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Maertens J, Slavin M, Hoenigl M, Thompson GR, Richardson M, Lass-Flörl C. Breaking the mould: challenging the status quo of clinical trial response definitions for invasive fungal diseases-a debate. J Antimicrob Chemother 2024; 79:1786-1793. [PMID: 39084680 PMCID: PMC11334067 DOI: 10.1093/jac/dkae158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/01/2024] [Indexed: 08/02/2024] Open
Affiliation(s)
- Johan Maertens
- University Hospitals Leuven, Department of Haematology and ECMM Excellence Center of Medical Mycology, Campus Gasthuisberg Leuven, Belgium
| | - Monica Slavin
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center of Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - George R Thompson
- Division of Infectious Diseases, and Departments of Internal Medicine and Medical Microbiology and Immunology, University of California-Davis, Sacramento, CA, USA
| | - Malcolm Richardson
- Mycology Reference Centre Manchester, ECMM Excellence Center of Medical Mycology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Cornelia Lass-Flörl
- Christian-Doppler Laboratory for Invasive Fungal Infections, Institute of Hygiene and Medical Microbiology, ECMM Excellence Center of Medical Mycology, Medical University of Innsbruck, Innsbruck, Austria
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Vergidis P, Sendi P, Alkhateeb HB, Nguyen MH. How do I manage refractory invasive pulmonary aspergillosis. Clin Microbiol Infect 2024; 30:755-761. [PMID: 38286175 DOI: 10.1016/j.cmi.2024.01.015] [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: 08/11/2023] [Revised: 11/06/2023] [Accepted: 01/20/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Invasive aspergillosis is associated with significant morbidity and mortality in patients with haematologic malignancies and haematopoietic cell transplant recipients. The prognosis is worse among patients who have failed primary antifungal treatment. OBJECTIVES We aim to provide guidance on the diagnosis and management of refractory invasive pulmonary aspergillosis. SOURCES Using PubMed, we performed a review of original articles, meta-analyses, and systematic reviews. CONTENT We discuss the diagnostic criteria for invasive pulmonary aspergillosis and the evidence on the treatment of primary infection. We outline our diagnostic approach to refractory disease. We propose a treatment algorithm for refractory disease and discuss the role of experimental antifungal agents. IMPLICATIONS For patients with worsening disease while on antifungal therapy, a thorough diagnostic evaluation is required to confirm the diagnosis of aspergillosis and exclude another concomitant infection. Treatment should be individualized. Current options include switching to another triazole, transitioning to a lipid formulation of amphotericin B, or using combination antifungal therapy.
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Affiliation(s)
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | | | - M Hong Nguyen
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
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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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Abstract
Introduction: Invasive fungal infection carries a high morbidity, mortality and economic cost. In recent times, a rising incidence of fungal infection and antifungal resistance is occurring which has prompted the development of novel antifungal agents.Areas covered:In this perspective, the authors describe the current status of registered antifungals and their limitations in the treatment of invasive fungal infection. They also go on to describe the new antifungal agents that are in the clinical stage of development and how they might be best utilized in patient care in the future.Expert opinion: The antifungal drug development pipeline has responded to a growing need for new agents to effectively treat fungal disease without concomitant toxicity or issues with drug tolerance. Olorofim (F901318), ibrexafungerp (SCY-078), fosmanogepix (APX001), rezafungin (CD101), oteseconazole (VT-1161), encochleated amphotericin B (MAT2203), nikkomycin Z (NikZ) and ATI-2307 are all in the clinical stage of development and offer great promise in offering clinicians better agents to treat these difficult infections.
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Affiliation(s)
- Adam G Stewart
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| | - David L Paterson
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
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Youngs J, Low JM, Whitney L, Logan C, Chase J, Yau T, Klammer M, Koh M, Bicanic T. Safety and Efficacy of Intermittent High-Dose Liposomal Amphotericin B Antifungal Prophylaxis in Haemato-Oncology: An Eight-Year Single-Centre Experience and Review of the Literature. J Fungi (Basel) 2020; 6:jof6040385. [PMID: 33371513 PMCID: PMC7767522 DOI: 10.3390/jof6040385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 12/26/2022] Open
Abstract
Triazoles remain first-line agents for antifungal prophylaxis in high-risk haemato-oncology patients, but their use is increasingly contraindicated due to drug–drug interactions and additive toxicities with novel treatments. In this retrospective, single-centre, observational study, we present our eight-year experience of antifungal prophylaxis using intermittent high-dose liposomal Amphotericin B (L-AmB). All adults identified through our Antifungal Stewardship Programme as receiving L-AmB prophylaxis at 7.5 mg/kg once-weekly between February 2012 and January 2020 were included. Adverse reactions, including infusion reactions, electrolyte loss, and nephrotoxicity, were recorded. ‘Breakthrough’ invasive fungal infection (IFI) occurring within four weeks of L-AmB was classified using European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) criteria. Moreover, 114 courses of intermittent high-dose L-AmB prophylaxis administered to 92 unique patients were analysed. Hypokalaemia was the most common grade 3–4 adverse event, with 26 (23%) courses. Grade 3 nephrotoxicity occurred in 8 (7%) and reversed in all six patients surviving to 90 days. There were two (1.8%) episodes of breakthrough IFI, one ‘probable’ and one ‘possible’. In this study, the largest evaluation of intermittent high-dose L-AmB prophylaxis conducted to date, toxicity was manageable and reversible and breakthrough IFI was rare. L-AmB prophylaxis represents a viable alternative for patients with a contraindication to triazoles.
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Affiliation(s)
- Jonathan Youngs
- Institute of Infection & Immunity, St George’s University of London, Cranmer Terrace, Tooting, London SW17 0RE, UK;
- Department of Infection, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK
- Clinical Academic Group in Infection and Immunity, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK;
- Correspondence: (J.Y.); (T.B.); Tel.: +078-5467-7681 (J.Y.); +020-8725-2911 (T.B.)
| | - Jen Mae Low
- St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK;
| | - Laura Whitney
- Pharmacy Department, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK; (L.W.); (J.C.); (T.Y.)
| | - Clare Logan
- Institute of Infection & Immunity, St George’s University of London, Cranmer Terrace, Tooting, London SW17 0RE, UK;
- Department of Infection, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK
- Clinical Academic Group in Infection and Immunity, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK;
| | - Janice Chase
- Pharmacy Department, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK; (L.W.); (J.C.); (T.Y.)
| | - Ting Yau
- Pharmacy Department, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK; (L.W.); (J.C.); (T.Y.)
| | - Matthias Klammer
- Department of Haematology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK;
| | - Mickey Koh
- Clinical Academic Group in Infection and Immunity, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK;
- Department of Haematology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK;
| | - Tihana Bicanic
- Institute of Infection & Immunity, St George’s University of London, Cranmer Terrace, Tooting, London SW17 0RE, UK;
- Department of Infection, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK
- Clinical Academic Group in Infection and Immunity, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK;
- Correspondence: (J.Y.); (T.B.); Tel.: +078-5467-7681 (J.Y.); +020-8725-2911 (T.B.)
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Shaw KJ, Ibrahim AS. Fosmanogepix: A Review of the First-in-Class Broad Spectrum Agent for the Treatment of Invasive Fungal Infections. J Fungi (Basel) 2020; 6:E239. [PMID: 33105672 PMCID: PMC7711534 DOI: 10.3390/jof6040239] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/26/2022] Open
Abstract
Fosmanogepix is a first-in-class antifungal currently in Phase 2 clinical trials for the treatment of invasive fungal infections caused by Candida, Aspergillus and rare molds. Fosmanogepix is the N-phosphonooxymethylene prodrug of manogepix, an inhibitor of the fungal enzyme Gwt1. Manogepix demonstrates broad spectrum in vitro activity against yeasts and molds, including difficult to treat pathogens. Because of its novel mechanism of action, manogepix retains potency against many resistant strains including echinocandin-resistant Candida and azole-resistant Aspergillus. Manogepix is also active against pathogens that demonstrate intrinsic resistance to other drug classes, such as Scedosporium, Lomentospora prolificans, and Fusarium with variable activity against Mucorales. Fosmanogepix demonstrates significant in vivo efficacy in mouse and rabbit disseminated infection models due to C. albicans, C. glabrata, C. auris, C. tropicalis, Coccidioides immitis, and F. solani as well as pulmonary infection models of A. fumigatus, A. flavus, S. prolificans, S. apiospermum and Rhizopus arrhizus. Clinical trials demonstrated high oral bioavailability (>90%), enabling switching between fosmanogepix intravenous and oral formulations without compromising blood levels. Favorable drug-drug interaction, tolerability, and wide tissue distribution profiles are observed making fosmanogepix an attractive option for the treatment of invasive fungal infections. This systematic review summarizes the findings of published data on fosmanogepix.
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Affiliation(s)
| | - Ashraf S. Ibrahim
- The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, CA 90502, USA
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA
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In Vitro Activity of Manogepix (APX001A) and Comparators against Contemporary Molds: MEC Comparison and Preliminary Experience with Colorimetric MIC Determination. Antimicrob Agents Chemother 2020; 64:AAC.00730-20. [PMID: 32513793 DOI: 10.1128/aac.00730-20] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/02/2020] [Indexed: 12/26/2022] Open
Abstract
Manogepix (APX001A) is the active moiety of the drug candidate fosmanogepix (APX001), currently in clinical development for the treatment of invasive fungal infections. We compared manogepix EUCAST minimum effective concentrations (MECs) to MICs of five comparators and CLSI MECs and MICs by a colorimetric method against contemporary molds. EUCAST susceptibility testing was performed for 161 isolates. Interlaboratory and intermethod reproducibility were determined by comparison with published manogepix MECs. Colorimetric MICs (measuring metabolic activity) were evaluated using three Aspergillus fumigatus isolates and one Aspergillus flavus isolate with four inocula at 24 to 48 h of incubation and 1 to 3 h 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide salt (XTT)/menadione (MEN) exposure. Manogepix modal MECs (range in mg/liter) against Aspergillus species were 0.03 to 0.06 (0.008 to 0.125) and unaffected by itraconazole resistance. Manogepix was as active against two Fusarium isolates but inactive against Trichophyton interdigitale, Lichtheimia ramosa, and Rhizomucor pusillus isolates (MECs >0.5). Modal MEC/MICs were ≥3 2-fold dilutions apart without overlapping ranges comparing manogepix with amphotericin B, isavuconazole, and voriconazole against Aspergillus isolates. Manogepix and posaconazole MECs/MICs correlated for Aspergillus niger (Pearson's r = 0.711; P = 0.0044). The MEC at which 50% of the isolates tested are inhibited (MEC50), mode, and MEC90 values were within ±1 dilution in all cases compared with published EUCAST and CLSI data. The colorimetric method showed excellent agreement with the MECs when plates were inoculated with the lowest inoculum (1 × 102 CFU/ml to 2.5 × 102 CFU/ml), incubated for 24 h, and exposed for 1 to 3 h to XTT/MEN. Broad-spectrum in vitro activity of manogepix against clinically relevant molds was confirmed with excellent agreement across EUCAST and CLSI methods reported from experienced mycology laboratories. Colorimetric MIC determination warrants further investigation as a potential alternative that is less dependent on mycology expertise.
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