , USA.,d Divisions Pediatric Infectious Diseases & Clinical Pharmacology , Toxicology, and Therapeutic Innovation Children's Mercy Hospital , Kansas City , MO , USA
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18
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Successful Treatment of Refractory Majocchi's Granuloma with Voriconazole and Review of Published Literature. Mycopathologia 2015; 180:237-43. [PMID: 26045285 DOI: 10.1007/s11046-015-9902-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
Abstract
Majocchi's granuloma (MG) is a rare deep skin dermatophyte infection that can occur either in immunocompetent or in immunocompromised individuals. Oral itraconazole or terbinafine is considered to be the first choice of treatment. We report an immunocompetent man with deep nodular form of MG, the form which is generally found in immunosuppressed individuals. Previous treatment with either oral itraconazole or terbinafine yielded no apparent improvement. After a series of examination, the man was diagnosed as having Trichophyton rubrum-induced MG mixed with bacterial infection as evidenced by growth of Klebsiella pneumoniae in tissue bacterial culture. The patient was treated with a combination of cefoselis and levofloxacin for bacterial clearance followed by voriconazole treatment. After approximately 4 months of voriconazole treatment, the lesions completely resolved. Alternative medicine (voriconazole) can be considered in case of refractory infections during MG treatment.
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Tauber SC, Eiffert H, Kellner S, Lugert R, Bunkowski S, Schütze S, Perske C, Brück W, Nau R. Fungal encephalitis in human autopsy cases is associated with extensive neuronal damage but only minimal repair. Neuropathol Appl Neurobiol 2015; 40:610-27. [PMID: 23517274 DOI: 10.1111/nan.12044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 02/15/2013] [Indexed: 11/30/2022]
Abstract
AIMS The present study aimed at examining neuronal injury and repair in post mortem brain sections of humans who died from fungal central nervous system infections. METHODS Histological and immunohistochemical abnormalities in 15 autopsy cases with fungal central nervous system infections from 1990 to 2008 were compared with findings in 10 age- und sex-matched control cases that died from acute non-neurological causes. The fungal pathogens were identified by culture or polymerase chain reaction and morphology in post mortem tissue. Seven patients with fungal encephalitis had either an organ transplantation or a malignant haematological disorder; five out of 15 did not have a classical predisposing illness but suffered from severe septic infections as the principal cause of immunosuppression, and three from alcoholism. RESULTS Fungal organisms detected were Aspergillus spp. and other moulds, Candida spp. and black yeast-like fungi including Cladosporium spp. Histological analyses identified microglial activation, astrocytosis and axonal injury in the white matter without additional demyelination as characteristic features of this infectious disease. An increased rate of hippocampal neuronal apoptosis was detected in fungal encephalitis, while the number of recently generated TUC-4 and calretinin-expressing neurones in the dentate gyrus did not differ between patients and controls. CONCLUSIONS Unlike in other infectious diseases of the nervous system where a coexistence of damage and repair was observed, fungal encephalitis is characterized by strong damage and minimal neuronal regeneration.
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Affiliation(s)
- Simone C Tauber
- Department of Neurology, RWTH University Hospital, Aachen, Germany
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Neves N, Santos L, Reis C, Sarmento A. Candida albicans brain abscesses in an injection drug user patient: a case report. BMC Res Notes 2014; 7:837. [PMID: 25421883 PMCID: PMC4255923 DOI: 10.1186/1756-0500-7-837] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/19/2014] [Indexed: 12/26/2022] Open
Abstract
Background Fungal brain abscess is an uncommon disease, mostly associated with immunocompromised states and poorly controlled diabetes. Its incidence, however, is rising as a result of the increasing use of immunosuppressive agents, corticosteroids and broad-spectrum antimicrobial therapy. Candida species have emerged as the most prevalent etiologic agents of brain abscesses in autopsy studies. Case presentation A 46-year-old male with a history of injection drug abuse, chronic hepatitis C and diabetes mellitus presented to the Emergency Department of our hospital following a generalized tonic-clonic seizure without recovery of mental status. On admission, the patient was in coma, febrile, with severe acidemia with respiratory and metabolic acidosis, requiring invasive mechanical ventilation. Brain imaging revealed multiple ring-enhancing lesions with oedema and mass effect. Microbiologic studies, including cerebrospinal fluid, blood, sputum and urine cultures, were all negative. A stereotactic brain biopsy was performed and culture of brain specimens revealed Candida albicans. The patient was successfully treated with fluconazole therapy for 48 weeks presenting a good clinical response and a complete radiological resolution of brain abscesses. Conclusion Despite advances in diagnostic and therapeutic procedures, fungal brain abscess remains a life-threatening disease with a poor outcome. Successful treatment requires an early diagnosis and usually a combined medical and surgical approach. A long-term antibiotic regimen is a cornerstone of fungal brain abscesses treatment, with the endpoint determined by clinical and neuroimaging response. The authors report an uncommon case of successfully treated Candida albicans brain abscesses with anti-fungal therapy consisting of fluconazole alone. This case illustrates the importance of early recognition of predisposing factors and multidisciplinary approach in timely therapeutic intervention, in order to prevent neurologic sequelae and improve the outcome of the patients with this severe and challenging form of central nervous system infection.
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Affiliation(s)
- Nélia Neves
- Infectious Diseases Department, Centro Hospitalar São João and Faculty of Medicine of Porto University, Porto, Portugal.
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Zane NR, Thakker DR. A Physiologically Based Pharmacokinetic Model for Voriconazole Disposition Predicts Intestinal First-pass Metabolism in Children. Clin Pharmacokinet 2014; 53:1171-82. [DOI: 10.1007/s40262-014-0181-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Cervera C, van Delden C, Gavaldà J, Welte T, Akova M, Carratalà J. Multidrug-resistant bacteria in solid organ transplant recipients. Clin Microbiol Infect 2014; 20 Suppl 7:49-73. [DOI: 10.1111/1469-0691.12687] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 05/16/2014] [Accepted: 05/18/2014] [Indexed: 12/23/2022]
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Moon WJ, Scheller EL, Suneja A, Livermore JA, Malani AN, Moudgal V, Kerr LE, Ferguson E, Vandenberg DM. Plasma fluoride level as a predictor of voriconazole-induced periostitis in patients with skeletal pain. Clin Infect Dis 2014; 59:1237-45. [PMID: 24992954 DOI: 10.1093/cid/ciu513] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Voriconazole is a triazole antifungal medication used for prophylaxis or to treat invasive fungal infections. Inflammation of the periosteum resulting in skeletal pain, known as periostitis, is a reported side effect of long-term voriconazole therapy. The trifluorinated molecular structure of voriconazole suggests a possible link between excess fluoride and periostitis, as elevated blood fluoride has been reported among patients with periostitis who received voriconazole. METHODS Two hundred sixty-four patients from Michigan were impacted by the multistate outbreak of fungal infections as a result of contaminated methylprednisolone injections. A retrospective study was conducted among 195 patients who received voriconazole therapy at St Joseph Mercy Hospital during this outbreak. Twenty-eight patients who received both bone scan and plasma fluoride measurements for skeletal pain were included in the statistical analyses. Increased tracer uptake on bone scan was considered positive for periostitis. The primary outcome measure was the correlation between plasma fluoride and bone scan results. RESULTS Blood fluoride (P < .001), alkaline phosphatase (P = .020), daily voriconazole dose (P < .001), and cumulative voriconazole dose (P = .027) were significantly elevated in patients who had periostitis compared with those who did not. Discontinuation or dose reduction of voriconazole resulted in improvement of pain in 89% of patients. CONCLUSIONS High plasma fluoride levels coupled with skeletal pain among patients who are on long-term voriconazole therapy is highly suggestive of periostitis. Initial measurement of fluoride may be considered when bone scan is not readily available. Early detection should be sought, as discontinuation of voriconazole is effective at reversing the disease.
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Affiliation(s)
- Woo J Moon
- Department of Internal Medicine, St Joseph Mercy Hospital
| | - Erica L Scheller
- Department of Molecular and Integrative Physiology, University of Michigan
| | - Anupam Suneja
- Department of Internal Medicine, St Joseph Mercy Hospital
| | | | - Anurag N Malani
- Department of Internal Medicine, St Joseph Mercy Hospital Section of Infectious Diseases
| | - Varsha Moudgal
- Department of Internal Medicine, St Joseph Mercy Hospital Section of Infectious Diseases
| | - Lisa E Kerr
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, Michigan
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Abstract
Understanding the tissue penetration of systemically administered antifungal agents is critical for a proper appreciation of their antifungal efficacy in animals and humans. Both the time course of an antifungal drug and its absolute concentrations within tissues may differ significantly from those observed in the bloodstream. In addition, tissue concentrations must also be interpreted within the context of the pathogenesis of the various invasive fungal infections, which differ significantly. There are major technical obstacles to the estimation of concentrations of antifungal agents in various tissue subcompartments, yet these agents, even those within the same class, may exhibit markedly different tissue distributions. This review explores these issues and provides a summary of tissue concentrations of 11 currently licensed systemic antifungal agents. It also explores the therapeutic implications of their distribution at various sites of infection.
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Autmizguine J, Guptill JT, Cohen-Wolkowiez M, Benjamin DK, Capparelli EV. Pharmacokinetics and pharmacodynamics of antifungals in children: clinical implications. Drugs 2014; 74:891-909. [PMID: 24872147 PMCID: PMC4073603 DOI: 10.1007/s40265-014-0227-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Invasive fungal disease (IFD) remains life threatening in premature infants and immunocompromised children despite the recent development of new antifungal agents. Optimal dosing of antifungals is one of the few factors clinicians can control to improve outcomes of IFD. However, dosing in children cannot be extrapolated from adult data because IFD pathophysiology, immune response, and drug disposition differ from adults. We critically examined the literature on pharmacokinetics (PK) and pharmacodynamics (PD) of antifungal agents and highlight recent developments in treating pediatric IFD. To match adult exposure in pediatric patients, dosing adjustment is necessary for almost all antifungals. In young infants, the maturation of renal and metabolic functions occurs rapidly and can significantly influence drug exposure. Fluconazole clearance doubles from birth to 28 days of life and, beyond the neonatal period, agents such as fluconazole, voriconazole, and micafungin require higher dosing than in adults because of faster clearance in children. As a result, dosing recommendations are specific to bracketed ranges of age. PD principles of antifungals mostly rely on in vitro and in vivo models but very few PD studies specifically address IFD in children. The exposure-response relationship may differ in younger children compared with adults, especially in infants with invasive candidiasis who are at higher risk of disseminated disease and meningoencephalitis, and by extension severe neurodevelopmental impairment. Micafungin is the only antifungal agent for which a specific target of exposure was proposed based on a neonatal hematogenous Candida meningoencephalitis animal model. In this review, we found that pediatric data on drug disposition of newer triazoles and echinocandins are lacking, dosing of older antifungals such as fluconazole and amphotericin B products still need optimization in young infants, and that target PK/PD indices need to be clinically validated for almost all antifungals in children. A better understanding of age-specific PK and PD of new antifungals in infants and children will help improve clinical outcomes of IFD by informing dosing and identifying future research areas.
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Affiliation(s)
- Julie Autmizguine
- Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705, USA
| | | | | | | | - Edmund V. Capparelli
- Department of Pediatric Pharmacology, University of California, 9500 Gilman Drive, La Jolla, CA 92093-0831, USA
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Agbetile J, Bourne M, Fairs A, Hargadon B, Desai D, Broad C, Morley J, Bradding P, Brightling CE, Green RH, Haldar P, Pashley CH, Pavord ID, Wardlaw AJ. Effectiveness of voriconazole in the treatment of Aspergillus fumigatus-associated asthma (EVITA3 study). J Allergy Clin Immunol 2013; 134:33-9. [PMID: 24290286 DOI: 10.1016/j.jaci.2013.09.050] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/13/2013] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND IgE sensitization to Aspergillus fumigatus and a positive sputum fungal culture result are common in patients with refractory asthma. It is not clear whether these patients would benefit from antifungal treatment. OBJECTIVES We sought to determine whether a 3-month course of voriconazole improved asthma-related outcomes in patients with asthma who are IgE sensitized to A fumigatus. METHODS Asthmatic patients who were IgE sensitized to A fumigatus with a history of at least 2 severe exacerbations in the previous 12 months were treated for 3 months with 200 mg of voriconazole twice daily, followed by observation for 9 months, in a double-blind, placebo-controlled, randomized design. Primary outcomes were improvement in quality of life at the end of the treatment period and a reduction in the number of severe exacerbations over the 12 months of the study. RESULTS Sixty-five patients were randomized. Fifty-nine patients started treatment (32 receiving voriconazole and 27 receiving placebo) and were included in an intention-to-treat analysis. Fifty-six patients took the full 3 months of medication. Between the voriconazole and placebo groups, there were no significant differences in the number of severe exacerbations (1.16 vs 1.41 per patient per year, respectively; mean difference, 0.25; 95% CI, 0.19-0.31), quality of life (change in Asthma Quality of Life Questionnaire score, 0.68 vs 0.88; mean difference between groups, 0.2; 95% CI, -0.05 to -0.11), or any of our secondary outcome measures. CONCLUSION We were unable to show a beneficial effect of 3 months of treatment with voriconazole in patients with moderate-to-severe asthma who were IgE sensitized to A fumigatus on either the rate of severe exacerbations, quality of life, or other markers of asthma control.
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Affiliation(s)
- Joshua Agbetile
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Michelle Bourne
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Abbie Fairs
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Beverley Hargadon
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Dhananjay Desai
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Clare Broad
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Joseph Morley
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Peter Bradding
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Christopher E Brightling
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Ruth H Green
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Pranabashis Haldar
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Catherine H Pashley
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Ian D Pavord
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Andrew J Wardlaw
- Institute for Lung Health, Department of Infection, Immunity and Inflammation, University of Leicester, and the Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, United Kingdom.
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Quantification of brain voriconazole levels in healthy adults using fluorine magnetic resonance spectroscopy. Antimicrob Agents Chemother 2013; 57:5271-6. [PMID: 23939898 DOI: 10.1128/aac.00394-13] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Voriconazole is more effective for aspergillosis infections with central nervous system involvement than other antifungal agents. The clinical efficacy of voriconazole for central nervous system infections has been attributed to its ability to cross the blood-brain barrier. However, pharmacokinetic studies are limited to plasma and cerebrospinal fluid, so it remains unclear how much of the drug enters the brain. Fluorinated compounds such as voriconazole can be quantified in the brain using fluorine-19 magnetic resonance spectroscopy (MRS). Twelve healthy adult males participated in a pharmacokinetic analysis of voriconazole levels in the brain and plasma. Open-label voriconazole was dosed per clinical protocol with a loading dose of 400 mg every 12 h on day 1, followed by 200 mg every 12 h administered orally over a 3-day period. MRS was performed before and after dosing on the third day. Voriconazole levels in the brain exceeded the MIC for Aspergillus. The brain/plasma ratios were 3.0 at steady state on day 3 (predose) and 1.9 postdose. We found that voriconazole is able to penetrate the brain tissue, which can be quantified using a noninvasive MRS technique. (This study has been registered at ClinicalTrials.gov under registration no. NCT00300677.).
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Cornely OA, Bassetti M, Calandra T, Garbino J, Kullberg BJ, Lortholary O, Meersseman W, Akova M, Arendrup MC, Arikan-Akdagli S, Bille J, Castagnola E, Cuenca-Estrella M, Donnelly JP, Groll AH, Herbrecht R, Hope WW, Jensen HE, Lass-Flörl C, Petrikkos G, Richardson MD, Roilides E, Verweij PE, Viscoli C, Ullmann AJ. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients. Clin Microbiol Infect 2013; 18 Suppl 7:19-37. [PMID: 23137135 DOI: 10.1111/1469-0691.12039] [Citation(s) in RCA: 843] [Impact Index Per Article: 76.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This part of the EFISG guidelines focuses on non-neutropenic adult patients. Only a few of the numerous recommendations can be summarized in the abstract. Prophylactic usage of fluconazole is supported in patients with recent abdominal surgery and recurrent gastrointestinal perforations or anastomotic leakages. Candida isolation from respiratory secretions alone should never prompt treatment. For the targeted initial treatment of candidaemia, echinocandins are strongly recommended while liposomal amphotericin B and voriconazole are supported with moderate, and fluconazole with marginal strength. Treatment duration for candidaemia should be a minimum of 14 days after the end of candidaemia, which can be determined by one blood culture per day until negativity. Switching to oral treatment after 10 days of intravenous therapy has been safe in stable patients with susceptible Candida species. In candidaemia, removal of indwelling catheters is strongly recommended. If catheters cannot be removed, lipid-based amphotericin B or echinocandins should be preferred over azoles. Transoesophageal echocardiography and fundoscopy should be performed to detect organ involvement. Native valve endocarditis requires surgery within a week, while in prosthetic valve endocarditis, earlier surgery may be beneficial. The antifungal regimen of choice is liposomal amphotericin B +/- flucytosine. In ocular candidiasis, liposomal amphotericin B +/- flucytosine is recommended when the susceptibility of the isolate is unknown, and in susceptible isolates, fluconazole and voriconazole are alternatives. Amphotericin B deoxycholate is not recommended for any indication due to severe side effects.
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Affiliation(s)
- O A Cornely
- Department I of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, BMBF 01KN1106, Center for Integrated Oncology CIO KölnBonn, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany.
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Pharmacological and Host Considerations in the Selection of Dose and Duration of Azole Therapy for Adult Patients. CURRENT FUNGAL INFECTION REPORTS 2012. [DOI: 10.1007/s12281-012-0089-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Beinborn NA, Du J, Wiederhold NP, Smyth HDC, Williams RO. Dry powder insufflation of crystalline and amorphous voriconazole formulations produced by thin film freezing to mice. Eur J Pharm Biopharm 2012; 81:600-8. [PMID: 22569473 DOI: 10.1016/j.ejpb.2012.04.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 04/21/2012] [Accepted: 04/24/2012] [Indexed: 12/31/2022]
Abstract
Attention has begun to focus on the pulmonary delivery of antifungal agents for invasive fungal infections as inhalation of the fungal spores is often the initial step in the pathogenesis of many of these infections, including invasive pulmonary aspergillosis (IPA). IPA in immunocompromised patients has high mortality rates despite current systemic (oral or intravenous) therapies. In this study, particulate voriconazole (VRC) formulations were designed with suitable properties for inhalation using thin film freezing (TFF), a particle engineering process capable of producing low-density porous aggregate particles. Nanostructured amorphous morphology of VRC was less favorable in vitro and in vivo than microstructured crystalline morphology, despite being a poorly water-soluble compound. Using a Handihaler dry powder inhaler (DPI), microstructured crystalline TFF-VRC and nanostructured amorphous TFF-VRC-PVP K25 (1:3) had fine particle fractions of 37.8% and 32.4% and mass median aerodynamic diameters of 4.2 and 5.2 μm, respectively. Single dose 24-h pharmacokinetic studies were conducted in ICR mice. AUC(0-24h) in the lung tissue and plasma was 452.6 μg h/g wet lung weight and 38.4 μg h/mL, respectively, following a 10mg/kg insufflated dose of TFF-VRC directly into the lungs of the mice, while AUC(0-24 h) in the lung tissue and plasma was 232.1 μg h/g wet lung weight and 18.6 μg h/mL, respectively, following a 10mg/kg insufflated dose of TFF-VRC-PVP K25 (1:3). High concentrations of VRC in lung tissue coupled with clinically relevant plasma concentrations suggest that pulmonary delivery of microstructured crystalline VRC could potentially be a beneficial strategy for administration of VRC to patients with invasive pulmonary fungal infections.
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Affiliation(s)
- Nicole A Beinborn
- College of Pharmacy, The University of Texas at Austin, TX 78712, USA.
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31
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Racil Z, Winterova J, Kouba M, Zak P, Malaskova L, Buresova L, Toskova M, Lengerova M, Kocmanova I, Weinbergerova B, Timilsina S, Rolencova M, Cetkovsky P, Mayer J. Monitoring trough voriconazole plasma concentrations in haematological patients: real life multicentre experience. Mycoses 2012; 55:483-92. [PMID: 22429709 DOI: 10.1111/j.1439-0507.2012.02186.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The objective of this retrospective study was to evaluate results from voriconazole therapeutic drug monitoring (TDM) in haematological patients in routine clinical practice. Between 2005 and 2010, 1228 blood samples were obtained from 264 haematological patients (median 3 samples/patient; range 1-27) receiving voriconazole for targeted/preemptive treatment of invasive aspergillosis (IA) (46.3% of samples), empirical therapy (12.9%) or prophylaxis (40.8%). A high-pressure liquid chromatography assay was used to analyse voriconazole concentrations. Clinical and laboratory data were analysed retrospectively. The median of the detected voriconazole plasma concentration was 1.00 μg ml(-1) (range <0.20-13.47 μg ml(-1)). Significant inter- and intra-patients variability of measured concentrations (81.9% and 50.5%) were identified. With the exception of omeprazole administration, there was no relevant relationship between measured voriconazole concentrations and drug dose, route administration, age, gender, CYP2C19*2 genotype, gastrointestinal tract abnormality, administration via nasogastric tube, serum creatinine, and liver enzymes. However, per patient analysis identified significant role of individual voriconazole dose and drug form change on measured plasma concentration. Measured voriconazole concentrations did not correlate with the treatment outcome of patients with IA. We only identified a limited number of adverse events related to voriconazole therapy; however, the median plasma concentration was not different from concentrations measured in samples without reported toxicity. Our retrospective study has suggested that routine monitoring of voriconazole plasma concentrations has probably only a limited role in daily haematological practice.
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Affiliation(s)
- Zdenek Racil
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Masaryk University, Brno, Czech Republic.
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32
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Bellmann R, Weiler S. Treatment of invasive fungal infections. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2011. [DOI: 10.1007/s12254-011-0290-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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