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Smith DJ, Gold JAW, Chiller T, Bustamante ND, Marinissen MJ, Rodriquez GG, Cortes VBG, Molina CD, Williams S, Vazquez Deida AA, Byrd K, Pappas PG, Patterson TF, Wiederhold NP, Thompson GR, Ostrosky-Zeichner L. Update on Outbreak of Fungal Meningitis Among US Residents Who Received Epidural Anesthesia at Two Clinics in Matamoros, Mexico. Clin Infect Dis 2024; 78:1554-1558. [PMID: 37739479 PMCID: PMC10957502 DOI: 10.1093/cid/ciad570] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/28/2023] [Accepted: 09/19/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Public health officials are responding to an outbreak of fungal meningitis among patients who received procedures under epidural anesthesia at 2 clinics (River Side Surgical Center and Clinica K-3) in Matamoros, Mexico, during 1 January to 13 May 2023. This report describes outbreak epidemiology and outlines interim diagnostic and treatment recommendations. METHODS Interim recommendations for diagnosis and management were developed by the Mycoses Study Group Research Education and Consortium (MSGERC) based on the clinical experience of clinicians caring for patients during the current outbreak or during previous outbreaks of healthcare-associated fungal meningitis in Durango, Mexico, and the United States. RESULTS As of 7 July 2023, the situation has evolved into a multistate and multinational fungal meningitis outbreak. A total of 185 residents in 22 US states and jurisdictions have been identified who might be at risk of fungal meningitis because they received epidural anesthesia at the clinics of interest in 2023. Among these patients, 11 suspected, 10 probable, and 10 confirmed US cases have been diagnosed, with severe vascular complications and 8 deaths occurring. Fusarium solani species complex has been identified as the causative agent, with antifungal susceptibility testing of a single isolate demonstrating poor in vitro activity for most available antifungals. Currently, triple therapy with intravenous voriconazole, liposomal amphotericin B, and fosmanogepix is recommended. CONCLUSIONS Efforts to understand the source of this outbreak and optimal treatment approaches are ongoing, but infectious diseases physicians should be aware of available treatment recommendations. New information will be available on the Centers for Disease Control and Prevention's (CDC's) website.
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Affiliation(s)
- Dallas J Smith
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jeremy A W Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nirma D Bustamante
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maria Julia Marinissen
- Health Attache, U.S. Embassy, Mexico City, Mexico
- U.S. Section, U.S.-Mexico Border Health Commission, U.S. Department of Health and Human Services, Washington D.C., USA
| | | | | | - Celida Duque Molina
- Director of Medical Services, Mexican Social Security Institute, México City, México
| | - Samantha Williams
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Axel A Vazquez Deida
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katrina Byrd
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Peter G Pappas
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center, San Antonio, Texas, USA
| | - Nathan P Wiederhold
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center, San Antonio, Texas, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California, Davis, Davis, California, USA
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Hoenigl M, Arastehfar A, Arendrup MC, Brüggemann R, Carvalho A, Chiller T, Chen S, Egger M, Feys S, Gangneux JP, Gold JAW, Groll AH, Heylen J, Jenks JD, Krause R, Lagrou K, Lamoth F, Prattes J, Sedik S, Wauters J, Wiederhold NP, Thompson GR. Novel antifungals and treatment approaches to tackle resistance and improve outcomes of invasive fungal disease. Clin Microbiol Rev 2024; 37:e0007423. [PMID: 38602408 PMCID: PMC11237431 DOI: 10.1128/cmr.00074-23] [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] [Indexed: 04/12/2024] Open
Abstract
SUMMARYFungal infections are on the rise, driven by a growing population at risk and climate change. Currently available antifungals include only five classes, and their utility and efficacy in antifungal treatment are limited by one or more of innate or acquired resistance in some fungi, poor penetration into "sequestered" sites, and agent-specific side effect which require frequent patient reassessment and monitoring. Agents with novel mechanisms, favorable pharmacokinetic (PK) profiles including good oral bioavailability, and fungicidal mechanism(s) are urgently needed. Here, we provide a comprehensive review of novel antifungal agents, with both improved known mechanisms of actions and new antifungal classes, currently in clinical development for treating invasive yeast, mold (filamentous fungi), Pneumocystis jirovecii infections, and dimorphic fungi (endemic mycoses). We further focus on inhaled antifungals and the role of immunotherapy in tackling fungal infections, and the specific PK/pharmacodynamic profiles, tissue distributions as well as drug-drug interactions of novel antifungals. Finally, we review antifungal resistance mechanisms, the role of use of antifungal pesticides in agriculture as drivers of drug resistance, and detail detection methods for antifungal resistance.
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Affiliation(s)
- Martin Hoenigl
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Amir Arastehfar
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Roger Brüggemann
- Department of Pharmacy and Radboudumc Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc-CWZ Center of Expertise in Mycology, Nijmegen, The Netherlands
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW South Wales Health Pathology, Westmead Hospital, Westmead, Australia
- The University of Sydney, Sydney, Australia
| | - Matthias Egger
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Simon Feys
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Jean-Pierre Gangneux
- Centre National de Référence des Mycoses et Antifongiques LA-AspC Aspergilloses chroniques, European Excellence Center for Medical Mycology (ECMM EC), Centre hospitalier Universitaire de Rennes, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) UMR_S 1085, Rennes, France
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andreas H. Groll
- Department of Pediatric Hematology/Oncology and Infectious Disease Research Program, Center for Bone Marrow Transplantation, University Children’s Hospital, Muenster, Germany
| | - Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Jeffrey D. Jenks
- Department of Public Health, Durham County, Durham, North Carolina, USA
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Robert Krause
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Frédéric Lamoth
- Department of Laboratory Medicine and Pathology, Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Medicine, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Juergen Prattes
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Sarah Sedik
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Nathan P. Wiederhold
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - George R. Thompson
- Department of Internal Medicine, Division of Infectious Diseases University of California-Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
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Akinosoglou K, Rigopoulos EA, Papageorgiou D, Schinas G, Polyzou E, Dimopoulou E, Gogos C, Dimopoulos G. Amphotericin B in the Era of New Antifungals: Where Will It Stand? J Fungi (Basel) 2024; 10:278. [PMID: 38667949 PMCID: PMC11051097 DOI: 10.3390/jof10040278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
Amphotericin B (AmB) has long stood as a cornerstone in the treatment of invasive fungal infections (IFIs), especially among immunocompromised patients. However, the landscape of antifungal therapy is evolving. New antifungal agents, boasting novel mechanisms of action and better safety profiles, are entering the scene, presenting alternatives to AmB's traditional dominance. This shift, prompted by an increase in the incidence of IFIs, the growing demographic of immunocompromised individuals, and changing patterns of fungal resistance, underscores the continuous need for effective treatments. Despite these challenges, AmB's broad efficacy and low resistance rates maintain its essential status in antifungal therapy. Innovations in AmB formulations, such as lipid complexes and liposomal delivery systems, have significantly mitigated its notorious nephrotoxicity and infusion-related reactions, thereby enhancing its clinical utility. Moreover, AmB's efficacy in treating severe and rare fungal infections and its pivotal role as prophylaxis in high-risk settings highlight its value and ongoing relevance. This review examines AmB's standing amidst the ever-changing antifungal landscape, focusing on its enduring significance in current clinical practice and exploring its potential future therapeutic adaptations.
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Affiliation(s)
- Karolina Akinosoglou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Rio, Greece
| | | | - Despoina Papageorgiou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - Georgios Schinas
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - Eleni Polyzou
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | | | - Charalambos Gogos
- School of Medicine, University of Patras, 26504 Patras, Greece; (E.A.R.); (D.P.); (G.S.); (E.P.); (C.G.)
| | - George Dimopoulos
- 3rd Department of Critical Care, Evgenidio Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
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Almajid A, Bazroon A, Al-Awami HM, Albarbari H, Alqahtani I, Almutairi R, Alsuwayj A, Alahmadi F, Aljawad J, Alnimer R, Asiri N, Alajlani S, Alshelali R, Aljishi Y. Fosmanogepix: The Novel Anti-Fungal Agent's Comprehensive Review of in Vitro, in Vivo, and Current Insights From Advancing Clinical Trials. Cureus 2024; 16:e59210. [PMID: 38807795 PMCID: PMC11131969 DOI: 10.7759/cureus.59210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2024] [Indexed: 05/30/2024] Open
Abstract
Fosmanogepix, a prodrug of Manogepix (MGX), is a groundbreaking antifungal agent with broad-spectrum activity against yeasts, including Cryptococcus and Candida, as well as molds. It exhibits effectiveness against drug-resistant strains, such as Candida strains resistant to echinocandins and Aspergillus strains resistant to azoles. Furthermore, fosmanogepix shows activity against pathogens that typically resist other classes of drugs, such as Scedosporium, Lomentospora prolificans, and Fusarium, although its efficacy against Mucorales varies. In animal models, fosmanogepix has demonstrated notable effectiveness against disseminated infections caused by various Candida species, Coccidioides immitis, and Fusarium solani. It has also shown efficacy in pulmonary infection models involving Aspergillus fumigatus, Aspergillus flavus, Scedosporium prolificans, Scedosporium apiospermum, and Rhizopus arrhizus. Clinical trials have revealed excellent oral bioavailability (>90%), enabling a seamless transition between intravenous and oral formulations without compromising blood concentrations. Fosmanogepix exhibits favorable profiles in terms of drug interactions, tolerability, and extensive distribution in various tissues, making it an appealing choice for treating invasive fungal infections. This comprehensive review aims to examine the outcomes of published data on fosmanogepix, encompassing in vitro, in vivo, and clinical investigations.
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Affiliation(s)
- Ali Almajid
- Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | - Ali Bazroon
- Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | | | | | | | - Rehab Almutairi
- College of Medicine, University of Szeged Albert Szent-Györgyi Medical School, Szeged, HUN
| | - Abbas Alsuwayj
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Jinan Aljawad
- College of Medicine, University of Szeged Albert Szent-Györgyi Medical School, Szeged, HUN
| | - Razan Alnimer
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Nawal Asiri
- College of Medicine, King Khalid University, Abha, SAU
| | - Shouq Alajlani
- College of Medicine, Umm Al Qura University, Makkah, SAU
| | - Reem Alshelali
- Internal Medicine, King Abdullah Medical Complex, Jeddah, SAU
| | - Yamama Aljishi
- Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
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5
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Kriegl L, Egger M, Boyer J, Hoenigl M, Krause R. New treatment options for critically important WHO fungal priority pathogens. Clin Microbiol Infect 2024:S1198-743X(24)00118-6. [PMID: 38461942 DOI: 10.1016/j.cmi.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Yet often overlooked in public health discourse, fungal infections pose a crucial global disease burden associated with annual mortality rates approximately equal to tuberculosis and HIV. In response, the WHO published its first global priority list of fungal pathogens in 2022 assigning Aspergillus fumigatus, Candida albicans, Candida auris, and Cryptococcus neoformans to the critical group. OBJECTIVES This review provides succinct insights into novel antifungals in development, aiming to contribute valuable information and perspectives with a focus on recent clinical findings and new treatment approaches for critical members of the WHO fungal pathogen priority list. SOURCES PubMed literature search using 'Aspergillus fumigatus', 'Cryptococcus neoformans', 'Candida auris', and 'Candida albicans', along with the names of novel antifungal substances, including 'fosmanogepix', 'ibrexafungerp', 'opelconazole', 'oteseconazole', 'MAT2203', 'olorofim', and 'rezafungin' was conducted. CONTENT For each critical pathogen, current issues and global clinical data from recent trials are covered. The remarkable development of three new antifungal therapeutics recently receiving Food and Drug Administration approval (ibrexafungerp-June 2021, oteseconazole -April 2022, and rezafungin-March 2023) is outlined, with two more exciting new antifungal substances, namely, olorofim and fosmanogepix expecting approval within the next years. Ibrexafungerp, fosmanogepix, and rezafungin have additionally been granted orphan drug status by the European Medicines Agency in Europe (ibrexafungerp-November 2021, fosmanogepix-July 2022, and rezafungin-January 2024). IMPLICATIONS Although the limited number of targets and the emergence of resistance have posed challenges to antifungal treatment, new drugs such as ibrexafungerp, rezafungin, fosmanogepix, or olorofim have shown promising clinical efficacy. These drugs not only provide alternative options for invasive fungal infections but also alleviate treatment in outpatient settings. More clinical data, implementation of stewardship programmes, and surveillance, including utilization of drugs in agriculture, are necessary to prevent resistance development and to ensure the safety and efficacy of these new agents.
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Affiliation(s)
- Lisa Kriegl
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria; BioTechMed-Graz, Graz, Austria
| | - Matthias Egger
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria; BioTechMed-Graz, Graz, Austria
| | - Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria; BioTechMed-Graz, Graz, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, ECMM Excellence Center for Clinical Mycology, Medical University of Graz, Graz, Austria; BioTechMed-Graz, Graz, Austria.
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6
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Nzimande SP, Govender NP, Maphanga TG. In vitro manogepix susceptibility testing of South African Emergomyces africanus, Emergomyces pasteurianus, and Blastomyces emzantsi clinical isolates. Antimicrob Agents Chemother 2023; 67:e0110423. [PMID: 37971237 PMCID: PMC10720492 DOI: 10.1128/aac.01104-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/06/2023] [Indexed: 11/19/2023] Open
Abstract
We performed in vitro antifungal susceptibility testing of manogepix against the yeast phase of 78 Emergomyces africanus, 2 Emergomyces pasteurianus, and 5 Blastomyces emzantsi isolates using a reference broth microdilution method following Clinical and Laboratory Standards Institute recommendations. All three pathogens had low minimum inhibitory concentrations ranging from <0.0005 to 0.008 mg/L. Manogepix should be investigated in animal models and potentially in future human clinical trials for endemic mycoses.
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Affiliation(s)
- Silondiwe P. Nzimande
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Nelesh P. Govender
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand, South Africa
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Tsidiso G. Maphanga
- National Institute for Communicable Diseases (NICD), a Division of the National Health Laboratory Service, Johannesburg, South Africa
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7
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Ordaya EE, Clement J, Vergidis P. The Role of Novel Antifungals in the Management of Candidiasis: A Clinical Perspective. Mycopathologia 2023; 188:937-948. [PMID: 37470902 PMCID: PMC10687117 DOI: 10.1007/s11046-023-00759-5] [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: 03/31/2023] [Accepted: 05/31/2023] [Indexed: 07/21/2023]
Abstract
Mucosal and invasive candidiasis can be challenging to treat in the setting of drug intolerance, antifungal resistance, drug-drug interactions, or host immune status. Antifungals with novel mechanisms of action and distinct pharmacokinetic/pharmacodynamic properties have been developed in recent years. Rezafungin is an echinocandin with high-tissue penetration and an extended half-life that allows for once-weekly administration, making it a convenient treatment option for invasive candidiasis while obviating the need for central catheter placement. Ibrexafungerp is an oral glucan synthase inhibitor that is active against most echinocandin-resistant Candida species. At present, it is approved for the treatment of acute vulvovaginal candidiasis and is under investigation as an oral step-down therapy following initial treatment with an echinocandin for cases of invasive candidiasis. Oteseconazole is a long-acting tetrazole that exhibits a higher affinity for the fungal enzyme CYP51, resulting in a potentially lower risk of drug-drug interactions and side effects compared to other azoles. It is currently approved for the treatment of recurrent vulvovaginal candidiasis. Fosmanogepix has a novel mechanism of action and potent activity against several Candida strains resistant to other antifungals. Due to its considerable bioavailability and tissue penetration, it holds promise as a potential treatment option in patients with invasive candidiasis, including those with chorioretinitis or meningitis. Results from clinical trials and observational studies will further delineate the role of these agents in the management of candidiasis. As the usage of these novel antifungals becomes widespread, we expect to acquire a greater understanding of their efficacy and potential benefits.
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Affiliation(s)
- Eloy E Ordaya
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Josh Clement
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Paschalis Vergidis
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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8
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Cornely OA, Ostermann H, Koehler P, Teschner D, Limburg E, Kramer WG, Barbat SH, Tawadrous M, Hodges MR. Phase 1b safety and pharmacokinetics of intravenous and oral fosmanogepix in patients with acute myeloid leukaemia and neutropenia. J Antimicrob Chemother 2023; 78:2645-2652. [PMID: 37681450 PMCID: PMC10631825 DOI: 10.1093/jac/dkad269] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/15/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVES Fosmanogepix (APX001), a first-in-class, intravenous (IV) and oral (PO) antifungal prodrug, is being developed to treat invasive fungal diseases (IFDs). Manogepix (APX001A; active moiety) targets fungal glycosylphosphatidylinositol-anchored cell wall transfer protein 1, inhibiting cell wall synthesis causing loss of viability. This open-label, multicentre, Phase 1b study in patients with AML and neutropenia (absolute neutrophil count <500 cells/μL; >10 days) undergoing chemotherapy aimed to assess tolerability, safety and pharmacokinetics (PK) of IV and PO fosmanogepix. METHODS Of 21 adult AML patients undergoing remission induction chemotherapy, 10 received IV fosmanogepix (600 mg; q24h) and 11 received oral fosmanogepix (500 mg; q24h) over 14 days, with a 28 day follow-up. Patients also received remission induction chemotherapy [sequential high-dose cytarabine and mitoxantrone (S-HAM) or 7 + 3 regimen] for AML and IFD prophylaxis (posaconazole). A two-compartmental PK model from previous studies in healthy volunteers was fitted to manogepix plasma data. RESULTS Of 26 fosmanogepix-related adverse events (AEs; IV: 14; PO: 12) in 9 (42.9%) patients [IV: 5 (50%); PO: 4 (36.4%)], none were serious or resulted in fosmanogepix discontinuation. Most frequently occurring fosmanogepix-related AEs were Grade 1/2 nausea [four events in three patients (14.3%)]; vomiting, ALT increase, and delirium [two events; two patients (9.5%) each]. One patient experienced fosmanogepix-related Grade 3 hypertension. Dose-corrected geometric mean ratio of AUC (PO-to-IV) was 95%. Elimination half-lives (∼2 days) were consistent with prior studies in healthy volunteers. CONCLUSIONS Fosmanogepix was safe and well tolerated in AML patients with neutropenia receiving remission induction chemotherapy. Safety and PK profiles were comparable to healthy volunteers.
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Affiliation(s)
- Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- University Hospital of Cologne, Department of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Helmut Ostermann
- Department of Hematology/Oncology, Ludwig Maximilian University of Munich, Munich, Germany
| | - Philipp Koehler
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- University Hospital of Cologne, Department of Internal Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Daniel Teschner
- University Medical Center of the Johannes Gutenberg University Mainz, Department of Hematology, and Medical Oncology, Mainz, Germany
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Endrik Limburg
- Clinical Trials Centre Cologne (CTCC), University of Cologne, Cologne, Germany
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9
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Friedman DZP, Schwartz IS. Emerging Diagnostics and Therapeutics for Invasive Fungal Infections. Infect Dis Clin North Am 2023; 37:593-616. [PMID: 37532392 DOI: 10.1016/j.idc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Recently, there have been significant advances in the diagnosis and management of invasive fungal infections. Compared with traditional fungal diagnostics, molecular assays promise improved sensitivity and specificity, the ability to test a range of samples (including noninvasive samples, ie, blood), the detection of genetic mutations associated with antifungal resistance, and the potential for a faster turnaround time. Antifungals in late-stage clinical development include agents with novel mechanisms of action (olorofim and fosmanogepix) and new members of existing classes with distinct advantages over existing antifungals in toxicity, drug-drug interactions, and dosing convenience (oteseconazole, opelconazole, rezafungin, ibrexafungerp, encochleated amphotericin B).
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Affiliation(s)
- Daniel Z P Friedman
- Section of Infectious Diseases and Global Health, The University of Chicago, 5841 South Maryland Avenue, MC5065, Chicago, IL 60637, USA
| | - Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, 315 Trent Drive, Durham, NC 27705, USA.
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10
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Goggin KP, Londeree J, Freeman AF, Garro R, George RP. Successful Use of Fosmanogepix for Treatment of Rare Highly Resistant Cutaneous Fusariosis in a Pediatric Patient With STAT3 Hyper-Immunoglobulin E Syndrome and End-Stage Kidney Disease. Open Forum Infect Dis 2023; 10:ofad285. [PMID: 37305844 PMCID: PMC10249262 DOI: 10.1093/ofid/ofad285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/19/2023] [Indexed: 06/13/2023] Open
Abstract
We describe the successful use of the novel antifungal drug fosmanogepix to treat a chronic case of multidrug-resistant cutaneous Fusarium suttonianum infection in a pediatric patient with STAT3 hyper-IgE syndrome and end-stage kidney disease on peritoneal dialysis.
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Affiliation(s)
- Kathryn P Goggin
- Correspondence: Kathryn P. Goggin, MD, MSc, Infectious Diseases Division Emory Department of Pediatrics 2015 Uppergate Drive, Suite 534 Atlanta, GA 30322 ()
| | - Jackson Londeree
- Division of Nephrology, Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Rouba Garro
- Division of Nephrology, Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
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11
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de Oliveira H, Bezerra BT, Rodrigues ML. Antifungal Development and the Urgency of Minimizing the Impact of Fungal Diseases on Public Health. ACS BIO & MED CHEM AU 2023; 3:137-146. [PMID: 37101810 PMCID: PMC10125384 DOI: 10.1021/acsbiomedchemau.2c00055] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 04/28/2023]
Abstract
Fungal infections are a major public health problem resulting from the lack of public policies addressing these diseases, toxic and/or expensive therapeutic tools, scarce diagnostic tests, and unavailable vaccines. In this Perspective, we discuss the need for novel antifungal alternatives, highlighting new initiatives based on drug repurposing and the development of novel antifungals.
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Affiliation(s)
| | - Bárbara T. Bezerra
- Instituto
Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba81310-020, Brazil
| | - Marcio L. Rodrigues
- Instituto
Carlos Chagas, Fundação Oswaldo Cruz (Fiocruz), Curitiba81310-020, Brazil
- Instituto
de Microbiologia Paulo de Góes (IMPG), Universidade Federal do Rio de Janeiro, Rio de Janeiro21941-902, Brazil
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12
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Lamoth F. Novel Therapeutic Approaches to Invasive Candidiasis: Considerations for the Clinician. Infect Drug Resist 2023; 16:1087-1097. [PMID: 36855391 PMCID: PMC9968438 DOI: 10.2147/idr.s375625] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/01/2023] [Indexed: 02/24/2023] Open
Abstract
Invasive candidiasis (IC), due to the yeast pathogen Candida, is still a major cause of in-hospital morbidity and mortality. The limited number of antifungal drug classes and the emergence of multi-resistant Candida species, such as Candida auris and some Candida glabrata isolates, is concerning. However, recent advances in antifungal drug development provide promising perspectives for the therapeutic approach of IC. Notably, three novel antifungal agents, currently in Phase II/III clinical trials, are expected to have an important place for the treatment of IC in the future. Rezafungin is a novel echinocandin with prolonged half-life. Ibrexafungerp and fosmanogepix are two first-in-class antifungal drugs with broad spectrum activity against Candida spp., including C. auris and echinocandin-resistant species. These novel antifungal agents also represent interesting alternative options because of their acceptable oral bioavailability (ibrexafungerp and fosmanogepix) or their large interdose interval (once weekly intravenous administration for rezafungin) for prolonged and/or outpatient treatment of complicated IC. This review discusses the potential place of these novel antifungal drugs for the treatment of IC considering their pharmacologic properties and their preclinical and clinical data.
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Affiliation(s)
- Frederic Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Microbiology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Correspondence: Frederic Lamoth, Service of Infectious Diseases and Institute of Microbiology, CHUV | Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 48, Lausanne, 1011, Switzerland, Tel +41 21 314 10 10, Email
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13
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Armstrong‐James D. Antifungal chemotherapies and immunotherapies for the future. Parasite Immunol 2023; 45:e12960. [PMID: 36403106 PMCID: PMC10078527 DOI: 10.1111/pim.12960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
Human fungal pathogens cause a broad plethora of infections, spanning cutaneous dermatophytoses to invasive infections in immunocompromised hosts. As eukaryotic pathogens are capable of morphotype switching, they present unique challenges both for drug development and the immunological response. Whilst current antifungal therapies are limited to the orally available triazoles, intravenous echonocandins and polyenes, and flucytosine and terbinafine, there has been recent significant progress in the antifungal armamentorium with ibrexafungerp, a novel orally available terpanoid that inhibits 1,3-beta-D-glucan-approved by Food and Drug Administration in 2021, and fosmanogepix, an orally available pro-drug of manogepix, which targets glycosylphosphatidylinositol-anchored protein maturation entering Phase 3 studies for candidaemia. A number of further candidates are in development. There has been significant use of existing immunotherapies such as recombinant interferon-γ and G-CSF for fungal disease in immunocompromised patients, and there are emerging opportunities for monoclonal antibodies targeting TH2 inflammation. Omalizumab, an anti-IgE monoclonal antibody in asthma, is now used routinely for the treatment of allergic bronchopulmonary aspergillosis, and further agents targeting IL-4 and IL-5 are being evaluated. In addition, T-cell CAR therapy is showing early promise for fungal disease. Thus, we are likely to see rapid advances to our approach to the management of fungal disease in the near future.
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Affiliation(s)
- Darius Armstrong‐James
- Department of Infectious DiseasesMedical Research Council Centre for Molecular Bacteriology and Infection, Imperial College LondonLondonUK
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14
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Punia A, Choudhary P, Sharma N, Dahiya S, Gulia P, Chhillar AK. Therapeutic Approaches for Combating Aspergillus Associated Infection. Curr Drug Targets 2022; 23:1465-1488. [PMID: 35748549 DOI: 10.2174/1389450123666220623164548] [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: 09/28/2021] [Revised: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 01/25/2023]
Abstract
Now-a-days fungal infection emerges as a significant problem to healthcare management systems due to high frequency of associated morbidity, mortality toxicity, drug-drug interactions, and resistance of the antifungal agents. Aspergillus is the most common mold that cause infection in immunocompromised hosts. It's a hyaline mold that is cosmopolitan and ubiquitous in nature. Aspergillus infects around 10 million population each year with a mortality rate of 30-90%. Clinically available antifungal formulations are restricted to four classes (i.e., polyene, triazole, echinocandin, and allylamine), and each of them have their own limitations associated with the activity spectrum, the emergence of resistance, and toxicity. Consequently, novel antifungal agents with modified and altered chemical structures are required to combat these invasive fungal infections. To overcome these limitations, there is an urgent need for new antifungal agents that can act as potent drugs in near future. Currently, some compounds have shown effective antifungal activity. In this review article, we have discussed all potential antifungal therapies that contain old antifungal drugs, combination therapies, and recent novel antifungal formulations, with a focus on the Aspergillus associated infections.
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Affiliation(s)
- Aruna Punia
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Pooja Choudhary
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Namita Sharma
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Sweety Dahiya
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Prity Gulia
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
| | - Anil K Chhillar
- Department of Biotechnology, Maharishi Dayanand University, Rohtak, Haryana 124001, India
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15
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Lamoth F, Lewis RE, Kontoyiannis DP. Investigational Antifungal Agents for Invasive Mycoses: A Clinical Perspective. Clin Infect Dis 2022; 75:534-544. [PMID: 34986246 DOI: 10.1093/cid/ciab1070] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Indexed: 01/13/2023] Open
Abstract
Treatment of invasive fungal infections (IFIs) remains challenging, because of the limitations of the current antifungal agents (ie, mode of administration, toxicity, and drug-drug interactions) and the emergence of resistant fungal pathogens. Therefore, there is an urgent need to expand our antifungal armamentarium. Several compounds are reaching the stage of phase II or III clinical assessment. These include new drugs within the existing antifungal classes or displaying similar mechanism of activity with improved pharmacologic properties (rezafungin and ibrexafungerp) or first-in-class drugs with novel mechanisms of action (olorofim and fosmanogepix). Although critical information regarding the performance of these agents in heavily immunosuppressed patients is pending, they may provide useful additions to current therapies in some clinical scenarios, including IFIs caused by azole-resistant Aspergillus or multiresistant fungal pathogens (eg, Candida auris, Lomentospora prolificans). However, their limited activity against Mucorales and some other opportunistic molds (eg, some Fusarium spp.) persists as a major unmet need.
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Affiliation(s)
- Frederic Lamoth
- Infectious Diseases Service and Institute of Microbiology, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Russell E Lewis
- Clinic of Infectious Diseases, S'Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italyand
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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16
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Gebremariam T, Gu Y, Alkhazraji S, Youssef E, Shaw KJ, Ibrahim AS. The Combination Treatment of Fosmanogepix and Liposomal Amphotericin B Is Superior to Monotherapy in Treating Experimental Invasive Mold Infections. Antimicrob Agents Chemother 2022; 66:e0038022. [PMID: 35670592 PMCID: PMC9295579 DOI: 10.1128/aac.00380-22] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/11/2022] [Indexed: 12/27/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA), invasive mucormycosis (IM), and invasive fusariosis (IF) are associated with high mortality and morbidity. Fosmanogepix (FMGX) is a first-in-class antifungal in clinical development with demonstrated broad-spectrum activity in animal models of infections. We sought to evaluate the benefit of combination therapy of FMGX plus liposomal amphotericin B (L-AMB) in severe delayed-treatment models of murine IPA, IM, and IF. While FMGX was equally as effective as L-AMB in prolonging the survival of mice infected with IPA, IM, or IF, combination therapy was superior to monotherapy in all three models. These findings were validated by greater reductions in the tissue fungal burdens (determined by quantitative PCR) of target organs in all three models versus the burdens in infected vehicle-treated (placebo) or monotherapy-treated mice. In general, histopathological examination of target organs corroborated the findings for fungal tissue burdens among all treatment arms. Our results show that treatment with the combination of FMGX plus L-AMB demonstrated high survival rates and fungal burden reductions in severe animal models of invasive mold infections, at drug exposures in mice similar to those achieved clinically. These encouraging results warrant further investigation of the FMGX-plus-L-AMB combination treatment for severely ill patients with IPA, IM, and IF.
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Affiliation(s)
| | - Yiyou Gu
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Sondus Alkhazraji
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Eman Youssef
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
- Beni-Suef University, Beni-Suef, Egypt
| | | | - Ashraf S. Ibrahim
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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17
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Abstract
Candida albicans is a commensal yeast fungus of the human oral, gastrointestinal, and genital mucosal surfaces, and skin. Antibiotic-induced dysbiosis, iatrogenic immunosuppression, and/or medical interventions that impair the integrity of the mucocutaneous barrier and/or perturb protective host defense mechanisms enable C. albicans to become an opportunistic pathogen and cause debilitating mucocutaneous disease and/or life-threatening systemic infections. In this review, we synthesize our current knowledge of the tissue-specific determinants of C. albicans pathogenicity and host immune defense mechanisms.
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Affiliation(s)
- José Pedro Lopes
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Michail S Lionakis
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
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18
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McCarty TP, Pappas PG. Antifungal Pipeline. Front Cell Infect Microbiol 2021; 11:732223. [PMID: 34552887 PMCID: PMC8450443 DOI: 10.3389/fcimb.2021.732223] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
In many ways, fungal diseases are forgotten or neglected. Given the significantly lower frequency compared to similar bacterial etiologies across the spectrum of infectious syndromes, it makes sense that anti-bacterial agents have seen the bulk of development in recent decades. The vast majority of new antifungal medications approved for use in the past 10 years have been new versions in the same class as existing agents. Clinical mycology is crying out for new mechanisms of action in the setting of rising resistance and emergence of new organisms. Fortunately, this trend appears to be reversing. There are numerous agents in advanced stages of development offering novel dosing regimens and mechanisms of action to combat these threats. Herein we review seven antifungal agents that we hope to see come to market in the coming years to aid physicians in the treatment of mucocutaneous and invasive fungal infections.
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Affiliation(s)
- Todd Patrick McCarty
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States.,Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, AL, United States
| | - Peter G Pappas
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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19
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Abstract
Anti-fungal therapies remain sub-optimal, and resistant pathogens are increasing. New therapies are desperately needed, especially options that are less toxic than most of the currently available selection. In this review, I will discuss anti-fungal therapies that are in at least phase I human trials. These include VT-1161 and VT-1598, modified azoles with a tetrazole metal-binding group; the echinocandin rezafugin; the novel β-1,3-d-glucan synthase inhibitor ibrexafungerp; fosmanogepix, a novel anti-fungal targeting Gwt1; the arylamidine T-2307; the dihydroorotate inhibitor olorofim; and the cyclic hexapeptide ASP2397. The available data including spectrum of activity, toxicity and stage of clinical development will be discussed for each of these so clinicians are aware of promising anti-fungal agents with a strong likelihood of clinical availability in the next 5–7 years.
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Affiliation(s)
- Grant Waterer
- University of Western Australia, Royal Perth Hospital, Level 3 Executive Corridor, Wellington St, Perth, 6000, Australia.
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