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Lepak AJ, VanScoy B, Rubino C, Ambrose PG, Andes DR. In vivo pharmacodynamic characterization of a next-generation polyene, SF001, in the invasive pulmonary aspergillosis mouse model. Antimicrob Agents Chemother 2024; 68:e0163123. [PMID: 38319077 PMCID: PMC10916380 DOI: 10.1128/aac.01631-23] [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: 12/12/2023] [Accepted: 01/14/2024] [Indexed: 02/07/2024] Open
Abstract
SF001 is a next-generation polyene antifungal drug in development, designed to have increased specificity to fungal ergosterol, which is absent in humans, and decreased binding to cholesterol. SF001 demonstrates long-acting, potent, broad-spectrum fungicidal activity. The goal of the current study was to determine the pharmacodynamic index and target of SF001 in an immunocompromised mouse model of invasive pulmonary aspergillosis against six Aspergillus fumigatus isolates. Minimum inhibitory concentration (MIC) values ranged from 0.5 to 2.0 mg/L. Plasma and epithelial lining fluid (ELF) pharmacokinetics were performed following single intraperitoneal doses of 1, 4, 16, and 64 mg/kg. Treatment efficacy was assessed with each of the six fungal isolates using daily doses of SF001 ranging from 0.25 to 64 mg/kg/day over a 96-h treatment duration. Efficacy was assessed by A. fumigatus quantitative PCR of conidial equivalents from lung homogenates. Nonlinear regression analysis using the Hill equation demonstrated that the 24-h exposure-response relationships for both plasma and ELF area under the concentration/MIC and Cmax/MIC ratios were strong and relatively similar [coefficient of determination (R2) = 0.74-0.75). Exposure-response relationships included a median plasma 24-h Cmax/MIC target for stasis and 1-log kill endpoint of 0.5 and 0.6, respectively. The present studies demonstrated in vitro and in vivo SF001 potency against A. fumigatus. These results have potential relevance for SF001 clinical dose selection and evaluation of susceptibility breakpoints.
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Affiliation(s)
- Alexander J. Lepak
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brian VanScoy
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - Chris Rubino
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - Paul G. Ambrose
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - David R. Andes
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, Wisconsin, USA
- William S. Middleton Memorial VA Hospital, Madison, Wisconsin, USA
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2
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Chen L, Krekels EHJ, Dong Y, Chen L, Maertens JA, Blijlevens NMA, Knibbe CAJ, Brüggemann RJ. Meta-pharmacokinetic analysis of posaconazole following dosing of oral suspension, delayed-release tablet, and intravenous infusion in patients vs. healthy volunteers: Impact of clinical characteristics and race. Int J Antimicrob Agents 2023; 62:106995. [PMID: 37806462 DOI: 10.1016/j.ijantimicag.2023.106995] [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: 06/02/2023] [Revised: 08/29/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVES To investigate the potential impact of clinical characteristics and the Chinese race on posaconazole pharmacokinetics in patients using an integrated population pharmacokinetic model for posaconazole oral suspension (SUS), delayed-release tablet (DR-tablet), and intravenous (IV) infusion that was developed in healthy volunteers (HV). METHODS 1046 concentrations from 105 prospectively studied Caucasian patients receiving either of the three posaconazole formulations were pooled with 3898 concentrations from 182 HV. Clinical characteristics were tested for significance. The impact of Chinese race was assessed using 292 opportunistic samples from 80 Chinese patients receiving SUS. RESULTS Bioavailability of SUS (Fsus) in patients decreased from 38.2% to 24.6% when the dose was increased from 100 mg to 600 mg. Bioavailability of DR-tablet (Ftab) was 59% regardless of dose. Mucositis, diarrhoea, administration through a nasogastric tube, and concomitant use of proton pump inhibitors or metoclopramide reduced Fsus by 61%, 36%, 44%, 48%, and 29%, respectively, putting patients with these characteristics at increased risk of inadequate exposure. Clearance decreased from 7.0 to 5.1 L/h once albumin levels were <30 g/L. Patients showed an 84.4% larger peripheral volume of distribution (Vp) and 67.5% lower intercompartmental clearance (Q) compared with HV. No racial difference could be identified. CONCLUSIONS Pharmacokinetics of posaconazole in patients differ considerably to those in HV, with altered Fsus that is also impacted by clinical covariates, an Ftab similar to fasted conditions in HV, and altered parameters for clearance, Vp, and Q. There was no evidence to indicate that Chinese patients require a different dose to Caucasian patients.
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Affiliation(s)
- Lu Chen
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Elke H J Krekels
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Limei Chen
- Department of Haematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Johan A Maertens
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Nicole M A Blijlevens
- Department of Haematology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands; Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands; Radboudumc Centre for Infectious Diseases and Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.
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Howard A, Hope W. Assessment of Antifungal Pharmacodynamics. J Fungi (Basel) 2023; 9:jof9020192. [PMID: 36836307 PMCID: PMC9960731 DOI: 10.3390/jof9020192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
Pharmacokinetic-pharmacodynamic (PK-PD) analysis is of central importance to the progress of an antifungal agent into clinical use. It is crucial to ensure that preclinical studies give the best possible prediction of the way drugs are likely to behave in a clinical setting. This review details the last 30 years of progress in terms of disease model design, efficacy outcome selection and translational modelling in antifungal PK-PD studies. The principles of how PK-PD parameters inform current clinical practice are also discussed, including a review of how these apply to existing and novel agents.
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An Integrated Population Pharmacokinetic Analysis for Posaconazole Oral Suspension, Delayed-Release Tablet, and Intravenous Infusion in Healthy Volunteers. Drugs 2023; 83:75-86. [PMID: 36607589 DOI: 10.1007/s40265-022-01819-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Posaconazole is widely used for the prophylaxis and treatment of invasive fungal diseases. Because of the limited and variable absorption of the initially available oral suspension, a delayed-release tablet and intravenous formulation were developed. OBJECTIVE This study aimed to characterize the pharmacokinetics, including the absolute oral bioavailability, of all posaconazole formulations in healthy volunteers. METHODS Data from 182 healthy volunteers with 3898 densely sampled posaconazole concentrations were pooled from eight phase I clinical studies on the three formulations of various single and multiple dosage regimens between 50 and 400 mg. Analysis and simulations were performed using NONMEM 7.5.0. In the covariate analysis, the influence of food (fed vs fasted), nonlinearity, and for the delayed-release tablet, comedication (antacid, ranitidine, esomeprazole, and metoclopramide) were tested. RESULTS A two-compartment model with respectively, four and eight absorption transit compartments, best described the profiles of the oral suspension and delayed-release tablet. For the suspension, both a food effect and a dose-dependent nonlinear bioavailability were quantified, resulting in lower bioavailability when fasted or at a higher dose. The typical bioavailability of the suspension at 100 mg and 400 mg was derived to be respectively, 17.1% and 10.1% under fasted conditions and 59.1% and 49.2% under fed conditions. The absolute bioavailability of the delayed-release tablet was 58.8% (95% confidence interval 33.2-80.4) under fasted conditions and approached complete absorption under fed conditions for dosages up to 300 mg. Food intake reduced the absorption rate constant of the suspension by 52.2% (confidence interval 45.2-59.2). The impact of comedication on the absorption of the delayed-release tablet was not statistically significant. Model-based simulations indicate that under fed conditions, the licensed dosages of the three formulations yield a steady-state trough concentration ≥ 0.7 mg/L in over 90% of healthy volunteers. About 35% of healthy volunteers who receive the licensed 300-mg delayed-release tablet under fasted conditions do not achieve this target, while for the suspension this percentage varies between 55 and 85%, depending on the dose. CONCLUSIONS For both oral posaconazole formulations, we quantified bioavailability and absorption rate, including food effects, in healthy volunteers. The pharmacokinetic superiority of the delayed-release tablet was demonstrated under both fed and fasted conditions, compared with the oral suspension. The impact of food on the bioavailability of the delayed-release tablet was larger than anticipated, suggesting that administering the delayed-release tablet with food enhances absorption.
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Jean SS, Yang HJ, Hsieh PC, Huang YT, Ko WC, Hsueh PR. In Vitro Susceptibilities of Worldwide Isolates of Intrapulmonary Aspergillus Species and Important Candida Species in Sterile Body Sites against Important Antifungals: Data from the Antimicrobial Testing Leadership and Surveillance Program, 2017-2020. Microbiol Spectr 2022; 10:e0296522. [PMID: 36314941 PMCID: PMC9769544 DOI: 10.1128/spectrum.02965-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
To understand the changes of resistance in clinically commonly encountered fungi, we used the Antimicrobial Testing Leadership and Surveillance (ATLAS) database to explore in vitro antifungal susceptibilities against clinically important isolates of Aspergillus and Candida species (collected from intrapulmonary and sterile body areas, respectively). We applied the CLSI antifungal 2020 and the EUCAST antifungal 2020 guidelines. From 2017 to 2020, isolates of intrapulmonary Aspergillus fumigatus (n = 660), Aspergillus niger (n = 107), Aspergillus flavus (n = 96), Aspergillus terreus (n = 40), and Aspergillus nidulans species complex (n = 26) and sterile site-originated isolates of Candida albicans (n = 1,810), Candida glabrata (n = 894), Candida krusei (n = 120), Candida dubliniensis (n = 107), Candida lusitaniae (n = 82), Candida guilliermondii (n = 28), and Candida auris (n = 7) were enrolled in this study. Using the EUCAST 2020 breakpoints, it was demonstrated that amphotericin B and posaconazole displayed poor in vitro susceptibility rates against A. fumigatus isolates (<50% and 18.9%, respectively). In contrast, isavuconazole and itraconazole showed high in vitro potency against most Aspergillus isolates (>92%). Most intrapulmonary Aspergillus isolates exhibited MICs of ≤0.06 μg/mL to anidulafungin. Furthermore, intrapulmonary A. fumigatus isolates collected from Italy and the United Kingdom exhibited lower in vitro susceptibility to isavuconazole (72.2% and 69%, respectively) than those in the remaining ATLAS participant countries (>85%). Higher isavuconazole MIC90s against C. auris and C. guilliermondii (1 and 4 μg/mL, respectively) were observed compared to the other five Candida species. Despite the aforementioned MICs and susceptibilities against fungi, research needs to consider the pharmacokinetic (PK) profiles, pharmacodynamic (PD) parameters, and clinical treatment experience with antifungals against specific Aspergillus species. IMPORTANCE In addition to monitoring the antifungal susceptibilities of clinically important fungi, reviewing the PK/PD indices and the clinical therapy experience of antifungals under evaluation are important to guide an appropriate antifungal prescription. The efficacies of liposomal amphotericin B complex and anidulafungin for the treatment of pulmonary aspergillosis caused by different Aspergillus species need to be periodically evaluated in the future.
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Affiliation(s)
- Shio-Shin Jean
- Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
- Department of Pharmacy, College of Pharmacy and Health Care, Tajen University, Pingtung, Taiwan
- Department of Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Hung-Jen Yang
- Department of Family Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Po-Chuen Hsieh
- Department of Pharmacy, College of Pharmacy and Health Care, Tajen University, Pingtung, Taiwan
| | - Yu-Tsung Huang
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chien Ko
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Laboratory Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
- Ph.D Program for Aging, School of Medicine, China Medical University, Taichung, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
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Prayag PS, Panchakshari SP, Mahalle NP, Dhupad S, Patwardhan SA, Naik SS, Narawade S, Melinkeri S, Prayag AP. Factors associated with subtherapeutic levels of oral posaconazole tablet- a detailed analysis from a tertiary care center in India. Int J Infect Dis 2022; 124:76-80. [PMID: 36089153 DOI: 10.1016/j.ijid.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/30/2022] [Accepted: 09/03/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Posaconazole is a broad spectrum triazole antifungal with activity against various clinically important fungi. The delayed release (DR) tablet of posaconazole has been shown to have a superior pharmacokinetic profile in comparison with the oral suspension. METHODS We retrospectively analyzed the factors associated with posaconazole levels < 1.25 μg/ml in 164 patients receiving the DR tablet for therapeutic purposes. RESULTS Of the 164 patients, 53 (32.3%) showed subtherapeutic trough levels of posaconazole. The use of proton pump inhibitors (PPIs) (95% CI: 1.41 - 3.91; p value = 0.028) and the presence of diarrhea (95% CI: 1.95 - 6.93; p value = 0.001) were significantly associated with subtherapeutic levels. Thirteen of the 21 patients receiving posaconazole tablets via the nasogastric (NG) tube had therapeutic levels. CONCLUSION This is the largest study from India analyzing factors associated with subtherapeutic levels of the DR tablet of posaconazole. These findings reinforce the importance of therapeutic drug monitoring. Unlike in previous studies, obesity and hypoalbuminemia were not found to be significant factors in our settings. The use of PPIs and diarrhea remained significant factors as found in previous studies. Administering the DR tablet of posaconazole via the NG tube may be a viable option.
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Affiliation(s)
- Parikshit S Prayag
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, India.
| | | | - Namita P Mahalle
- Department of Biochemistry, Deenanath Mangeshkar Hospital, Pune, India
| | - Surabhi Dhupad
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, India
| | | | - Sadanand S Naik
- Department of Biochemistry, Deenanath Mangeshkar Hospital, Pune, India
| | - Sharwari Narawade
- Department of Biochemistry, Deenanath Mangeshkar Hospital, Pune, India
| | - Sameer Melinkeri
- Department of Clinical Hematology, Deenanath Mangeshkar Hospital, Pune, India
| | - Amrita P Prayag
- Department of In-house research, Deenanath Mangeshkar Hospital, Pune, India
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7
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Resendiz-Sharpe A, da Silva RP, Geib E, Vanderbeke L, Seldeslachts L, Hupko C, Brock M, Lagrou K, Vande Velde G. Longitudinal multimodal imaging-compatible mouse model of triazole-sensitive and -resistant invasive pulmonary aspergillosis. Dis Model Mech 2022; 15:274857. [PMID: 35352801 PMCID: PMC8990085 DOI: 10.1242/dmm.049165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 01/09/2022] [Indexed: 12/18/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) caused by the mold Aspergillus fumigatus is one of the most important life-threatening infections in immunocompromised patients. The alarming increase of isolates resistant to the first-line recommended antifungal therapy urges more insights into triazole-resistant A. fumigatus infections. In this study, we systematically optimized a longitudinal multimodal imaging-compatible neutropenic mouse model of IPA. Reproducible rates of pulmonary infection were achieved through immunosuppression (sustained neutropenia) with 150 mg/kg cyclophosphamide at day −4, −1 and 2, and an orotracheal inoculation route in both sexes. Furthermore, increased sensitivity of in vivo bioluminescence imaging for fungal burden detection, as early as the day after infection, was achieved by optimizing luciferin dosing and through engineering isogenic red-shifted bioluminescent A. fumigatus strains, one wild type and two triazole-resistant mutants. We successfully tested appropriate and inappropriate antifungal treatment scenarios in vivo with our optimized multimodal imaging strategy, according to the in vitro susceptibility of our luminescent fungal strains. Therefore, we provide novel essential mouse models with sensitive imaging tools for investigating IPA development and therapy in triazole-susceptible and triazole-resistant scenarios. Summary: A novel reproducible longitudinal multimodal imaging-compatible neutropenic mouse model of invasive pulmonary aspergillosis provides increased early fungal detection through novel red-shifted luciferase-expressing triazole-susceptible and -resistant Aspergillus fumigatus strains, and boosted bioluminescence.
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Affiliation(s)
- Agustin Resendiz-Sharpe
- Laboratory of Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit (KU) Leuven, 3000 Leuven, Belgium
| | - Roberta Peres da Silva
- Fungal Biology Group, School of Life Sciences, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Elena Geib
- Fungal Biology Group, School of Life Sciences, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Lore Vanderbeke
- Laboratory of Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit (KU) Leuven, 3000 Leuven, Belgium
| | - Laura Seldeslachts
- Department of Imaging and Pathology, Biomedical MRI unit/MoSAIC, KU Leuven, 3000 Leuven, Belgium
| | - Charlien Hupko
- Laboratory of Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit (KU) Leuven, 3000 Leuven, Belgium
| | - Matthias Brock
- Fungal Biology Group, School of Life Sciences, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Katrien Lagrou
- Laboratory of Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit (KU) Leuven, 3000 Leuven, Belgium.,Department of Laboratory Medicine and National Reference Centre for Mycosis, Excellence Centre for Medical Mycology (ECMM), University Hospitals Leuven, 3000 Leuven, Belgium
| | - Greetje Vande Velde
- Department of Imaging and Pathology, Biomedical MRI unit/MoSAIC, KU Leuven, 3000 Leuven, Belgium
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Dow G, Smith B. Tafenoquine exhibits broad spectrum antifungal activity at clinically relevant concentrations in vitro and decreases lung fungal burden in an invasive pulmonary model of rhizopus in vivo. New Microbes New Infect 2022; 45:100964. [PMID: 35284080 PMCID: PMC8913336 DOI: 10.1016/j.nmni.2022.100964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 01/23/2022] [Accepted: 01/28/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- G. Dow
- Corresponding author: Dow G.
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9
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Arastehfar A, Carvalho A, Houbraken J, Lombardi L, Garcia-Rubio R, Jenks J, Rivero-Menendez O, Aljohani R, Jacobsen I, Berman J, Osherov N, Hedayati M, Ilkit M, Armstrong-James D, Gabaldón T, Meletiadis J, Kostrzewa M, Pan W, Lass-Flörl C, Perlin D, Hoenigl M. Aspergillus fumigatus and aspergillosis: From basics to clinics. Stud Mycol 2021; 100:100115. [PMID: 34035866 PMCID: PMC8131930 DOI: 10.1016/j.simyco.2021.100115] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The airborne fungus Aspergillus fumigatus poses a serious health threat to humans by causing numerous invasive infections and a notable mortality in humans, especially in immunocompromised patients. Mould-active azoles are the frontline therapeutics employed to treat aspergillosis. The global emergence of azole-resistant A. fumigatus isolates in clinic and environment, however, notoriously limits the therapeutic options of mould-active antifungals and potentially can be attributed to a mortality rate reaching up to 100 %. Although specific mutations in CYP 51A are the main cause of azole resistance, there is a new wave of azole-resistant isolates with wild-type CYP 51A genotype challenging the efficacy of the current diagnostic tools. Therefore, applications of whole-genome sequencing are increasingly gaining popularity to overcome such challenges. Prominent echinocandin tolerance, as well as liver and kidney toxicity posed by amphotericin B, necessitate a continuous quest for novel antifungal drugs to combat emerging azole-resistant A. fumigatus isolates. Animal models and the tools used for genetic engineering require further refinement to facilitate a better understanding about the resistance mechanisms, virulence, and immune reactions orchestrated against A. fumigatus. This review paper comprehensively discusses the current clinical challenges caused by A. fumigatus and provides insights on how to address them.
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Affiliation(s)
- A. Arastehfar
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - A. Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - J. Houbraken
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | - L. Lombardi
- UCD Conway Institute and School of Medicine, University College Dublin, Dublin 4, Ireland
| | - R. Garcia-Rubio
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - J.D. Jenks
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA, 92093, USA
| | - O. Rivero-Menendez
- Medical Mycology Reference Laboratory, National Center for Microbiology, Instituto de Salud Carlos III, Madrid, 28222, Spain
| | - R. Aljohani
- Department of Infectious Diseases, Imperial College London, London, UK
| | - I.D. Jacobsen
- Department of Microbial Pathogenicity Mechanisms, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
- Institute for Microbiology, Friedrich Schiller University, Jena, Germany
| | - J. Berman
- Research Group Microbial Immunology, Leibniz Institute for Natural Product Research and Infection Biology—Hans Knöll Institute, Jena, Germany
| | - N. Osherov
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine Ramat-Aviv, Tel-Aviv, 69978, Israel
| | - M.T. Hedayati
- Invasive Fungi Research Center/Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - M. Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, Çukurova University, 01330, Adana, Turkey
| | | | - T. Gabaldón
- Life Sciences Programme, Supercomputing Center (BSC-CNS), Jordi Girona, Barcelona, 08034, Spain
- Mechanisms of Disease Programme, Institute for Research in Biomedicine (IRB), Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Pg. Lluís Companys 23, 08010, Barcelona, Spain
| | - J. Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - W. Pan
- Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China
| | - C. Lass-Flörl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - D.S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, 07110, USA
| | - M. Hoenigl
- Department of Medicine, University of California San Diego, San Diego, CA, 92103, USA
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036, Graz, Austria
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
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10
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Mueller SW, Kedzior SK, Miller MA, Reynolds PM, Kiser TH, Krsak M, Molina KC. An overview of current and emerging antifungal pharmacotherapy for invasive fungal infections. Expert Opin Pharmacother 2021; 22:1355-1371. [PMID: 33878996 DOI: 10.1080/14656566.2021.1892075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Invasive fungal infections (IFIs) remain a significant cause of morbidity and mortality despite significant advancements in currently available therapy. With a flush pipeline of investigational antifungals, the clinician must identify appropriate roles of currently available therapies, potential advantages of emerging antifungals, and shortcomings in the evolving clinical evidence.Areas covered: Standard and developing treatment approaches for IFIs with currently available antifungals are summarized with a focus on invasive candidiasis and invasive aspergillosis. Emerging investigational antifungals are discussed in depth, including mechanisms of action, fungal activity, clinical evidence, and ongoing research. An opinion on the impact and potential role of therapy for emerging antifungals of interest is also provided.Expert opinion: Despite advances and clinical studies optimizing antifungal use, current therapies fall short in preventing IFI morbidity and mortality. Further optimization of currently available antifungals may improve outcomes; however, novel agents are required for historically difficult-to-treat infections, transitions to oral treatment, minimizing adverse drug effects, decreasing drug interactions, and ultimately improving patient quality of life. Emerging antifungals may positively revolutionize the treatment of IFIs.
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Affiliation(s)
- Scott W Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Sonya K Kedzior
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Matthew A Miller
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Martin Krsak
- Department of Medicine, Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kyle C Molina
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
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Ukai Y, Nishiyama Y, Okazaki K, Maki H, Naito A. A highly sensitive and specific method to evaluate viable fungal burden of Aspergillus fumigatus in mice by RT-qPCR for 18S ribosomal RNA. J Microbiol Methods 2021; 184:106214. [PMID: 33811935 DOI: 10.1016/j.mimet.2021.106214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
Potent fungicidal activity is one of the key factors of antifungals to overcome invasive pulmonary aspergillosis (IPA). To date, quantification of Aspergillus DNA in the lungs and galactomannan (GM) in serum or bronchoalveolar lavage fluid have been developed as general methods for measuring fungal burden in IPA animal models. However, GM quantification is not supposed to be a suitable method for precise evaluation of the fungicidal effects of antifungals, because killed Aspergillus hyphae can release GM for a certain period until they are eliminated by the host. Therefore, in terms of detecting viable fungal burden of Aspergillus, quantification of Aspergillus DNA has been thought to be a suitable method. Here, to obtain a method with much higher sensitivity, we applied reverse transcription quantitative PCR (RT-qPCR) for A. fumigatus 18S ribosomal RNA to measure the viable fungal burden in murine IPA models. Prior to in vivo tests, we confirmed that the sensitivity of 18S rRNA was nearly 50-fold higher than that of 18S ribosomal DNA in vitro. This highly sensitive method made it possible to evaluate the fungicidal effects of antifungals in a low-inoculation murine IPA model. In this model, single administrations of higher doses of voriconazole and posaconazole, which have fungicidal activity, were able to display fungicidal effects with ≥1 log10 reductions by 18S rRNA quantification, whereas significant reductions in serum GM were not observed. These results suggest that 18S rRNA quantification is a powerful tool for screening novel antifungals with potent fungicidal activity only after a single administration.
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Affiliation(s)
- Yuuta Ukai
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Osaka, Japan; Research Area for Anti-infectious Drug Efficacy Evaluation, Shionogi TechnoAdvance Research Co., Ltd., Osaka, Japan.
| | - Yuri Nishiyama
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Osaka, Japan
| | - Kenichi Okazaki
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Osaka, Japan
| | - Hideki Maki
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Osaka, Japan
| | - Akira Naito
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Osaka, Japan
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Rayner CR, Smith PF, Andes D, Andrews K, Derendorf H, Friberg LE, Hanna D, Lepak A, Mills E, Polasek TM, Roberts JA, Schuck V, Shelton MJ, Wesche D, Rowland‐Yeo K. Model-Informed Drug Development for Anti-Infectives: State of the Art and Future. Clin Pharmacol Ther 2021; 109:867-891. [PMID: 33555032 PMCID: PMC8014105 DOI: 10.1002/cpt.2198] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/05/2021] [Indexed: 12/13/2022]
Abstract
Model-informed drug development (MIDD) has a long and rich history in infectious diseases. This review describes foundational principles of translational anti-infective pharmacology, including choice of appropriate measures of exposure and pharmacodynamic (PD) measures, patient subpopulations, and drug-drug interactions. Examples are presented for state-of-the-art, empiric, mechanistic, interdisciplinary, and real-world evidence MIDD applications in the development of antibacterials (review of minimum inhibitory concentration-based models, mechanism-based pharmacokinetic/PD (PK/PD) models, PK/PD models of resistance, and immune response), antifungals, antivirals, drugs for the treatment of global health infectious diseases, and medical countermeasures. The degree of adoption of MIDD practices across the infectious diseases field is also summarized. The future application of MIDD in infectious diseases will progress along two planes; "depth" and "breadth" of MIDD methods. "MIDD depth" refers to deeper incorporation of the specific pathogen biology and intrinsic and acquired-resistance mechanisms; host factors, such as immunologic response and infection site, to enable deeper interrogation of pharmacological impact on pathogen clearance; clinical outcome and emergence of resistance from a pathogen; and patient and population perspective. In particular, improved early assessment of the emergence of resistance potential will become a greater focus in MIDD, as this is poorly mitigated by current development approaches. "MIDD breadth" refers to greater adoption of model-centered approaches to anti-infective development. Specifically, this means how various MIDD approaches and translational tools can be integrated or connected in a systematic way that supports decision making by key stakeholders (sponsors, regulators, and payers) across the entire development pathway.
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Affiliation(s)
- Craig R. Rayner
- CertaraPrincetonNew JerseyUSA
- Monash Institute of Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
| | | | - David Andes
- University of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Kayla Andrews
- Bill & Melinda Gates Medical Research InstituteCambridgeMassachusettsUSA
| | | | | | - Debra Hanna
- Bill & Melinda Gates FoundationSeattleWashingtonUSA
| | - Alex Lepak
- University of Wisconsin‐MadisonMadisonWisconsinUSA
| | | | - Thomas M. Polasek
- CertaraPrincetonNew JerseyUSA
- Centre for Medicines Use and SafetyMonash UniversityMelbourneVictoriaAustralia
- Department of Clinical PharmacologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jason A. Roberts
- Faculty of MedicineUniversity of Queensland Centre for Clinical ResearchThe University of QueenslandBrisbaneQueenslandAustralia
- Departments of Pharmacy and Intensive Care MedicineRoyal Brisbane and Women’s HospitalBrisbaneQueenslandAustralia
- Division of Anaesthesiology Critical Care Emergency and Pain MedicineNîmes University HospitalUniversity of MontpellierMontpellierFrance
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Garvey EP, Sharp AD, Warn PA, Yates CM, Atari M, Thomas S, Schotzinger RJ. The novel fungal CYP51 inhibitor VT-1598 displays classic dose-dependent antifungal activity in murine models of invasive aspergillosis. Med Mycol 2021; 58:505-513. [PMID: 32476008 DOI: 10.1093/mmy/myz092] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/11/2019] [Accepted: 08/21/2019] [Indexed: 01/18/2023] Open
Abstract
Aspergillus spp. infections remain a global concern, with ∼30% attributable mortality of invasive aspergillosis (IA). VT-1598 is a novel fungal CYP51 inhibitor designed for exquisite selectivity versus human CYP enzymes to achieve a maximal therapeutic index and therefore maximal antifungal efficacy. Previously, its broad-spectrum in vitro antifungal activity was reported. We report here the pharmacokinetics (PK) and pharmacodynamics (PD) of VT-1598 in neutropenic mouse models of IA. The plasma area-under-the-curve (AUC) of VT-1598 increased nearly linearly between 5 and 40 mg/kg after 5 days of QD administration (155 and 1033 μg*h/ml, respectively), with a further increase with 40 mg/kg BID dosing (1354 μg*h/ml). When A. fumigatus isolates with in vitro susceptibilities of 0.25 and 1.0 μg/ml were used in a disseminated IA model, VT-1598 treatment produced no decrease in kidney fungal burden at QD 10 mg/kg, intermediate decreases at QD 20 mg/kg and maximum or near maximum decreases at 40 mg/kg QD and BID. The PK/PD relationships of AUCfree/MIC for 1-log killing for the two strains were 5.1 and 1.6 h, respectively, similar to values reported for approved CYP51 inhibitors. In a survival study where animals were observed for 12 days after the last treatment, survival was 100% at the doses tested (20 and 40 mg/kg QD), and fungal burden remained suppressed even though drug wash-out was complete. Similar dose-dependent reductions in lung fungal burden were observed in a pulmonary model of IA. These data strongly support further exploration of VT-1598 for the treatment of this lethal mold infection.
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Affiliation(s)
- E P Garvey
- Viamet Pharmaceuticals, Inc., Durham, NC 27703
| | - A D Sharp
- Evotec UK Ltd., Macclesfield, England
| | - P A Warn
- Evotec UK Ltd., Macclesfield, England
| | - C M Yates
- Viamet Pharmaceuticals, Inc., Durham, NC 27703
| | - M Atari
- Cyprotex Discovery Ltd. Macclesfield, England
| | - S Thomas
- Cyprotex Discovery Ltd. Macclesfield, England
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Abstract
Posaconazole is typically used for preventing invasive yeast and mold infections such as invasive aspergillosis in high-risk immunocompromised patients. The oral suspension was the first released formulation and many pharmacokinetic and pharmacodynamic studies of this formulation have been published. Erratic absorption profiles associated with this formulation were widely reported. Posaconazole exposure was found to be significantly influenced by food and many gastrointestinal conditions, including pH and motility. As a result, low posaconazole plasma concentrations were obtained in large groups of patients. These issues of erratic absorption urged the development of the subsequently marketed delayed-release tablet, which proved to be associated with higher and more stable exposure profiles. Shortly thereafter, an intravenous formulation was released for patients who are not able to take oral formulations. Both new formulations require a loading dose on day 1 to achieve high posaconazole concentrations more quickly, which was not possible with the oral suspension. So far, there appears to be no evidence of increased toxicity correlated to the higher posaconazole exposure achieved with the regimen for these formulations. The higher systemic availability of posaconazole for the delayed-release tablet and intravenous formulation have resulted in these two formulations being preferable for both prophylaxis and treatment of invasive fungal disease. This review aimed to integrate the current knowledge on posaconazole pharmacokinetics, pharmacodynamics, major toxicity, existing resistance, clinical experience in special populations, and new therapeutic strategies in order to get a clear understanding of the clinical use of this drug.
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Lamoth F, Lewis RE, Kontoyiannis DP. Role and Interpretation of Antifungal Susceptibility Testing for the Management of Invasive Fungal Infections. J Fungi (Basel) 2020; 7:jof7010017. [PMID: 33396870 PMCID: PMC7823995 DOI: 10.3390/jof7010017] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/18/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022] Open
Abstract
Invasive fungal infections (IFIs) are associated with high mortality rates and timely appropriate antifungal therapy is essential for good outcomes. Emerging antifungal resistance among Candida and Aspergillus spp., the major causes of IFI, is concerning and has led to the increasing incorporation of in vitro antifungal susceptibility testing (AST) to guide clinical decisions. However, the interpretation of AST results and their contribution to management of IFIs remains a matter of debate. Specifically, the utility of AST is limited by the delay in obtaining results and the lack of pharmacodynamic correlation between minimal inhibitory concentration (MIC) values and clinical outcome, particularly for molds. Clinical breakpoints for Candida spp. have been substantially revised over time and appear to be reliable for the detection of azole and echinocandin resistance and for outcome prediction, especially for non-neutropenic patients with candidemia. However, data are lacking for neutropenic patients with invasive candidiasis and some non-albicans Candida spp. (notably emerging Candida auris). For Aspergillus spp., AST is not routinely performed, but may be indicated according to the epidemiological context in the setting of emerging azole resistance among A. fumigatus. For non-Aspergillus molds (e.g., Mucorales, Fusarium or Scedosporium spp.), AST is not routinely recommended as interpretive criteria are lacking and many confounders, mainly host factors, seem to play a predominant role in responses to antifungal therapy. This review provides an overview of the pre-clinical and clinical pharmacodynamic data, which constitute the rationale for the use and interpretation of AST testing of yeasts and molds in clinical practice.
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Affiliation(s)
- Frederic Lamoth
- Infectious Diseases Service and Institute of Microbiology, University Hospital of Lausanne, Lausanne University, 1011 Lausanne, Switzerland;
| | - Russell E. Lewis
- Clinic of Infectious Diseases, S’Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-792-6237; Fax: +1-713-745-6839
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16
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Zhang F, Zhao M, Braun DR, Ericksen SS, Piotrowski JS, Nelson J, Peng J, Ananiev GE, Chanana S, Barns K, Fossen J, Sanchez H, Chevrette MG, Guzei IA, Zhao C, Guo L, Tang W, Currie CR, Rajski SR, Audhya A, Andes DR, Bugni TS. A marine microbiome antifungal targets urgent-threat drug-resistant fungi. Science 2020; 370:974-978. [PMID: 33214279 PMCID: PMC7756952 DOI: 10.1126/science.abd6919] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/05/2020] [Indexed: 12/29/2022]
Abstract
New antifungal drugs are urgently needed to address the emergence and transcontinental spread of fungal infectious diseases, such as pandrug-resistant Candida auris. Leveraging the microbiomes of marine animals and cutting-edge metabolomics and genomic tools, we identified encouraging lead antifungal molecules with in vivo efficacy. The most promising lead, turbinmicin, displays potent in vitro and mouse-model efficacy toward multiple-drug-resistant fungal pathogens, exhibits a wide safety index, and functions through a fungal-specific mode of action, targeting Sec14 of the vesicular trafficking pathway. The efficacy, safety, and mode of action distinct from other antifungal drugs make turbinmicin a highly promising antifungal drug lead to help address devastating global fungal pathogens such as C. auris.
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Affiliation(s)
- Fan Zhang
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Miao Zhao
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Doug R Braun
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Spencer S Ericksen
- Small Molecule Screening Facility, University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | | | | | - Jian Peng
- Department of Computer Science, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Gene E Ananiev
- Small Molecule Screening Facility, University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Shaurya Chanana
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Kenneth Barns
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Jen Fossen
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Hiram Sanchez
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Marc G Chevrette
- Department of Genetics, University of Wisconsin-Madison, Madison, WI, USA
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI, USA
- Wisconsin Institute for Discovery and Department of Plant Pathology, University of Wisconsin-Madison, Madison, WI, USA
| | - Ilia A Guzei
- Department of Chemistry, University of Wisconsin-Madison, Madison, WI, USA
| | - Changgui Zhao
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Le Guo
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Weiping Tang
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Cameron R Currie
- Department of Genetics, University of Wisconsin-Madison, Madison, WI, USA
- Department of Bacteriology, University of Wisconsin-Madison, Madison, WI, USA
| | - Scott R Rajski
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA
| | - Anjon Audhya
- Department of Biomolecular Chemistry, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - David R Andes
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA.
| | - Tim S Bugni
- Pharmaceutical Sciences Division, University of Wisconsin-Madison, Madison, WI, USA.
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Modeling Invasive Aspergillosis: How Close Are Predicted Antifungal Targets? J Fungi (Basel) 2020; 6:jof6040198. [PMID: 33007839 PMCID: PMC7712059 DOI: 10.3390/jof6040198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
Animal model systems are a critical component of the process of discovery and development of new antifungal agents for treatment and prevention of invasive aspergillosis. The persistently neutropenic rabbit model of invasive pulmonary aspergillosis (IPA) has been a highly predictive system in identifying new antifungal agents for treatment and prevention of this frequently lethal infection. Since its initial development, the persistently neutropenic rabbit model of IPA has established a strong preclinical foundation for dosages, drug disposition, pharmacokinetics, safety, tolerability, and efficacy for deoxycholate amphotericin B, liposomal amphotericin B, amphotericin B lipid complex, amphotericin B colloidal dispersion, caspofungin, micafungin, anidulafungin, voriconazole, posaconazole, isavuconazole, and ibrexafungerp in treatment of patients with invasive aspergillosis. The findings of combination therapy with a mould-active triazole and an echinocandin in this rabbit model also predicted the outcome of the clinical trial for voriconazole plus anidulafungin for treatment of IPA. The plasma pharmacokinetic parameters and tissue disposition for most antifungal agents approximate those of humans in persistently neutropenic rabbits. Safety, particularly nephrotoxicity, has also been highly predictive in the rabbit model, as exemplified by the differential glomerular filtration rates observed in animals treated with deoxycholate amphotericin B, liposomal amphotericin B, amphotericin B lipid complex, and amphotericin B colloidal dispersion. A panel of validated outcome variables measures therapeutic outcome in the rabbit model: residual fungal burden, markers of organism-mediated pulmonary injury (lung weights and infarct scores), survival, and serum biomarkers. In selected antifungal studies, thoracic computerized tomography (CT) is also used with diagnostic imaging algorithms to measure therapeutic response of pulmonary infiltrates, which exhibit characteristic radiographic patterns, including nodules and halo signs. Further strengthening the predictive properties of the model, therapeutic response to successfully developed antifungal agents for treatment of IPA has been demonstrated over the past two decades by biomarkers of serum galactomannan and (1→3)-β-D-glucan with patterns of resolution, that closely mirror those documented responses in patients with IPA. The decision to move from laboratory to clinical trials should be predicated upon a portfolio of complementary and mutually validating preclinical laboratory animal models studies. Other model systems, including those in mice, rats, and guinea pigs, are also valuable tools in developing clinical protocols. Meticulous preclinical investigation of a candidate antifungal compound in a robust series of complementary laboratory animal models will optimize study design, de-risk clinical trials, and ensure tangible benefit to our most vulnerable immunocompromised patients with invasive aspergillosis.
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Rybak JM, Fortwendel JR, Rogers PD. Emerging threat of triazole-resistant Aspergillus fumigatus. J Antimicrob Chemother 2020; 74:835-842. [PMID: 30561652 DOI: 10.1093/jac/dky517] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Invasive aspergillosis is a leading cause of morbidity and mortality among immunocompromised populations and is predicted to cause more than 200 000 life-threatening infections each year. Aspergillus fumigatus is the most prevalent pathogen isolated from patients with invasive aspergillosis, accounting for more than 60% of all cases. Currently, the only antifungal agents available with consistent activity against A. fumigatus are the mould-active triazoles and amphotericin B, of which the triazoles commonly represent both front-line and salvage therapeutic options. Unfortunately, the treatment of infections caused by A. fumigatus has recently been further complicated by the global emergence of triazole resistance among both clinical and environmental isolates. Mutations in the A. fumigatus sterol-demethylase gene cyp51A, overexpression of cyp51A and overexpression of efflux pump genes are all known to contribute to resistance, yet much of the triazole resistance among A. fumigatus still remains unexplained. Also lacking is clinical experience with therapeutic options for the treatment of triazole-resistant A. fumigatus infections and mortality associated with these infections remains unacceptably high. Thus, further research is greatly needed to both better understand the emerging threat of triazole-resistant A. fumigatus and to develop novel therapeutic strategies to combat these resistant infections.
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Affiliation(s)
- Jeffrey M Rybak
- Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
| | - Jarrod R Fortwendel
- Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
| | - P David Rogers
- Department of Clinical Pharmacy and Translational Sciences, University of Tennessee Health Science Center, 881 Madison Avenue, Memphis, TN, USA
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Bustamante B, Illescas LR, Posadas A, Campos PE. Azole resistance among clinical isolates of Aspergillus fumigatus in Lima-Peru. Med Mycol 2020; 58:54-60. [PMID: 31329931 DOI: 10.1093/mmy/myz032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/05/2019] [Accepted: 03/13/2019] [Indexed: 11/13/2022] Open
Abstract
Azole resistance among Aspergillus fumigatus isolates, which is mainly related to mutations in the cyp51A gene, is a concern because it is rising, worldwide disseminated, and associated with treatment failure and death. Data on azole resistance of aspergillus from Latin American countries is very scarce and do not exist for Peru. Two hundred and seven Aspergillus clinical isolates collected prospectively underwent mycology and molecular testing for specie identification, and 143 isolates were confirmed as A. fumigatus sensu stricto (AFSS). All AFSS were tested for in vitro azole susceptibility, and resistant isolates underwent PCR amplification and sequencing of the whole cyp51A gene and its promoter. The in vitro susceptibility showed a minimal inhibitory concentration (MIC) range, MIC50 and MIC90 of 0.125 to >16, 0.25, and 0.5 μg/ml for itraconazole; 0.25 to 2, 0.5, and 0.5 μg/ml for voriconazole; and 0.003 to 1, 0.06, and 0.125 μg/ml for posaconazole. Three isolates (2%) showed resistance to itraconazole and exhibited different mutations of the cyp51A gene. One isolate harbored the mutation M220K, while a second one exhibited the G54 mutation plus a modification in the cyp51A gene promoter. The third isolate, from an azole naive patient, presented an integration of a 34-bp tandem repeat (TR34) in the promoter region of the gene and a substitution of leucine 98 by histidine (L98H). The three source patients had a diagnosis or suspicion of chronic pulmonary aspergillosis.
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Affiliation(s)
- Beatriz Bustamante
- Nacional Cayetano Heredia, Lima, Perú, and Instituto de Medicina Tropical Alexander von Humboldt-Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Andrés Posadas
- Unidad de Epidemiología Molecular-Instituto de Medicina Tropical Alexander von Humboldt-Universidad Peruana Cayetano Heredia, Lima, Peru
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Implications of Evolving and Emerging Pharmacokinetic-Pharmacodynamic Research for Triazoles and Echinocandins. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00391-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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21
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Novak AR, Bradley ME, Kiser TH, Mueller SW. Azole-resistant Aspergillus and Echinocandin-resistant Candida - What are the treatment options? CURRENT FUNGAL INFECTION REPORTS 2020; 14:141-152. [PMID: 32699568 DOI: 10.1007/s12281-020-00379-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review This review summarizes current treatment options for echinocandin-resistant Candida spp. (ERC) and azole-resistant Aspergillus fumigatus (ARAF), emphasizing recent in vitro/in vivo data, clinical reports, and consensus statements. Recent Findings Advances in ERC and ARAF treatment are limited to specific antifungal combinations and dose optimization but remain reliant on amphotericin products. Although novel antifungals may provide breakthroughs in the treatment of resistant fungi, these agents are not yet available. Early identification and appropriate treatment remain a paramount, albeit elusive, task. Summary When either ERC or ARAF are suspected or proven, amphotericin products remain the cornerstone of initial therapy. For ERC, azoles are de-escalation options for susceptible isolates in stable patients to avoid amphotericin toxicities. Although combination echinocandin with high-dose salvage posaconazole or isavuconazole may be attempted in ARAF, it requires careful consideration following patient stabilization. Future research defining optimal therapies and early identification of ERC and ARAF is of extreme importance.
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Affiliation(s)
- Alison R Novak
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Mary E Bradley
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Scott W Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
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22
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Stevens VM, Mueller SW, Reynolds PM, MacLaren R, Kiser TH. Extrapolating Antifungal Animal Data to Humans - Is it reliable? CURRENT FUNGAL INFECTION REPORTS 2020; 14:50-62. [PMID: 32201545 PMCID: PMC7083583 DOI: 10.1007/s12281-020-00370-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW This article aimed to review animal models of antifungals and identifies human literature to assess if the extrapolation of results is reliable. RECENT FINDINGS Animal studies have helped identify AUC/MIC targets for new drugs and formulations such as isavuconazole and delayed release posaconazole that have translated to successful outcomes in humans. Models have also been influential in the identification of possible combination therapies for the treatment of aspergillosis, such as voriconazole and echinocandins. However, challenges are endured with animal models when it comes to replicating the pharmacokinetics of humans which has been exemplified with the newest itraconazole formulation. Additionally, animal models have displayed a survival benefit with the use of iron chelators and amphotericin for mucormycosis which was not demonstrated in humans. SUMMARY Animal models have been a staple in the development and optimization of antifungal agents. They afford the ability to investigate uncommon diseases, such as invasive fungal infections, that would otherwise take years and many resources to complete. Although there are many benefits of animal models there are also shortcomings. This is why the reliability of extrapolating data from animal models to humans is often scrutinized.
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Affiliation(s)
- Victoria M Stevens
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Scott W Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
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Schauwvlieghe AFAD, Buil JB, Verweij PE, Hoek RAS, Cornelissen JJ, Blijlevens NMA, Henriet SSV, Rijnders BJA, Brüggemann RJM. High-dose posaconazole for azole-resistant aspergillosis and other difficult-to-treat mould infections. Mycoses 2019; 63:122-130. [PMID: 31660650 PMCID: PMC7003872 DOI: 10.1111/myc.13028] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022]
Abstract
Background Oral follow‐up therapy is problematic in moulds with reduced azole‐susceptibility, such as azole‐resistant Aspergillus fumigatus infection. Currently, only intravenous liposomal amphotericin B (L‐AmB) is advocated by guidelines for the treatment of azole‐resistant aspergillosis infections. Preclinical research indicates that high‐dose posaconazole (HD‐POS) might be a feasible option provided that high drug exposure (ie POS serum through levels >3 mg/L) can be achieved and is safe. Objectives To describe our experience with the use of oral HD‐POS as treatment strategies for patients infected with pathogens with a POS MIC close to the clinical breakpoint. Patients/Methods We review evidence supporting the use of HD‐POS and describe our experience on safety and efficacy in 16 patients. In addition, we describe the adverse events (AE) observed in 25 patients with POS concentrations at the higher end of the population distribution during treatment with the licensed dose. Results Sixteen patients were treated intentionally with HD‐POS for voriconazole‐resistant invasive aspergillosis (7/16), mucormycosis (4/16), salvage therapy for IA (4/16) and IA at a sanctuary site (spondylodiscitis) in 1. Grade 3‐4 AEs were observed in 6, and all of them were considered at least possibly related. Grade 3‐4 AEs were observed in 5 of the 25 patients with spontaneous high POS serum through levels considered at least possibly related using Naranjo scale. Conclusions High‐dose posaconazole is a treatment option if strict monitoring for both exposure and for AE is possible.
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Affiliation(s)
- Alexander F A D Schauwvlieghe
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.,Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Rogier A S Hoek
- Department of Pulmonary Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Jan J Cornelissen
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Stefanie S V Henriet
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Paediatric Infectious Diseases and Immunology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Roger J M Brüggemann
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
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24
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Increased Efficacy of Oral Fixed-Dose Combination of Amphotericin B and AHCC ® Natural Adjuvant against Aspergillosis. Pharmaceutics 2019; 11:pharmaceutics11090456. [PMID: 31484389 PMCID: PMC6781303 DOI: 10.3390/pharmaceutics11090456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/17/2019] [Accepted: 08/19/2019] [Indexed: 12/21/2022] Open
Abstract
Invasive pulmonary aspergillosis represents one of the most serious fungal infections among immunocompromised patients. In this study, we aimed to analyze the in vivo efficacy of prophylactic oral amphotericin B (AMB) encapsulated in modified chitosan-nanoparticles (Nanomerics’ Molecular Envelope Technology (MET)) supplemented with a standardized extract of cultured Lentinula edodes mycelia (AHCC®) in a murine model of pulmonary aspergillosis. We determined fungal burden and survival of mice and additionally, we carried out a cytokine analysis in an attempt to understand the immunomodulation of the extract. Our results evidenced equivalent efficacy between orally administered AMB-MET and the intravenous liposomal AMB marketed formulation. Addition of the AHCC® supplement significantly improved efficacy in terms of burden reduction and survival increase of both oral and intravenous AMB therapies compared to the untreated control group. Moreover, a protective effect of the extract was observed in terms of weight loss. Regarding the cytokine profiles, the Th1 immune response was stimulated in treated animals when compared to the control group. This response was marked by an enhancement in the MCP-1, GM-CSF, VEGF, RANTES and IL-17 levels and a decrease in the IL-6, a biomarker related to the severity of the infection.
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25
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Leelawattanachai P, Montakantikul P, Nosoongnoen W, Chayakulkeeree M. Pharmacokinetic/pharmacodynamic study of posaconazole delayed-release tablet in a patient with coexisting invasive aspergillosis and mucormycosis. Ther Clin Risk Manag 2019; 15:589-595. [PMID: 31114213 PMCID: PMC6497849 DOI: 10.2147/tcrm.s203625] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/30/2019] [Indexed: 11/24/2022] Open
Abstract
Limited information exists regarding the optimal dose of posaconazole delayed-release tablet for the treatment of invasive mold infection. Here, we report the case of a previously healthy 44-year-old Thai man who developed coexisting invasive pulmonary aspergillosis and mucormycosis following a car accident. He was treated with posaconazole delayed-release tablet. This report describes the pharmacokinetic/pharmacodynamic study, safety profile, and determination of the appropriate dosage of posaconazole delayed-release tablet in a patient with coexisting invasive aspergillosis and mucormycosis. Posaconazole exposure was analyzed by noncompartmental model. Ratio of area under the plasma concentration-time curve over the minimum inhibitory concentration (AUC/MIC) was applied to maximize the efficacy of posaconazole. The loading dose of 300 mg q 12 hrs was found to be potentially insufficient for achieving the AUC/MIC target for treatment of invasive mold infection with minimum inhibitory concentrations >0.01 mg/L. Early therapeutic drug monitoring to detect the drug concentration of posaconazole delayed-release tablet is necessary so that dosing adjustments can be made, as needed. In addition, a maintenance dose of either 400 or 300 mg once daily could achieve the AUC/MIC targets. These maintenance dosing regimens effectuated a successful clinical outcome with minimal adverse events.
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Affiliation(s)
- Pannee Leelawattanachai
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand.,Department of Pharmacy, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Preecha Montakantikul
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Wichit Nosoongnoen
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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26
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APX001 Pharmacokinetic/Pharmacodynamic Target Determination against Aspergillus fumigatus in an In Vivo Model of Invasive Pulmonary Aspergillosis. Antimicrob Agents Chemother 2019; 63:AAC.02372-18. [PMID: 30670426 DOI: 10.1128/aac.02372-18] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/15/2019] [Indexed: 12/26/2022] Open
Abstract
APX001, the prodrug of APX001A, is a first-in-class antifungal agent that has a potent activity against Aspergillus fumigatus The goal of current study was to determine the pharmacodynamic (PD) index and target of APX001 in an immunocompromised murine model of invasive pulmonary aspergillosis against 6 A. fumigatus isolates. Minimum effective concentration (MEC) values ranged from 0.03 to 0.06 mg/liter. Dose fractionation was performed against isolate AF293 using total doses of APX001 ranging from 81 to 768 mg/kg of body weight/day fractionated into every 3-, 6-, and 8-h regimens over a 96-h treatment duration. Efficacy was assessed by A. fumigatus quantitative PCR (qPCR) of conidial equivalents from lung homogenates. Nonlinear regression analysis using the Hill equation demonstrated that the 24-h area under the concentration-time curve (AUC)/MEC ratio was the pharmacokinetic (PK)/PD index that best correlated with efficacy (coefficient of determination [R 2] = 0.79). Treatment studies with the remaining strains utilized regimens of 40 to 1,536 mg/kg of APX001 administered every 3 h for a 96-h duration. Exposure-response relationships for all strains were similar, and the median free drug AUC/MEC PK/PD targets for stasis and 1-log-kill endpoints were 47.6 and 89.4, respectively. The present studies demonstrated in vitro and in vivo APX001A/APX001 potency against A. fumigatus These results have potential relevance for clinical dose selection and evaluation of susceptibility breakpoints.
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27
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Espinel-Ingroff A, Sanguinetti M, Posteraro B. Usefulness of Antifungal Reference In Vitro Susceptibility Tests as a Guide in Therapeutic Management. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-0336-2] [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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28
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Blickensdorf M, Timme S, Figge MT. Comparative Assessment of Aspergillosis by Virtual Infection Modeling in Murine and Human Lung. Front Immunol 2019; 10:142. [PMID: 30804941 PMCID: PMC6370618 DOI: 10.3389/fimmu.2019.00142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/17/2019] [Indexed: 01/01/2023] Open
Abstract
Aspergillus fumigatus is a ubiquitous opportunistic fungal pathogen that can cause severe infections in immunocompromised patients. Conidia that reach the lower respiratory tract are confronted with alveolar macrophages, which are the resident phagocytic cells, constituting the first line of defense. If not efficiently removed in time, A. fumigatus conidia can germinate causing severe infections associated with high mortality rates. Mice are the most extensively used model organism in research on A. fumigatus infections. However, in addition to structural differences in the lung physiology of mice and the human host, applied infection doses in animal experiments are typically orders of magnitude larger compared to the daily inhalation doses of humans. The influence of these factors, which must be taken into account in a quantitative comparison and knowledge transfer from mice to humans, is difficult to measure since in vivo live cell imaging of the infection dynamics under physiological conditions is currently not possible. In the present study, we compare A. fumigatus infection in mice and humans by virtual infection modeling using a hybrid agent-based model that accounts for the respective lung physiology and the impact of a wide range of infection doses on the spatial infection dynamics. Our computer simulations enable comparative quantification of A. fumigatus infection clearance in the two hosts to elucidate (i) the complex interplay between alveolar morphometry and the fungal burden and (ii) the dynamics of infection clearance, which for realistic fungal burdens is found to be more efficiently realized in mice compared to humans.
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Affiliation(s)
- Marco Blickensdorf
- Research Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
- Faculty of Biological Sciences, Friedrich Schiller University of Jena, Jena, Germany
| | - Sandra Timme
- Research Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
- Faculty of Biological Sciences, Friedrich Schiller University of Jena, Jena, Germany
| | - Marc Thilo Figge
- Research Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knöll Institute, Jena, Germany
- Faculty of Biological Sciences, Friedrich Schiller University of Jena, Jena, Germany
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29
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Buil JB, Hagen F, Chowdhary A, Verweij PE, Meis JF. Itraconazole, Voriconazole, and Posaconazole CLSI MIC Distributions for Wild-Type and Azole-Resistant Aspergillus fumigatus Isolates. J Fungi (Basel) 2018; 4:E103. [PMID: 30158470 PMCID: PMC6162657 DOI: 10.3390/jof4030103] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/17/2022] Open
Abstract
Azole resistance in Aspergillus fumigatus is most frequently conferred by mutations in the cyp51A gene encoding 14α-sterol demethylases. TR34/L98H and TR46/Y121F/T289A are the two most common mutations associated with environmental resistance selection. We studied the minimal inhibitory concentration (MIC) distribution of clinical A. fumigatus isolates to characterize the Clinical and Laboratory Standards Institute (CLSI) susceptibility profiles of isolates with the wild-type (WT) cyp51A genotype, and isolates with the TR34/L98H and TR46/Y121F/T289A cyp51A mutations. Susceptibility testing was performed according to CLSI M38-A2. The MICs of 363 A. fumigatus isolates were used in this study. Based on the CLSI epidemiological cut-off values (ECVs), 141 isolates were phenotypically non-WT and 222 isolates had a phenotypically WT susceptibility. All isolates with the TR34/L98H mutation had an itraconazole MIC > 1 mg/L which is above the CLSI ECV. Eighty-six of 89 (97%) isolates with the TR34/L98H mutation had voriconazole and posaconazole MICs above the CLSI ECV, i.e., MICs of 1 and 0.25 mg/L, respectively. The isolates with a TR46/Y121F/T289A mutation showed a different phenotype. All 37 isolates with a TR46/Y121F/T289A mutation had a voriconazole MIC above the CLSI ECV, while 28/37 (76%) isolates had an itraconazole MIC > 1 mg/L. Interestingly, only 13 of 37 (35%) isolates had a posaconazole MIC > 0.25 mg/L.
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Affiliation(s)
- Jochem B Buil
- Department of Medical Microbiology, Radboud University Medical Center, 6525 Nijmegen, The Netherlands.
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6532 Nijmegen, The Netherlands.
- Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, 3584 Utrecht, The Netherlands.
| | - Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi 110021, India.
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, 6525 Nijmegen, The Netherlands.
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
| | - Jacques F Meis
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 Nijmegen, The Netherlands.
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, 6532 Nijmegen, The Netherlands.
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30
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Sime FB, Stuart J, Butler J, Starr T, Wallis SC, Pandey S, Lipman J, Roberts JA. A pharmacokinetic case study of intravenous posaconazole in a critically ill patient with hypoalbuminaemia receiving continuous venovenous haemodiafiltration. Int J Antimicrob Agents 2018; 52:506-509. [PMID: 30031203 DOI: 10.1016/j.ijantimicag.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/27/2018] [Accepted: 07/07/2018] [Indexed: 11/18/2022]
Abstract
This article reports a pharmacokinetic case study of intravenous posaconazole in a 49-year-old male patient with intra-abdominal sepsis and hypoalbuminaemia receiving continuous venovenous haemodiafiltration. Concentration-time data following 300 mg intravenous posaconazole was analysed using a population pharmacokinetics approach. The 300-mg intravenous dose appears to be adequate for the treatment of yeast infections; however, for the treatment of invasive aspergillosis in isolated cases of critically ill patients with hypoalbuminaemia, the current dosing may not achieve desired exposure, although steady state exposure data are needed.
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Affiliation(s)
- Fekade B Sime
- School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
| | - Janine Stuart
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jenie Butler
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Therese Starr
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Saurabh Pandey
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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31
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Desoubeaux G, Cray C. Animal Models of Aspergillosis. Comp Med 2018; 68:109-123. [PMID: 29663936 PMCID: PMC5897967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/29/2017] [Accepted: 07/09/2017] [Indexed: 06/08/2023]
Abstract
Aspergillosis is an airborne fungal disease caused by Aspergillus spp., a group of ubiquitous molds. This disease causes high morbidity and mortality in both humans and animals. The growing importance of this infection over recent decades has created a need for practical and reproducible models of aspergillosis. The use of laboratory animals provides a platform to understand fungal virulence and pathophysiology, assess diagnostic tools, and evaluate new antifungal drugs. In this review, we describe the fungus, various Aspergillus-related diseases in humans and animals and various experimental animal models. Overall, we highlight the advantages and limitations of the animal models, the experimental variables that can affect the course of the disease and the reproducibility of infection, and the critical need for standardization of the species, immunosuppressive drugs, route of infection, and diagnostic criteria to use.
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Affiliation(s)
- Guillaume Desoubeaux
- Department of Pathology and Laboratory Medicine, Division of Comparative Pathology, Miller School of Medicine, University of Miami, Miami, Florida, USA; Parasitology-Mycology Service, Tropical Medicine Program, University Hospital of Tours, CEPR - Inserm U1100, Medical Faculty, François Rabelais University, Tours, France
| | - Carolyn Cray
- Department of Pathology and Laboratory Medicine, Division of Comparative Pathology, Miller School of Medicine, University of Miami, Miami, Florida, USA.,
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32
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Posaconazole MIC Distributions for Aspergillus fumigatus Species Complex by Four Methods: Impact of cyp51A Mutations on Estimation of Epidemiological Cutoff Values. Antimicrob Agents Chemother 2018; 62:AAC.01916-17. [PMID: 29437624 DOI: 10.1128/aac.01916-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/28/2018] [Indexed: 12/27/2022] Open
Abstract
Estimating epidemiological cutoff endpoints (ECVs/ECOFFS) may be hindered by the overlap of MICs for mutant and nonmutant strains (strains harboring or not harboring mutations, respectively). Posaconazole MIC distributions for the Aspergillus fumigatus species complex were collected from 26 laboratories (in Australia, Canada, Europe, India, South and North America, and Taiwan) and published studies. Distributions that fulfilled CLSI criteria were pooled and ECVs were estimated. The sensitivity of three ECV analytical techniques (the ECOFFinder, normalized resistance interpretation [NRI], derivatization methods) to the inclusion of MICs for mutants was examined for three susceptibility testing methods (the CLSI, EUCAST, and Etest methods). The totals of posaconazole MICs for nonmutant isolates (isolates with no known cyp51A mutations) and mutant A. fumigatus isolates were as follows: by the CLSI method, 2,223 and 274, respectively; by the EUCAST method, 556 and 52, respectively; and by Etest, 1,365 and 29, respectively. MICs for 381 isolates with unknown mutational status were also evaluated with the Sensititre YeastOne system (SYO). We observed an overlap in posaconazole MICs among nonmutants and cyp51A mutants. At the commonly chosen percentage of the modeled wild-type population (97.5%), almost all ECVs remained the same when the MICs for nonmutant and mutant distributions were merged: ECOFFinder ECVs, 0.5 μg/ml for the CLSI method and 0.25 μg/ml for the EUCAST method and Etest; NRI ECVs, 0.5 μg/ml for all three methods. However, the ECOFFinder ECV for 95% of the nonmutant population by the CLSI method was 0.25 μg/ml. The tentative ECOFFinder ECV with SYO was 0.06 μg/ml (data from 3/8 laboratories). Derivatization ECVs with or without mutant inclusion were either 0.25 μg/ml (CLSI, EUCAST, Etest) or 0.06 μg/ml (SYO). It appears that ECV analytical techniques may not be vulnerable to overlap between presumptive wild-type isolates and cyp51A mutants when up to 11.6% of the estimated wild-type population includes mutants.
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33
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Lewis RE, Verweij PE. Animal Models for Studying Triazole Resistance in Aspergillus fumigatus. J Infect Dis 2017; 216:S466-S473. [PMID: 28911046 DOI: 10.1093/infdis/jix222] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Infections caused by triazole-resistant Aspergillus fumigatus are associated with a higher probability of treatment failure and mortality. Because clinical experience in managing these infections is still limited, mouse models of invasive aspergillosis fulfill a critical void for studying treatment regimens designed to overcome resistance. The type of immunosuppression, the route of infection, the timing of antifungal administration, and the end points used to assess antifungal activity affect the interpretation of data from these models. Nevertheless, these models provide important insights that help guide treatment decisions in patients with triazole-resistant invasive aspergillosis. Animal models confirmed that a high triazole minimal inhibitory concentration corresponded with triazole treatment failure and that the efficacy of other classes of drugs, such as the polyenes and echinocandins, was not affected by the presence of triazole resistance mutations. Furthermore, the feasibility of triazole dose escalation, combination therapy, and prophylaxis were explored as strategies to overcome resistance.
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Affiliation(s)
- Russell E Lewis
- Infectious Diseases Unit, S. Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center.,Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, the Netherlands
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34
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Isavuconazole: Has It Saved Us? A Pharmacotherapy Review and Update on Clinical Experience. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2017. [DOI: 10.1007/s40506-017-0133-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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35
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Desoubeaux G, Cray C. Rodent Models of Invasive Aspergillosis due to Aspergillus fumigatus: Still a Long Path toward Standardization. Front Microbiol 2017; 8:841. [PMID: 28559881 PMCID: PMC5432554 DOI: 10.3389/fmicb.2017.00841] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 04/24/2017] [Indexed: 01/09/2023] Open
Abstract
Invasive aspergillosis has been studied in laboratory by the means of plethora of distinct animal models. They were developed to address pathophysiology, therapy, diagnosis, or miscellaneous other concerns associated. However, there are great discrepancies regarding all the experimental variables of animal models, and a thorough focus on them is needed. This systematic review completed a comprehensive bibliographic analysis specifically-based on the technical features of rodent models infected with Aspergillus fumigatus. Out the 800 articles reviewed, it was shown that mice remained the preferred model (85.8% of the referenced reports), above rats (10.8%), and guinea pigs (3.8%). Three quarters of the models involved immunocompromised status, mainly by steroids (44.4%) and/or alkylating drugs (42.9%), but only 27.7% were reported to receive antibiotic prophylaxis to prevent from bacterial infection. Injection of spores (30.0%) and inhalation/deposition into respiratory airways (66.9%) were the most used routes for experimental inoculation. Overall, more than 230 distinct A. fumigatus strains were used in models. Of all the published studies, 18.4% did not mention usage of any diagnostic tool, like histopathology or mycological culture, to control correct implementation of the disease and to measure outcome. In light of these findings, a consensus discussion should be engaged to establish a minimum standardization, although this may not be consistently suitable for addressing all the specific aspects of invasive aspergillosis.
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Affiliation(s)
- Guillaume Desoubeaux
- Division of Comparative Pathology, Department of Pathology and Laboratory Medicine, Miller School of Medicine, University of MiamiMiami, FL, USA.,Service de Parasitologie-Mycologie-Médecine tropicale, Centre Hospitalier Universitaire de ToursTours, France.,Centre d'Etude des Pathologies Respiratoires (CEPR) Institut National de la Santé et de la Recherche Médicale U1100/Équipe 3, Université François-RabelaisTours, France
| | - Carolyn Cray
- Division of Comparative Pathology, Department of Pathology and Laboratory Medicine, Miller School of Medicine, University of MiamiMiami, FL, USA
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36
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Gonzalez JM, Rodriguez CA, Agudelo M, Zuluaga AF, Vesga O. Antifungal pharmacodynamics: Latin America's perspective. Braz J Infect Dis 2016; 21:79-87. [PMID: 27821250 PMCID: PMC9425464 DOI: 10.1016/j.bjid.2016.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/14/2016] [Accepted: 09/19/2016] [Indexed: 11/23/2022] Open
Abstract
The current increment of invasive fungal infections and the availability of new broad-spectrum antifungal agents has increased the use of these agents by non-expert practitioners, without an impact on mortality. To improve efficacy while minimizing prescription errors and to reduce the high monetary cost to the health systems, the principles of pharmacokinetics (PK) and pharmacodynamics (PD) are necessary. A systematic review of the PD of antifungals agents was performed aiming at the practicing physician without expertise in this field. The initial section of this review focuses on the general concepts of antimicrobial PD. In vitro studies, fungal susceptibility and antifungal serum concentrations are related with different doses and dosing schedules, determining the PD indices and the magnitude required to obtain a specific outcome. Herein the PD of the most used antifungal drug classes in Latin America (polyenes, azoles, and echinocandins) is discussed.
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Affiliation(s)
- Javier M Gonzalez
- Clinica CARDIO VID, Medellín, Colombia; Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia
| | - Carlos A Rodriguez
- Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia
| | - Maria Agudelo
- Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia; Hospital Universitario San Vicente Fundación, Unidad de Enfermedades Infecciosas, Medellín, Colombia
| | - Andres F Zuluaga
- Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia
| | - Omar Vesga
- Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia; Hospital Universitario San Vicente Fundación, Unidad de Enfermedades Infecciosas, Medellín, Colombia.
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37
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Galactomannan enzyme immunoassay and quantitative Real Time PCR as tools to evaluate the exposure and response in a rat model of aspergillosis after posaconazole prophylaxis. Enferm Infecc Microbiol Clin 2016; 34:571-576. [DOI: 10.1016/j.eimc.2015.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 11/10/2015] [Accepted: 11/14/2015] [Indexed: 11/18/2022]
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Cendejas-Bueno E, Forastiero A, Ruiz I, Mellado E, Gavaldà J, Gomez-Lopez A. Blood and tissue distribution of posaconazole in a rat model of invasive pulmonary aspergillosis. Diagn Microbiol Infect Dis 2016; 87:112-117. [PMID: 27889253 DOI: 10.1016/j.diagmicrobio.2016.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 09/08/2016] [Accepted: 10/05/2016] [Indexed: 12/31/2022]
Abstract
Posaconazole is the recommended prophylactic agent in patients at high risk of invasive fungal infection, since adequate drug levels seem to be reached in target sites despite the relatively low levels detected in blood. The objective of this study is to obtain pharmacokinetic (PK) information associated to blood and tissue distribution of posaconazole in an animal model of invasive pulmonary aspergillosis. The PK parameters in lung samples were systematically higher than in serum. After multiple-dose administration of posaconazole, a significant accumulation of the drug was evident in lung tissue. The PK behavior of posaconazole in this particular experimental model is similar to that observed in humans. Thus, we believe this model could be a valid tool to evaluate posaconazole exposure-response relationship.
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Affiliation(s)
- E Cendejas-Bueno
- Instituto de Salud Carlos III, Madrid, 28220, Spain; Clinical Microbiology Department, Hospital Universitario La Paz, Madrid, 28046, Spain
| | - A Forastiero
- Instituto de Salud Carlos III, Madrid, 28220, Spain
| | - I Ruiz
- Hospital Valld'Hebrón, Barcelona, 08035, Spain
| | - E Mellado
- Instituto de Salud Carlos III, Madrid, 28220, Spain
| | - J Gavaldà
- Hospital Valld'Hebrón, Barcelona, 08035, Spain
| | - A Gomez-Lopez
- Instituto de Salud Carlos III, Madrid, 28220, Spain.
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39
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Hope W, Drusano GL, Rex JH. Pharmacodynamics for antifungal drug development: an approach for acceleration, risk minimization and demonstration of causality. J Antimicrob Chemother 2016; 71:3008-3019. [PMID: 27494925 DOI: 10.1093/jac/dkw298] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The treatment of invasive fungal diseases constitutes a significant unmet medical need. There are relatively few antifungal agents in clinical development and a paucity of novel targets. Morbidity and mortality remain high and clinical outcomes are compromised by submaximal efficacy, emergence of drug resistance and drug-related toxicity. Thus, new antifungal agents are urgently required. A deep understanding of exposure-response relationships underpins the development of safe and effective clinical regimens of any therapeutic agent. Pharmacokinetics (PK) and pharmacodynamics (PD) is increasingly recognized as a vital tool in the development of new antimicrobial agents and maximizes the probability that the right dose will be studied the first time. There is currently no information or agreement as to what constitutes an adequate PK/PD package for the development of a new antifungal agent. This review provides a summary of the achievements of antifungal PK/PD for the treatment of invasive candidiasis, invasive aspergillosis and cryptococcal meningoencephalitis, and outlines the necessary components of a PK/PD package for a new antifungal agent. Such information is critical for the accelerated and efficient development of new agents and enables improved clinical outcomes to be secured.
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Affiliation(s)
| | | | - John H Rex
- AstraZeneca Pharmaceuticals, Waltham, MA, USA.,F2G Pharmaceuticals, Eccles, Cheshire, UK
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40
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Espinel-Ingroff A, Turnidge J. The role of epidemiological cutoff values (ECVs/ECOFFs) in antifungal susceptibility testing and interpretation for uncommon yeasts and moulds. Rev Iberoam Micol 2016; 33:63-75. [PMID: 27296911 DOI: 10.1016/j.riam.2016.04.001] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/07/2016] [Accepted: 04/18/2016] [Indexed: 12/01/2022] Open
Abstract
The role of antimicrobial susceptibility testing is to aid in selecting the best agent for the treatment of bacterial and fungal diseases. This has been best achieved by the setting of breakpoints by Clinical Laboratory Standards Institute (CLSI) for prevalent Candida spp. versus anidulafungin, caspofungin, micafungin, fluconazole, and voriconazole. The European Committee on Antimicrobial Susceptibility Testing (EUCAST) also has set breakpoints for prevalent and common Candida and Aspergillus species versus amphotericin B, itraconazole, and posaconazole. Recently, another interpretive category, the epidemiological cut off value, could aid in the early identification of strains with acquired resistance mechanisms. CLSI has postulated that epidemiological cut off values may, with due caution, aid physicians in managing mycosis by species where breakpoints are not available. This review provides (1) the criteria and statistical approach to establishing and estimating epidemiological cut off values (ECVs), (2) the role of the epidemiological cut off value in establishing breakpoints, (3) the potential role of epidemiological cut off values in clinical practice, (4) and the wide range of CLSI-based epidemiological cut off values reported in the literature as well as EUCAST and Sensititre Yeast One-ECVs. Additionally, we provide MIC/MEC (minimal inhibitory concentrations/minimum effective concentrations) ranges/modes of each pooled distribution used for epidemiological cut off value calculation. We focus on the epidemiological cut off value, the new interpretive endpoint that will identify the non-wild type strains (defined as potentially harboring resistance mechanisms). However, we emphasize that epidemiological cut off values will not categorize a fungal isolate as susceptible or resistant as breakpoints do, because the former do not account for the pharmacology of the antifungal agent or the findings from clinical outcome studies.
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Rybak JM, Marx KR, Nishimoto AT, Rogers PD. Isavuconazole: Pharmacology, Pharmacodynamics, and Current Clinical Experience with a New Triazole Antifungal Agent. Pharmacotherapy 2015; 35:1037-51. [DOI: 10.1002/phar.1652] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jeffrey M. Rybak
- Department of Clinical Pharmacy; University of Tennessee Health Science Center; Memphis Tennessee
| | - Kayleigh R. Marx
- Division of Pharmacy; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Andrew T. Nishimoto
- Department of Clinical Pharmacy; University of Tennessee Health Science Center; Memphis Tennessee
| | - P. David Rogers
- Department of Clinical Pharmacy; University of Tennessee Health Science Center; Memphis Tennessee
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42
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In Vivo Synergy of Amphotericin B plus Posaconazole in Murine Aspergillosis. Antimicrob Agents Chemother 2015; 60:296-300. [PMID: 26503653 DOI: 10.1128/aac.01462-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/18/2015] [Indexed: 11/20/2022] Open
Abstract
Aspergillus fumigatus is the main mold causing invasive fungal infection that shows high mortality rates. Therapeutic failure and the increase in drug resistance make it necessary to explore alternative treatments for this infection. We have evaluated the efficacy of amphotericin B at 0.8 mg/kg or 0.3 mg/kg of body weight combined with 40 mg/kg of posaconazole against three A. fumigatus isolates in a murine model of disseminated infection. The combination of the polyene and the azole led to a greater increase in survival and a significantly greater reduction in tissue burden than monotherapies.
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Forastiero A, Bernal-Martínez L, Mellado E, Cendejas E, Gomez-Lopez A. In vivo efficacy of voriconazole and posaconazole therapy in a novel invertebrate model of Aspergillus fumigatus infection. Int J Antimicrob Agents 2015; 46:511-7. [PMID: 26358971 DOI: 10.1016/j.ijantimicag.2015.07.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 06/05/2015] [Accepted: 07/07/2015] [Indexed: 02/05/2023]
Abstract
The emergence of azole resistance in Aspergillus fumigatus is a clinically important issue in the management of invasive aspergillosis as it could limit therapeutic options. Accurate measurement of in vitro antifungal activity in terms of minimum inhibitory concentration (MIC) is considered of clinical relevance and often gives useful therapeutic information for physicians. However, the lack of in vitro-in vivo correlation is frequent and the observed in vitro phenotype does not always correlate with the in vivo response. In this regard, a wild-type strain and five A. fumigatus cyp51A mutated strains showing different azole susceptibility profiles were used to investigate whether the greater wax moth (Galleria mellonella) is an alternative model to assess the in vivo efficacy of voriconazole and posaconazole. Administration of both azoles improved the survival of larvae infected with susceptible strains. However, those larvae infected with resistant strains did not respond to treatment. The phenotype observed in vitro was found to correlate with the efficacy observed in vivo. Moreover, using this in vivo model, the pharmacodynamic target predicting therapeutic success (AUC(0-24)/MIC) was in the same range as previously described, allowing the use of the G. mellonella model to predict the azole susceptibility profile of A. fumigatus strains.
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Affiliation(s)
- A Forastiero
- Mycology Reference Laboratory, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda-Pozuelo km 2, Majadahonda, 28220 Madrid, Spain
| | - L Bernal-Martínez
- Mycology Reference Laboratory, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda-Pozuelo km 2, Majadahonda, 28220 Madrid, Spain
| | - E Mellado
- Mycology Reference Laboratory, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda-Pozuelo km 2, Majadahonda, 28220 Madrid, Spain
| | - E Cendejas
- Mycology Reference Laboratory, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda-Pozuelo km 2, Majadahonda, 28220 Madrid, Spain
| | - A Gomez-Lopez
- Mycology Reference Laboratory, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Carretera Majadahonda-Pozuelo km 2, Majadahonda, 28220 Madrid, Spain.
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International expert opinion on the management of infection caused by azole-resistant Aspergillus fumigatus. Drug Resist Updat 2015; 21-22:30-40. [PMID: 26282594 DOI: 10.1016/j.drup.2015.08.001] [Citation(s) in RCA: 230] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An international expert panel was convened to deliberate the management of azole-resistant aspergillosis. In culture-positive cases, in vitro susceptibility testing should always be performed if antifungal therapy is intended. Different patterns of resistance are seen, with multi-azole and pan-azole resistance more common than resistance to a single triazole. In confirmed invasive pulmonary aspergillosis due to an azole-resistant Aspergillus, the experts recommended a switch from voriconazole to liposomal amphotericin B (L-AmB; Ambisome(®)). In regions with environmental resistance rates of ≥10%, a voriconazole-echinocandin combination or L-AmB were favoured as initial therapy. All experts recommended L-AmB as core therapy for central nervous system aspergillosis suspected to be due to an azole-resistant Aspergillus, and considered the addition of a second agent with the majority favouring flucytosine. Intravenous therapy with either micafungin or L-AmB given as either intermittent or continuous therapy was recommended for chronic pulmonary aspergillosis due to a pan-azole-resistant Aspergillus. Local and national surveillance with identification of clinical and environmental resistance patterns, rapid diagnostics, better quality clinical outcome data, and a greater understanding of the factors driving or minimising environmental resistance are areas where research is urgently needed, as well as the development of new oral agents outside the azole drug class.
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45
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Davis SA, Vincent BM, Endo MM, Whitesell L, Marchillo K, Andes DR, Lindquist S, Burke MD. Nontoxic antimicrobials that evade drug resistance. Nat Chem Biol 2015; 11:481-7. [PMID: 26030729 PMCID: PMC4472574 DOI: 10.1038/nchembio.1821] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 04/10/2015] [Indexed: 01/21/2023]
Abstract
Drugs that act more promiscuously provide fewer routes for the emergence of resistant mutants. But this benefit often comes at the cost of serious off-target and dose-limiting toxicities. The classic example is the antifungal amphotericin B (AmB), which has evaded resistance for more than half a century. We report dramatically less toxic amphotericins that nevertheless evade resistance. They are scalably accessed in just three steps from the natural product, and bind their target (the fungal sterol, ergosterol) with far greater selectivity than AmB. Hence, they are less toxic and far more effective in a mouse model of systemic candidiasis. Surprisingly, exhaustive efforts to select for mutants resistant to these more selective compounds revealed that they are just as impervious to resistance as AmB. Thus, highly selective cytocidal action and the evasion of resistance are not mutually exclusive, suggesting practical routes to the discovery of less toxic, resistance-evasive therapies.
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Affiliation(s)
- Stephen A Davis
- 1] Howard Hughes Medical Institute, Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA. [2] Roger Adam Laboratory, Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Benjamin M Vincent
- 1] Microbiology Graduate Program, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA. [2] Whitehead Institute for Biomedical Research, Cambridge, Massachusetts, USA
| | - Matthew M Endo
- 1] Howard Hughes Medical Institute, Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA. [2] Roger Adam Laboratory, Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Luke Whitesell
- Whitehead Institute for Biomedical Research, Cambridge, Massachusetts, USA
| | - Karen Marchillo
- 1] Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA. [2] Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, Wisconsin, USA
| | - David R Andes
- 1] Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA. [2] Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, Wisconsin, USA
| | - Susan Lindquist
- 1] Whitehead Institute for Biomedical Research, Cambridge, Massachusetts, USA. [2] Howard Hughes Medical Institute, Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Martin D Burke
- 1] Howard Hughes Medical Institute, Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA. [2] Roger Adam Laboratory, Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
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46
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Ananda-Rajah MR, Kontoyiannis D. Isavuconazole: a new extended spectrum triazole for invasive mold diseases. Future Microbiol 2015; 10:693-708. [DOI: 10.2217/fmb.15.34] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
ABSTRACT Isavuconazole is the first broad spectrum prodrug triazole with efficacy against invasive fungal diseases including aspergillosis and mucormycosis. Characteristics include linear dose-proportional pharmacokinetics, intravenous and oral formulations allowing therapeutic streamlining, once daily dosing, absence of nephrotoxic solubilizing agents and excellent oral bioavailability independent of prandial status and gastric acidity. An open label noncomparator study demonstrated encouraging results for isavuconazole as primary or salvage therapy for a range of fungi including mucormycosis. Isavuconazole had fewer premature drug discontinuations and adverse events in the eye, hepatobiliary and psychiatry systems than the comparator agent, voriconazole in a randomized double-blind clinical trial. Cross-resistance of isavuconazole best correlates with voriconazole. In vitro resistance is not invariably predictive of clinical failure. Isavuconazole signals progress in pharmacokinetics, bioavailability and toxicity/tolerability supported by clinical efficacy from Phase III trials.
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Affiliation(s)
| | - Dimitrios Kontoyiannis
- Department of Infectious Diseases, Infection Control & Employee Health, Unit 1416, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Sheppard DC, Campoli P, Duarte RF. Understanding antifungal prophylaxis with posaconazole in hematology patients: an evolving bedside to bench story. Haematologica 2015; 99:603-4. [PMID: 24688107 DOI: 10.3324/haematol.2013.100263] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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48
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Pharmacodynamics of amphotericin B deoxycholate, amphotericin B lipid complex, and liposomal amphotericin B against Aspergillus fumigatus. Antimicrob Agents Chemother 2015; 59:2735-45. [PMID: 25712363 DOI: 10.1128/aac.04723-14] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/19/2015] [Indexed: 11/20/2022] Open
Abstract
Amphotericin B is a first-line agent for the treatment of invasive aspergillosis. However, relatively little is known about the pharmacodynamics of amphotericin B for invasive pulmonary aspergillosis. We studied the pharmacokinetics (PK) and pharmacodynamics (PD) of amphotericin B deoxycholate (DAMB), amphotericin B lipid complex (ABLC), and liposomal amphotericin B (LAMB) by using a neutropenic-rabbit model of invasive pulmonary aspergillosis. The study endpoints were lung weight, infarct score, and levels of circulating galactomannan and (1 → 3)-β-D-glucan. Mathematical models were used to describe PK-PD relationships. The experimental findings were bridged to humans by Monte Carlo simulation. Each amphotericin B formulation induced a dose-dependent decline in study endpoints. Near-maximal antifungal activity was evident with DAMB at 1 mg/kg/day and ABLC and LAMB at 5 mg/kg/day. The bridging study suggested that the "average" patient receiving LAMB at 3 mg/kg/day was predicted to have complete suppression of galactomannan and (1 → 3)-β-D-glucan levels, but 20 to 30% of the patients still had a galactomannan index of >1 and (1 → 3)-β-D-glucan levels of >60 pg/ml. All formulations of amphotericin B induce a dose-dependent reduction in markers of lung injury and circulating fungus-related biomarkers. A clinical dosage of liposomal amphotericin B of 3 mg/kg/day is predicted to cause complete suppression of galactomannan and (1 → 3)-β-D-glucan levels in the majority of patients.
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The strength of synergistic interaction between posaconazole and caspofungin depends on the underlying azole resistance mechanism of Aspergillus fumigatus. Antimicrob Agents Chemother 2015; 59:1738-44. [PMID: 25583716 DOI: 10.1128/aac.04469-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The majority of azole resistance mechanisms in Aspergillus fumigatus correspond to mutations in the cyp51A gene. As azoles are less effective against infections caused by multiply azole-resistant A. fumigatus isolates, new therapeutic options are warranted for treating these infections. We therefore investigated the in vitro combination of posaconazole (POSA) and caspofungin (CAS) against 20 wild-type and resistant A. fumigatus isolates with 10 different resistance mechanisms. Fungal growth was assessed with the XTT [2,3-bis (2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide inner salt] method. Pharmacodynamic interactions were assessed with the fractional inhibitory concentration (FIC) index (FICi) on the basis of 10% (FICi-0), 25% (FICi-1), or 53 0% (FICi-2) growth, and FICs were correlated with POSA and CAS concentrations. Synergy and antagonism were concluded when the FICi values were statistically significantly (t test, P < 0.05) lower than 1 and higher than 1.25, respectively. Significant synergy was found for all isolates with mean FICi-0 values ranging from 0.28 to 0.75 (median, 0.46). Stronger synergistic interactions were found with FICi-1 (median, 0.18; range, 0.07 to 0.47) and FICi-2 (0.31; 0.07 to 0.6). The FICi-2 values of isolates with tandem-repeat-containing mutations or codon M220 were lower than those seen with the other isolates (P < 0.01). FIC-2 values were inversely correlated with POSA MICs (rs = -0.52, P = 0.0006) and linearly with the ratio of drug concentrations in combination over the MIC of POSA (rs = 0.76, P < 0.0001) and CAS (rs = 0.52, P = 0.0004). The synergistic effect of the combination of POSA and CAS (POSA/CAS) against A. fumigatus isolates depended on the underlying azole resistance mechanism. Moreover, the drug combination synergy was found to be increased against isolates with elevated POSA MICs compared to wild-type isolates.
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50
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Posaconazole prophylaxis in experimental azole-resistant invasive pulmonary aspergillosis. Antimicrob Agents Chemother 2014; 59:1487-94. [PMID: 25534731 DOI: 10.1128/aac.03850-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
We investigated the efficacy of posaconazole prophylaxis in preventing invasive aspergillosis due to azole-resistant Aspergillus fumigatus isolates. Using a neutropenic murine model of pulmonary infection, posaconazole prophylaxis was evaluated using three isogenic clinical isolates, with posaconazole MICs of 0.063 mg/liter (wild type), 0.5 mg/liter (F219I mutation), and 16 mg/liter. A fourth isolate harboring TR34/L98H (MIC of 0.5 mg/liter) was also tested. Posaconazole prophylaxis was effective in A. fumigatus with posaconazole MICs of ≤0.5 mg/liter, where 100% survival was reached. However, breakthrough infection was observed in mice infected with the isolate for which the posaconazole MIC was >16 mg/liter.
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