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Beredaki MI, Arendrup MC, Pournaras S, Meletiadis J. Comparative pharmacodynamics and dose optimization of liposomal amphotericin B against Candida species in an in vitro pharmacokinetic/pharmacodynamic model. Antimicrob Agents Chemother 2024:e0022524. [PMID: 38958455 DOI: 10.1128/aac.00225-24] [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: 02/11/2024] [Accepted: 05/23/2024] [Indexed: 07/04/2024] Open
Abstract
As comparative pharmacokinetic/pharmacodynamic (PK/PD) studies of liposomal amphotericin B (L-AMB) against Candida spp. are lacking, we explored L-AMB pharmacodynamics against different Candida species in an in vitro PK/PD dilution model. Eight Candida glabrata, Candida parapsilosis, and Candida krusei isolates (EUCAST/CLSI AMB MIC 0.125-1 mg/L) were studied in the in vitro PK/PD model simulating L-AMB Cmax = 0.25-64 mg/L and t1/2 = 9 h. The model was validated with one susceptible and one resistant Candida albicans isolate. The Cmax/MIC-log10CFU/mL reduction from the initial inoculum was analyzed with the Emax model, and Monte Carlo analysis was performed for the standard (3 mg/kg with Cmax = 21.87 ± 12.47 mg/L) and higher (5 mg/kg with Cmax = 83 ± 35.2 mg/L) L-AMB dose. A ≥1.5 log10CFU/mL reduction was found at L-AMB Cmax = 8 mg/L against C. albicans, C. parapsilosis, and C. krusei isolates (MIC 0.25-0.5 mg/L) whereas L-AMB Cmax ≥ 32 mg/L was required for C. glabrata isolates. The in vitro PK/PD relationship followed a sigmoidal pattern (R2 ≥ 0.85) with a mean Cmax/MIC required for stasis of 2.1 for C. albicans (close to the in vivo stasis), 24/17 (EUCAST/CLSI) for C. glabrata, 8 for C. parapsilosis, and 10 for C. krusei. The probability of target attainment was ≥99% for C. albicans wild-type (WT) isolates with 3 mg/kg and for wild-type isolates of the other species with 5 mg/kg. L-AMB was four- to eightfold less active against the included non-C. albicans species than C. albicans. A standard 3-mg/kg dose is pharmacodynamically sufficient for C. albicans whereas our data suggest that 5 mg/kg may be recommendable for the included non-C. albicans species.
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Affiliation(s)
- Maria-Ioanna Beredaki
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, NKUA, Athens, Greece
| | - Maiken C Arendrup
- Unit of Mycology, Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Spyros Pournaras
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, NKUA, Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, NKUA, Athens, Greece
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Chieochanthanakij R, Wattanasatja V, Passorn P, Wannigama DL, Kanjanabuch T. Caregiver skin infection causing peritoneal dialysis-associated peritonitis. Med Mycol Case Rep 2024; 44:100653. [PMID: 38884003 PMCID: PMC11176955 DOI: 10.1016/j.mmcr.2024.100653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/08/2024] [Accepted: 05/23/2024] [Indexed: 06/18/2024] Open
Abstract
We present the first case report of peritoneal dialysis (PD)-associated peritonitis due to Gibellulopsis nigrescens, with the same pathogen detected in her caregiver's tinea capitis. This confirms that touch contamination from the caregiver's infection was the primary source of this rare organism. The species of pathogen causing peritonitis and her caregiver's scalp lesions were identified by DNA barcoding. The patient responded well to timely PD catheter removal and a 2-week course of systemic amphotericin B deoxycholate. Preventive strategies should prioritize hygiene practices, including maintaining adequate personal hygiene and practicing thorough hand washing, to mitigate the risk of touch contamination and subsequent infection with fungal pathogens.
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Affiliation(s)
| | - Veerapat Wattanasatja
- Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Panthira Passorn
- Department of Internal Medicine, Sawanpracharak Hospital, Nakhon Sawan, 60000, Thailand
| | - Dhammika Leshan Wannigama
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence in Antimicrobial Resistance and Stewardship, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia
- Biofilms and Antimicrobial Resistance Consortium of ODA Receiving Countries, The University of Sheffield, Sheffield, United Kingdom
- Pathogen Hunter's Research Collaborative Team, Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Talerngsak Kanjanabuch
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- CAPD Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Beredaki MI, Sanidopoulos I, Pournaras S, Meletiadis J. Defining Optimal Doses of Liposomal Amphotericin B Against Candida auris: Data From an In Vitro Pharmacokinetic/Pharmacodynamic Model. J Infect Dis 2024; 229:599-607. [PMID: 38109276 PMCID: PMC10873176 DOI: 10.1093/infdis/jiad583] [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: 08/16/2023] [Revised: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Candida auris isolates exhibit elevated amphotericin B (AMB) minimum inhibitory concentrations (MICs). As liposomal AMB (L-AMB) can be safely administered at high doses, we explored L-AMB pharmacodynamics against C. auris isolates in an in vitro pharmacokinetic/pharmacodynamic (PK/PD) dilution model. METHODS Four C. auris isolates with Clinical and Laboratory Standards Institute (CLSI) AMB MICs = 0.5-2 mg/L were tested in an in vitro PK/PD model simulating L-AMB pharmacokinetics. The in vitro model was validated using a Candida albicans isolate tested in animals. The peak concentration (Cmax)/MIC versus log10 colony-forming units (CFU)/mL reduction from the initial inoculum was analyzed with the sigmoidal model with variable slope (Emax model). Monte Carlo analysis was performed for the standard (3 mg/kg) and higher (5 mg/kg) L-AMB doses. RESULTS The in vitro PK/PD relationship Cmax/MIC versus log10 CFU/mL reduction followed a sigmoidal pattern (R2 = 0.91 for C. albicans, R2 = 0.86 for C. auris). The Cmax/MIC associated with stasis was 2.1 for C. albicans and 9 for C. auris. The probability of target attainment was >95% with 3 mg/kg for wild-type C. albicans isolates with MIC ≤2 mg/L and C. auris isolates with MIC ≤1 mg/L whereas 5 mg/kg L-AMB is needed for C. auris isolates with MIC 2 mg/L. CONCLUSIONS L-AMB was 4-fold less active against C. auris than C. albicans. Candida auris isolates with CLSI MIC 2 mg/L would require a higher L-AMB dose.
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Affiliation(s)
- Maria-Ioanna Beredaki
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Sanidopoulos
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyros Pournaras
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Franconi I, Lupetti A. In Vitro Susceptibility Tests in the Context of Antifungal Resistance: Beyond Minimum Inhibitory Concentration in Candida spp. J Fungi (Basel) 2023; 9:1188. [PMID: 38132789 PMCID: PMC10744879 DOI: 10.3390/jof9121188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023] Open
Abstract
Antimicrobial resistance is a matter of rising concern, especially in fungal diseases. Multiple reports all over the world are highlighting a worrisome increase in azole- and echinocandin-resistance among fungal pathogens, especially in Candida species, as reported in the recently published fungal pathogens priority list made by WHO. Despite continuous efforts and advances in infection control, development of new antifungal molecules, and research on molecular mechanisms of antifungal resistance made by the scientific community, trends in invasive fungal diseases and associated antifungal resistance are on the rise, hindering therapeutic options and clinical cures. In this context, in vitro susceptibility testing aimed at evaluating minimum inhibitory concentrations, is still a milestone in the management of fungal diseases. However, such testing is not the only type at a microbiologist's disposal. There are other adjunctive in vitro tests aimed at evaluating fungicidal activity of antifungal molecules and also exploring tolerance to antifungals. This plethora of in vitro tests are still left behind and performed only for research purposes, but their role in the context of invasive fungal diseases associated with antifungal resistance might add resourceful information to the clinical management of patients. The aim of this review was therefore to revise and explore all other in vitro tests that could be potentially implemented in current clinical practice in resistant and difficult-to-treat cases.
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Affiliation(s)
- Iacopo Franconi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy;
- Mycology Unit, Pisa University Hospital, 56126 Pisa, Italy
| | - Antonella Lupetti
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy;
- Mycology Unit, Pisa University Hospital, 56126 Pisa, Italy
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Novy E, Roger C, Roberts JA, Cotta MO. Pharmacokinetic and pharmacodynamic considerations for antifungal therapy optimisation in the treatment of intra-abdominal candidiasis. Crit Care 2023; 27:449. [PMID: 37981676 PMCID: PMC10659066 DOI: 10.1186/s13054-023-04742-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023] Open
Abstract
Intra-abdominal candidiasis (IAC) is one of the most common of invasive candidiasis observed in critically ill patients. It is associated with high mortality, with up to 50% of deaths attributable to delays in source control and/or the introduction of antifungal therapy. Currently, there is no comprehensive guidance on optimising antifungal dosing in the treatment of IAC among the critically ill. However, this form of abdominal sepsis presents specific pharmacokinetic (PK) alterations and pharmacodynamic (PD) challenges that risk suboptimal antifungal exposure at the site of infection in critically ill patients. This review aims to describe the peculiarities of IAC from both PK and PD perspectives, advocating an individualized approach to antifungal dosing. Additionally, all current PK/PD studies relating to IAC are reviewed in terms of strength and limitations, so that core elements for the basis of future research can be provided.
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Affiliation(s)
- Emmanuel Novy
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia
- Department of Anaesthesiology, Critical Care and Peri-Operative Medicine, University Hospital of Nancy, Nancy, France
- Université de Lorraine, SIMPA, 54500, Nancy, France
| | - Claire Roger
- Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nimes University Hospital, Place du Professeur Robert Debré, 30029, Nîmes Cedex 9, France
- UR UM103 IMAGINE, Univ Montpellier, Montpellier, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia.
- Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nimes University Hospital, Place du Professeur Robert Debré, 30029, Nîmes Cedex 9, France.
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia.
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane & Women's Hospital Campus Herston, Brisbane, QLD, 4029, Australia
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Jauregizar N, Quindós G, Gil-Alonso S, Suárez E, Sevillano E, Eraso E. Postantifungal Effect of Antifungal Drugs against Candida: What Do We Know and How Can We Apply This Knowledge in the Clinical Setting? J Fungi (Basel) 2022; 8:jof8070727. [PMID: 35887482 PMCID: PMC9317160 DOI: 10.3390/jof8070727] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 02/07/2023] Open
Abstract
The study of the pharmacological properties of an antifungal agent integrates the drug pharmacokinetics, the fungal growth inhibition, the fungicidal effect and the postantifungal activity, laying the basis to guide optimal dosing regimen selection. The current manuscript reviews concepts regarding the postantifungal effect (PAFE) of the main classes of drugs used to treat Candida infections or candidiasis. The existence of PAFE and its magnitude are highly dependent on both the fungal species and the class of the antifungal agent. Therefore, the aim of this article was to compile the information described in the literature concerning the PAFE of polyenes, azoles and echinocandins against the Candida species of medical interest. In addition, the mechanisms involved in these phenomena, methods of study, and finally, the clinical applicability of these studies relating to the design of dosing regimens were reviewed and discussed. Additionally, different factors that could determine the variability in the PAFE were described. Most PAFE studies were conducted in vitro, and a scarcity of PAFE studies in animal models was observed. It can be stated that the echinocandins cause the most prolonged PAFE, followed by polyenes and azoles. In the case of the triazoles, it is worth noting the inconsistency found between in vitro and in vivo studies.
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Affiliation(s)
- Nerea Jauregizar
- Department of Pharmacology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain;
- Correspondence:
| | - Guillermo Quindós
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain; (G.Q.); (S.G.-A.); (E.S.); (E.E.)
| | - Sandra Gil-Alonso
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain; (G.Q.); (S.G.-A.); (E.S.); (E.E.)
| | - Elena Suárez
- Department of Pharmacology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain;
| | - Elena Sevillano
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain; (G.Q.); (S.G.-A.); (E.S.); (E.E.)
| | - Elena Eraso
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain; (G.Q.); (S.G.-A.); (E.S.); (E.E.)
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Hashemian SM, Farhadi T, Velayati AA. Caspofungin: a review of its characteristics, activity, and use in intensive care units. Expert Rev Anti Infect Ther 2020; 18:1213-1220. [PMID: 32662712 DOI: 10.1080/14787210.2020.1794817] [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
INTRODUCTION Candidemia is the fourth frequent reason of healthcare-related bloodstream infections in critically ill patients. For initial management of (suspected) invasive candidiasis in critically ill patients, usage of an echinocandin, e.g. caspofungin, has been recommended. AREAS COVERED In this study, characteristics of caspofungin and its use in intensive care unit (ICU) patients are reviewed based on an electronic search using PubMed and Google scholar. EXPERT OPINION Caspofungin is a semisynthetic derivative from pneumocandin B and the first member of the echinocandins that was approved by the U.S. Food and Drug Administration (FDA) to fight fungal infection. Caspofungin inhibits the enzyme β(1,3)-D-glucan synthase of the fungal cell wall resulted in inhibition of the synthesis of β(1,3)-D-glucan. For critically ill patients, inter- and intraindividual variations affect the caspofungin concentration. The incidence rates and densities of candidemia in surgical ICUs may be higher than medical ICUs resulting in a higher burden of candidemia in surgical ICUs. However, the mortality rate in surgical ICU patients with candidemia is higher than that medical ICU patients due to differences in their underlying conditions.
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Affiliation(s)
- Seyed MohammadReza Hashemian
- Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences , Tehran, Iran.,Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences , Tehran, Iran
| | - Tayebeh Farhadi
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences , Tehran, Iran
| | - Ali Akbar Velayati
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences , Tehran, Iran
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Abstract
PURPOSE OF REVIEW The successful treatment of surgical fungal infections depends of a timely and adequate source control alongside with the use of prompt systemic antifungals. The main challenge of antifungal use in critically ill surgical patients is to find a balance between rational versus indiscriminate use in order to accomplish an antifungal stewardship program. RECENT FINDINGS Surgical fungal infections represent an important burden in the daily clinical activity in many ICUs. The efficacy of the available antifungal drugs has not been adequately assessed in randomized controlled trials with surgical fungal infections in ICU patients. Most clinical experience is limited to case reports or uncontrolled case series. Due to the lack of adequate scientific evidence to assess the role of the different antifungals in surgical ICU patients, it is usually suggested to follow the recommendations for invasive candidiasis and candidemia. SUMMARY Antifungal use in the surgical patients admitted to an ICU is a complex matter and there are several elements to consider like the presence of septic shock and multiorgan failure, local epidemiology and antifungal resistance, among others. The proper use of antifungals alongside early recognition and prompt source control, are critical factors for improved outcomes.
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Nagy F, Bozó A, Tóth Z, Daróczi L, Majoros L, Kovács R. In vitro antifungal susceptibility patterns of planktonic and sessile Candida kefyr clinical isolates. Med Mycol 2019; 56:493-500. [PMID: 28992253 DOI: 10.1093/mmy/myx062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/13/2017] [Indexed: 12/25/2022] Open
Abstract
The activity of fluconazole, amphotericin B, caspofungin and micafungin was determined using XTT-based fungal damage assays against planktonic cells, early and mature biofilms of Candida kefyr. Median MICs of planktonic cells were 0.25 mg/l, 0.25 mg/l, 0.5 mg/l, and 0.06 mg/l for fluconazole, amphotericin B, caspofungin, and micafungin, respectively. Fluconazole showed at least 50% fungal damage at ≥4 mg/l (51.5% ± 6.63% to 78.38% ± 1.44%) and at ≥128 mg/l (57.88% ± 9.2% to 67.25% ± 9.59%), while amphotericin B produced an even higher anti-biofilm effect at ≥0.5 mg/l (64.63% ± 6.79% to 79.5% ± 5.9%) and at ≥0.12 mg/l (77.63% ± 8.43% to 92.75% ± 1.89%) against early and mature biofilms, respectively. In case of micafungin, 50% fungal damage was observed at ≥0.06 mg/l (66.88% ± 10.16% to 98.63% ± 1.24%) and ≥0.25 mg/l (74.13% ± 10.77% to 99.38% ± 0.38%) for early and mature biofilms, respectively. Caspofungin-exposed cells showed an unexpected susceptibility pattern, that is, planktonic cells showed significantly decreased susceptibility at concentrations ranging from 0.015 mg/l to 1 mg/l compared to biofilms (P < .05-.01). The damage in planktonic cells and biofilms was comparable at higher concentrations. For planktonic cells and biofilms, 50% fungal damage was observed first at 0.5 mg/l (59.75% ± 3.16%) and at 0.06 mg/l (70.25% ± 10.95%), respectively. This unexpected pattern was confirmed using scanning electron microscopy. The unusual susceptibility pattern observed at lower caspofungin concentrations may explain the poorer outcome of caspofungin-treated C. kefyr infections documented in certain patient populations. As this phenomenon was markedly less apparent in case of micafungin, these data suggest that micafungin may be a more reliable option than caspofungin for the treatment of C. kefyr infections.
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Affiliation(s)
- Fruzsina Nagy
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Hungary
| | - Aliz Bozó
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Hungary
| | - Zoltán Tóth
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Hungary
| | - Lajos Daróczi
- Department of Solid State Physics, Faculty of Science and Technology, University of Debrecen, Hungary
| | - László Majoros
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Hungary
| | - Renátó Kovács
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Hungary.,Faculty of Pharmacy, University of Debrecen, Hungary
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Dudiuk C, Berrio I, Leonardelli F, Morales-Lopez S, Theill L, Macedo D, Yesid-Rodriguez J, Salcedo S, Marin A, Gamarra S, Garcia-Effron G. Antifungal activity and killing kinetics of anidulafungin, caspofungin and amphotericin B against Candida auris. J Antimicrob Chemother 2019; 74:2295-2302. [DOI: 10.1093/jac/dkz178] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/08/2019] [Accepted: 04/02/2019] [Indexed: 01/21/2023] Open
Abstract
AbstractBackgroundCandida auris is an emerging MDR pathogen. It shows reduced susceptibility to azole drugs and, in some strains, high amphotericin B MICs have been described. For these reasons, echinocandins were proposed as first-line treatment for C. auris infections. However, information on how echinocandins and amphotericin B act against this species is lacking.ObjectivesOur aim was to establish the killing kinetics of anidulafungin, caspofungin and amphotericin B against C. auris by time–kill methodology and to determine if these antifungals behave as fungicidal or fungistatic agents against this species.MethodsThe susceptibility of 50 C. auris strains was studied. Nine strains were selected (based on echinocandin MICs) to be further studied. Minimal fungicidal concentrations, in vitro dose–response and time–kill patterns were determined.ResultsEchinocandins showed lower MIC values than amphotericin B (geometric mean of 0.12 and 0.94 mg/L, respectively). Anidulafungin and caspofungin showed no fungicidal activity at any concentration (maximum log decreases in cfu/mL between 1.34 and 2.22). On the other hand, amphotericin B showed fungicidal activity, but at high concentrations (≥2.00 mg/L). In addition, the tested polyene was faster than echinocandins at killing 50% of the initial inoculum (0.92 versus >8.00 h, respectively).ConclusionsAmphotericin B was the only agent regarded as fungicidal against C. auris. Moreover, C. auris should be considered tolerant to caspofungin and anidulafungin considering that their MFC:MIC ratios were mostly ≥32 and that after 6 h of incubation the starting inoculum was not reduced in >90%.
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Affiliation(s)
- Catiana Dudiuk
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), CCT, Santa Fe, Argentina
| | - Indira Berrio
- Medical and Experimental Mycology Group, Corporación para Investigaciones Biológicas (CIB), Medellín, Colombia
- Hospital general de Medellin ‘Luz Castro de Gutiérrez’ ESE, Medellín, Colombia
| | - Florencia Leonardelli
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), CCT, Santa Fe, Argentina
| | - Soraya Morales-Lopez
- Universidad de Santander, Facultad de Ciencias de la Salud, Grupo de Investigación CIENCIA UDES, Valledupar, Colombia
- Laboratorios Nancy Flórez García S.A.S., Valledupar, Colombia
| | - Laura Theill
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
| | - Daiana Macedo
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), CCT, Santa Fe, Argentina
| | - José Yesid-Rodriguez
- Centro de Investigaciones Microbiológicas del Cesar, CIMCE, Valledupar, Colombia
| | | | | | - Soledad Gamarra
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
| | - Guillermo Garcia-Effron
- Laboratorio de Micología y Diagnóstico Molecular, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Santa Fe, Argentina
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), CCT, Santa Fe, Argentina
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Martin-Loeches I, Antonelli M, Cuenca-Estrella M, Dimopoulos G, Einav S, De Waele JJ, Garnacho-Montero J, Kanj SS, Machado FR, Montravers P, Sakr Y, Sanguinetti M, Timsit JF, Bassetti M. ESICM/ESCMID task force on practical management of invasive candidiasis in critically ill patients. Intensive Care Med 2019; 45:789-805. [PMID: 30911804 DOI: 10.1007/s00134-019-05599-w] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 03/09/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The term invasive candidiasis (IC) refers to both bloodstream and deep-seated invasive infections, such as peritonitis, caused by Candida species. Several guidelines on the management of candidemia and invasive infection due to Candida species have recently been published, but none of them focuses specifically on critically ill patients admitted to intensive care units (ICUs). MATERIAL AND METHODS In the absence of available scientific evidence, the resulting recommendations are based solely on epidemiological and clinical evidence in conjunction with expert opinion. The task force used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to evaluate the recommendations and assign levels of evidence. The recommendations and their strength were decided by consensus and, if necessary, by vote (modified Delphi process). Descriptive statistics were used to analyze the results of the Delphi process. Statements obtaining > 80% agreement were considered to have achieved consensus. CONCLUSIONS The heterogeneity of this patient population necessitated the creation of a mixed working group comprising experts in clinical microbiology, infectious diseases and intensive care medicine, all chosen on the basis of their expertise in the management of IC and/or research methodology. The working group's main goal was to provide clinicians with clear and practical recommendations to optimize microbiological diagnosis and treatment of IC. The Systemic Inflammation and Sepsis and Infection sections of the European Society of Intensive Care Medicine (ESICM) and the Critically Ill Patients Study Group of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) therefore decided to develop a set of recommendations for application in non-immunocompromised critically ill patients.
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Affiliation(s)
- Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland. .,Hospital Clinic, Universidad de Barcelona, CIBERes, Barcelona, Spain.
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, National and Kapodistrian University of Athens, Athens, Greece
| | - Sharon Einav
- General Intensive Care Unit, Shaare Zedek Medical Centre and the Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain.,Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Souha S Kanj
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
| | - Flavia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Philippe Montravers
- Paris Diderot, Sorbonne Cite University, and Anaesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP, INSERM, UMR 1152, Paris, France
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Maurizio Sanguinetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Institute of Microbiology, Rome, Italy
| | - Jean-Francois Timsit
- UMR 1137, IAME Inserm/University Paris Diderot, Paris, France.,APHP, Bichat Hospital, Intensive Care Unit, Paris, France
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
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Keane S, Geoghegan P, Povoa P, Nseir S, Rodriguez A, Martin-Loeches I. Systematic review on the first line treatment of amphotericin B in critically ill adults with candidemia or invasive candidiasis. Expert Rev Anti Infect Ther 2018; 16:839-847. [PMID: 30257597 DOI: 10.1080/14787210.2018.1528872] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Invasive candidiasis is the most common fungal infection affecting critically ill adults. International guidelines provide differing recommendations for first-line antifungal therapy, with echinocandins considered first-line in the majority. Amphotericin B has broad activity and low minimum inhibitory concentration resistance patterns across most Candida species and guidance away from its use should be supported by the available evidence. Areas Covered: A systematic literature review was conducted from August to September 2017 to determine whether treatment with echinocandins or other available drugs, namely voriconazole, confers a therapeutic or survival benefit over amphotericin B in critically ill adults with invasive candidiasis. Inclusion criteria were: (1) studies describing critically ill adults with invasive candidiasis, (2) studies describing therapeutic benefit or survival as an outcome, and (3) studies comparing amphotericin B, deoxycholate or lipid preparations, with any newer antifungal agent. Eight studies were included in the final review, incorporating 2352 unique patients. No difference in treatment efficacy or mortality outcomes in critically ill patients with invasive candidiasis receiving an amphotericin B formulation compared with those receiving an echinocandin or voriconazole was shown. Expert Commentary: We conclude that in the existing literature, there is no evidence that choice between echinocandins, voriconazole, or amphotericin B formulations as first-line therapy for critically ill adults with invasive candidiasis is associated with a therapeutic or survival benefit. Clinicians must therefore consider other factors in the selection of first-line therapy.
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Affiliation(s)
- Sean Keane
- a Department of Anaesthesia and Critical Care Medicine , St. James's Hospital , Dublin , Ireland
| | - Pierce Geoghegan
- a Department of Anaesthesia and Critical Care Medicine , St. James's Hospital , Dublin , Ireland
| | - Pedro Povoa
- b Polyvalent Intensive Care Unit , Hospital de São Francisco Xavier, Centro Hospital de Lisboa Ocidental , Lisboa , Portugal.,c NOVA Medical School , New University of Lisbon , Lisboa , Portugal
| | - Saad Nseir
- d Centre de Réanimation , CHU Lille , Lille , France.,e Medicine School , Lille University , Lille , France
| | - Alejandro Rodriguez
- f Critical Care Department , Hospital Universitario de Tarragona Joan XXIII, URV, IISPV, CIBERES , Tarragona , Spain
| | - Ignacio Martin-Loeches
- g Pulmonary Intensive Care Unit , Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS , Barcelona , Spain.,h St. James's Hospital , Multidisciplinary Intensive Care Research Organization (MICRO) , Dublin , Ireland
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Gómez-Sequeda N, Torres R, Ortiz C. Synthesis, characterization, and in vitro activity against Candida spp. of fluconazole encapsulated on cationic and conventional nanoparticles of poly(lactic-co-glycolic acid). Nanotechnol Sci Appl 2017; 10:95-104. [PMID: 28572725 PMCID: PMC5441665 DOI: 10.2147/nsa.s96018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
In this study, nanoparticles (NPs) of poly(lactic-co-glycolic acid) (PLGA) loaded with fluconazole (FLZ) and FLZ-NPs coated with the cationic polymer polyethylenimine (PEI) (FLZ-NP-PEI) were synthetized in order to improve antimycotic activity against four strains of Candida spp. of clinical relevance. FLZ-NPs and FLZ-NP-PEI were synthesized by double emulsion solvent-diffusion (DES-D) and characterized. Minimum inhibitory concentration (MIC50) and minimum fungicide concentration (MFC) were determined in vitro by culturing Candida strains in the presence of these nanocompounds. FLZ-NPs were spherical in shape with hydrodynamic sizes of ~222 nm and surface charge of -11.6 mV. The surface charges of these NPs were successfully modified using PEI (FLZ-NP-PEI) with mean hydrodynamic sizes of 281 nm and surface charge of 23.5 mV. The efficiency of encapsulation (~53%) and a quick release of FLZ (≥90% after 3 h) were obtained. Cytotoxicity assay showed a good cell viability for FLZ-NPs (≥86%), and PEI-modified NPs presented a decrease in cell viability (~38%). FLZ-NPs showed an increasing antifungal activity of FLZ for sensitive (Candida parapsilosis ATCC22019 and Candida albicans ATCC10231, MIC50 =0.5 and 0.1 µg/mL, respectively) and resistant strains (Candida glabrata EMLM14 and Candida krusei ATCC6258, MIC50 =0.1 and 0.5 µg/mL, respectively). FLZ-NP-PEI showed fungicidal activity even against C. glabrata and C. krusei (MFC =4 and 8 µg/mL, respectively). MIC50 values showed best results for FLZ-NPs and FLZ-NP-PEI. Nevertheless, only FLZ-NP-PEI displayed fungicidal activity against the studied strains.
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Affiliation(s)
| | | | - Claudia Ortiz
- School of Microbiology, Faculty of Health, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
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14
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Aversa F, Busca A, Candoni A, Cesaro S, Girmenia C, Luppi M, Nosari AM, Pagano L, Romani L, Rossi G, Venditti A, Novelli A. Liposomal amphotericin B (AmBisome®) at beginning of its third decade of clinical use. J Chemother 2017; 29:131-143. [DOI: 10.1080/1120009x.2017.1306183] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Franco Aversa
- Department of Clinical and Experimental Medicine, Hematology and BMT Unit, University of Parma, Parma, Italy
| | - Alessandro Busca
- Department of Oncology and Hematology, BMT Unit, A.O. Citta’ della Salute e della Scienza di Torino, Torino, Italy
| | - Anna Candoni
- Hematology and Center for Stem Cell Transplantation and Cell Therapy, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, G.B. Rossi Hosptial, Verona, Italy
| | | | - Mario Luppi
- Department of Medical and Surgical Sciences UNIMORE, Division of Hematology AOU Policlinico, Modena, Italy
| | - Anna Maria Nosari
- Dipartimento di Ematologia ed Oncologia, Niguarda Cancer Centre ASST Grande Ospedale Metropolitano Niguarda Piazza Ospedale, Milano, Italy
| | - Livio Pagano
- Hematology Unit, Catholic University Holy Hearth, Roma, Italy
| | - Luigina Romani
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Giuseppe Rossi
- Ematologia e Dipartimento di Oncologia Clinica, A.O. Spedali Civili, Brescia, Italy
| | | | - Andrea Novelli
- Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Florence, Florence, Italy
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15
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Bona E, Cantamessa S, Pavan M, Novello G, Massa N, Rocchetti A, Berta G, Gamalero E. Sensitivity of Candida albicans to essential oils: are they an alternative to antifungal agents? J Appl Microbiol 2016; 121:1530-1545. [PMID: 27568869 DOI: 10.1111/jam.13282] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/14/2016] [Accepted: 08/25/2016] [Indexed: 11/30/2022]
Abstract
AIMS Candida albicans is an important opportunistic pathogen, responsible for the majority of yeast infections in humans. Essential oils, extracted from aromatic plants, are well-known antimicrobial agents, characterized by a broad spectrum of activities, including antifungal properties. The aim of this work was to assess the sensitivity of 30 different vaginal isolated strains of C. albicans to 12 essential oils, compared to the three main used drugs (clotrimazole, fluconazole and itraconazole). METHODS AND RESULTS Thirty strains of C. albicans were isolated from vaginal swab on CHROMagar™ Candida. The agar disc diffusion method was employed to determine the sensitivity to the essential oils. The antifungal activity of the essential oils and antifungal drugs (clotrimazole, itraconazole and fluconazole) were investigated using a microdilution method. Transmission and scanning electron microscopy analyses were performed to get a deep inside on cellular damages. Mint, basil, lavender, tea tree oil, winter savory and oregano essential oils inhibited both the growth and the activity of C. albicans more efficiently than clotrimazole. Damages induced by essential oils at the cellular level were stronger than those caused by clotrimazole. CONCLUSIONS Candida albicans is more sensitive to different essential oils compared to the main used drugs. Moreover, the essential oil affected mainly the cell wall and the membranes of the yeast. SIGNIFICANCE AND IMPACT OF THE STUDY The results of this work support the research for new alternatives or complementary therapies against vaginal candidiasis.
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Affiliation(s)
- E Bona
- Dipartimento di Scienze e Innovazione Tecnologica, Università del Piemonte Orientale, Alessandria, Italy
| | - S Cantamessa
- Dipartimento di Scienze e Innovazione Tecnologica, Università del Piemonte Orientale, Alessandria, Italy
| | - M Pavan
- Dipartimento di Scienze e Innovazione Tecnologica, Università del Piemonte Orientale, Alessandria, Italy
| | - G Novello
- Dipartimento di Scienze e Innovazione Tecnologica, Università del Piemonte Orientale, Alessandria, Italy
| | - N Massa
- Dipartimento di Scienze e Innovazione Tecnologica, Università del Piemonte Orientale, Alessandria, Italy
| | - A Rocchetti
- Azienda Sanitaria Santi Antonio, Biagio e Cesare Arrigo, Alessandria, Italy
| | - G Berta
- Dipartimento di Scienze e Innovazione Tecnologica, Università del Piemonte Orientale, Alessandria, Italy
| | - E Gamalero
- Dipartimento di Scienze e Innovazione Tecnologica, Università del Piemonte Orientale, Alessandria, Italy
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Gil-Alonso S, Jauregizar N, Eraso E, Quindós G. Postantifungal effect of caspofungin against the Candida albicans and Candida parapsilosis clades. Diagn Microbiol Infect Dis 2016; 86:172-7. [DOI: 10.1016/j.diagmicrobio.2016.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/07/2016] [Accepted: 07/10/2016] [Indexed: 01/05/2023]
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17
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Sanchis M, Martin-Vicente A, Capilla J, Guarro J. Antifungal therapies in murine infections byCandida kefyr. Mycoses 2016; 59:253-258. [DOI: 10.1111/myc.12468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Marta Sanchis
- Unitat de Microbiologia; Facultat de Medicina i Ciències de la Salut; IISPV; Universitat Rovira i Virgili; Reus Tarragona Spain
| | - Adela Martin-Vicente
- Unitat de Microbiologia; Facultat de Medicina i Ciències de la Salut; IISPV; Universitat Rovira i Virgili; Reus Tarragona Spain
| | - Javier Capilla
- Unitat de Microbiologia; Facultat de Medicina i Ciències de la Salut; IISPV; Universitat Rovira i Virgili; Reus Tarragona Spain
| | - Josep Guarro
- Unitat de Microbiologia; Facultat de Medicina i Ciències de la Salut; IISPV; Universitat Rovira i Virgili; Reus Tarragona Spain
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18
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Song JC, Stevens DA. Caspofungin: Pharmacodynamics, pharmacokinetics, clinical uses and treatment outcomes. Crit Rev Microbiol 2015; 42:813-46. [PMID: 26369708 DOI: 10.3109/1040841x.2015.1068271] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Over the past decade, echinocandins have emerged as first-line antifungal agents for many Candida infections. The echinocandins have a unique mechanism of action, inhibiting the synthesis of β-1,3-d-glucan polymers, key components of the cell wall in pathogenic fungi. Caspofungin was the first echinocandin antifungal agent to become licensed for use. The objectives of this review are to summarize the existing published data on caspofungin, under the subject headings of chemistry and mechanism of action, spectrum of activity, pharmacodynamics, pharmacokinetics, clinical studies, safety, drug interactions, dosing, and an overview of the drug's current place in therapy.
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Affiliation(s)
- Jessica C Song
- a Department of Pharmacy , Santa Clara Valley Medical Center , San Jose , CA , USA .,b California Institute for Medical Research , San Jose , CA , USA , and
| | - David A Stevens
- b California Institute for Medical Research , San Jose , CA , USA , and.,c Division of Infectious Diseases and Geographic Medicine , Stanford University School of Medicine , Stanford , CA , USA
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Dolton MJ, McLachlan AJ. Voriconazole pharmacokinetics and exposure-response relationships: assessing the links between exposure, efficacy and toxicity. Int J Antimicrob Agents 2014; 44:183-93. [PMID: 25106074 DOI: 10.1016/j.ijantimicag.2014.05.019] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 05/19/2014] [Indexed: 11/15/2022]
Abstract
The triazole antifungal voriconazole (VCZ) exhibits broad-spectrum antifungal activity and is the first-line treatment for invasive aspergillosis. Highly variable, non-linear pharmacokinetics, metabolism via the polymorphic drug-metabolising enzyme CYP2C19, and a range of serious adverse events (AEs) including hepatotoxicity and neurotoxicity complicate the clinical utility of VCZ. As interest in optimising VCZ treatment has increased, a growing number of studies have examined the relationships between VCZ exposure and efficacy in the treatment and prevention of invasive fungal infections, as well as associations with VCZ-related AEs. This review provides a critical analysis of VCZ pharmacokinetics and exposure-response (E-R) relationships, assessing the links between VCZ exposure, efficacy and toxicity. Low VCZ exposure has frequently been associated with a higher incidence of treatment failure; fewer studies have addressed E-R relationships with prophylactic VCZ. VCZ-related neurotoxicity appears common at high VCZ concentrations and can be minimised by maintaining concentrations below the recommended upper concentration thresholds; hepatotoxicity appears to be associated with increased VCZ exposure but is also prevalent at low concentrations. Further research should aim to inform and optimise the narrow therapeutic range of VCZ as well as develop interventions to individualise VCZ dosing to achieve maximal efficacy with minimal toxicity.
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Affiliation(s)
- Michael J Dolton
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia; Centre for Education and Research on Ageing, Concord Repatriation General Hospital, Sydney, NSW, Australia.
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Paredes K, Pastor FJ, Capilla J, Sutton DA, Mayayo E, Fothergill AW, Guarro J. Therapies against murine Candida guilliermondii infection, relationship between in vitro antifungal pharmacodynamics and outcome. Rev Iberoam Micol 2014; 32:34-9. [PMID: 24594291 DOI: 10.1016/j.riam.2013.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 10/09/2013] [Accepted: 10/11/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Candida guilliermondii has been recognized as an emerging pathogen showing a decreased susceptibility to fluconazole and considerably high echinocandin MICs. AIMS Evaluate the in vitro activity of anidulafungin in comparison to amphotericin B and fluconazole against different isolates of C. guilliermondii, and their efficacy in an immunosuppressed murine model of disseminated infection. METHODS The in vitro susceptibility of four strains against amphotericin B, fluconazole and anidulafungin was performed by using a reference broth microdilution method and time-kill curves. The in vivo efficacy was evaluated by determination of fungal load reduction in kidneys of infected animals receiving deoxycholate AMB at 0,8 mg/kg i.v., liposomal amphotericin B at 10 mg/kg i.v., fluconazole at 50 mg/kg, or anidulafungin at 10 mg/kg. RESULTS Amphotericin B and anidulafungin showed fungicidal activity, while fluconazole was fungistatic for all the strains. In the murine model, liposomal amphotericin B at 10 mg/kg/day was effective in reducing the tissue burden in kidneys of mice infected with any of the tested strains. However, amphotericin B, anidulafungin and fluconazole were only effective against those strains showing low MIC values. CONCLUSIONS Liposomal amphotericin B showed the higher activity and efficacy against the two strains of C. guilliermondii, in contrast to the poor effect of fluconazole and anidulafungin. Further studies with more isolates of C. guilliermondii representing a wider range of MICs should be carried out to assess whether there is any relationship between MIC values and anidulafungin efficacy.
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Affiliation(s)
- Katihuska Paredes
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Reus, Tarragona, Spain
| | - Francisco Javier Pastor
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Reus, Tarragona, Spain
| | - Javier Capilla
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Reus, Tarragona, Spain.
| | - Deanna A Sutton
- Fungus Testing Laboratory, University of Texas Health Science Center, San Antonio, TX, USA
| | - Emilio Mayayo
- Unitat de Anatomia Patològica, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Reus, Tarragona, Spain
| | - Annette W Fothergill
- Fungus Testing Laboratory, University of Texas Health Science Center, San Antonio, TX, USA
| | - Josep Guarro
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV, Universitat Rovira i Virgili, Reus, Tarragona, Spain
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Sandoval-Denis M, Pastor FJ, Capilla J, Sutton DA, Fothergill AW, Guarro J. In vitro pharmacodynamics and in vivo efficacy of fluconazole, amphotericin B and caspofungin in a murine infection by Candida lusitaniae. Int J Antimicrob Agents 2014; 43:161-4. [DOI: 10.1016/j.ijantimicag.2013.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 09/02/2013] [Accepted: 10/24/2013] [Indexed: 11/27/2022]
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Head-to-head comparison of inhibitory and fungicidal activities of fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole against clinical isolates of Trichosporon asahii. Antimicrob Agents Chemother 2013; 57:4841-7. [PMID: 23877683 DOI: 10.1128/aac.00850-13] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Treatment of disseminated Trichosporon infections still remains difficult. Amphotericin B frequently displays inadequate fungicidal activity and echinocandins have no meaningful antifungal effect against this genus. Triazoles are currently the drugs of choice for the treatment of Trichosporon infections. This study evaluates the inhibitory and fungicidal activities of five triazoles against 90 clinical isolates of Trichosporon asahii. MICs (μg/ml) were determined according to Clinical and Laboratory Standards Institute microdilution method M27-A3 at 24 and 48 h using two endpoints, MIC-2 and MIC-0 (the lowest concentrations that inhibited ∼50 and 100% of growth, respectively). Minimum fungicidal concentrations (MFCs; μg/ml) were determined by seeding 100 μl of all clear MIC wells (using an inoculum of 10(4) CFU/ml) onto Sabouraud dextrose agar. Time-kill curves were assayed against four clinical T. asahii isolates and the T. asahii ATCC 201110 strain. The MIC-2 (∼50% reduction in turbidity compared to the growth control well)/MIC-0 (complete inhibition of growth)/MFC values that inhibited 90% of isolates at 48 h were, respectively, 8/32/64 μg/ml for fluconazole, 1/2/8 μg/ml for itraconazole, 0.12/0.5/2 μg/ml for voriconazole, 0.5/2/4 μg/ml for posaconazole, and 0.25/1/4 μg/ml for isavuconazole. The MIC-0 endpoints yielded more consistent MIC results, which remained mostly unchanged when extending the incubation to 48 h (98 to 100% agreement with 24-h values) and are easier to interpret. Based on the time-kill experiments, none of the drugs reached the fungicidal endpoint (99.9% killing), killing activity being shown but at concentrations not reached in serum. Statistical analysis revealed that killing rates are dose and antifungal dependent. The lowest concentration at which killing activity begins was for voriconazole, and the highest was for fluconazole. These results suggest that azoles display fungistatic activity and lack fungicidal effect against T. asahii. By rank order, the most active triazole is voriconazole, followed by itraconazole ∼ posaconazole ∼ isavuconazole > fluconazole.
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Oz Y, Kiremitci A, Dag I, Metintas S, Kiraz N. Postantifungal effect of the combination of caspofungin with voriconazole and amphotericin B against clinicalCandida kruseiisolates. Med Mycol 2013; 51:60-5. [DOI: 10.3109/13693786.2012.697198] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cantón E, Pemán J, Hervás D, Espinel-Ingroff A. Examination of the in vitro fungicidal activity of echinocandins against Candida lusitaniae by time-killing methods. J Antimicrob Chemother 2012; 68:864-8. [PMID: 23228935 DOI: 10.1093/jac/dks489] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Candida lusitaniae fungaemia, although infrequent (1%), is more common in immunocompromised patients than Candida albicans. Although infections produced by Candida spp. are therapeutic targets for treatment with echinocandins, little information is available regarding their killing kinetics against C. lusitaniae. The objectives of this study were to determine the killing kinetics of anidulafungin, micafungin and caspofungin against four blood isolates of C. lusitaniae by time-kill methodology. METHODS Time-kill studies were performed in RMPI 1640 medium (5 mL, inoculum ∼10(5) cfu/mL). The number of cfu/mL was determined at 0, 2, 4, 6 and 24 h. The anidulafungin concentrations assayed were 0.03, 0.12, 0.5, 2 and 8 mg/L, while micafungin and caspofungin concentrations were 0.25, 1, 4, 16 and 32 mg/L. RESULTS MIC ranges were 0.03-1 mg/L (anidulafungin), 0.016-0.06 mg/L (micafungin) and 0.03-1 mg/L (caspofungin). The mean maximum log decrease in cfu/mL was reached with 2 mg/L anidulafungin (1.85 ± 0.4 log), 32 mg/L caspofungin (5.5 ± 0.2 log) and 32 mg/L micafungin (2.65 ± 1.9 log). Only caspofungin and micafungin reached the fungicidal endpoint (99.9% growth reduction or a 3 log decrease) with 32 mg/L at 22.8 h (caspofungin) and 26.5 h (micafungin). Analysis of variance showed significant differences in killing activity among isolates, but not among concentrations reached in serum or echinocandins. CONCLUSIONS Anidulafungin and micafungin exhibit greater killing rates than caspofungin. Caspofungin was the only echinocandin that reached the fungicidal endpoint before 24 h, but at drug concentrations (≥ 16 mg/L) not usually reached in serum. The echinocandin killing rate was isolate dependent and concentration independent.
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Affiliation(s)
- Emilia Cantón
- Unidad de Microbiología Experimental, Centro de Investigación, Hospital Universitario y Politécnico La Fe, Valencia 46009, Spain.
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Moriyama B, Henning SA, Penzak SR, Walsh TJ. The postantifungal and paradoxical effects of echinocandins against Candida spp. Future Microbiol 2012; 7:565-9. [PMID: 22568712 DOI: 10.2217/fmb.12.31] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Echinocandins induce a postantifungal effect and a paradoxical effect. The postantifungal effect is a concentration-dependent process that allows for sustained kill of Candida spp. after relatively brief exposures to a compound. The paradoxical effect is growth that occurs at high echinocandin concentrations above the MIC. Paradoxical growth varies in terms of media, species, strain and type of echinocandin. The study by Shields et al. evaluated the impact of a brief exposure of caspofungin on paradoxical growth and postantifungal effects in Candida albicans isolates. In the postantifungal effect experiments, prolonged concentration-dependent killing occurred. Maximum postantifungal effects occurred with caspofungin exposures of 5 or 15 min. A brief exposure of caspofungin eliminated the paradoxical growth that was observed in the time-kill experiments. The report by Shields et al. illustrates that short exposures to an echinocandin may lead to prolonged postantifungal effects and furthers our understanding of the paradoxical effect in C. albicans.
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Affiliation(s)
- Brad Moriyama
- NIH Clinical Center, Pharmacy Department, Bethesda, MD, USA
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Oz Y, Dag I, Kiraz N. Broth Microdilution and Time–Kill Testing of Caspofungin, Voriconazole, Amphotericin B and their Combinations Against Clinical Isolates of Candida krusei. Mycopathologia 2011; 173:27-34. [DOI: 10.1007/s11046-011-9459-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 08/03/2011] [Indexed: 10/17/2022]
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Five-minute exposure to caspofungin results in prolonged postantifungal effects and eliminates the paradoxical growth of Candida albicans. Antimicrob Agents Chemother 2011; 55:3598-602. [PMID: 21537017 DOI: 10.1128/aac.00095-11] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We studied the impact of brief caspofungin exposures on postantifungal effects (PAFEs) and paradoxical effects for five Candida albicans isolates. In time-kill studies, caspofungin at 4× and 16× the MIC resulted in significant killing of all isolates. Caspofungin at 8 μg/ml resulted in lower levels of killing, and paradoxical effects were evident with 4 isolates. Caspofungin exposures of 5 to 60 min caused prolonged, concentration-dependent killing that approached or exceeded the results seen with time-kill experiments and eliminated paradoxical growth.
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Pound MW, Townsend ML, Dimondi V, Wilson D, Drew RH. Overview of treatment options for invasive fungal infections. Med Mycol 2011; 49:561-80. [PMID: 21366509 DOI: 10.3109/13693786.2011.560197] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The introduction of several new antifungals has significantly expanded both prophylaxis and treatment options for invasive fungal infections (IFIs). Relative to amphotericin B deoxycholate, lipid-based formulations of amphotericin B have significantly reduced the incidence of nephrotoxicity, but at a significant increase in drug acquisition cost. Newer, broad-spectrum triazoles (notably voriconazole and posaconazole) have added significantly to both the prevention and treatment of IFIs, most notably Aspergillus spp. (with voriconazole) and the treatment of some emerging fungal pathogens. Finally, a new class of parenteral antifungals, the echinocandins, is employed most frequently against invasive candidal infections. While the role of these newer agents continues to evolve, this review summarizes the activity, safety and clinical applications of agents most commonly employed in the treatment of IFIs.
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Affiliation(s)
- Melanie W Pound
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC 27506, USA.
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Póvoa P, Gonçalves-Pereira J. Treatment of candidemia in adult patients without neutropenia--an inconvenient truth. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:114. [PMID: 21345263 PMCID: PMC3222043 DOI: 10.1186/cc9414] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In 2009 the Infectious Diseases Society of America reviewed the guidelines on the treatment of candidemia in non-neutropenic patients. In this document the preferred treatment was either fluconazole or an echinocandin. Amphotericin-B formulations were considered an alternative. However, careful assessment of published data showed similar efficacy between these drugs.
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Affiliation(s)
- Pedro Póvoa
- Unidade de Cuidados Intensivos Polivalente, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, EPE, Estrada do Forte do Alto do Duque, 1449-005 Lisboa, Portugal.
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Kamysz E, Simonetti O, Cirioni O, Arzeni D, Ganzetti G, Campanati A, Giacometti A, Gabrielli E, Silvestri C, Kamysz W, Offidani A, Barchiesi F. In vitro activity of the lipopeptide PAL-Lys-Lys-NH2, alone and in combination with antifungal agents, against clinical isolates of Candida spp. Peptides 2011; 32:99-103. [PMID: 21055432 DOI: 10.1016/j.peptides.2010.10.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 10/20/2010] [Accepted: 10/20/2010] [Indexed: 11/18/2022]
Abstract
Candida albicans is known to be the organism most often associated with serious fungal infection, but other Candida spp. are emerging as clinical pathogens associated with opportunistic infections. Among antimycotic treatments, increasing attention is currently given to anti-infective drugs based upon naturally occurring peptides, such as the short lipopeptide palmitoyl PAL-Lys-Lys-NH2 (PAL). The aim of this study is to evaluate the activity of this peptide compared to the traditional antifungal agents Fluconazole (FLU), amphotericin B (AMB) and caspofungin (CAS) on Candida spp. 24 clinical isolates of Candida spp. were tested against PAL, FLU, AMB and CAS using in vitro susceptibility tests, time killing and checkerboard assay. All of the drugs studied showed good activity against clinical isolates of candida; in particular CAS and AMB which have MICs value lower than PAL and FLU. Moreover we observed synergistic interactions for PAL/FLU (81.25%), PAL/AMB (75%) and particularly for PAL/CAS (87.5). We think that our results are interesting since synergy between PAL and CAS might be useful in clinic trails to treat invasive fungal infections.
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Affiliation(s)
- E Kamysz
- Faculty of Pharmacy, Medical University of Gdańsk University of Gdańsk, Poland
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Savini V, Catavitello C, Onofrillo D, Masciarelli G, Astolfi D, Balbinot A, Febbo F, D'Amario C, D'Antonio D. What do we know about Candida guilliermondii? A voyage throughout past and current literature about this emerging yeast. Mycoses 2010; 54:434-41. [PMID: 21039941 DOI: 10.1111/j.1439-0507.2010.01960.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Candida guilliermondii is an uncommon isolate throughout most of the world, the behaviour of which as an environmental fungus, a human saprophyte and an agent of serious infections has been emphasised over the years. Notably, illnesses caused by this pathogen mostly involve compromised cancer hosts and commonly lead patients to unfavourable outcomes. It is of concern that the yeast may acquire or inherently express reduced in vitro sensitivity to all antifungal classes, although widespread resistance has not yet been described, and poor correlation exists between MICs and clinical outcome. However, the organism appears as constitutively less susceptible to polyenes and echinocandins than other yeast-like fungi, so that the emergence of such pathogen in the clinical settings is of concern and may appear as a new challenge in the context of mycoses and antifungal therapy.
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Affiliation(s)
- Vincenzo Savini
- Clinical Microbiology and Virology Unit, Department of Transfusion Medicine, Spirito Santo Hospital, Pescara, Italy.
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Caspofungin affects growth of Paracoccidioides brasiliensis in both morphological phases. Antimicrob Agents Chemother 2010; 54:5391-4. [PMID: 20937789 DOI: 10.1128/aac.00617-10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Five Paracoccidioides brasiliensis isolates were grown in the presence of caspofungin (0 to 1 μg/ml). Inhibition of the yeast phase ranged from 20 to 65%, while in the mycelial form it ranged from 75% to 82%. Such variability was loosely related to the amount of cell wall β-1,3-glucan. No association with point mutations in the β-1,3-glucan synthase was detected. Caspofungin induced physical changes and cytoplasmic deterioration in both fungal phases.
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Pound MW, Townsend ML, Drew RH. Echinocandin pharmacodynamics: review and clinical implications. J Antimicrob Chemother 2010; 65:1108-18. [PMID: 20335190 DOI: 10.1093/jac/dkq081] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Echinocandins have made a significant impact in the treatment of select invasive fungal infections, most notably invasive candidiasis and aspergillosis. However, treatment outcomes for such infections are still less than optimal, prompting an examination of dosing and administration techniques in an attempt to exploit known pharmacodynamic properties and improve outcomes. Echinocandins generally exhibit concentration-dependent, fungicidal activity against Candida spp. and fungistatic activity against Aspergillus spp. However, increasing drug concentrations of echinocandins above the organism's MIC may result in a paradoxical increase in fungal growth as demonstrated in some in vitro and in vivo models (known most commonly as the 'Eagle effect'). Therefore, the potential impact of dose escalations on improving the clinical efficacy of echinocandins based on in vitro and animal models are uncertain and are still being evaluated. In addition, such strategies have to consider the potential for increased treatment-related toxicities and costs. To date, published clinical studies (both superiority and non-inferiority) demonstrating the potential for dose-related improvements in treatment outcomes have been limited to mucocutaneous and oesophageal candidiasis. Further research is needed to determine if a role exists for optimizing echinocandin pharmacodynamics in various clinical settings.
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Affiliation(s)
- Melanie W Pound
- Campbell University School of Pharmacy, Buies Creek, NC, USA.
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Mazzei T, Novelli A. Pharmacological Properties of Antifungal Drugs with a Focus on Anidulafungin. Drugs 2009; 69 Suppl 1:79-90. [DOI: 10.2165/11315550-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Moen MD, Lyseng-Williamson KA, Scott LJ. Liposomal amphotericin B: a review of its use as empirical therapy in febrile neutropenia and in the treatment of invasive fungal infections. Drugs 2009; 69:361-92. [PMID: 19275278 DOI: 10.2165/00003495-200969030-00010] [Citation(s) in RCA: 217] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Liposomal amphotericin B (AmBisome) is a lipid-associated formulation of the broad-spectrum polyene antifungal agent amphotericin B. It is active against clinically relevant yeasts and moulds, including Candida spp., Aspergillus spp. and filamentous moulds such as Zygomycetes, and is approved for the treatment of invasive fungal infections in many countries worldwide. It was developed to improve the tolerability profile of amphotericin B deoxycholate, which was for many decades considered the gold standard of antifungal treatment, despite being associated with infusion-related events and nephrotoxicity. In well controlled trials, liposomal amphotericin B had similar efficacy to amphotericin B deoxycholate and amphotericin B lipid complex as empirical therapy in adult and paediatric patients with febrile neutropenia. In addition, caspofungin was noninferior to liposomal amphotericin B as empirical therapy in adult patients with febrile neutropenia. For the treatment of confirmed invasive fungal infections, liposomal amphotericin B was more effective than amphotericin B deoxycholate treatment in patients with disseminated histoplasmosis and AIDS, and was noninferior to amphotericin B deoxycholate in patients with acute cryptococcal meningitis and AIDS. In adults, micafungin was shown to be noninferior to liposomal amphotericin B for the treatment of candidaemia and invasive candidiasis. Data from animal studies suggested that higher dosages of liposomal amphotericin B might improve efficacy; however, in the AmBiLoad trial in patients with invasive mould infection, there was no statistical difference in efficacy between the standard dosage of liposomal amphotericin B 3 mg/kg/day and a higher 10 mg/kg/day dosage, although the standard dosage was better tolerated. Despite being associated with fewer infusion-related adverse events and less nephrotoxicity than amphotericin B deoxycholate and amphotericin B lipid complex, liposomal amphotericin B use is still limited to some extent by these adverse events. Both echinocandins were better tolerated than liposomal amphotericin B. The cost of liposomal amphotericin B therapy may also restrict its use, but further pharmacoeconomic studies are required to fully define its cost effectiveness compared with other antifungal agents. Based on comparative data from well controlled trials, extensive clinical experience and its broad spectrum of activity, liposomal amphotericin B remains a first-line option for empirical therapy in patients with febrile neutropenia and in those with disseminated histoplasmosis, and is an option for the treatment of AIDS-associated cryptococcal meningitis, and for invasive Candida spp. or Aspergillus spp. infections. Amphotericin B, a macrocyclic, polyene antifungal agent, is thought to act by binding to ergosterol, the principal sterol in fungal cell membranes and Leishmania cells. This results in a change in membrane permeability, causing metabolic disturbance, leakage of small molecules and, as a consequence, cell death. In vitro and in vivo studies have shown that liposomal amphotericin B remains closely associated with the liposomes in the circulation, thereby reducing the potential for nephrotoxicity and infusion-related toxicity associated with conventional amphotericin B. Amphotericin B shows very good in vitro activity against a broad spectrum of clinically relevant fungal isolates, including most strains of Candida spp. and Aspergillus spp., and other filamentous fungi such as Zygomycetes. Liposomal amphotericin B has proven effective in various animal models of fungal infections, including those for candidiasis, aspergillosis, fusariosis and zygomycosis. Liposomal amphotericin B also shows immunomodulatory effects, although the mechanisms involved are not fully understood, and differ from those of amphotericin B deoxycholate and amphotericin B colloidal dispersion. In adult patients with febrile neutropenia, intravenous liposomal amphotericin B has nonlinear pharmacokinetics, with higher than dose-proportional increases in exposure being consistent with reticuloendothelial saturation and redistribution of amphotericin B in the plasma compartment. Liposomal amphotericin B is rapidly and extensively distributed after single and multiple doses, with steady-state concentrations of amphotericin B attained within 4 days and no clinically relevant accumulation of the drug following multiple doses of 1-7.5 mg/kg/day. In autopsy tissue, the highest concentrations of the drug were found in the liver and spleen, followed by the kidney, lung, myocardium and brain tissue. Elimination of liposomal amphotericin B, like that of amphotericin B deoxycholate, is poorly understood; its route of metabolism is not known and its excretion has not been studied. The terminal elimination half-life is about 7 hours. No dosage adjustment is required based on age or renal impairment. In several randomized, double-blind trials (n = 73-1095) in adult and/or paediatric patients, liposomal amphotericin B was effective as empirical therapy or as treatment for confirmed invasive fungal infections, including invasive candidiasis, candidaemia, invasive mould infection (mainly aspergillosis), histoplasmosis and cryptococcal meningitis. All agents were administered as an intravenous infusion; the typical dosage for liposomal amphotericin B was 3 mg/kg/day. Treatment was generally given for 1-2 weeks. Participants in trials evaluating empirical therapy had neutropenia and a persistent fever despite antibacterial treatment and had received chemotherapy or undergone haematopoietic stem cell transplantation. As empirical therapy in adult and paediatric patients, liposomal amphotericin B appeared to be as effective as amphotericin B deoxycholate (approximately 50% of patients in each group achieved treatment success) or amphotericin B lipid complex (approximately 40% of liposomal amphotericin B recipients experienced treatment success). Of note, in the first trial, results of the statistical test to determine equivalence between treatments were not reported. In the second trial, efficacy was assessed as an 'other' endpoint. In another trial, caspofungin was shown to be noninferior to liposomal amphotericin B, with approximately one-third of patients in each group experiencing treatment success. Liposomal amphotericin B was significantly more effective than amphotericin B deoxycholate for the treatment of moderate to severe disseminated histoplasmosis in patients with AIDS, with 88% and 64% of patients, respectively, having a successful response. Liposomal amphotericin B was noninferior to amphotericin B deoxycholate for the treatment of cryptococcal meningitis in terms of mycological success. Micafungin therapy was shown to be noninferior to liposomal amphotericin B for the treatment of adult patients with candidaemia or invasive candidiasis. In a substudy in paediatric patients, which was not powered to determine noninferiority, liposomal amphotericin B was as effective as micafungin for the treatment of candidaemia or invasive candidiasis. In this patient population, within each trial, 90% of adult patients and approximately three-quarters of paediatric patients in both treatment groups experienced a successful response. In patients with invasive mould infection (mainly aspergillosis), there was no difference in efficacy between a higher dosage of liposomal amphotericin B (10 mg/kg/day) and the standard dosage (3 mg/kg/day), with 46% and 50% of patients experiencing a favourable overall response. In well designed clinical trials, liposomal amphotericin B was generally at least as well tolerated as other lipid-associated formulations of amphotericin B and better tolerated than amphotericin B deoxycholate in adult and paediatric patients. Compared with other amphotericin B formulations, liposomal amphotericin B treatment was associated with a lower incidence of infusion-related adverse events and nephrotoxicity. A higher than recommended dosage of liposomal amphotericin B (10 mg/kg/day) was associated with an increased incidence of nephrotoxicity compared with the standard dosage (3 mg/kg/day), although the incidence of infusion-related reactions did not differ between treatment groups. In general, liposomal amphotericin B treatment was not as well tolerated as echinocandin therapy in well designed clinical trials. As empirical therapy or for the treatment of confirmed invasive fungal infections in adult patients, liposomal amphotericin B recipients experienced more infusion-related events and nephrotoxicity than caspofungin or micafungin recipients. There was no difference in the incidence of these adverse events between the liposomal amphotericin B and micafungin groups in a study in paediatric patients.
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Affiliation(s)
- Marit D Moen
- Wolters Kluwer Health
- Adis, Auckland, New Zealand.
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de Aquino Lemos J, Costa CR, de Araújo CR, Souza LKHE, Silva MDRR. Susceptibility testing of Candida albicans isolated from oropharyngeal mucosa of HIV(+) patients to fluconazole, amphotericin B and Caspofungin. killing kinetics of caspofungin and amphotericin B against fluconazole resistant and susceptible isolates. Braz J Microbiol 2009; 40:163-9. [PMID: 24031337 PMCID: PMC3768489 DOI: 10.1590/s1517-838220090001000028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 03/09/2008] [Accepted: 02/17/2009] [Indexed: 11/22/2022] Open
Abstract
A clear understanding of the pharmacodynamic properties of antifungal agents is important for the adequate treatment of fungal infections like candidiasis. For certain antifungal agents, the determination of Minimal Fungicidal Concentration (MFC) and time kill curve could be clinically more relevant than the determination of the Minimal Inhibitory Concentration (MIC). In this study, MIC and MFC to fluconazole, amphotericin B and caspofungin against C. albicans isolates and the killing patterns obtained with caspofungin and amphotericin B against susceptible and resistant strains to fluconazole were determined. The results of MICs showed that all C. albicans isolates were highly susceptible to amphotericin B, but two isolates were fluconazole resistant. The comparative analysis between MIC and MFC showed that MFC of fluconazole was fourfold higher than MIC in 41.9% of the C. albicans isolates. Same values of MFC and MIC of amphotericin B and caspofungin were found for 71% of the isolates. Correlation between time kill curves and MFC of amphotericin B and caspofungin against all 4 isolates tested was observed. The caspofungin killing effect was more evident at MFC in 6 hours of incubation than at MIC in this time, suggesting dependence of concentration. The similarity of results of time-kill curve and MFC values indicate that determination of MFC is an alternative for the detection of the fungicidal activity of these drugs.
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Affiliation(s)
- Janine de Aquino Lemos
- Instituto de Patologia Tropical e Saúde Pública da Universidade Federal de Goiás , Goiínia, GO , Brasil
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Abstract
Antifungal susceptibility testing is a very dynamic field of medical mycology. Standardization of in vitro susceptibility tests by the Clinical and Laboratory Standards Institute (CLSI) and the European Committee for Antimicrobial Susceptibility Testing (EUCAST), and current availability of reference methods constituted the major remarkable steps in the field. Based on the established minimum inhibitory concentration (MIC) breakpoints, it is now possible to determine the susceptibilities of Candida strains to fluconazole, itraconazole, voriconazole, and flucytosine. Moreover, utility of fluconazole antifungal susceptibility tests as an adjunct in optimizing treatment of candidiasis has now been validated. While the MIC breakpoints and clinical significance of susceptibility testing for the remaining fungi and antifungal drugs remain yet unclear, modifications of the available methods as well as other methodologies are being intensively studied to overcome the present drawbacks and limitations. Among the other methods under investigation are Etest, colorimetric microdilution, agar dilution, determination of fungicidal activity, flow cytometry, and ergosterol quantitation. Etest offers the advantage of practical application and favorable agreement rates with the reference methods that are frequently above acceptable limits. However, MIC breakpoints for Etest remain to be evaluated and established. Development of commercially available, standardized colorimetric panels that are based on CLSI method parameters has added more to the antifungal susceptibility testing armamentarium. Flow cytometry, on the other hand, appears to offer rapid susceptibility testing but requires specified equipment and further evaluation for reproducibility and standardization. Ergosterol quantitation is another novel approach, which appears potentially beneficial particularly in discrimination of azole-resistant isolates from heavy trailers. The method is yet investigational and requires to be further studied. Developments in methodology and applications of antifungal susceptibility testing will hopefully provide enhanced utility in clinical guidance of antifungal therapy. However, and particularly in immunosuppressed host, in vitro susceptibility is and will remain only one of several factors that influence clinical outcome.
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Affiliation(s)
- Sevtap Arikan
- Department of Microbiology and Clinical Microbiology, Hacettepe University Medical School, Ankara, Turkey.
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Li Y, Nguyen MH, Derendorf H, Cheng S, Clancy CJ. Measurement of voriconazole activity against Candida albicans, C. glabrata, and C. parapsilosis isolates using time-kill methods validated by high-performance liquid chromatography. Antimicrob Agents Chemother 2007; 51:2985-7. [PMID: 17517840 PMCID: PMC1932531 DOI: 10.1128/aac.00308-07] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We developed a high-performance liquid chromatography (HPLC) assay to validate time-kill and postantifungal-effect (PAFE) experiments for voriconazole against Candida albicans, Candida glabrata, and Candida parapsilosis isolates. Voriconazole exerted prolonged fungistatic activity but no PAFE at concentrations achievable in human sera. HPLC confirmed that experiments were conducted at the desired steady-state voriconazole concentrations.
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Affiliation(s)
- Yanjun Li
- Department of Pharmaceutics, University of Florida College of Pharmacy, Gainesville, FL 32610, USA
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Abstract
Voriconazole (VFEND), a synthetic second-generation, broad-spectrum triazole derivative of fluconazole, inhibits the cytochrome P450 (CYP)-dependent enzyme 14-alpha-sterol demethylase, thereby disrupting the cell membrane and halting fungal growth. In the US, intravenous and/or oral voriconazole is recommended in adults for the treatment of invasive aspergillosis, candidaemia in non-neutropenic patients, disseminated infections caused by Candida spp., oesophageal candidiasis, and in patients with scedosporiosis and fusariosis who are refractory to or intolerant of other antifungal therapy. In Europe, intravenous and/or oral voriconazole is recommended in adults and paediatric patients of at least 2 years of age for the treatment of invasive aspergillosis, candidaemia in non-neutropenic patients, fluconazole-resistant serious invasive Candida spp. infections, scedosporiosis and fusariosis. In large randomised trials, voriconazole was an effective and generally well tolerated primary treatment for candidiasis and invasive aspergillosis in adults and adolescents. More limited data also support the use of voriconazole for the treatment of invasive fungal infections in children, in those with rare fungal infections, such as Fusarium spp. or Scedosporium spp., and in those refractory to or intolerant of other standard antifungal therapies. The availability of both parenteral and oral formulations and the almost complete absorption of the drug after oral administration provide for ease of use and potential cost savings, and ensure that therapeutic plasma concentrations are maintained when switching from intravenous to oral therapy. On the other hand, the numerous drug interactions associated with voriconazole may limit its usefulness in some patients. Further clinical experience will help to more fully determine the position of voriconazole in relation to other licensed antifungal agents. In the meantime, voriconazole is a valuable emerging option for the treatment of invasive aspergillosis and rare fungal infections, including Fusarium spp. and Scedosporium spp. infections, and provides an alternative option for the treatment of candidiasis, particularly where the causative organism is inherently resistant to other licensed antifungal agents.
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Barchiesi F, Spreghini E, Tomassetti S, Della Vittoria A, Arzeni D, Manso E, Scalise G. Effects of caspofungin against Candida guilliermondii and Candida parapsilosis. Antimicrob Agents Chemother 2006; 50:2719-27. [PMID: 16870764 PMCID: PMC1538640 DOI: 10.1128/aac.00111-06] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The in vitro activity of caspofungin (CAS) was investigated against 28 yeast isolates belonging to Candida albicans (n = 5), Candida guilliermondii (n = 10), and Candida parapsilosis (n = 13). CAS MICs obtained by broth dilution and Etest methods clearly showed a rank order of susceptibility to the echinocandin compound with C. albicans > C. parapsilosis > C. guilliermondii. Similarly, time-kill assays performed on selected isolates showed that CAS was fungistatic against C. albicans and C. parapsilosis, while it did not exert any activity against C. guilliermondii. In a murine model of systemic candidiasis, CAS given at doses as low as 1 mg/kg of body weight/day was effective at reducing the kidney burden of mice infected with either C. albicans or C. guilliermondii isolates. Depending on the isolate tested, mice infected with C. parapsilosis responded to CAS given at 1 and/or 5 mg/kg/day. However, the overall CFU reduction for C. guilliermondii and C. parapsilosis was approximately 100-fold less than that for C. albicans. Our study shows that CAS was active in experimental systemic candidiasis due to C. guilliermondii and C. parapsilosis, but this activity required relatively high drug dosages.
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Affiliation(s)
- Francesco Barchiesi
- Istituto di Malattie Infettive e Medicina Pubblica, Università Politecnica delle Marche, Azienda, Ospedaliero-Universitaria, 60020 Torrette, Ancona, Italy.
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Clancy CJ, Huang H, Cheng S, Derendorf H, Nguyen MH. Characterizing the effects of caspofungin on Candida albicans, Candida parapsilosis, and Candida glabrata isolates by simultaneous time-kill and postantifungal-effect experiments. Antimicrob Agents Chemother 2006; 50:2569-72. [PMID: 16801448 PMCID: PMC1489803 DOI: 10.1128/aac.00291-06] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We measured time-kills and postantifungal effects (PAFEs) of caspofungin against Candida albicans, C. parapsilosis, and C. glabrata isolates. One-hour exposure to caspofungin during PAFE experiments accounted for the majority of killing during time-kill experiments. Regrowth of all isolates was inhibited for at least 24 h following drug washout.
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Affiliation(s)
- Cornelius J Clancy
- North Florida/South Georgia VA Medical Center, University of Florida College of Medicine, Gainesville, FL 32610, USA.
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Gibbs WJ, Drew RH, Perfect JR. Liposomal amphotericin B: clinical experience and perspectives. Expert Rev Anti Infect Ther 2006; 3:167-81. [PMID: 15918775 DOI: 10.1586/14787210.3.2.167] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While amphotericin B deoxycholate (Fungizone, Apothecon Pharmaceuticals) has been considered by many to be the gold standard for the treatment for numerous invasive fungal infections for over 45 years, toxicities associated with its use often necessitate treatment modification or discontinuation. Lipid-based formulations, including liposomal amphotericin B (AmBisome, Fujisawa Healthcare, Inc.), were developed to decrease many of these toxicities while retaining broad antifungal spectrum and potency of amphotericin B. In clinical trials, liposomal amphotericin B has demonstrated efficacy comparable to that of amphotericin B deoxycholate while reducing the incidence of treatment-related nephrotoxicity, electrolyte-wasting, and infusion-related reactions. In addition, recent clinical trials have also compared liposomal amphotericin B with other antifungal classes. Acquisition costs of liposomal amphotericin B are substantially higher than those of amphotericin B deoxycholate and other antifungals. While pharmacoeconomic analyses consider outcomes and other treatment-related costs, they have yet to clearly demonstrate the cost-effectiveness of liposomal amphotericin B when compared with amphotericin B deoxycholate or other antifungal agents. This review will focus primarily on recent liposomal amphotericin B experience and attempt to put its use into perspective considering other available antifungal agents.
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Affiliation(s)
- Winter J Gibbs
- Department of Pharmacy practice, Campbell University School of Pharmacy, Buies Creek.
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