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Wang H, Li D, Jiang Y, Liang J, Yu Q, Kuang L, Huang Y, Qin D, Li P, He J, Xu F, Li X, Wang F, Wei Y, Li X. Population pharmacokinetics of fluconazole for prevention or treatment of invasive candidiasis in Chinese young infants. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03184-7. [PMID: 38850301 DOI: 10.1007/s00210-024-03184-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/24/2024] [Indexed: 06/10/2024]
Abstract
The dosing of fluconazole for young infants remains empirical because of the limited pharmacokinetic (PK) data. We aimed to establish a population PK model and assess the systematic exposure-response of commonly used regimens of fluconazole in Chinese infants. We included infants with a postnatal age of less than 120 days and received intravenous fluconazole. Both scheduled and scavenged plasma samples were collected, and fluconzaole concentration was determined by a validated ultra-performance liquid chromatography-tandem mass spectrometry assay. Population PK analysis was conducted using Phoenix NLME, and then Monte Carlo simulation was conducted to predict the probability of target attainment (PTA) of empirically used regimens of both prophylactic and therapeutic purposes. Based on 304 plasma samples from 183 young infants, fluconazole concentration data was best described by a one-compartment model with first-order elimination. Gestational Age (GA), postnatal age (PNA), and body weight (BW) were included in the final model as CL = 0.02*(GA/214)2.77*(PNA/13)0.24*exp(nCL); V = 1.56*(BW/1435)0.90*exp(nV). Model validation revealed the final model had qualified stability and acceptable predictive properties. Monte Carlo simulation indicated that under the same minimum inhibitory concentration (MIC) value and administration regimen, PTA decreased with GA and PNA. The commonly used prophylactic regimens can meet the clinical need, while higher doses might be needed for treatment of invasive candidiasis. This population PK model of fluconazole discriminated the impact of GA and PNA on CL and BW on V. Dosing adjustment was needed according to the GA and PNA of infants to achieve targeted exposures.
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Affiliation(s)
- Honghong Wang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University,, Beijing, China
| | - Yongjiang Jiang
- Department of Neonatology, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Jing Liang
- Department of Neonatology, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Qiaoai Yu
- Department of Laboratory, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Linghong Kuang
- School of Computer Science and Mathematics, Fujian University of Technology, Fuzhou, Fujian, China
| | - Yuling Huang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Dongjie Qin
- Pharmaceutical Division, Liuzhou Quality Inspection and Testing Research Center, Liuzhou, Guangxi, China
| | - Ping Li
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Jing He
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Feng Xu
- Department of Pharmacy, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Xueli Li
- Department of Laboratory, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Fei Wang
- Department of Pharmacy, Fujian Provincial Geriatric Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yanfei Wei
- Department of Neonatology, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China.
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University,, Beijing, China.
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2
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Locke JB, Pillar CM, Castanheira M, Carvalhaes CG, Andes D, Aram JA, Andrzejewski C, Bartizal K, Das AF, Sandison T, Thompson GR, Pappas PG. Outcomes by Candida spp. in the ReSTORE Phase 3 trial of rezafungin versus caspofungin for candidemia and/or invasive candidiasis. Antimicrob Agents Chemother 2024; 68:e0158423. [PMID: 38526046 PMCID: PMC11064504 DOI: 10.1128/aac.01584-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/16/2024] [Indexed: 03/26/2024] Open
Abstract
Rezafungin is a long-acting, intravenously administered echinocandin for the treatment of candidemia and invasive candidiasis (IC). Non-inferiority of rezafungin vs caspofungin for the treatment of adults with candidemia and/or IC was demonstrated in the Phase 3 ReSTORE study based on the primary endpoints of day 14 global cure and 30-day all-cause mortality. Here, an analysis of ReSTORE data evaluating efficacy outcomes by baseline Candida species is described. Susceptibility testing was performed for Candida species using the Clinical and Laboratory Standards Institute reference broth microdilution method. There were 93 patients in the modified intent-to-treat population who received rezafungin; 94 received caspofungin. Baseline Candida species distribution was similar in the two treatment groups; C. albicans (occurring in 41.9% and 42.6% of patients in the rezafungin and caspofungin groups, respectively), C. glabrata (25.8% and 26.6%), and C. tropicalis (21.5% and 18.1%) were the most common pathogens. Rates of global cure and mycological eradication at day 14 and day 30 all-cause mortality by Candida species were comparable in the rezafungin and caspofungin treatment groups and did not appear to be impacted by minimal inhibitory concentration (MIC) values for either rezafungin or caspofungin. Two patients had baseline isolates with non-susceptible MIC values (both in the rezafungin group: one non-susceptible to rezafungin and one to caspofungin, classified as intermediate); both were candidemia-only patients in whom rezafungin treatment was successful based on the day 30 all-cause mortality endpoint. This analysis of ReSTORE demonstrated the efficacy of rezafungin for candidemia and IC in patients infected with a variety of Candida species.
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Affiliation(s)
| | - Chris M. Pillar
- Science and Operations, Microbiologics, Kalamazoo, Michigan, USA
| | | | | | - David Andes
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jalal A. Aram
- Medical Affairs, Melinta Therapeutics, LLC, Parsippany, New Jersey, USA
| | | | - Ken Bartizal
- Cidara Therapeutics, Inc., San Diego, California, USA
| | - Anita F. Das
- Cidara Therapeutics, Inc., San Diego, California, USA
| | | | - George R. Thompson
- Division of Infectious Diseases, Department of Internal Medicine and Department of Medical Microbiology and Immunology, University of California Davis Medical Center, Sacramento, California, USA
| | - Peter G. Pappas
- Division of Infectious Diseases, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Facchini N, Wernli L, Rieken M, Bonkat G, Wirz D, Braissant O. Again and Again-Survival of Candida albicans in Urine Containing Antifungals. Pharmaceutics 2024; 16:605. [PMID: 38794267 PMCID: PMC11124869 DOI: 10.3390/pharmaceutics16050605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Relapse of Candida albicans urinary tract infection (UTI) is frequent despite appropriate treatment, as commonly used antifungals such fluconazole and flucytosine are only fungistatics. To improve treatment of Candida UTI and decrease relapses, understanding the long-term metabolic activity and survival of C. albicans in urine containing antifungals at minimal inhibitory concentration (MIC) is needed. METHODS we monitored the survival, metabolic activity and consumption of glucose and proteins by C. albicans using conventional methods and isothermal microcalorimetry (IMC). We also investigated the influence of dead Candida cells on the growth of their living counterparts. RESULTS For 33 days, weak activity was observed in samples containing antifungals in which C. albicans growth rate was reduced by 48%, 60% and 88%, and the lag increased to 172 h, 168 h and 6 h for amphotericin, flucytosine and fluconazole, respectively. The metabolic activity peaks corresponded to the plate counts but were delayed compared to the exhaustion of resources. The presence of dead cells promoted growth in artificial urine, increasing growth rate and reducing lag in similar proportions. CONCLUSIONS Even with antifungal treatment, C. albicans relapses are possible. The low metabolic activity of surviving cells leading to regrowth and chlamydospore formation possibly supported by autophagy are likely important factors in relapses.
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Affiliation(s)
- Nevio Facchini
- Department of Biomedical Engineering, University of Basel, Hegenheimermattweg 167B/C, 4123 Allschwil, Switzerland; (N.F.)
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Lukas Wernli
- Department of Biomedical Engineering, University of Basel, Hegenheimermattweg 167B/C, 4123 Allschwil, Switzerland; (N.F.)
- Department of Urology, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Malte Rieken
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
- alta uro AG, Centralbahnplatz 6, 4051 Basel, Switzerland
| | - Gernot Bonkat
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
- alta uro AG, Centralbahnplatz 6, 4051 Basel, Switzerland
| | - Dieter Wirz
- Department of Biomedical Engineering, University of Basel, Hegenheimermattweg 167B/C, 4123 Allschwil, Switzerland; (N.F.)
| | - Olivier Braissant
- Department of Biomedical Engineering, University of Basel, Hegenheimermattweg 167B/C, 4123 Allschwil, Switzerland; (N.F.)
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Novy E, Abdul-Aziz MH, Cheng V, Burrows F, Buscher H, Corley A, Diehl A, Gilder E, Levkovich BJ, McGuinness S, Ordonez J, Parke R, Parker S, Pellegrino V, Reynolds C, Rudham S, Wallis SC, Welch SA, Fraser JF, Shekar K, Roberts JA. Population pharmacokinetics of fluconazole in critically ill patients receiving extracorporeal membrane oxygenation and continuous renal replacement therapy: an ASAP ECMO study. Antimicrob Agents Chemother 2024; 68:e0120123. [PMID: 38063399 PMCID: PMC10777822 DOI: 10.1128/aac.01201-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/07/2023] [Indexed: 01/11/2024] Open
Abstract
This multicenter study describes the population pharmacokinetics (PK) of fluconazole in critically ill patients receiving concomitant extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) and includes an evaluation of different fluconazole dosing regimens for achievement of target exposure associated with maximal efficacy. Serial blood samples were obtained from critically ill patients on ECMO and CRRT receiving fluconazole. Total fluconazole concentrations were measured in plasma using a validated chromatographic assay. A population PK model was developed and Monte Carlo dosing simulations were performed using Pmetrics in R. The probability of target attainment (PTA) of various dosing regimens to achieve fluconazole area under the curve to minimal inhibitory concentration ratio (AUC0-24/MIC) >100 was estimated. Eight critically ill patients receiving concomitant ECMO and CRRT were included. A two-compartment model including total body weight as a covariate on clearance adequately described the data. The mean (±standard deviation, SD) clearance and volume of distribution were 2.87 ± 0.63 L/h and 15.90 ± 13.29 L, respectively. Dosing simulations showed that current guidelines (initial loading dose of 12 mg/kg then 6 mg/kg q24h) achieved >90% of PTA for a MIC up to 1 mg/L. None of the tested dosing regimens achieved 90% of PTA for MIC above 2 mg/L. Current fluconazole dosing regimen guidelines achieved >90% PTA only for Candida species with MIC <1 mg/L and thus should be only used for Candida-documented infections in critically ill patients receiving concomitant ECMO and CRRT. Total body weight should be considered for fluconazole dose.
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Affiliation(s)
- Emmanuel Novy
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
- Université de Lorraine, SIMPA, Nancy, France
- Departement of anesthesiology, Critical care and peri-operative medicine, University hospital of Nancy, Nancy, France
| | - Mohd H. Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Vesa Cheng
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Fay Burrows
- Department of Pharmacy, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
- University of New South Wales, St Vincent’s Centre for Applied Medical Research, Sydney, New South Wales, Australia
| | - Amanda Corley
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eileen Gilder
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Bianca J. Levkovich
- Experiential Development and Graduate Education and Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shay McGuinness
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Jenny Ordonez
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The University of Auckland, School of Nursing, Auckland, New Zealand
| | - Suzanne Parker
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Claire Reynolds
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Sam Rudham
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Steven C. Wallis
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Susan A. Welch
- Department of Pharmacy, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - John F. Fraser
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kiran Shekar
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Jason A. Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Rather IA, Wani MY, Kamli MR, Sabir JSM, Hakeem KR, Firoz A, Park YH, Hor YY. Limosilactobacillus fermentum KAU0021 Abrogates Mono- and Polymicrobial Biofilms Formed by Candida albicans and Staphylococcus aureus. Pharmaceutics 2023; 15:pharmaceutics15041079. [PMID: 37111565 PMCID: PMC10145238 DOI: 10.3390/pharmaceutics15041079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/28/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Candida albicans and Staphylococcus aureus, representing two different kingdoms, are the most frequently isolated pathogens from invasive infections. Their pathogenic attributes, combined with drug resistance, make them a major threat and a challenge to successful treatments, mainly when involved in polymicrobial biofilm-associated infections. In the present study, we investigated the antimicrobial potential of Lactobacillus metabolite extracts (LMEs) purified from cell-free supernatant of four Lactobacillus strains (KAU007, KAU0010, KAU0021, and Pro-65). Furthermore, LME obtained from the strain KAU0021 (LMEKAU0021), being the most effective, was analyzed for its anti-biofilm property against mono- and polymicrobial biofilms formed by C. albicans and S. aureus. The impact of LMEKAU0021 on membrane integrity in single and mixed culture conditions was also evaluated using propidium iodide. The MIC values recorded for LMEKAU0021 was 406 µg/mL, 203 µg/mL, and 406 µg/mL against planktonic cells of C. albicans SC5314, S. aureus and polymicrobial culture, respectively. The LMEKAU0021 at sub-MIC values potentially abrogates both biofilm formation as well as 24 h mature mono- and polymicrobial biofilms. These results were further validated using different microscopy and viability assays. For insight mechanism, LMEKAU0021 displayed a strong impact on cell membrane integrity of both pathogens in single and mixed conditions. A hemolytic assay using horse blood cells at different concentrations of LMEKAU0021 confirmed the safety of this extract. The results from this study correlate the antimicrobial and anti-biofilm properties of lactobacilli against bacterial and fungal pathogens in different conditions. Further in vitro and in vivo studies determining these effects will support the aim of discovering an alternative strategy for combating serious polymicrobial infections caused by C. albicans and S. aureus.
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Izadi A, Aghaei Gharehbolagh S, Sadeghi F, Talebi M, Darmiani K, Zarrinnia A, Zarei F, Peymaeei F, Khojasteh S, Borman AM, Mahmoudi S. Drug repurposing against Candida auris: A systematic review. Mycoses 2022; 65:784-793. [PMID: 35665544 DOI: 10.1111/myc.13477] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022]
Abstract
Candida auris is a drug-resistant pathogen with several reported outbreaks. The treatment of C. auris infections is difficult due to a limited number of available antifungal drugs. Thus, finding alternative drugs through repurposing approaches would be clinically beneficial. A systematic search in PubMed, Scopus and Web of Science databases, as well as Google Scholar up to 1 November 2021, was conducted to find all articles with data regarding the antifungal activity of non-antifungal drugs against the planktonic and biofilm forms of C. auris. During database and hand searching, 290 articles were found, of which 13 were eligible for inclusion in the present study. Planktonic and biofilm forms have been studied in 11 and 8 articles (with both forms examined in 6 articles), respectively. In total, 22 and 12 drugs/compounds have been reported as repositionable against planktonic and biofilm forms of C. auris, respectively. Antiparasitic drugs, with the dominance of miltefosine, were the most common repurposed drugs against both forms of C. auris, followed by anticancer drugs (e.g. alexidine dihydrochloride) against the planktonic form and anti-inflammatory drugs (e.g. ebselen) against the biofilm form of the fungus. A collection of other drugs from various classes have also shown promising activity against C. auris. Following drug repurposing approaches, a number of drugs/compounds from various classes have been found to inhibit the planktonic and biofilm forms of C. auris. Accordingly, drug repurposing is an encouraging approach for discovering potential alternatives to conventional antifungal agents to combat drug resistance in fungi, especially C. auris.
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Affiliation(s)
- Alireza Izadi
- Department of Medical Parasitology and Mycology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran.,Medical Mycology and Bacteriology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Sanaz Aghaei Gharehbolagh
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Sadeghi
- Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Meysam Talebi
- Department of Medicinal Chemistry, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Kimia Darmiani
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Zarrinnia
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fateme Zarei
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Peymaeei
- Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Khojasteh
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Andrew M Borman
- Public Health England UK National Mycology Reference Laboratory, Southmead Hospital Bristol, Bristol, UK.,Medical Research Council Centre for Medical Mycology (MRC CMM), University of Exeter, Exeter, UK
| | - Shahram Mahmoudi
- Department of Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Davari A, Jafarzadeh J, Hedayati MT, Shokohi T, Abastabar M, Nikmanesh B, Moazeni M. High frequency of Candida krusei colonization in critically ill pediatrics: A cross-sectional study in children's medical center, Tehran, Iran. Curr Med Mycol 2022; 8:25-31. [PMID: 36654792 PMCID: PMC9825791 DOI: 10.18502/cmm.8.2.10329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/23/2022] [Accepted: 06/29/2022] [Indexed: 11/15/2022] Open
Abstract
Background and Purpose This study aimed to evaluate the species distribution and susceptibility pattern of the strains isolated from Candida colonization in pediatric patients staying at pediatric intensive care unit (ICU) and infant ICU of Children's Medical Center in Tehran, Iran. Materials and Methods This study was conducted in the Children's Medical Center in Tehran, Iran. In total, 440 samples from 56 patients with oral cavity, skin surrounded catheters, and ear, throat, nasal, and urine cultures were collected. All patients were evaluated in terms of Candida colonization on the admission day as well as the days 7, 14, and 28 according to the previous studies. CHROMagar Candida medium was applied for primary/multiple species identification and the isolates were identified by using polymerase chain reaction-based methods to the species-specific complex level. The antifungal susceptibility test was performed according to the Clinical and Laboratory Standards protocol published as M27-A3 and M60 documents. Results In total, 136 yeast samples from 26 individuals (30.9%) out of 440 samples were considered colonization. The most prevalent species in IICU was C. albicans (27%, n=20) followed by C. krusei (24 %, n=18) and C. parapsilosis (16%, n=12). In PICU, the predominant species was C. krusei (40%, n=24) followed by C. parapsilosis (18%, n=11) and C. dubliniensis (16%, n=10). Among the 40 tested isolates from both units, fluconazole-resistant isolates (n=11, 8.15%) were determined according to the new breakpoints. In the case of echinocandins, 2 isolates, including C. albicans (n=1) and C. krusei (n=1) were resistant against both caspofungin and anidulafungin (totally 1.48%). Conclusion In the present study, since C. krusei is intrinsically-resistance against fluconazole, emphasizing the importance of species-level identification of Candida isolates is outstanding. However, according to the antifungal susceptibility testing results, only 7.2% of the strains were resistant to fluconazole. It would be beneficial to monitor the ICU patients who are at high risk of invasive Candida infection.
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Affiliation(s)
- Amirhossein Davari
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran,
Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Jalal Jafarzadeh
- Department of Medical Mycology and Parasitology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Mohammad Taghi Hedayati
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran,
Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Tahereh Shokohi
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran,
Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Abastabar
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran,
Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Bahram Nikmanesh
- Department of Medical Laboratory Sciences, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Moazeni
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran,
Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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McCarty TP, Luethy PM, Baddley JW, Pappas PG. Clinical utility of antifungal susceptibility testing. JAC Antimicrob Resist 2022; 4:dlac067. [PMID: 35774069 PMCID: PMC9237445 DOI: 10.1093/jacamr/dlac067] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Invasive fungal diseases cause significant morbidity and mortality, in particular affecting immunocompromised patients. Resistant organisms are of increasing importance, yet there are many notable differences in the ability to both perform and interpret antifungal susceptibility testing compared with bacteria. In this review, we will highlight the strengths and limitations of resistance data of pathogenic yeasts and moulds that may be used to guide treatment and predict clinical outcomes.
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Affiliation(s)
- Todd P McCarty
- Department of Medicine, University of Alabama at Birmingham , Birmingham, AL , USA
- Birmingham VA Medical Center , Birmingham, AL , USA
| | - Paul M Luethy
- Department of Pathology, University of Maryland , Baltimore, MD , USA
| | - John W Baddley
- Department of Medicine, University of Maryland , Baltimore, MD , USA
| | - Peter G Pappas
- Department of Medicine, University of Alabama at Birmingham , Birmingham, AL , USA
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9
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Ashok A, Mangalore RP, Morrissey CO. Azole Therapeutic Drug Monitoring and its Use in the Management of Invasive Fungal Disease. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-022-00430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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10
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Precision Therapy for Invasive Fungal Diseases. J Fungi (Basel) 2021; 8:jof8010018. [PMID: 35049957 PMCID: PMC8780074 DOI: 10.3390/jof8010018] [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: 11/29/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 11/26/2022] Open
Abstract
Invasive fungal infections (IFI) are a common infection-related cause of death in immunocompromised patients. Approximately 10 million people are at risk of developing invasive aspergillosis annually. Detailed study of the pharmacokinetics (PK) and pharmacodynamics (PD) of antifungal drugs has resulted in a better understanding of optimal regimens for populations, drug exposure targets for therapeutic drug monitoring, and establishing in vitro susceptibility breakpoints. Importantly, however, each is an example of a “one size fits all strategy”, where complex systems are reduced to a singularity that ensures antifungal therapy is administered safely and effectively at the level of a population. Clearly, such a notion serves most patients adequately but is completely counter to the covenant at the centre of the clinician–patient relationship, where each patient should know whether they are well-positioned to maximally benefit from an antifungal drug. This review discusses the current therapy of fungal infections and areas of future research to maximise the effectiveness of antifungal therapy at an individual level.
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Chau MM, Daveson K, Alffenaar JWC, Gwee A, Ho SA, Marriott DJE, Trubiano JA, Zhao J, Roberts JA. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy and haemopoietic stem cell transplant recipients, 2021. Intern Med J 2021; 51 Suppl 7:37-66. [PMID: 34937141 DOI: 10.1111/imj.15587] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.
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Affiliation(s)
- Maggie M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases and Microbiology, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Jan-Willem C Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Camperdown, New South Wales, Australia.,Pharmacy Department, Westmead Hospital, Westmead, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Su Ann Ho
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Faculty of Science, University of Technology, Ultimo, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Zhao
- Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason A Roberts
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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12
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Wiederhold NP. Antifungal Susceptibility Testing: A Primer for Clinicians. Open Forum Infect Dis 2021; 8:ofab444. [PMID: 34778489 PMCID: PMC8579947 DOI: 10.1093/ofid/ofab444] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/26/2021] [Indexed: 12/13/2022] Open
Abstract
Clinicians treating patients with fungal infections may turn to susceptibility testing to obtain information regarding the activity of different antifungals against a specific fungus that has been cultured. These results may then be used to make decisions regarding a patient's therapy. However, for many fungal species that are capable of causing invasive infections, clinical breakpoints have not been established. Thus, interpretations of susceptible or resistant cannot be provided by clinical laboratories, and this is especially true for many molds capable of causing severe mycoses. The purpose of this review is to provide an overview of susceptibility testing for clinicians, including the methods used to perform these assays, their limitations, how clinical breakpoints are established, and how the results may be put into context in the absence of interpretive criteria. Examples of when susceptibility testing is not warranted are also provided.
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Affiliation(s)
- Nathan P Wiederhold
- Fungus Testing Laboratory, Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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13
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Kuzma BA, Pence IJ, Greenfield DA, Ho A, Evans CL. Visualizing and quantifying antimicrobial drug distribution in tissue. Adv Drug Deliv Rev 2021; 177:113942. [PMID: 34437983 DOI: 10.1016/j.addr.2021.113942] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/11/2021] [Accepted: 08/18/2021] [Indexed: 12/15/2022]
Abstract
The biodistribution and pharmacokinetics of drugs are vital to the mechanistic understanding of their efficacy. Measuring antimicrobial drug efficacy has been challenging as plasma drug concentration is used as a surrogate for tissue drug concentration, yet typically does not reflect that at the intended site(s) of action. Utilizing an image-guided approach, it is feasible to accurately quantify the biodistribution and pharmacokinetics within the desired site(s) of action. We outline imaging modalities used in visualizing drug distribution with examples ranging from in vitro cellular drug uptake to clinical treatment of microbial infections. The imaging modalities of interest are: radio-labeling, magnetic resonance, mass spectrometry imaging, computed tomography, fluorescence, and Raman spectroscopy. We outline the progress, limitations, and future outlook for each methodology. Further advances in these optical approaches would benefit patients and researchers alike, as non-invasive imaging could yield more profound insights with a lower clinical burden than invasive measurement approaches used today.
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Affiliation(s)
- Benjamin A Kuzma
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA
| | - Isaac J Pence
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA
| | - Daniel A Greenfield
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA
| | - Alexander Ho
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA
| | - Conor L Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
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14
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Therapeutic drug monitoring of antimicrobial drugs in neonates. An opinion paper. Ther Drug Monit 2021; 44:65-74. [PMID: 34369442 PMCID: PMC8994040 DOI: 10.1097/ftd.0000000000000919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Neonatal infections are associated with high morbidity and mortality rates. Optimal treatment of these infections requires knowledge of neonatal pharmacology and integration of neonatal developmental pharmacokinetics of antimicrobial drugs in the design of dosing regimens for use with different gestational and postnatal ages. Population pharmacokinetic (PK) and pharmacodynamic (PD) models are used to personalize the use of these drugs in these fragile patients. The final step to further minimize variability in an individual patient is therapeutic drug monitoring (TDM), where the same population PK/PD models are used in concert with optimally drawn blood samples to further fine-tune therapy. The purpose of this manuscript is to describe the present status and future role of model-based precision dosing and TDM of antimicrobial drugs in neonates. METHODS PubMed was searched for clinical trials or clinical studies of TDM in neonates. RESULTS A total of 447 papers were retrieved, of which 19 were concerned with antimicrobial drugs. Two papers (one aminoglycoside and one vancomycin) addressed the effects of TDM in neonates. We found that, in addition to aminoglycosides and vancomycin, TDM also plays a role in beta-lactam antibiotics and antifungal drugs. CONCLUSION There is a growing awareness that, in addition to aminoglycosides and vancomycin, the use of beta-lactam antibiotics, such as amoxicillin and meropenem, and other classes of antimicrobial drugs, such as antifungal drugs, may benefit from TDM. However, the added value must be shown. New analytical techniques and software development may greatly support these novel developments.
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Abstract
Pathogenic fungi have several mechanisms of resistance to antifungal drugs, driven by the genetic plasticity and versatility of their homeostatic responses to stressful environmental cues. We critically review the molecular mechanisms of resistance and cellular adaptations of pathogenic fungi in response to antifungals and discuss the factors contributing to such resistance. We offer suggestions for the translational and clinical research agenda of this rapidly evolving and medically important field. A better understanding of antifungal resistance should assist in developing better detection tools and inform optimal strategies for preventing and treating refractory mycoses in the future.
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Affiliation(s)
- Ronen Ben-Ami
- Infectious Diseases Department, Sackler School of Medicine, Tel Aviv University, Tel Aviv Sourasky Medical Center, 6 Weizmann, Tel Aviv 64239, Israel
| | - Dimitrios P Kontoyiannis
- Infectious Diseases, University of Texas M D Anderson Cancer Center, 1515 Holcombe, Houston, TX 77030, USA.
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Rayner CR, Smith PF, Andes D, Andrews K, Derendorf H, Friberg LE, Hanna D, Lepak A, Mills E, Polasek TM, Roberts JA, Schuck V, Shelton MJ, Wesche D, Rowland‐Yeo K. Model-Informed Drug Development for Anti-Infectives: State of the Art and Future. Clin Pharmacol Ther 2021; 109:867-891. [PMID: 33555032 PMCID: PMC8014105 DOI: 10.1002/cpt.2198] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/05/2021] [Indexed: 12/13/2022]
Abstract
Model-informed drug development (MIDD) has a long and rich history in infectious diseases. This review describes foundational principles of translational anti-infective pharmacology, including choice of appropriate measures of exposure and pharmacodynamic (PD) measures, patient subpopulations, and drug-drug interactions. Examples are presented for state-of-the-art, empiric, mechanistic, interdisciplinary, and real-world evidence MIDD applications in the development of antibacterials (review of minimum inhibitory concentration-based models, mechanism-based pharmacokinetic/PD (PK/PD) models, PK/PD models of resistance, and immune response), antifungals, antivirals, drugs for the treatment of global health infectious diseases, and medical countermeasures. The degree of adoption of MIDD practices across the infectious diseases field is also summarized. The future application of MIDD in infectious diseases will progress along two planes; "depth" and "breadth" of MIDD methods. "MIDD depth" refers to deeper incorporation of the specific pathogen biology and intrinsic and acquired-resistance mechanisms; host factors, such as immunologic response and infection site, to enable deeper interrogation of pharmacological impact on pathogen clearance; clinical outcome and emergence of resistance from a pathogen; and patient and population perspective. In particular, improved early assessment of the emergence of resistance potential will become a greater focus in MIDD, as this is poorly mitigated by current development approaches. "MIDD breadth" refers to greater adoption of model-centered approaches to anti-infective development. Specifically, this means how various MIDD approaches and translational tools can be integrated or connected in a systematic way that supports decision making by key stakeholders (sponsors, regulators, and payers) across the entire development pathway.
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Affiliation(s)
- Craig R. Rayner
- CertaraPrincetonNew JerseyUSA
- Monash Institute of Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
| | | | - David Andes
- University of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Kayla Andrews
- Bill & Melinda Gates Medical Research InstituteCambridgeMassachusettsUSA
| | | | | | - Debra Hanna
- Bill & Melinda Gates FoundationSeattleWashingtonUSA
| | - Alex Lepak
- University of Wisconsin‐MadisonMadisonWisconsinUSA
| | | | - Thomas M. Polasek
- CertaraPrincetonNew JerseyUSA
- Centre for Medicines Use and SafetyMonash UniversityMelbourneVictoriaAustralia
- Department of Clinical PharmacologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jason A. Roberts
- Faculty of MedicineUniversity of Queensland Centre for Clinical ResearchThe University of QueenslandBrisbaneQueenslandAustralia
- Departments of Pharmacy and Intensive Care MedicineRoyal Brisbane and Women’s HospitalBrisbaneQueenslandAustralia
- Division of Anaesthesiology Critical Care Emergency and Pain MedicineNîmes University HospitalUniversity of MontpellierMontpellierFrance
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Optimization of Fluconazole Dosing for the Prevention and Treatment of Invasive Candidiasis Based on the Pharmacokinetics of Fluconazole in Critically Ill Patients. Antimicrob Agents Chemother 2021; 65:AAC.01554-20. [PMID: 33361296 DOI: 10.1128/aac.01554-20] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/15/2020] [Indexed: 12/31/2022] Open
Abstract
The efficacy of fluconazole is related to the area under the plasma concentration-time curve (AUC) over the MIC of the microorganism. Physiological changes in critically ill patients may affect the exposure of fluconazole, and therefore dosing adjustments might be needed. The aim of this study was to evaluate variability in fluconazole drug concentration in intensive care unit (ICU) patients and to develop a pharmacokinetic model to support personalized fluconazole dosing. A prospective observational pharmacokinetic study was performed in critically ill patients receiving fluconazole either as prophylaxis or as treatment. The association between fluconazole exposure and patient variables was studied. Pharmacokinetic modeling was performed with a nonparametric adaptive grid (NPAG) algorithm using R package Pmetrics. Data from 33 patients were available for pharmacokinetic analysis. Patients on dialysis and solid organ transplant patients had a significantly lower exposure to fluconazole. The population was best described with a one-compartment model, where the mean volume of distribution was 51.52 liters (standard deviation [SD], 19.81) and the mean clearance was 0.767 liters/h (SD, 0.46). Creatinine clearance was tested as a potential covariate in the model, but was not included in the final population model. A significant positive correlation was found between the fluconazole exposure (AUC) and the trough concentration (C min). Substantial variability in fluconazole plasma concentrations in critically ill adults was observed, where the majority of patients were underexposed. Fluconazole C min therapeutic drug monitoring (TDM)-guided dosing can be used to optimize therapy in critically ill patients. (This study has been registered at ClinicalTrials.gov under identifier NCT02491151.).
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18
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Hornik CD, Bondi DS, Greene NM, Cober MP, John B. Review of Fluconazole Treatment and Prophylaxis for Invasive Candidiasis in Neonates. J Pediatr Pharmacol Ther 2021; 26:115-122. [PMID: 33603574 PMCID: PMC7887891 DOI: 10.5863/1551-6776-26.2.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/17/2020] [Indexed: 01/29/2023]
Abstract
Invasive candidiasis accounts for approximately 10% of nosocomial infections in preterm infants, with an incidence of 1% to 4% among neonatal intensive care unit (NICU) admissions and a mortality as high as 20% to 30%. These outcomes warrant improved treatment and prevention strategies for infants at highest risk. The Infectious Diseases Society of America provides guidelines on antifungal medications for the prophylaxis and treatment of candidiasis in NICUs; however, there are still variations in practice on the use of fluconazole for prophylaxis and treatment of invasive candidiasis. This review provides specific information regarding fluconazole activity, pharmacokinetics, and a literature evaluation of dosing strategies and comparisons to other treatments in the neonatal population.
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19
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Lamoth F, Lewis RE, Kontoyiannis DP. Role and Interpretation of Antifungal Susceptibility Testing for the Management of Invasive Fungal Infections. J Fungi (Basel) 2020; 7:jof7010017. [PMID: 33396870 PMCID: PMC7823995 DOI: 10.3390/jof7010017] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/18/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022] Open
Abstract
Invasive fungal infections (IFIs) are associated with high mortality rates and timely appropriate antifungal therapy is essential for good outcomes. Emerging antifungal resistance among Candida and Aspergillus spp., the major causes of IFI, is concerning and has led to the increasing incorporation of in vitro antifungal susceptibility testing (AST) to guide clinical decisions. However, the interpretation of AST results and their contribution to management of IFIs remains a matter of debate. Specifically, the utility of AST is limited by the delay in obtaining results and the lack of pharmacodynamic correlation between minimal inhibitory concentration (MIC) values and clinical outcome, particularly for molds. Clinical breakpoints for Candida spp. have been substantially revised over time and appear to be reliable for the detection of azole and echinocandin resistance and for outcome prediction, especially for non-neutropenic patients with candidemia. However, data are lacking for neutropenic patients with invasive candidiasis and some non-albicans Candida spp. (notably emerging Candida auris). For Aspergillus spp., AST is not routinely performed, but may be indicated according to the epidemiological context in the setting of emerging azole resistance among A. fumigatus. For non-Aspergillus molds (e.g., Mucorales, Fusarium or Scedosporium spp.), AST is not routinely recommended as interpretive criteria are lacking and many confounders, mainly host factors, seem to play a predominant role in responses to antifungal therapy. This review provides an overview of the pre-clinical and clinical pharmacodynamic data, which constitute the rationale for the use and interpretation of AST testing of yeasts and molds in clinical practice.
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Affiliation(s)
- Frederic Lamoth
- Infectious Diseases Service and Institute of Microbiology, University Hospital of Lausanne, Lausanne University, 1011 Lausanne, Switzerland;
| | - Russell E. Lewis
- Clinic of Infectious Diseases, S’Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-792-6237; Fax: +1-713-745-6839
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20
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Pea F. From bench to bedside: Perspectives on the utility of pharmacokinetics/pharmacodynamics in predicting the efficacy of antifungals in invasive candidiasis. Mycoses 2020; 63:854-858. [PMID: 32472719 DOI: 10.1111/myc.13121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 12/16/2022]
Abstract
The aim of this perspective is to give an overlook on the utility of pharmacokinetics/pharmacodynamics (PK/PD) in predicting the efficacy of antifungals in invasive candidiasis. Overall, from the available literature it appears that bridging data of PK/PD of antifungals from the laboratory to the clinic for the treatment of invasive candidiasis are feasible only partially. Fluconazole is the only antifungal agent having the pharmacodynamic threshold of efficacy identified in experimental animal models convincingly validated in the clinical setting of invasive candidiasis as well. Conversely, for voriconazole and posaconazole data on this topic are very limited. For the echinocandins, robust PK/PD identified in the laboratory represented the rationale for defining differential clinical breakpoints of echinocandins against different species of Candida by the regulatory agencies. However, translation of the findings in the clinical setting provided conflicting results. Data on PK/PD of amphotericin B and flucytosine in models of invasive candidiasis are quite limited, and clinical studies assessing the role of drug exposure on efficacy are currently lacking. The expectation is that prospective studies could test more and more frequently the validity of experimental PK/PD data of antifungals in the clinical setting of invasive candidiasis. The findings could represent a step forward in addressing adequate antifungal stewardship programmes.
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Affiliation(s)
- Federico Pea
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital of Udine, ASUFC, Udine, Italy
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21
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Abdul-Aziz MH, Alffenaar JWC, Bassetti M, Bracht H, Dimopoulos G, Marriott D, Neely MN, Paiva JA, Pea F, Sjovall F, Timsit JF, Udy AA, Wicha SG, Zeitlinger M, De Waele JJ, Roberts JA. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper .. Intensive Care Med 2020; 46:1127-1153. [PMID: 32383061 PMCID: PMC7223855 DOI: 10.1007/s00134-020-06050-1] [Citation(s) in RCA: 489] [Impact Index Per Article: 122.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Purpose This Position Paper aims to review and discuss the available data on therapeutic drug monitoring (TDM) of antibacterials, antifungals and antivirals in critically ill adult patients in the intensive care unit (ICU). This Position Paper also provides a practical guide on how TDM can be applied in routine clinical practice to improve therapeutic outcomes in critically ill adult patients.
Methods Literature review and analysis were performed by Panel Members nominated by the endorsing organisations, European Society of Intensive Care Medicine (ESICM), Pharmacokinetic/Pharmacodynamic and Critically Ill Patient Study Groups of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) and International Society of Antimicrobial Chemotherapy (ISAC). Panel members made recommendations for whether TDM should be applied clinically for different antimicrobials/classes. Results TDM-guided dosing has been shown to be clinically beneficial for aminoglycosides, voriconazole and ribavirin. For most common antibiotics and antifungals in the ICU, a clear therapeutic range has been established, and for these agents, routine TDM in critically ill patients appears meritorious. For the antivirals, research is needed to identify therapeutic targets and determine whether antiviral TDM is indeed meritorious in this patient population. The Panel Members recommend routine TDM to be performed for aminoglycosides, beta-lactam antibiotics, linezolid, teicoplanin, vancomycin and voriconazole in critically ill patients. Conclusion Although TDM should be the standard of care for most antimicrobials in every ICU, important barriers need to be addressed before routine TDM can be widely employed worldwide. Electronic supplementary material The online version of this article (10.1007/s00134-020-06050-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Hendrik Bracht
- Department of Anaesthesiology, University Ulm, Ulm, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Deborah Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael N Neely
- Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jose-Artur Paiva
- Department of Medicine, Faculty of Medicine of Porto, Porto, Portugal.,Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitario de São João, Porto, Portugal
| | - Federico Pea
- Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUFC, Udine, Italy
| | - Fredrik Sjovall
- Department of Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
| | - Jean F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), Paris Diderot University, Paris, France
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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Mabilat C, Gros MF, Nicolau D, Mouton JW, Textoris J, Roberts JA, Cotta MO, van Belkum A, Caniaux I. Diagnostic and medical needs for therapeutic drug monitoring of antibiotics. Eur J Clin Microbiol Infect Dis 2020; 39:791-797. [PMID: 31828686 PMCID: PMC7182631 DOI: 10.1007/s10096-019-03769-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Therapeutic drug monitoring (TDM) of antibiotics has been practiced for more than half a century, but it is still not widely applied for infected patients. It has a traditional focus on limiting toxicity of specific classes of antibiotics such as aminoglycosides and vancomycin. With more patients in critical care with higher levels of sickness severity and immunosuppression as well as an increasingly obese and ageing population, an increasing risk of suboptimal antibiotic exposure continues to escalate. As such, the value of TDM continues to expand, especially for beta-lactams which constitute the most frequently used antibiotic class. To date, the minimum inhibitory concentration (MIC) of infectious microbes rather than classification in terms of susceptible and resistant can be reported. In parallel, increasingly sophisticated TDM technology is becoming available ensuring that TDM is feasible and can deliver personalized antibiotic dosing schemes. There is an obvious need for extensive studies that will quantify the improvements in clinical outcome of individual TDM-guided dosing. We suggest that a broad diagnostic and medical investigation of the TDM arena, including market analyses and analytical technology assessment, is a current priority.
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Affiliation(s)
- Claude Mabilat
- Medical Affairs, bioMérieux, Marcy l'Étoile, Lyon, France.
| | | | - David Nicolau
- Center for Anti-Infective Research & Development, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, Dr Molewaterplein 40, 3015 GD, Rotterdam, Netherlands
| | | | - Jason A Roberts
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Menino O Cotta
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Alex van Belkum
- Data Analytics Department, bioMérieux, La Balme Les Grottes, Grenoble, France
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de Lange DW, Brüggemann RJM. Prophylaxis Against Invasive Fungal Disease for Neutropenic Children and Young Adults. JAMA 2020; 323:997-998. [PMID: 32154852 DOI: 10.1001/jama.2020.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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24
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Stevens VM, Mueller SW, Reynolds PM, MacLaren R, Kiser TH. Extrapolating Antifungal Animal Data to Humans - Is it reliable? CURRENT FUNGAL INFECTION REPORTS 2020; 14:50-62. [PMID: 32201545 PMCID: PMC7083583 DOI: 10.1007/s12281-020-00370-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW This article aimed to review animal models of antifungals and identifies human literature to assess if the extrapolation of results is reliable. RECENT FINDINGS Animal studies have helped identify AUC/MIC targets for new drugs and formulations such as isavuconazole and delayed release posaconazole that have translated to successful outcomes in humans. Models have also been influential in the identification of possible combination therapies for the treatment of aspergillosis, such as voriconazole and echinocandins. However, challenges are endured with animal models when it comes to replicating the pharmacokinetics of humans which has been exemplified with the newest itraconazole formulation. Additionally, animal models have displayed a survival benefit with the use of iron chelators and amphotericin for mucormycosis which was not demonstrated in humans. SUMMARY Animal models have been a staple in the development and optimization of antifungal agents. They afford the ability to investigate uncommon diseases, such as invasive fungal infections, that would otherwise take years and many resources to complete. Although there are many benefits of animal models there are also shortcomings. This is why the reliability of extrapolating data from animal models to humans is often scrutinized.
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Affiliation(s)
- Victoria M Stevens
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Scott W Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, Mail Stop C238, Aurora, CO 80045, USA
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25
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Chagas OJ, Buccheri R, de Souza Carvalho Melhem M, Szeszs W, dos Anjos Martins M, de Oliveira L, Marcusso R, Santos DW. Usefulness of Yeast Cell Counting and Lack of Clinical Correlation of the Antifungal Susceptibility Testing Results in Management of Aids-associated Cryptococcal Meningitis. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00368-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Cierpiał T, Kiełbasiński P, Kwiatkowska M, Łyżwa P, Lubelska K, Kuran D, Dąbrowska A, Kruszewska H, Mielczarek L, Chilmonczyk Z, Wiktorska K. Fluoroaryl analogs of sulforaphane - A group of compounds of anticancer and antimicrobial activity. Bioorg Chem 2019; 94:103454. [PMID: 31787344 DOI: 10.1016/j.bioorg.2019.103454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/24/2019] [Accepted: 11/18/2019] [Indexed: 12/26/2022]
Abstract
A series of new sulforaphane analogs bearing various (poly)fluoroaryl substituents bonded to the sulfinyl sulfur atom in place of the original methyl group and having different number of methylene groups in the central alkyl chain were synthesized and fully characterized. The new compounds were tested in vitro for their anticancer, antibacterial, antifungal and antiviral properties. Some of them demonstrated a much higher anticancer activity against selected lines of cancer: skin (MALME-3M), colon (HT-29) and breast (MCF7 and MDA-MB-231) cells than that exhibited by native sulforaphane (SFN). Related lines of untransformed (normal) cells, taken from the same organs as the cancer ones, i.e. MALME3, CRL-1790 and MCF10, respectively, were checked, which allowed for the determination of the selectivity indexes (SI). In certain cases, the latter exceeded 3.2. Concerning the antibacterial activity, gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) were susceptible to some newly synthesized SFN analogs, while the selected probiotic strains were from 10 to 100 fold more resistant to them, which gives a possibility of protection of symbiont strains during a potential therapy with such compounds. The antifungal activity of the new compounds possessing the fluorophenyl substituent was found to be higher than the activity of the parent SFN. In turn, most of the new compounds showed generally no anti-HIV activity. The influence of the particular structural differences in the new molecules, analogs of SFN, on their biological activity is discussed.
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Affiliation(s)
- Tomasz Cierpiał
- Division of Organic Chemistry, Centre of Molecular and Macromolecular Studies, Polish Academy of Sciences, Sienkiewicza 112, 90-363 Łódź, Poland.
| | - Piotr Kiełbasiński
- Division of Organic Chemistry, Centre of Molecular and Macromolecular Studies, Polish Academy of Sciences, Sienkiewicza 112, 90-363 Łódź, Poland
| | - Małgorzata Kwiatkowska
- Division of Organic Chemistry, Centre of Molecular and Macromolecular Studies, Polish Academy of Sciences, Sienkiewicza 112, 90-363 Łódź, Poland
| | - Piotr Łyżwa
- Division of Organic Chemistry, Centre of Molecular and Macromolecular Studies, Polish Academy of Sciences, Sienkiewicza 112, 90-363 Łódź, Poland
| | - Katarzyna Lubelska
- Department of Drug Biotechnology and Bioinformatics, National Medicines Institute, Chełmska 30/34, 00-725 Warszawa, Poland
| | - Dominika Kuran
- Department of Drug Biotechnology and Bioinformatics, National Medicines Institute, Chełmska 30/34, 00-725 Warszawa, Poland
| | - Aleksandra Dąbrowska
- Department of Drug Biotechnology and Bioinformatics, National Medicines Institute, Chełmska 30/34, 00-725 Warszawa, Poland
| | - Hanna Kruszewska
- Department of Antibiotics and Microbiology, National Medicines Institute, Chełmska 30/34, 00-725 Warszawa, Poland
| | - Lidia Mielczarek
- Department of Drug Biotechnology and Bioinformatics, National Medicines Institute, Chełmska 30/34, 00-725 Warszawa, Poland
| | - Zdzisław Chilmonczyk
- Department of Drug Biotechnology and Bioinformatics, National Medicines Institute, Chełmska 30/34, 00-725 Warszawa, Poland
| | - Katarzyna Wiktorska
- Department of Drug Biotechnology and Bioinformatics, National Medicines Institute, Chełmska 30/34, 00-725 Warszawa, Poland.
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27
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Vicente FM, González-Garcia M, Diaz Pico E, Moreno-Castillo E, Garay HE, Rosi PE, Jimenez AM, Campos-Delgado JA, Rivera DG, Chinea G, Pietro RCL, Stenger S, Spellerberg B, Kubiczek D, Bodenberger N, Dietz S, Rosenau F, Paixão MW, Ständker L, Otero-González AJ. Design of a Helical-Stabilized, Cyclic, and Nontoxic Analogue of the Peptide Cm-p5 with Improved Antifungal Activity. ACS OMEGA 2019; 4:19081-19095. [PMID: 31763531 PMCID: PMC6868880 DOI: 10.1021/acsomega.9b02201] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/04/2019] [Indexed: 05/15/2023]
Abstract
Following the information obtained by a rational design study, a cyclic and helical-stabilized analogue of the peptide Cm-p5 was synthetized. The cyclic monomer showed an increased activity in vitro against Candida albicans and Candida parapsilosis, compared to Cm-p5. Initially, 14 mutants of Cm-p5 were synthesized following a rational design to improve the antifungal activity and pharmacological properties. Antimicrobial testing showed that the activity was lost in each of these 14 analogues, suggesting, as a main conclusion, that a Glu-His salt bridge could stabilize Cm-p5 helical conformation during the interaction with the plasma membrane. A derivative, obtained by substitution of Glu and His for Cys, was synthesized and oxidized with the generation of a cyclic monomer with improved antifungal activity. In addition, two dimers were generated during the oxidation procedure, a parallel and antiparallel one. The dimers showed a helical secondary structure in water, whereas the cyclic monomer only showed this conformation in SDS. Molecular dynamic simulations confirmed the helical stabilizations for all of them, therefore indicating the possible essential role of the Glu-His salt bridge. In addition, the antiparallel dimer showed a moderate activity against Pseudomonas aeruginosa and a significant activity against Listeria monocytogenes. Neither the cyclic monomer nor the dimers were toxic against macrophages or THP-1 human cells. Due to its increased capacity for fungal control compared to fluconazole, its low cytotoxicity, together with a stabilized α-helix and disulfide bridges, that may advance its metabolic stability, and in vivo activity, the new cyclic Cm-p5 monomer represents a potential systemic antifungal therapeutic candidate.
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Affiliation(s)
- Fidel
E. Morales Vicente
- General
Chemistry Department, Faculty of Chemistry and Center for Natural Products Research,
Faculty of Chemistry, University of Havana, Zapata y G, 10400 La Habana, Cuba
- Synthetic
Peptides Group, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, 10600 La Habana, Cuba
- Center
of Excellence for Research in Sustainable Chemistry (CERSusChem),
Department of Chemistry, Federal University
of São Carlos-UFSCar, São Paulo 13565-905, Brazil
| | - Melaine González-Garcia
- Center
for Protein Studies, Faculty of Biology, University of Havana, 25 and I, 10400 La Habana, Cuba
| | - Erbio Diaz Pico
- Synthetic
Peptides Group, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, 10600 La Habana, Cuba
| | - Elena Moreno-Castillo
- General
Chemistry Department, Faculty of Chemistry and Center for Natural Products Research,
Faculty of Chemistry, University of Havana, Zapata y G, 10400 La Habana, Cuba
| | - Hilda E. Garay
- Synthetic
Peptides Group, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, 10600 La Habana, Cuba
| | - Pablo E. Rosi
- Department
of Inorganic Chemistry, Analytical and Physical Chemistry, Facultad
de Ciencias Exactas y Naturales, Universidad
de Buenos Aires, Buenos Aires C1428EGA, Argentina
| | - Asiel Mena Jimenez
- General
Chemistry Department, Faculty of Chemistry and Center for Natural Products Research,
Faculty of Chemistry, University of Havana, Zapata y G, 10400 La Habana, Cuba
| | - Jose A. Campos-Delgado
- Center
of Excellence for Research in Sustainable Chemistry (CERSusChem),
Department of Chemistry, Federal University
of São Carlos-UFSCar, São Paulo 13565-905, Brazil
| | - Daniel G. Rivera
- General
Chemistry Department, Faculty of Chemistry and Center for Natural Products Research,
Faculty of Chemistry, University of Havana, Zapata y G, 10400 La Habana, Cuba
| | - Glay Chinea
- Synthetic
Peptides Group, Center for Genetic Engineering and Biotechnology, P.O. Box 6162, 10600 La Habana, Cuba
| | - Rosemeire C. L.
R. Pietro
- Laboratory
of Pharmaceutical Biotechnology, Department of Drugs and Medicines,
School of Pharmaceutical Sciences, UNESP, Araraquara 14800-900, Brazil
| | - Steffen Stenger
- Institute
of Medical Microbiology and Hygiene, University
Clinic of Ulm, Robert Koch Str. 8, Ulm D-89081, Germany
| | - Barbara Spellerberg
- Institute
of Medical Microbiology and Hygiene, University
Clinic of Ulm, Robert Koch Str. 8, Ulm D-89081, Germany
| | - Dennis Kubiczek
- Institute
of Pharmaceutical Biotechnology, Ulm University, James-Frank-Ring N27, 89081 Ulm, Germany
| | - Nicholas Bodenberger
- Institute
of Pharmaceutical Biotechnology, Ulm University, James-Frank-Ring N27, 89081 Ulm, Germany
| | - Steffen Dietz
- Institute
of Pharmaceutical Biotechnology, Ulm University, James-Frank-Ring N27, 89081 Ulm, Germany
| | - Frank Rosenau
- Institute
of Pharmaceutical Biotechnology, Ulm University, James-Frank-Ring N27, 89081 Ulm, Germany
| | - Márcio Weber Paixão
- Center
of Excellence for Research in Sustainable Chemistry (CERSusChem),
Department of Chemistry, Federal University
of São Carlos-UFSCar, São Paulo 13565-905, Brazil
- E-mail: (W.P.)
| | - Ludger Ständker
- Core
Facility for Functional Peptidomics, Ulm Peptide Pharmaceuticals (U-PEP),
University Ulm, Faculty of Medicine, Ulm
University, 89081 Ulm, Germany
- E-mail: (L.S.)
| | - Anselmo J. Otero-González
- Center
for Protein Studies, Faculty of Biology, University of Havana, 25 and I, 10400 La Habana, Cuba
- E-mail: (A.J.O.-G.)
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28
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John J, Loo A, Mazur S, Walsh TJ. Therapeutic drug monitoring of systemic antifungal agents: a pragmatic approach for adult and pediatric patients. Expert Opin Drug Metab Toxicol 2019; 15:881-895. [PMID: 31550939 DOI: 10.1080/17425255.2019.1671971] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: Therapeutic drug monitoring (TDM) has been shown to optimize the management of invasive fungal infections (IFIs), particularly for select antifungal agents with a well-defined exposure-response relationship and an unpredictable pharmacokinetic profile or a narrow therapeutic index. Select triazoles (itraconazole, voriconazole, and posaconazole) and flucytosine fulfill these criteria, while the echinocandins, fluconazole, isavuconazole, and amphotericin B generally do not do so. Given the morbidity and mortality associated with IFIs and the challenges surrounding the use of currently available antifungal agents, TDM plays an important role in therapy.Areas covered: This review seeks to describe the rationale for TDM of antifungal agents, summarize their pharmacokinetic and pharmacodynamic properties, identify treatment goals for efficacy and safety, and provide recommendations for optimal dosing and therapeutic monitoring strategies.Expert opinion: Several new antifungal agents are currently in development, including compounds from existing antifungal classes with enhanced pharmacokinetic or safety profiles as well as agents with novel targets for the treatment of IFIs. Given the predictable pharmacokinetics of these newly developed agents, use of routine TDM is not anticipated. However, expanded knowledge of exposure-response relationships of these compounds may yield a role for TDM to improve outcomes for adult and pediatric patients.
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Affiliation(s)
- Jamie John
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY, USA
| | - Angela Loo
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY, USA
| | - Shawn Mazur
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
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30
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Ghanem-Zoubi N, Qasum M, Khoury J, Zorbavel D, Arnon M, Geffen Y, Paul M. The association between fluconazole dose and MIC with mortality and persistence in candidemia. Eur J Clin Microbiol Infect Dis 2019; 38:1773-1780. [PMID: 31197619 DOI: 10.1007/s10096-019-03611-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 06/04/2019] [Indexed: 01/27/2023]
Abstract
To evaluate the association between fluconazole exposure parameters and clinical outcomes in patients with candidemia. We retrospectively included all adults with candidemia in a single center from January 2009 to December 2017, treated initially with fluconazole for fluconazole-susceptible candidemia. We assessed the association between fluconazole exposure parameters and 30-day mortality or 14-day clinical failure, a composite of mortality at day 14 or persistent candidemia ≥ 72 h, in all patients and in patients with C. glabrata candidemia. During the study period, 158 patients fulfilled the inclusion criteria. Main species were C. albicans 66 (41.8%), C. glabrata 35 (22.2%), and C. parapsilosis 31 (19.6%). Sixty patients (38%) died within 30 days. Sixty-one patients (38.6%) experienced 14-day failure. In 30-day survivors, the median AUC24/MIC was 2279 [398, 5989] versus 1764 [238, 6714] h in non-survivors, p = 0.75. Median fluconazole MIC was 0.75 [0.25, 4] and 1 [0.22, 5.50] mg/L, p = 0.54, respectively. Similar non-significant differences were found for other fluconazole exposure parameters and in the 14-day clinical failure analysis. For C. glabrata, a higher AUC24/MIC was observed among 30-day survivors with a median of 230 [77, 539] compared to 96 [75, 164] h in non-survivors, p = 0.008, in parallel with a trend for lower MIC values (median 7 [1, 2] versus 16 [8, 24] mg/L, p = 0.06, respectively). Currently used fluconazole dosing has no association with clinical outcome in Candida with low MIC values. For Candida species with high MICs, attention to dosing is needed.
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Affiliation(s)
- Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel.
| | - Majd Qasum
- Internal Medicine Department D, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel
| | - Johad Khoury
- Internal Medicine Department B, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel
| | - Danny Zorbavel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Efron 1 St, 3525433, Haifa, Israel
| | - Merav Arnon
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Efron 1 St, 3525433, Haifa, Israel
| | - Yuval Geffen
- Microbiology Laboratory, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Ha-aliya 8 St, 3109601, Haifa, Israel
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31
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Righi E, Carnelutti A, Baccarani U, Sartor A, Cojutti P, Bassetti M, Pea F. Treatment of Candida infections with fluconazole in adult liver transplant recipients: Is TDM-guided dosing adaptation helpful? Transpl Infect Dis 2019; 21:e13113. [PMID: 31106504 DOI: 10.1111/tid.13113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/24/2019] [Accepted: 05/02/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Fluconazole represents a common antifungal option for the treatment of Candida infections in liver transplant recipients. Although adequate antifungal exposure is known to correlate with favorable outcomes in patients with invasive candidiasis, therapeutic drug monitoring (TDM) of fluconazole is currently not recommended. METHODS We conducted a retrospective study including adult liver transplant recipients receiving fluconazole for invasive candidiasis and undergoing TDM. We assessed the correlation between clinical variables, fluconazole trough plasma levels (Cmin ), and outcome. RESULTS Twenty-seven patients (74% males; median age 57 years) were included. Abdominal candidiasis was the most frequent infection (56%). Median duration of fluconazole therapy was 17 days (IQR 9-21). Fluconazole median Cmin was 11.0 mg/L (range 2.4-30.6 mg/L). Five (19%) patients required TDM-guided fluconazole dose increase. All-cause in hospital mortality was 33%. Fluconazole Cmin >11 mg/L significantly correlated with clinical success (OR 8.78, 95% CI 1.13-67.8, P = 0.04). CONCLUSIONS Our study identified decreased fluconazole Cmin as a factor associated with negative outcomes in liver transplant recipients with Candida infection. TDM of fluconazole may be advisable in this patient population.
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Affiliation(s)
- Elda Righi
- Infectious Diseases Division, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy.,Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alessia Carnelutti
- Infectious Diseases Division, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Umberto Baccarani
- General Surgery and Transplantation Unit, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Assunta Sartor
- Microbiology Unit, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Piergiorgio Cojutti
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Matteo Bassetti
- Infectious Diseases Division, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Federico Pea
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
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32
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Population Pharmacokinetic Study of Prophylactic Fluconazole in Preterm Infants for Prevention of Invasive Candidiasis. Antimicrob Agents Chemother 2019; 63:AAC.01960-18. [PMID: 30910892 DOI: 10.1128/aac.01960-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 03/14/2019] [Indexed: 12/18/2022] Open
Abstract
Fluconazole is an antifungal agent with reported evidence for its prophylactic effect against systemic fungal infection in preterm infants. The aim of this study was to build a population pharmacokinetic model to evaluate the pharmacokinetic characteristics of intravenous and oral fluconazole in preterm infants with the current prophylactic fluconazole dosing regimen. A pharmacokinetic model was developed using 301 fluconazole concentrations from 75 preterm infants with a baseline body weight (WT) ranging from 0.5 to 1.5 kg and an estimated glomerular filtration rate (eGFR) ranging from 12.9 to 58.5 ml/min/1.73 m2 Eligible infants received an intravenous or oral dose of 3 mg/kg of body weight of fluconazole, twice weekly with a ≥72-h dose interval, for 4 weeks. The model was qualified with basic goodness-of-fit diagnostics, visual predictive checks, and bootstrapping. The fluconazole pharmacokinetics was well described with a one-compartment linear model with a proportional residual error. The population clearance (CL) and volume of distribution (V) were derived as 0.0197 × (WT/1.00)0.746 × (eGFR/25.0)0.463 × exp(η) and 1.04 × WT × exp(η), respectively. Such covariate analyses augment the awareness of the need for personalized dosing in preterm infants. (This study has been registered at ClinicalTrials.gov under identifier NCT01683760).
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33
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Gerhart JG, Watt KM, Edginton A, Wade KC, Salerno SN, Benjamin DK, Smith PB, Hornik CP, Cohen-Wolkowiez M, Duara S, Ross A, Shattuck K, Stewart DL, Neu N, Gonzalez D. Physiologically-Based Pharmacokinetic Modeling of Fluconazole Using Plasma and Cerebrospinal Fluid Samples From Preterm and Term Infants. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:500-510. [PMID: 31087536 PMCID: PMC6656941 DOI: 10.1002/psp4.12414] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 12/16/2022]
Abstract
Fluconazole is used to treat hematogenous Candida meningoencephalitis in preterm and term infants. To characterize plasma and central nervous system exposure, an adult fluconazole physiologically‐based pharmacokinetic (PBPK) model was scaled to infants, accounting for age dependencies in glomerular filtration and metabolism. The model was optimized using 760 plasma samples from 166 infants (median postmenstrual age (range) 28 weeks (24–50)) and 27 cerebrospinal fluid (CSF) samples from 22 infants (postmenstrual age 28 weeks (24–33)). Simulations evaluated achievement of the surrogate efficacy target of area under the unbound concentration‐time curve ≥ 400 mg • hour/L over the dosing interval in plasma and CSF using dosing guidelines. Average fold error of predicted concentrations was 0.73 and 1.14 for plasma and CSF, respectively. Target attainment in plasma and CSF was reached faster after incorporating a loading dose of 25 mg/kg. PBPK modeling can be useful in exploring CNS kinetics of drugs in children.
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Affiliation(s)
- Jacqueline G Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kevin M Watt
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Kelly C Wade
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sara N Salerno
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Shahnaz Duara
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Ashley Ross
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Karen Shattuck
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, USA
| | - Dan L Stewart
- Department of Pediatrics, University of Louisville, Louisville, Kentucky, USA
| | - Natalie Neu
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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34
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Espinel-Ingroff A, Sanguinetti M, Posteraro B. Usefulness of Antifungal Reference In Vitro Susceptibility Tests as a Guide in Therapeutic Management. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-0336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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35
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Pea F, Lewis RE. Overview of antifungal dosing in invasive candidiasis. J Antimicrob Chemother 2019; 73:i33-i43. [PMID: 29304210 DOI: 10.1093/jac/dkx447] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In the past, most antifungal therapy dosing recommendations for invasive candidiasis followed a 'one-size fits all' approach with recommendations for lowering maintenance dosages for some antifungals in the setting of renal or hepatic impairment. A growing body of pharmacokinetic/pharmacodynamic research, however now points to a widespread 'silent epidemic' of antifungal underdosing for invasive candidiasis, especially among critically ill patients or special populations who have altered volume of distribution, protein binding and drug clearance. In this review, we explore how current adult dosing recommendations for antifungal therapy in invasive candidiasis have evolved, and special populations where new approaches to dose optimization or therapeutic drug monitoring may be needed, especially in light of increasing antifungal resistance among Candida spp.
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Affiliation(s)
- Federico Pea
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Russell E Lewis
- Infectious Diseases Unit, S. Orsola-Malpighi Hospital; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Design, synthesis, and biological activity of Schiff bases bearing salicyl and 7-hydroxycoumarinyl moieties. MONATSHEFTE FUR CHEMIE 2019. [DOI: 10.1007/s00706-018-2325-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Are In Vitro Susceptibilities to Azole Antifungals Predictive of Clinical Outcome in the Treatment of Candidemia? J Clin Microbiol 2018; 56:JCM.01072-18. [PMID: 30135234 DOI: 10.1128/jcm.01072-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The purpose of this review is to critically analyze published data evaluating the impact of azole pharmacokinetic and pharmacodynamic parameters, MICs, and Candida species on clinical outcomes in patients with candidemia. Clinical breakpoints (CBPs) for fluconazole and voriconazole, which are used to determine susceptibility, have been defined by the Clinical and Laboratory Standards Institute (CLSI) for Candida species. Studies evaluating the relationship between treatment efficacy and in vitro susceptibility, as well as the pharmacodynamic targets, have been conducted in patients treated with fluconazole for candidemia; however, for species other than Candida albicans and Candida glabrata, and for other forms of invasive candidiasis, data remain limited and randomized trials are not available. Limited data evaluating these relationships with voriconazole are available. While pharmacodynamic targets for posaconazole and isavuconazole have been proposed based upon studies conducted in murine models, CBPs have not been established by CLSI. Fluconazole remains an important antifungal agent for the treatment of candidemia, and data supporting its use based on in vitro susceptibility are growing, particularly for C. albicans and C. glabrata Further investigation is needed to establish the roles of voriconazole, posaconazole, and isavuconazole in the treatment of candidemia and for all agents in the treatment of other forms of invasive candidiasis.
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Watt KM, Cohen-Wolkowiez M, Barrett JS, Sevestre M, Zhao P, Brouwer KLR, Edginton AN. Physiologically Based Pharmacokinetic Approach to Determine Dosing on Extracorporeal Life Support: Fluconazole in Children on ECMO. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2018; 7:629-637. [PMID: 30033691 PMCID: PMC6202466 DOI: 10.1002/psp4.12338] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Extracorporeal life support (e.g., dialysis, extracorporeal membrane oxygenation (ECMO)) can affect drug disposition, placing patients at risk for therapeutic failure. In this population, dose selection to achieve safe and effective drug exposure is difficult. We developed a novel and flexible approach that uses physiologically based pharmacokinetic (PBPK) modeling to translate results from ECMO ex vivo experiments into bedside dosing recommendations. To determine fluconazole dosing in children on ECMO, we developed a PBPK model, which was validated using fluconazole pharmacokinetic (PK) data in adults and critically ill infants. Next, an ECMO compartment was added to the PBPK model and parameterized using data from a previously published ex vivo study. Simulations using the final ECMO PBPK model reasonably characterized observed PK data in infants on ECMO, and the model was used to derive dosing in children on ECMO across the pediatric age spectrum. This approach can be generalized to other forms of extracorporeal life support (ECLS), such as dialysis.
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Affiliation(s)
- Kevin M Watt
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Ping Zhao
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - Kim L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Andrea N Edginton
- University of Waterloo School of Pharmacy, Waterloo, Ontario, Canada
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Leroux S, Jacqz-Aigrain E, Elie V, Legrand F, Barin-Le Guellec C, Aurich B, Biran V, Dusang B, Goudjil S, Coopman S, Garcia Sanchez R, Zhao W, Manzoni P. Pharmacokinetics and safety of fluconazole and micafungin in neonates with systemic candidiasis: a randomized, open-label clinical trial. Br J Clin Pharmacol 2018; 84:1989-1999. [PMID: 29744900 DOI: 10.1111/bcp.13628] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/11/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022] Open
Abstract
AIMS The pharmacokinetics (PK) of fluconazole and micafungin differ in neonates compared with children and adults. Dosing instructions in product labels appear to be inconsistent with the emerging scientific evidence. Limited information is available on the safety profile of these agents in neonates. Our objective was to study the population PK and safety of both drugs, randomly administered in neonates with suspected or confirmed systemic candidiasis. METHODS Neonates were randomized 1:1 to fluconazole (loading dose 25 mg kg-1 ; maintenance dose 12 mg kg-1 day-1 or 20 mg kg-1 day-1 , respectively, for infants <30 weeks or ≥30 weeks' corrected gestational age) or micafungin (loading dose 15 mg kg-1 day-1 ; maintenance dose 10 mg kg-1 day-1 ). PK samples were taken on treatment days 1 and 5. Population parameters were determined using NONMEM and Monte Carlo simulations performed to reach predefined targets. Clinical and laboratory data, and adverse events were collected up to 36 weeks' corrected gestational age or hospital discharge. RESULTS Thirty-six neonates were enrolled. The median (range) gestational age was 28.2 (24.1-40.1) and 26.8 (23.5-40.0) weeks for fluconazole and micafungin, respectively. Based on 163 PK samples, the median population clearance (l h-1 kg-1 ) and volume of distribution (l kg-1 ) for fluconazole were: 0.015 [95% confidence interval (CI) 0.008, 0.039] and 0.913, and for micafungin were: 0.020 (95% CI 0.010, 0.023) and 0.354 (95% CI 0.225, 0.482), respectively. The loading dose was well tolerated. No adverse events associated with micafungin or fluconazole were reported. CONCLUSION Based on Monte Carlo simulations, a loading dose for fluconazole and dosing higher than recommended for both drugs are required to increase the area under the plasma drug concentration-time curve target attainment rate in neonates.
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Affiliation(s)
- S Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - E Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | - F Legrand
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - C Barin-Le Guellec
- EA4245, Faculté de Médecine, Université François Rabelais, Tours, France
| | - B Aurich
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - V Biran
- UMR 1141 INSERM, Université Paris 7-Diderot, Neonatal Intensive Care Unit, Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - B Dusang
- Neonatal Intensive Care Unit, CHU de La Réunion, Saint Pierre, La Réunion, France
| | - S Goudjil
- Neonatal Care Unit, CHU Amiens, Amiens, France
| | - S Coopman
- Centre d'Investigation Clinique, CIC1403, Lille University Hospital, Lille, France
| | | | - W Zhao
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - P Manzoni
- Neonatal Intensive Care Unit, S. Anna Hospital, Torino, Italy
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Ko JH, Peck KR, Jung DS, Lee JY, Kim HA, Ryu SY, Jung SI, Joo EJ, Cheon S, Kim YS, Kim SW, Cho SY, Ha YE, Kang CI, Chung DR, Lee NY, Song JH. Impact of high MIC of fluconazole on outcomes of Candida glabrata bloodstream infection: a retrospective multicenter cohort study. Diagn Microbiol Infect Dis 2018; 92:127-132. [PMID: 29929855 DOI: 10.1016/j.diagmicrobio.2018.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/27/2018] [Accepted: 05/07/2018] [Indexed: 12/22/2022]
Abstract
To evaluate the impacts of fluconazole minimum inhibitory concentration (MIC) according to primary antifungal agents on Candida glabrata bloodstream infection (BSI), a multicenter retrospective cohort study was conducted in Korea, concerning the time period from January 2010 to February 2016. A total of 197 adult patients with C. glabrata BSI were included in the study, and neutropenia (P = 0.026), APACHE II score (P = 0.004), and fluconazole resistance (HR 3.960, 95% CI 1.395-11.246, P = 0.010) were associated with 30-day mortality in multivariate analysis. In subgroup analysis, fluconazole MIC = 32 μg/mL in the azole-treated group (HR 6.691, 95% CI 1.569-28.542, P = 0.010) and fluconazole MIC ≥ 64 μg/mL in the non-azole-treated group (HR 3.337, 95% CI 1.183-9.411, P = 0.023) showed the highest hazard ratio (HR) for 30-day mortality. Increased fluconazole MIC was associated with poor outcome both in azole- and non-azole-treated patients with C. glabrata BSI.
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Affiliation(s)
- Jae-Hoon Ko
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Dong Sik Jung
- Division of Infectious Diseases, Dong-A University College of Medicine, Busan, Korea
| | - Ji Yeon Lee
- Division of Infectious Diseases, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyun Ah Kim
- Division of Infectious Diseases, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Seong Yeol Ryu
- Division of Infectious Diseases, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Sook-In Jung
- Division of Infectious Diseases, Chonnam National University Hospital, Gwangju, Korea
| | - Eun-Jeong Joo
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shinhye Cheon
- Division of Infectious Diseases, Chungnam National University School of Medicine, Daejeon, Korea
| | - Yeon-Sook Kim
- Division of Infectious Diseases, Chungnam National University School of Medicine, Daejeon, Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sun Young Cho
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Eun Ha
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Buchs R, Lehner B, Meuwly P, Schnyder B. Host-Pathogen Interaction Reconstituted in Three-Dimensional Cocultures of Mucosa and Candida albicans. Tissue Eng Part C Methods 2018; 24:412-417. [PMID: 29901432 DOI: 10.1089/ten.tec.2018.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Candida albicans frequently causes recurrent intimal infectious disease (ID). This demands the treatment of multiple phases of the infection. The objective of this study was to uncover the host-pathogen interaction using two-dimensional (2D) epithelium cell-barrier and three-dimensional (3D) subepithelium tissue cells of human mucosa. The 2D cell cultures assessed C. albicans adhesion. Addition of the antifungal drug Fluconazol did not inhibit the adhesion, despite its pathogen growth inhibition (minimal inhibitory concentration value 0.08 μg/mL). A 3D tissue was engineered in multitranswells by placing human fibroblast cultures on a thick porous scaffold. This contained the yeast placed in the top compartment and prevented passive penetration. After 28 h, the pathogen transmigrated the barrier and was collected in the bottom compartment. A change in pathogen morphology was observed where hypha formed and grew to be 231 μm long after 28 h. The hypha was thus long enough to cross the 200 μm thick 3D tissue. The 3D infection was inhibited by addition of Fluconazol (0.08 μg/mL), confirming that penetration is dependent on pathogen growth. In conclusion, ID was reconstituted step-by-step on 2D epithelium surface and in 3D connective tissue of human mucosa. Fluconazol growth-inhibition of the pathogen C. albicans was confirmed in the 3D tissue. We thus propose that this ID in vitro test is suitable for the identification and characterization of new treatments against C. albicans.
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Affiliation(s)
- Romina Buchs
- 1 School of Engineering, Institute of Life Technologies, University of Applied Sciences , HES-SO Valais/Wallis, Sion, Switzerland
| | - Bruno Lehner
- 1 School of Engineering, Institute of Life Technologies, University of Applied Sciences , HES-SO Valais/Wallis, Sion, Switzerland
| | | | - Bruno Schnyder
- 1 School of Engineering, Institute of Life Technologies, University of Applied Sciences , HES-SO Valais/Wallis, Sion, Switzerland
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Sun N, Li D, Zhang Y, Killeen K, Groutas W, Calderone R. Repurposing an inhibitor of ribosomal biogenesis with broad anti-fungal activity. Sci Rep 2017; 7:17014. [PMID: 29209049 PMCID: PMC5717060 DOI: 10.1038/s41598-017-17147-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 11/22/2017] [Indexed: 12/23/2022] Open
Abstract
The lack of new antifungal compounds with unique mechanisms of action is a concern for therapeutic management of patients. To identify inhibitors against human pathogenic fungi, we screened ~3000 compounds provided by the Developmental Therapeutics Program of NIH/NCI against a panel of pathogenic fungi including Candida species, Aspergillus fumigatus, and Cryptococcus neoformans. NSC319726 (a thiosemicarbazone) had broad antifungal activity in the range of 0.1–2.0 µg/ml and was also inhibitory to fluconazole-resistant isolates of Candida species. Synergy was demonstrated with NSC319726 and azoles, as well as caspofungin. The inhibitory concentration 50% (IC50) of NSC319726 was 35–800-fold higher than the Minimum Inhibitory Concentration 50% (MIC50 values), which indicates low compound toxicity to human cells in vitro. Transcriptome analysis of treated and untreated C. albicans using Gene Ontology (GO) revealed a large cluster of down regulated genes that encode translational proteins, especially those with ribosome biogenesis functions. As NSC319726 was first shown to have anti-cancer activity, its affects against human pathogenic fungi establish NSC319726 as a repurposed, off-patent compound that has potential antifungal activity. The minimal in vitro toxicity of lead optimized NSC319726 and its reasonable inhibitory activity against pathogens suggest advancing this compound to in vivo toxicity testing and protection studies against candidiasis.
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Affiliation(s)
- Nuo Sun
- Georgetown University Medical Center, Washington DC, 20057, USA
| | - Dongmei Li
- Georgetown University Medical Center, Washington DC, 20057, USA
| | - Yuhan Zhang
- Georgetown University Medical Center, Washington DC, 20057, USA
| | - Kyle Killeen
- Georgetown University Medical Center, Washington DC, 20057, USA
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Rawat P, Agarwal S, Tripathi S. Effect of Addition of Antifungal Agents on Physical and Biological Properties of a Tissue Conditioner: An In-Vitro Study. Adv Pharm Bull 2017; 7:485-490. [PMID: 29071233 PMCID: PMC5651072 DOI: 10.15171/apb.2017.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 08/19/2017] [Accepted: 08/23/2017] [Indexed: 12/02/2022] Open
Abstract
Purpose: Tissue conditioners are used for healing of abused oral tissues. They may harbour microorganisms causing oral diseases such as candidiasis compromising the health of the patient. Also, addition of antifungal agents into tissue conditioner may alter its properties. This study compares the anti-fungal property and mechanical properties of tissue conditioner containing different antifungal agents. Methods: Three antifungal agents, one synthetic – fluconazole, and two natural - oregano oil and virgin coconut oil were added into the tissue conditioner (Viscogel) in different concentrations. The antifungal property, tensile bond strength and viscoelasticity of Viscogel containing these antifungal agents were assessed after 24 hours, three days and seven days. Results: While, the highest antifungal activity was shown by Viscogel containing fluconazole, the maximum tensile bond strength was found to be of Viscogel alone (control). Although Viscogel alone and in combination of fluconazole showed deterioration in viscoelasticity, Viscogel in combination of natural agents showed no significant changes over the period of seven days. Conclusion: Incorporation of the natural agents in the tissue conditioner can be used as an effective alternative to systemic or topical synthetic antifungal agents.
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Affiliation(s)
- Pragati Rawat
- Department of Prosthodontics and Crown & Bridge, Kothiwal dental college and research center, Moradabad, UP-244001, India
| | - Swatantra Agarwal
- Department of Prosthodontics and Crown & Bridge, Kothiwal dental college and research center, Moradabad, UP-244001, India
| | - Siddhi Tripathi
- Department of Prosthodontics and Crown & Bridge, Kothiwal dental college and research center, Moradabad, UP-244001, India
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44
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Ostrosky-Zeichner L, Andes D. The Role of In Vitro Susceptibility Testing in the Management of Candida and Aspergillus. J Infect Dis 2017; 216:S452-S457. [PMID: 28911047 DOI: 10.1093/infdis/jix239] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Antifungal susceptibility testing has evolved from a research technique to a standardized and well-validated tool for the clinical management of fungal infections and for epidemiological studies. Genetic mutations and phenotypic resistance in vitro have been shown to correlate with clinical outcomes and treatment failures, and this in turn has led to the creation of clinical breakpoints and, more recently, epidemiological cutoff values for clinically relevant fungal pathogens. Resistance mechanisms for Candida and Aspergillus species have been extensively described and their corresponding genetic mutations can now be readily detected. Epidemiological studies have been able to detect the emergence of regional clonal and nonclonal resistance in several countries. The clinical microbiology laboratory is expected to transition from culture and traditional susceptibility testing to molecular methods for detection, identification, and resistance profiling over the next 5-10 years.
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Affiliation(s)
- Luis Ostrosky-Zeichner
- Division of Infectious Diseases, McGovern Medical School, University of Texas Health Science Center at Houston
| | - David Andes
- Division of Infectious Diseases, University of Wisconsin, Madison
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Qiao Y, Song L, Zhu C, Wang Q, Guo T, Yan Y, Li Q. Development of a phosphorylated Momordica charantia protein system for inhibiting susceptible dose-dependent C. albicans to available antimycotics: An allosteric regulation of protein. Eur J Pharm Sci 2017; 109:262-268. [PMID: 28834733 DOI: 10.1016/j.ejps.2017.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 08/14/2017] [Accepted: 08/18/2017] [Indexed: 02/01/2023]
Abstract
A regulatory Momordica charantia protein system was constructed allosterically by in vitro protein phosphorylation, in an attempt to evaluate antimycological pluripotency against dose-dependent susceptibilities in C. albicans. Fungal strain lineages susceptible to ketoconazole, econazole, miconazole, 5-flucytosine, nystatin and amphotericin B were prepared in laboratory, followed by identification via antifungal susceptibility testing. Protein phosphorylation was carried out in reactions with 5'-adenylic, guanidylic, cytidylic and uridylic acids and cyclic adenosine triphosphate, through catalysis of cyclin-dependent kinase 1, protein kinase A and protein kinase C respectively. Biochemical analysis of enzymatic reactions indicated the apparent Michaelis-Menten constants and maximal velocity values of 16.57-91.97mM and 55.56-208.33μM·min-1, together with an approximate 1:1 reactant stoichiometric ratio. Three major protein phosphorylation sites were theoretically predicted at Thr255, Thr102 and Thr24 by a KinasePhos tool. Additionally, circular dichroism spectroscopy demonstrated that upon phosphorylation, protein folding structures were decreased in random coil, β6-sheet and α1-helix partial regions. McFarland equivalence standard testing yielded the concentration-dependent inhibition patterns, while fungus was grown in Sabouraud's dextrose agar. The minimal inhibitory concentrations of 0.16-0.51μM (at 50% response) were obtained for free protein and phosphorylated counterparts. With respect to the 3-cycling susceptibility testing regimen, individuals of total protein forms were administrated in-turn at 0.14μM/cycle. Relative inhibition ratios were retained to 66.13-81.04% of initial ones regarding the ketoconazole-susceptible C. albicans growth. An inhibitory protein system, with an advantage of decreasing antifungal susceptibilities to diverse antimycotics, was proposed because of regulatory pluripotency whereas little contribution to susceptibility in itself.
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Affiliation(s)
- Yuanbiao Qiao
- Graduate Institute of Pharmaceutical Chemistry, Luliang University, Shanxi 033001, PR China.
| | - Li Song
- Department of Bioscience, Luliang University, Shanxi 033001, PR China
| | - Chenchen Zhu
- Department of Bioscience, Luliang University, Shanxi 033001, PR China
| | - Qian Wang
- Department of Bioscience, Luliang University, Shanxi 033001, PR China
| | - Tianyan Guo
- Department of Bioscience, Luliang University, Shanxi 033001, PR China
| | - Yanhua Yan
- Department of Bioscience, Luliang University, Shanxi 033001, PR China
| | - Qingshan Li
- College of Traditional Chinese Pharmacology, Shanxi University of Traditional Chinese Medicine, Shanxi 030619, PR China; School of Pharmaceutical Sciences, Shanxi Medical University, Shanxi 030001, PR China.
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Fernández-Ruiz M, Guinea J, Lora-Pablos D, Zaragoza Ó, Puig-Asensio M, Almirante B, Cuenca-Estrella M, Aguado JM. Impact of fluconazole susceptibility on the outcome of patients with candidaemia: data from a population-based surveillance. Clin Microbiol Infect 2017; 23:672.e1-672.e11. [PMID: 28143788 DOI: 10.1016/j.cmi.2017.01.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/05/2017] [Accepted: 01/21/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The clinical correlation of fluconazole antifungal susceptibility testing (AST) for Candida isolates and its integration with pharmacokinetics/pharmacodynamics (PK/PD) parameters is unclear. We analysed the impact of fluconazole minimum inhibitory concentration (MIC) values, 24-hour area under the concentration-time curve (AUC24) and AUC24/MIC ratio on the outcome of candidemic patients. METHODS We included 257 episodes of candidaemia treated with fluconazole monotherapy for ≥72 hours from a population-based surveillance conducted in 29 hospitals (CANDIPOP Project). AST was centrally performed by European Committee on Antimicrobial Susceptibility Testing (EUCAST) and Clinical and Laboratory Standards Institute (CLSI) microdilution methods. Primary outcome was clinical failure (30-day mortality and/or persistent candidaemia for ≥72 hours from initiation of therapy). Secondary outcomes included early (3-7 days) and late (3-30 days) mortality. RESULTS Rates of clinical failure, early and late mortality among evaluable episodes were 32.3% (80/248), 3.1% (8/257) and 23.4% (59/248). There was no relationship between fluconazole MIC values or PK/PD parameters and clinical failure. Although MIC values ≥2 mg/L by EUCAST (positive predictive value 32.1%, negative predictive value 68.7%) and ≥0.5 mg/L by CLSI (positive predictive value 34.8%, negative predictive value 74.4%) appeared to be optimal for predicting clinical failure, no significant associations remained after multivariate adjustment (odds ratio 1.67; 95% confidence interval 0.48-5.79; p 0.423). Lack of association was consistent for alternative thresholds (including proposed clinical breakpoints). The only association found for secondary outcomes was between an AUC24/MIC ratio >400 h by CLSI and early mortality (odds ratio 0.18; 95% confidence interval 0.04-0.98; p 0.026). CONCLUSIONS High fluconazole MIC values did not negatively impact outcome of patients with candidaemia treated with fluconazole. No effect of PK/PD targets on the risk of clinical failure was found.
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Affiliation(s)
- M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Universidad Complutense, Madrid, Spain.
| | - J Guinea
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario 'Gregorio Marañón', Universidad Complutense, Madrid, Spain
| | - D Lora-Pablos
- Unit of Clinical Research, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Madrid, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Ó Zaragoza
- Department of Mycology, Spanish National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - M Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari 'Vall d'Hebron', Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - B Almirante
- Department of Infectious Diseases, Hospital Universitari 'Vall d'Hebron', Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Cuenca-Estrella
- Department of Mycology, Spanish National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Universidad Complutense, Madrid, Spain
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Tan TY, Hsu LY, Alejandria MM, Chaiwarith R, Chinniah T, Chayakulkeeree M, Choudhury S, Chen YH, Shin JH, Kiratisin P, Mendoza M, Prabhu K, Supparatpinyo K, Tan AL, Phan XT, Tran TTN, Nguyen GB, Doan MP, Huynh VA, Nguyen SMT, Tran TB, Van Pham H. Antifungal susceptibility of invasive Candida bloodstream isolates from the Asia-Pacific region. Med Mycol 2016; 54:471-7. [PMID: 26868904 DOI: 10.1093/mmy/myv114] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 12/09/2015] [Indexed: 11/14/2022] Open
Abstract
Bloodstream infections caused by Candida species are of increasing importance and associated with significant mortality. We performed a multi-centre prospective observational study to identify the species and antifungal susceptibilities of invasive bloodstream isolates of Candida species in the Asia-Pacific region. The study was carried out over a two year period, involving 13 centers from Brunei, Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam. Identification of Candida species was performed at each study center, and reconfirmed at a central laboratory. Susceptibility testing was performed using a commercial broth dilution panel (Sensititre YeastOne YST-010, Thermofisher, United Kingdom) with susceptibility categorisation (S = susceptible, S-DD = susceptible dose-dependent) applied using breakpoints from the Clinical Laboratory Standards Institute. Eight hundred and sixty-one Candida isolates were included in the study. The most common species were C. albicans (35.9%), C. tropicalis (30.7%), C. parapsilosis (15.7%), and C. glabrata (13.6%). Non-albicans species exceeded C. albicans species in centers from all countries except Taiwan. Fluconazole susceptibility was almost universal for C. albicans (S = 99.7%) but lower for C. tropicalis (S = 75.8%, S-DD = 6.1%), C. glabrata (S-DD = 94.9%), and C. parapsilosis (S = 94.8%). Echinocandins demonstrated high rates of in vitro susceptibility (S>99%) against C. albicans, C. tropicalis, and C. parapsilosis This study demonstrates that non-albicans species are the most common isolates from bloodstream infections in most countries in the Asia-Pacific region, with C. tropicalis as the predominant species. Because of the prevalence of reduced susceptibility to fluconazole in non-albicans species, the study indicates that echinocandins should be the antifungal of choice in clinically unstable or high-risk patients with documented candidemia.
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Affiliation(s)
- Thean Yen Tan
- Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Li Yang Hsu
- National University Health System, 1E Kent Ridge Road, Singapore 119228
| | - Marissa M Alejandria
- University of the Philippines - Philippine General Hospital, Taft Avenue, Ermita, Manila 1000, Metro Manila, Philippines
| | - Romanee Chaiwarith
- Maharaj Nakorn Chiang Mai Hospital, 110 Intavaroros Road, Sribhoom, Muang District, Chiang Mai, Thailand
| | - Terrence Chinniah
- Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Jalan Putera Al-Muhtadee Billah / Jalan Tutong Brunei Darussalam BA1710
| | | | | | - Yen Hsu Chen
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan National Chiao Tung University, HsinChu City, Taiwan Center for Dengue Fever Control and Research, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Jong Hee Shin
- Chonnam National University Hospital, 42 Jebongro, Dongku, Gwangju, Korea 501-575
| | | | - Myrna Mendoza
- National Kidney and Transplant Institute Hospital, East Ave, Diliman, Quezon City, Metro Manila, Philippines
| | - Kavitha Prabhu
- Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Jalan Putera Al-Muhtadee Billah / Jalan Tutong Brunei Darussalam BA1710
| | - Khuanchai Supparatpinyo
- Maharaj Nakorn Chiang Mai Hospital, 110 Intavaroros Road, Sribhoom, Muang District, Chiang Mai, Thailand
| | - Ai Ling Tan
- Singapore General Hospital, Outram Rd, Singapore 169608
| | - Xuan Thi Phan
- Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Vietnam
| | - Thi Thanh Nga Tran
- Cho Ray Hospital, 201B Nguyen Chi Thanh, District 5, Ho Chi Minh City, Vietnam
| | - Gia Binh Nguyen
- Bach Mai Hospital, 78 Giai Phong, Phuong Mai, Dong Da, Hanoi, Vietnam
| | - Mai Phuong Doan
- Bach Mai Hospital, 78 Giai Phong, Phuong Mai, Dong Da, Hanoi, Vietnam
| | - Van An Huynh
- Nhan Dan Gia Dinh Hospital, 01 No Trang Long, Binh Thanh District, Ho Chi Minh City, Vietnam
| | - Su Minh Tuyet Nguyen
- Nhan Dan Gia Dinh Hospital, 01 No Trang Long, Binh Thanh District, Ho Chi Minh City, Vietnam
| | - Thanh Binh Tran
- Nguyen Tri Phuong Hospital, 468 Nguyen Trai Street, Ward 8, District 5, Ho Chi Minh City, Vietnam
| | - Hung Van Pham
- Nguyen Tri Phuong Hospital, 468 Nguyen Trai Street, Ward 8, District 5, Ho Chi Minh City, Vietnam
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Wang L, Wang L, Han L, Yin W. Study of Pathogens of Fungal Keratitis and the Sensitivity of Pathogenic Fungi to Therapeutic Agents with the Disk Diffusion Method. Curr Eye Res 2015; 40:1095-101. [PMID: 26268399 DOI: 10.3109/02713683.2015.1056802] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE/AIM OF THE STUDY To identify the causative fungi of fungal keratitis, test their susceptibility to antifungal agents with the disk diffusion method and study the relationship between the organisms, the inhibition zones and the clinical outcomes. MATERIALS AND METHODS 535 patients with fungal keratitis in one eye were included in this study. Pathogenic fungi were isolated by corneal scraping, identified by fungal cultivation and subjected to drug sensitivity tests conducted with the disk diffusion method. The patients were treated initially with voriconazole, terbinafine and natamycin eye drops for one week. Further treatment continued using the most effective drug according to the drug sensitivity results. The patients were followed up every week until three months after cured. The inhibition zones of fungi cultured with voriconazole, terbinafine and natamycin were compared. The relationship between inhibition zones and organism, organism and treatment results measure, and each treatment results measure and inhibition zones were evaluated. RESULTS Of 535 patients, 53.84%, 19.25% and 26.91% were infected with Aspergillus, Fusarium and other fungi, respectively. Keratitis patients infected with Aspergillus keratitis had the worst outcome. The size of the inhibition zones of Aspergillus spp., Fusarium spp. and other fungal genera differed significantly in response to voriconazole, terbinafine and natamycin. The inhibition zone associated with natamycin correlated significantly with the clinical outcome of fungal keratitis (OR = 0.925), but no other such correlations were found for the other drugs tested. CONCLUSIONS Aspergillus and Fusarium were the predominant pathogenic genera causing fungal keratitis in our patients. Among the causative fungi, infections due to Aspergillus spp. were associated with the worst outcomes. The inhibition zones of fungal isolates in response to natamycin significantly correlated with the treatment outcomes of keratitis. Specifically, the smaller the natamycin inhibition zone, the lower the probability that the fungal keratitis had been eliminated.
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Affiliation(s)
- Lulu Wang
- a Department of Ophthalmology , Zhengzhou University People's Hospital , Zhengzhou , P.R. China
| | - Liya Wang
- a Department of Ophthalmology , Zhengzhou University People's Hospital , Zhengzhou , P.R. China
| | - Lei Han
- a Department of Ophthalmology , Zhengzhou University People's Hospital , Zhengzhou , P.R. China
| | - Weijing Yin
- a Department of Ophthalmology , Zhengzhou University People's Hospital , Zhengzhou , P.R. China
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First dose in neonates: are juvenile mice, adults and in vitro-in silico data predictive of neonatal pharmacokinetics of fluconazole. Clin Pharmacokinet 2015; 53:1005-18. [PMID: 25154507 DOI: 10.1007/s40262-014-0169-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Selection of the first-dose-in-neonates is challenging. The objective of this proof-of-concept study was to evaluate a pharmacokinetic bridging approach to predict a neonatal dosing regimen. METHODS We selected fluconazole as a paradigm compound. We used data from studies in juvenile mice and adults to develop population pharmacokinetic models using NONMEM. We also develop a physiologically-based pharmacokinetic model from in vitro-in silico data using Simcyp. These three models were then used to predict neonatal pharmacokinetics and dosing regimens for fluconazole. RESULTS From juvenile mice to neonates, a correction factor of maximum lifespan potential should be used for extrapolation, while a "renal factor" taking into account renal maturation was required for successful bridging based on adult and in vitro-in silico data. Simulations results demonstrated that the predicted drug exposure based on bridging approach was comparable to the observed value in neonates. The prediction errors were -2.2, +10.1 and -4.6 % for juvenile mice, adults and in vitro-in silico data, respectively. CONCLUSION A model-based bridging approach provided consistent predictions of fluconazole pharmacokinetic parameters in neonates and demonstrated the feasibility of this approach to justify the first-dose-in-neonates, based on all data available from different sources (including physiological informations, preclinical studies and adult data), allowing evidence-based decisions of neonatal dose rather than empiricism.
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Brosh-Nissimov T, Ben-Ami R. Differential association of fluconazole dose and dose/MIC ratio with mortality in patients with Candida albicans and non-albicans bloodstream infection. Clin Microbiol Infect 2015; 21:1011-7. [PMID: 26183300 DOI: 10.1016/j.cmi.2015.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 06/26/2015] [Accepted: 07/03/2015] [Indexed: 10/23/2022]
Abstract
Targeting fluconazole therapy to achieve predefined pharmacodynamic goals has been suggested as a means of optimizing the treatment of patients with candidaemia. However, data regarding species-specific dosing targets are inconclusive. We retrospectively analysed a cohort of 75 adult patients with Candida bloodstream infection (BSI) who received initial treatment with fluconazole for ≥48 h (36 Candida albicans and 39 non-albicans Candida (NAC)). Fluconazole dose, the dose/MIC ratio and the 24-h area under the concentration-time curve (AUC24)/MIC ratio were determined for each patient, and classification and regression tree analysis was used to determine breakpoints for significant interactions with 30-day survival. Both fluconazole exposure parameters and patient-related and disease-related variables were assessed in univariable and multivariable survival models. The crude 30-day mortality rate was 32% (44% and 21% for C. albicans and NAC, respectively). An average fluconazole dose of >200 mg/day, a dose/MIC ratio of >400 and an AUC24/MIC ratio of >400 were associated with a higher 30-day survival rate and better microbiological response in patients with C. albicans BSI but not in those with NAC BSI. Baseline chronic kidney disease was a risk factor for fluconazole underdosing and mortality. Severity of sepsis (Sequential Organ Failure Assessment score) was the only significant predictor of death in patients with NAC BSI. We conclude that, although pharmacodynamic target-directed fluconazole dosing may help to optimize outcomes for patients with C. albicans BSI, additional studies are needed to define the role of fluconazole in the treatment of NAC BSI.
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Affiliation(s)
- T Brosh-Nissimov
- Infectious Disease Unit, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - R Ben-Ami
- Infectious Disease Unit, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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