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Su S, Yan H, Min L, Wang H, Chen X, Shi J, Sun S. The antifungal activity of caspofungin in combination with antifungals or non-antifungals against Candida species in vitro and in clinical therapy. Expert Rev Anti Infect Ther 2021; 20:161-178. [PMID: 34128761 DOI: 10.1080/14787210.2021.1941868] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Candida species have been regarded as global health threats due to their ability to cause invasive infections. It is challenging to treat Candida bloodstream infections, which are associated with high mortality levels. Monotherapy with antifungals is sometimes not effective against severe Candida infections, and combination therapy is needed in clinical practice.Areas covered: This review was undertaken based on data from a PubMed search for English language reports published before March 2021 by using the terms 'caspofungin,' 'Candida species,' 'combination therapy,' 'antifungal effect,' and 'novel antifungal agent.'Expert opinion: Combination therapy is an empirical strategy for treating refractory Candida infections. Caspofungin has been recommended to treat candidaemia. Caspofungin in combination therapy has some applications, while the efficacy of combination therapy in the treatment of refractory Candida infections needs more study, such as randomized controlled trials. In addition, novel compounds or drugs with potential antifungal activities have been examined, and some of them exhibit synergistic interactions with caspofungin. Thus, the antifungal activity of caspofungin in combination with antifungals or non-antifungals against Candida species in vitro and in clinical therapy is summarized.
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Affiliation(s)
- Shan Su
- Department of Clinical Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, People's Republic of China.,School of Pharmaceutical Sciences, Shandong University, Jinan, People's Republic of China
| | - Haiying Yan
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, People's Republic of China
| | - Li Min
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, People's Republic of China
| | - Hongmei Wang
- Department of Pharmacy, Zibo Sixth People's Hospital, Zibo, Shandong, People's Republic of China
| | - Xueqi Chen
- School of Pharmaceutical Sciences, Shandong University, Jinan, People's Republic of China
| | - Jinyi Shi
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, People's Republic of China
| | - Shujuan Sun
- Department of Clinical Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, People's Republic of China.,Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, People's Republic of China
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Niu CH, Xu H, Gao LL, Nie YM, Xing LP, Yu LP, Wu SL, Wang Y. Population Pharmacokinetics of Caspofungin and Dosing Optimization in Children With Allogeneic Hematopoietic Stem Cell Transplantation. Front Pharmacol 2020; 11:184. [PMID: 32194415 PMCID: PMC7061854 DOI: 10.3389/fphar.2020.00184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/10/2020] [Indexed: 01/12/2023] Open
Abstract
Caspofungin is the first echinocandin antifungal agent that licented for pediatric use in invasive candidiasis and aspergillosis. In this study, we evaluated the population pharmacokinetics of caspofungin and investigate appropriate dosing optimization against Candida spp. in children with allogeneic hematopoietic stem cell transplantation (allo-HSCT) in order to improve therapeutic efficacy. All participants received a recommended caspofungin 70 mg/m2 loading dose followed by 50 mg/m2 maintenance dose. A one-compartment model with first-order elimination was best fitted the data from 48 pediatric patients. Body surface area and aspartate aminotransferase had significant influence on caspofungin clearance from covariate analysis. Our results reviewed that dose adjustment is not necessary in patients with mild liver dysfunction. Monte Carlo simulations were performed using pharmacokinetic data from our study to evaluate the probability of target attainment (PTA) of caspofungin regimen in terms of AUC24/MIC targets against Candida spp. The results of simulations predicted that a caspofungin 70 mg/m2 at first dose, 50 mg/m2 of daily dose may have a high probability of successful outcome against C. albicans and C. glabrata whilst 60 mg/m2 maintenance dose was required for fungistatic target against C. parapsilosis but may be not sufficient to achieve optimal fungicidal activity. Caspofungin standard regimen had high probability of successful outcome against C. albicans (MIC ⩽ 0.25 mg/L) and C. glabrata (MIC ⩽ 0.5 mg/L) but insufficient for C. parapsilosis with MIC > 0.25 mg/L. That may provide an evidence based support to caspofungin individualized administration and decrease the risk of therapeutic failure in allo-HSCT pediatric patients.
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Affiliation(s)
- Chang-He Niu
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Hua Xu
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Liu-Liu Gao
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Ying-Ming Nie
- Department of Cell Therapy and Transplantation Medicine, Wuhan Children' Hospital, Wuhan, China
| | - Li-Peng Xing
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Li-Peng Yu
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - San-Lan Wu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology (HUST), Wuhan, China
| | - Yang Wang
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Wuhan Maternal and Child Healthcare Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
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Body Surface Area-Based Dosing Regimen of Caspofungin in Children: a Population Pharmacokinetics Confirmatory Study. Antimicrob Agents Chemother 2019; 63:AAC.00248-19. [PMID: 30988148 DOI: 10.1128/aac.00248-19] [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: 02/02/2019] [Accepted: 04/10/2019] [Indexed: 11/20/2022] Open
Abstract
We evaluated the population pharmacokinetics of caspofungin in children (2 to 12 years of age). The real-world data from 48 children were best fit by a two-compartment model with first-order elimination. Subsequent covariate analysis demonstrated that body surface area had a significant correlation with caspofungin pharmacokinetics, compared to body weight. The population pharmacokinetics of caspofungin confirmed that adjustment of caspofungin dosage based on body surface area is most appropriate for pediatric use.
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Chromatographic methods for echinocandin antifungal drugs determination in bioanalysis. Bioanalysis 2019; 11:1217-1228. [DOI: 10.4155/bio-2019-0045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The increase of fungal resistance to drugs, such as azole family, gave rise to the development of new antifungals. In this context, echinocandins emerged as a promising alternative for antifungal therapies. Following the commercialization of caspofungin in 2001, echinocandins became the first-line therapy for invasive candidiasis in different patient populations. The quantification of these drugs has gained importance since pharmacokinetic/pharmacodynamic and resistance studies are a paramount concern. This fact has led us to exhaustively examine the methodologies used for the analysis of echinocandins in biological fluids, which are mainly based on LC coupled to different detection techniques. In this review, we summarize the analytical methods for the quantification of echinocandins focusing on sample treatment, chromatographic separation and detection methods.
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The Role of Antifungals in Pediatric Critical Care Invasive Fungal Infections. Crit Care Res Pract 2018; 2018:8469585. [PMID: 30595916 PMCID: PMC6282141 DOI: 10.1155/2018/8469585] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/20/2018] [Accepted: 10/30/2018] [Indexed: 12/11/2022] Open
Abstract
Invasive fungal infections (IFIs) have seen considerable increase in pediatric intensive care units over the past several decades. IFIs are predominantly caused by Candida species, and candidemia is the third most common cause of healthcare-associated bloodstream infections (BSIs) in children. IFIs are opportunistic infections that affect pediatric patients in critical care resulting in significant morbidity and mortality especially in those with a compromised immune system. IFIs are the leading cause of death in children with comorbidities such as immunosuppression, and pediatric ICU admission has been shown to be an independent risk factor for mortality. Management of IFI and fungal sepsis is broad and encompasses several key components that include prompt initiation of therapy and rapid source identification and control. This study reviews important antifungals in the pediatric critical care setting including the pharmacologic properties, antifungal spectrum, adverse effects, and clinical uses of agents belonging to the four major classes of antifungals—the polyenes, azoles, echinocandins, and pyrimidine analogue flucytosine. The polyenes and azoles are the most often used classes of antifungals. The echinocandins are a relatively newer class of antifungal agents that offer excellent Candida activity and are currently recommended as the first-line therapy for invasive candidiasis.
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Swaminathan S, Kamat S, Pinto NA. Echinocandins: Their role in the management of Candida biofilms. Indian J Med Microbiol 2018; 36:87-92. [PMID: 29735833 DOI: 10.4103/ijmm.ijmm_17_400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The importance of antifungal agents and their clinical implications has received little attention in comparison to antibiotics, particularly in the health-care setting. However, apart from bacterial infections rising in hospitals, the incidences of fungal infections are growing with the development of resistance to conventional antifungal agents. Newer antifungal agents such as echinocandins (ECs) have been extensively studied over the past decade and are recognised as a superior treatment compared with prior antifungals as a first line of therapy in tertiary institutions. Caspofungin (CAS), micafungin (MICA) and anidulafungin (ANID) are the three most widely used EC antifungal agents. The treatment of biofilm-associated fungal infections affecting patients in tertiary health-care facilities has been identified as a challenge, particularly in Indian Intensive Care Unit (ICU) settings. With the rising number of critically ill patients requiring invasive devices such as central venous catheters for treatment, especially in ICUs, these devices serve as a potential source of nosocomial infections. Candida spp. colonisation is a major precursor of these infections and further complicates and prolongs treatment procedures, adding to increasing costs both for hospitals and the patient. Analysing studies involving the use of these agents can help in making critical decisions for antifungal therapy in the event of a fungal infection in the ICU. In addition, the development of resistance to antifungal agents is a crucial factor for assessing the appropriate antifungals that can be used for treatment. This review provides an overview of ANID in biofilms, along with CAS and MICA, in terms of clinical efficacy, resistance development and potency, primarily against Candida spp.
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Affiliation(s)
| | - Shweta Kamat
- Medical Affairs, Pfizer Ltd., Mumbai, Maharashtra, India
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Foster CE, Edwards MS, Brackett J, Schady DA, Healy CM, Baker CJ. Trichosporonosis in Pediatric Patients With a Hematologic Disorder. J Pediatric Infect Dis Soc 2018; 7:199-204. [PMID: 28510690 DOI: 10.1093/jpids/pix031] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/05/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Trichosporonosis is an emerging and often fatal opportunistic fungal infection in immunocompromised patients, particularly those with hematologic malignancy, but data in children are lacking. METHODS We report here 3 cases of invasive infection caused by Trichosporon asahii in pediatric patients with acute lymphoblastic leukemia at Texas Children's Hospital in Houston, Texas. We also conducted a literature review and identified 16 additional reports of pediatric patients with invasive T asahii infection and an underlying malignant or nonmalignant hematologic disorder. RESULTS Of the 19 cases of invasive T asahii infection, the most commonly reported underlying hematologic disorder was acute lymphoblastic leukenia (47%), followed by acute myelogenous leukemia (21%). Most of the patients (94%) had neutropenia, defined as an absolute neutrophil count of <500 cells/mm3. Antifungal prophylaxis information was available in 6 of the 19 cases, and micafungin use was reported in 5 cases. Treatment regimens frequently included voriconazole monotherapy (47%) or the combination of an azole antifungal with amphotericin B (35%). The mortality rate was 58%. CONCLUSIONS Recognizing that echinocandins, which are increasingly used for prophylaxis in patients with a hematologic malignancy, are not active against Trichosporon species is of critical importance. The recommended first-line therapy for trichosporonosis is voriconazole, but successful outcome depends largely on the underlying immune status of the host.
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Affiliation(s)
- Catherine E Foster
- Section of Infectious Diseases, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Morven S Edwards
- Section of Infectious Diseases, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Julienne Brackett
- Section of Hematology-Oncology, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Deborah A Schady
- Section of Pathology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - C Mary Healy
- Section of Infectious Diseases, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Carol J Baker
- Section of Infectious Diseases, Baylor College of Medicine and Texas Children's Hospital, Houston
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Mantadakis E, Pana ZD, Zaoutis T. Candidemia in children: Epidemiology, prevention and management. Mycoses 2018; 61:614-622. [PMID: 29762868 DOI: 10.1111/myc.12792] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Candidemia is the leading cause of invasive fungal infections in hospitalised children. The highest rates of candidemia have been recorded in neonates and infants <1 year of age. Candidemia is more frequent in neonates and young infants than in adults, and is associated with better clinical outcomes, but higher inpatient costs. Over the last 10 years, a declining trend has been noted in the incidence of paediatric candidemia in the US and elsewhere due to the hospital-wide implementation of central-line insertion and maintenance bundles that emphasise full sterile barrier precautions, chlorhexidine skin preparation during line insertion, meticulous site and tubing care, and daily discussion of catheter necessity. Additional interventions aiming at reducing gut-associated candidemia are required in immunocompromised and critically ill children.
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Affiliation(s)
- Elpis Mantadakis
- Faculty of Medicine, Associate Professor of Pediatrics and Pediatric Hematology/Oncology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Zoe Dorothea Pana
- Department of Pediatrics, Hippokration General Hospital, Thessaloniki, Greece
| | - Theoklis Zaoutis
- Werner and Gertrude Henle Professor of Pediatrics, Professor of Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Chief, Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Özen M, Dündar NO. Invasive aspergillosis in children with hematological malignancies. Expert Rev Anti Infect Ther 2014; 9:299-306. [DOI: 10.1586/eri.10.177] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tobal JM, Balieiro MEDSF. Role of carbonic anhydrases in pathogenic micro-organisms: a focus on Aspergillus fumigatus. J Med Microbiol 2014; 63:15-27. [DOI: 10.1099/jmm.0.064444-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Aspergillus fumigatus is a ubiquitous saprophytic fungus responsible for organic material decomposition, and plays an important role in recycling environmental carbon and nitrogen. Besides its important role in the environment, this fungus has been reported as one of the most important fungal pathogens in immunocompromised patients. Due to changes in CO2 concentration that some pathogens face during the infection process, studies have been undertaken to understand the pathogenic roles of carbonic anhydrases (CAs), well-known CO2 hydration catalytic enzymes. As a basis for a discussion of the possible roles of CAs in A. fumigatus pathogenicity, this review describes the main characteristics of the A. fumigatus infection and the challenges for its treatment. In addition, it gathers findings from studies with CA inhibitor drugs as anti-infective agents in different pathogens.
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Affiliation(s)
- Jaqueline Moisés Tobal
- Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
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Valerio C, Perillo T, Brescia L, Russo FG. Antifungal Agents in Current Pediatric Practice. Curr Infect Dis Rep 2013; 15:278-87. [DOI: 10.1007/s11908-013-0337-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cecinati V, Guastadisegni C, Russo FG, Brescia LP. Antifungal therapy in children: an update. Eur J Pediatr 2013; 172:437-46. [PMID: 22652706 DOI: 10.1007/s00431-012-1758-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 05/09/2012] [Indexed: 10/28/2022]
Abstract
Invasive fungal infections are a common problem in children affected by primary or secondary immunodeficiencies. Thanks to an increased knowledge about their mechanisms of action and their pharmacokinetic and toxicity profiles, the use of these drugs in common and uncommon invasive infections in immunocompromised children has improved over the last decades. Choosing the most appropriate antifungal drug is a serious challenge for any clinician, also considering that, in most cases, therapy has to be started before cultures are available, the choice being driven by clinical symptoms and statistical criteria only. In this study, we performed a systematic review of literature, providing antifungal treatment recommendations for paediatric patients which can help clinicians find the most suitable treatment for each specific case. Principal antifungal drugs-ranging from first-generation antimycotics to the latest molecules-are classified according to their targets, and of each group, the pharmacokinetic profile, clinical indications and side effects are extensively described.
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Affiliation(s)
- Valerio Cecinati
- Division of Pediatric Hematology and Oncology, Department of Hematology, Spirito Santo Hospital, Via Fonte Romana, Pescara, Italy.
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Wilke MH. Invasive fungal infections in infants-focus on anidulafungin. CLINICAL MEDICINE INSIGHTS-PEDIATRICS 2013; 7:7-11. [PMID: 23641173 PMCID: PMC3620775 DOI: 10.4137/cmped.s8028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction: Invasive fungal infection in pediatric intensive care units (PICU) is a rising challenge. Candida species are the most common microorganisms in these infections. Due to growing resistance against fluconazole, echinocandins are being used for the appropriate therapy. However, the recent IDSA guidelines recommend them only in cases where fluconazole or Amphotericin B cause treatment failure or are contraindicated. In a literature review, the importance of invasive fungal infections in PICU settings and the role of anidulafungin shall be examined. Materials and Methods: Articles were retrieved form PubMed covering the years 2000–2012. Various search terms were used. Then the articles were clustered in different types like ‘review,’ ‘pharmacokinetics,’ ‘case reports’ and others. Results: From 67 search results, 14 articles were selected. Of these, 7 were related to anidulafungin, while 7 were related to echinocandins or fungal infections in the PICU. Anidulafungin was examined in 4 PK/PD studies where a good safety profile was found. No serious adverse events occurred. The articles reporting risk factors show that central venous catheters, receipt of antibiotics, receipt of parenteral nutrition, and neutropenia are the most important independent risk factors for invasive fungal infections in PICU. Three reviews of antifungal agents show that echinocandins may be useful due to their safety profile; micafungin is the best examined one and further trials are needed. Discussion: The published literature on invasive fungal infections in PICU settings has grown over the years. There are only a few articles, however, which are directly related to the use of anidulafungin in this setting. A most recent publication showed good PK/PD dynamics and a good safety profile for anidulafungin. So far, no RCT in the area of invasive candidiasis in infants and neonates has been published. A review of currently registered trials at ClinicalTrials.gov has shown one more trial related to PK/PD and two trials that investigate the use of anidulafungin or anidulafungin in combination with Voriconazole in pediatrics. Conclusion: The small body of existing literature on anidulafungin in infants shows success in treatment, no drug-related adverse events, and good pharmacodynamics. A dosing of 0.75 mg/kg/day or 1.5 mg/kg/day is as effective as 50 mg/day or 100 mg/day in adults. More trials on the use in clinical reality of PICU or NICU should follow.
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Abstract
PURPOSE OF REVIEW In recent years there has been an evolution of a better understanding of the pharmacology and clinical indications of existing antifungal agents and also the development of new broad-spectrum triazoles and a newer class of antifungal agents, the echinocandins. The availability of these agents has broadened the therapeutic options of invasive fungal disease among children and consequently antifungal therapy has become increasingly complex. RECENT FINDINGS Adoption of adult guidelines' recommendations has been used to guide pediatric treatment as specific pediatric data were often lacking. This approach has not always selected the most appropriate therapy for newborns or young infants, as the under-dosage of voriconazole based on adult data revealed. Therefore, a detailed understanding of the available antifungal agents in children is crucial for the successful treatment of these serious infections. SUMMARY In this review we summarize the main findings regarding antifungal treatment among children that have been recently published, focusing on the pharmacology and pediatric use of newer antifungal agents.
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Abstract
BACKGROUND A variety of antifungal drugs, drug preparations and drug combinations are available to treat newborn infants with suspected or confirmed invasive fungal infection. There is a need to assess their relative merits. OBJECTIVES To assess the effect of treatment with different antifungal drugs, drug preparations or drug combinations on mortality and morbidity in newborn infants with suspected or confirmed invasive fungal infection. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012, Issue 2), MEDLINE, EMBASE, CINAHL (to March 2012), conference proceedings and previous reviews. SELECTION CRITERIA Randomised and quasi-randomised control trials comparing one antifungal agent or combination of agents with another in newborn infants with suspected or confirmed invasive fungal infection. DATA COLLECTION AND ANALYSIS We extracted the data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author, and synthesis of data using risk ratio and risk difference. MAIN RESULTS We identified only one small trial in which 24 newborn infants participated. This trial compared the use of fluconazole versus amphotericin B (plus 5-fluorocytosine if fungal meningitis present). The trial did not detect a statistically significant effect on mortality (risk ratio 0.73; 95% confidence interval 0.26 to 2.05). AUTHORS' CONCLUSIONS There are insufficient data to inform practice. Large randomised controlled trials are required to compare antifungal drugs, drug preparations or drug combinations for treating newborn infants with invasive fungal infection.
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Affiliation(s)
- Linda Clerihew
- Tayside Children's HospitalDepartment of PaediatricsDundeeUKDD1 9SY
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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Wiederhold NP, Herrera LA. Caspofungin for the treatment of immunocompromised and severely ill children and neonates with invasive fungal infections. Clin Med Insights Pediatr 2012; 6:19-31. [PMID: 23641163 PMCID: PMC3620773 DOI: 10.4137/cmped.s8016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Caspofungin is the first member of the echinocandin class of antifungals to receive an indication for the use in infants, children, and adolescents from the United States Food and Drug Administration. Daily doses of 50 mg/m(2) result in pharmacokinetic parameters that are similar to those observed in adults. Although fewer data are available, the response rates in pediatric patients who received caspofungin either as treatment or empiric therapy in clinical trials are similar to those reported in adults. In addition, caspofungin appears to be generally safe and well tolerated in this population. This represents a significant step forward in the treatment of invasive fungal infections within this population, as caspofungin is associated with few clinically significant drug-interactions and toxicities compared to other antifungals, such as the azoles and amphotericin B.
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Affiliation(s)
- Nathan P. Wiederhold
- University of Texas at Austin College of Pharmacy, Austin, TX
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Lydia A. Herrera
- Methodist Hospital System, Department of Pharmacy, San Antonio, TX
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Use of matrix-assisted laser desorption ionization-time of flight mass spectrometry for caspofungin susceptibility testing of Candida and Aspergillus species. J Clin Microbiol 2012; 50:2479-83. [PMID: 22535984 DOI: 10.1128/jcm.00224-12] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) was evaluated for testing susceptibility to caspofungin of wild-type and fks mutant isolates of Candida and Aspergillus. Complete essential agreement was observed with the CLSI reference method, with categorical agreement for 94.1% of the Candida isolates tested. Thus, MALDI-TOF MS is a reliable and accurate method to detect fungal isolates with reduced caspofungin susceptibility.
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Cugno C, Cesaro S. Epidemiology, risk factors and therapy of candidemia in pediatric hematological patients. Pediatr Rep 2012; 4:e9. [PMID: 22690315 PMCID: PMC3357622 DOI: 10.4081/pr.2012.e9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 01/09/2012] [Accepted: 01/10/2012] [Indexed: 11/23/2022] Open
Abstract
Invasive fungal infections (IFI) are an important cause of morbidity, increased hospitalization and healthcare costs in critically ill or immunocompromised children. The mortality is comprised between 5 and 20%. In the last 2 decades, the epidemiology of candidemia has changed with an increase of episodes caused by non-Candida albicans species. Central venous catheter, diagnosis of malignancy, and receipt of either vancomycin or antimicrobials with activity against anaerobic organisms for >3 days have been associated with the development of candidemia in the pediatric intensive care unit (PICU). Additional risk factors found in hematological patients were the diagnosis of aplastic anemia, performing an unrelated bone marrow or cord blood transplant, the occurrence of a graft versus host disease and the use of steroids. Early antifungal treatment is recommended to reduce mortality. In neutropenic patients, liposomal amphotericin B, an echinocandin (caspofungin, micafungin), and voriconazole are considered the best option especially for C. glabrata and C. krusei. Fluconazole remains a valid option for infection by Candida albicans in patients not exposed to fluconazole prophylaxis. Amphotericn B deoxy-cholate is generally not recommended because of its nephrotoxicity.
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Affiliation(s)
- Chiara Cugno
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata Verona, Italy
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Caudle KE, Inger AG, Butler DR, Rogers PD. Echinocandin use in the neonatal intensive care unit. Ann Pharmacother 2011; 46:108-16. [PMID: 22190252 DOI: 10.1345/aph.1q346] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the literature regarding the use of echinocandins to treat invasive fungal infections caused by Candida spp. in patients in the neonatal intensive care unit. DATA SOURCES Literature retrieval was accessed through MEDLINE (Jan 2000-September 2011) using the search terms echinocandin, caspofungin, micafungin, anidulafungin, and neonate with limits for age group (ie, birth to 1 month). Reference citations from identified articles were also reviewed. STUDY SELECTION AND DATA EXTRACTION Relevant information on the pharmacokinetics, efficacy, and safety of echinocandins in neonates was selected. Prospective studies, retrospective studies, and case series in English identified from MEDLINE were evaluated. DATA SYNTHESIS Neonates, especially preterm neonates, have many risk factors that predispose them for invasive fungal infections caused by Candida spp. To date, the only antifungals recommended for use in neonates for treatment of candidiasis are amphotericin B (deoxycholate or a lipid formulation) and fluconazole; however, the toxicities associated with amphotericin B and resistance of certain Candida spp. to fluconazole limit their use in neonates. There is a need for a broad-spectrum antifungal agent with limited toxicity for use in this patient population. The echinocandins may represent such a class of antifungals. To date, micafungin is the most studied echinocandin in the neonatal population, followed by caspofungin; however, studies evaluating their efficacy and pharmacokinetic parameters in neonates are few. CONCLUSIONS Although studies suggest that the echinocandins may have a favorable safety profile, the lack of pharmacokinetic data and standardized study designs limit current recommendations of use of echinocandins as first-line agents in neonates in the treatment of fungal infections. However, if an echinocandin is to be used in this population, the data presented in this review suggest the use of micafungin over the other echinocandins, and higher doses of micafungin (10-15 mg/kg/day) should be used when central nervous system involvement is suspected.
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Affiliation(s)
- Kelly E Caudle
- Division of Pharmacy Practice and Administrative Sciences, The James L Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA.
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Abstract
It has been nearly a decade since caspofungin was approved for clinical use as the first echinocandin class antifungal agent, followed by micafungin and anidulafungin. The echinocandin drugs target the fungal cell wall by inhibiting the synthesis of β-1,3-D-glucan, a critical cell wall component of many pathogenic fungi. They are fungicidal for Candida spp. and fungistatic for moulds, such as Aspergillus fumigatus, where they induce abnormal morphology and growth properties. The echinocandins have a limited antifungal spectrum but are highly active against most Candida spp., including azole-resistant strains and biofilms. As they target glucan synthase, an enzyme absent in mammalian cells, the echinocandins have a favorable safety profile. They show potent MIC and epidemiological cutoff values against susceptible Candida and Aspergillus isolates, and the frequency of resistance is low. When clinical breakthrough occurs, it is associated with high MIC values and mutations in Fks subunits of glucan synthase, which can reduce the sensitivity of the enzyme to the drug by several thousand-fold. Such strains were not adequately captured by an early clinical breakpoint for susceptibility prompting a revised lower value, which addresses the FKS resistance mechanism and new pharmacokinetic/pharmacodynamic studies. Elevated MIC values unlinked to therapeutic failure can occur and result from adaptive cell behavior, which is FKS-independent and involves the molecular chaperone Hsp90 and the calcineurin pathway. Mutations in FKS1 and/or FKS2 alter the kinetic properties of glucan synthase, which reduces the relative fitness of mutant strains causing them to be less pathogenic. The echinocandin drugs also modify the cell wall architecture exposing buried glucans, which in turn induce a variety of important host immune responses. Finally, the future for glucan synthase inhibitors looks bright with the development of new orally active compounds.
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Affiliation(s)
- David S Perlin
- Public Health Research Institute, New Jersey Medical School-UMDNJ, Newark, NJ 07103, USA.
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Somer A, Törün SH, Salman N. Caspofungin therapy in immunocompromised children and neonates. Expert Rev Anti Infect Ther 2011; 9:347-55. [PMID: 21417874 DOI: 10.1586/eri.11.4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The prevalence of invasive fungal infections is increasing and the infections are becoming a major problem in immunocompromised children and neonates. Fortunately, there has been a recent surge in the development of new antifungal agents. Caspofungin, the first licensed echinocandin, is a novel class of antifungal and is approved for use in children 3 months of age or older for the treatment of invasive candidiasis, salvage therapy for invasive aspergillosis and as empirical therapy for febrile neutropenia. This article reviews the published data on the use of caspofungin in immunocompromised children and neonates with invasive fungal infections.
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Affiliation(s)
- Ayper Somer
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Infectious Diseases, Millet Cad. 34390 Capa, Istanbul, Turkey.
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Ramos Amador JT, Prieto Tato L, Guillén Martín S. [Why might micafungin be the drug of choice in pediatric patients?]. Enferm Infecc Microbiol Clin 2011; 29 Suppl 2:23-8. [PMID: 21420573 DOI: 10.1016/s0213-005x(11)70005-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Micafungin is an echinocandin approved by the European Medicines Evaluation Agency for the treatment of invasive candidiasis in children, including premature infants born before 29 weeks of pregnancy, and as prophylaxis in children undergoing hematopoietic stem-cell transplantation or patients at risk of prolonged neutropenia. This drug has good activity in several Candida spp., including those resistant to fluconazole. Although micafungin is active against Aspergillus spp., it has been used mainly in combination therapy for invasive aspergillosis. There is ample information on the use of micafungin in children, including neonates, and this drug is the only echinocandin approved for use in infants aged less than 3 months. The efficacy, pharmacokinetics and safety of micafungin have been evaluated in phase II and III clinical trials in children, in which its efficacy and safety were demonstrated in comparison with liposomal amphotericin B and fluconazole. The pharmacokinetic profile of micafungin in children allows once daily intravenous administration, with greater clearance than in adults, and consequently pediatric doses are relatively higher. The most appropriate dose in children weighing less than 40 kg is 2 mg/kg/day in the treatment of invasive candidiasis and 1 mg/kg/day as prophylaxis in children undergoing hematopoietic stem-cell transplantation. Doses in neonates should be higher. In premature infants, the most appropriate doses to achieve levels in the brain parenchyma are 7 mg/kg/day and 10 mg/kg/day in those weighing more and less than 1,000 g, respectively. Micafungin has few drug-drug interactions and an acceptable safety profile. Withdrawal of this drug due to adverse effects is rare, although transaminase monitoring is recommended during treatment, as well as evaluation of the risk-benefit balance in patients with liver disease or concomitant administration of hepatotoxic drugs.
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Affiliation(s)
- José Tomás Ramos Amador
- Unidad de Enfermedades Infecciosas, Servicio de Pediatría, Hospital Universitario de Getafe, Madrid, España
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23
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Finco G, Sanna D, Evangelista M, Mura P, Musu M. Fungal infections in pediatric intensive care units. J Matern Fetal Neonatal Med 2011; 24 Suppl 2:21-3. [DOI: 10.3109/14767058.2011.601922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Holt SL, Drew RH. Echinocandins: Addressing outstanding questions surrounding treatment of invasive fungal infections. Am J Health Syst Pharm 2011; 68:1207-20. [DOI: 10.2146/ajhp100456] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Leverger G, Le Guyader N. [Echinocandins in children]. Arch Pediatr 2011; 18 Suppl 1:S33-41. [PMID: 21596285 DOI: 10.1016/s0929-693x(11)70938-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Echinocandins are a new class of antifungal agents with a specific mechanism of action. These drugs inhibit the enzyme 1,3β-D-glucan synthetase which is responsible for the formation of 1,3β-D-glucan, an essential fungal cell wall component. They have a good activity against Candida species and Aspergillus. Three agents are available at the present time or under development : caspofungin, micafungin and anidulafungin. These drugs require intravenous administration. Efficacy, safety, rare drugs interactions and specificity of action are advantages for therapy of invasive fungal infections. In France, micafungin and caspofungin are approved for a pediatric use.
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Affiliation(s)
- G Leverger
- Service d'hématologie-oncologie pédiatrique, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France.
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Grau Cerrato S, Luque Pardos S, Ferrández Quirante O. [Differential pharmacokinetic characteristics of micafungin. Experience in special populations]. Enferm Infecc Microbiol Clin 2011; 29 Suppl 2:10-4. [PMID: 21420571 DOI: 10.1016/s0213-005x(11)70003-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Currently, three echinocandins are available for the treatment of fungal infections. Micafungin is the latest drug to be incorporated into this group of antifungal agents. Although the mechanism of action of micafungin is similar to that of other echinocandins, this molecule has certain pharmacokinetic characteristics that distinguish it from other drugs in this group. Nowadays, there is wide information on the pharmacokinetic behavior of micafungin, mainly from patients included in clinical trials. However, there is far less knowledge of the pharmacokinetics of this echinocandin in special populations. The aim of the current review was to analyze the available information on the pharmacokinetics of micafungin in pediatric patients, the elderly, patients with renal insufficiency or liver failure, and transplant recipient.
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Faria NCG, Kim JH, Gonçalves LAP, Martins MDL, Chan KL, Campbell BC. Enhanced activity of antifungal drugs using natural phenolics against yeast strains of Candida and Cryptococcus. Lett Appl Microbiol 2011; 52:506-13. [PMID: 21332761 DOI: 10.1111/j.1472-765x.2011.03032.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Determine whether certain, natural phenolic compounds enhance activity of commercial antifungal drugs against yeast strains of Candida and Cryptococcus neoformans. METHODS AND RESULTS Twelve natural phenolics were examined for fungicidal activity against nine reference strains of Candida and one of C. neoformans. Six compounds were selected for synergistic enhancement of antifungal drugs, amphotericin B (AMB), fluconazole (FLU) and itraconazole (ITR). Matrix assays of phenolic and drug combinations conducted against one reference strain, each, of Candida albicans and C. neoformans showed cinnamic and benzoic acids, thymol, and 2,3- and 2,5-dihydroxybenzaldehydes (-DBA) had synergistic interactions depending upon drug and yeast strain. 2,5-DBA was synergistic with almost all drug and strain combinations. Thymol was synergistic with all drugs against Ca. albicans and with AMB in C. neoformans. Combinations of benzoic acid or thymol with ITR showed highest synergistic activity. Of 36 combinations of natural product and drug tested, none were antagonistic. CONCLUSIONS Relatively nontoxic natural products can synergistically enhance antifungal drug activity, in vitro. SIGNIFICANCE AND IMPACT OF THE STUDY This is a proof-of-concept, having clinical implications. Natural chemosensitizing agents could lower dosages needed for effective chemotherapy of invasive mycoses. Further studies against clinical yeast strains and use of animal models are warranted.
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Affiliation(s)
- N C G Faria
- Instituto de Higiene e Medicina Tropical/CREM, Universidade Nova de Lisboa, Portugal
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Dotis J, Roilides E. Candidemia in the Pediatric Intensive Care Unit: What’s Different from Candidemia in Adults? CURRENT FUNGAL INFECTION REPORTS 2011. [DOI: 10.1007/s12281-010-0043-5] [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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Groll AH, Lehrnbecher T, Arshad M, Benjamin DK, Cohen-Wolkowiez M. Commentaries on ‘Antifungal therapy in infants and children with proven, probable or suspected invasive fungal infections’ with a response from the review authors. ACTA ACUST UNITED AC 2010. [DOI: 10.1002/ebch.631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Seriously ill or immunocompromised children are at increased risk of invasive fungal infections, particularly candidemia. Candida albicans and Candida parapsilosis are the two most frequent causes of candidemia in pediatric patients. Candidemia in children is associated with high morbidity and mortality, increased length of hospital stays, and higher healthcare costs. Early effective antifungal therapy is the key to improved outcomes. Risk factors for candidemia may be used to identify patients suitable for empiric therapy. Such risk factors include prolonged stay in an intensive care unit, immunosuppression, prior bacterial infection, and recent surgery, as well as the use of a central venous catheter, mechanical ventilation, and/or total parenteral nutrition. Recent guidelines from the Infectious Diseases Society of America recommend consideration of fluconazole or an echinocandin for empiric therapy in suitable candidates, with a preference for an echinocandin in patients with moderate-to-severe disease, recent azole exposure, or high risk of Candida glabrata or Candida krusei infection. Fluconazole or an echinocandin is also preferred initial therapy for non-neutropenic candidemia, depending on disease severity and other characteristics. The guidelines recommend treatment with an echinocandin or lipid formulation of amphotericin B for most patients with neutropenic candidemia, although fluconazole is identified as an alternative for less critically ill patients without recent azole exposure. Risk factors for candidemia - and, hence, criteria for prophylaxis - are less well established in older children than in neonates. Further research is needed to better establish criteria for antifungal prophylaxis in children at high risk for candidemia.
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Affiliation(s)
- Theoklis Zaoutis
- Divisionof Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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