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Weerdenburg H, Walker H, Curtis N, Duffull S, Haeusler G, Cole T, Gwee A. Posaconazole in paediatric malignancy and haematopoietic stem cell transplant: dosing to achieve therapeutic concentration. J Antimicrob Chemother 2024; 79:1493-1507. [PMID: 38637310 DOI: 10.1093/jac/dkae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/05/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVES Posaconazole is increasingly used for the treatment and prophylaxis of invasive fungal infections in immunocompromised children. We aimed to review evidence for paediatric posaconazole dosing regimens focusing on attainment of target concentrations and frequency of adverse effects. METHODS In May 2023, the Cochrane, Embase, MEDLINE and PubMed databases were searched for articles reporting posaconazole dosing in children with malignancy or post-haematopoietic stem cell transplantation. Studies reporting the attainment of target serum concentrations were included. RESULTS Overall, 24 studies were included. Eighteen studies of the oral suspension consistently reported poor attainment of target concentrations for prophylaxis (≥0.7 µg/mL, 12%-78%) despite high daily doses of 14-23 mg/kg/day (max. 1200 mg/day). Target attainment was significantly affected by gastric pH and food intake. Six studies of the delayed-release tablet (DRT) reported 58%-94% achieved concentrations ≥0.7 µg/mL, with the majority using lower doses of 4-12 mg/kg/day (max. 300 mg/day). Similarly, one study of powder for oral suspension found 67%-100% achieved target concentrations with a dose of 6 mg/kg/day (max. 300 mg/day). As expected, the IV formulation had high attainment of prophylaxis targets (81%-90%) with 6-10 mg/kg/day (max. 400 mg/day). All formulations were well tolerated, and no relationship between adverse effects and posaconazole concentrations was identified. CONCLUSIONS The required posaconazole dose in immunocompromised children varies depending on the formulation. The IV infusion had the highest attainment of therapeutic concentration followed by the DRT and powder for suspension. By contrast, the oral suspension had low attainment of target concentrations despite higher daily doses.
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Affiliation(s)
- Heather Weerdenburg
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Hannah Walker
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel Curtis
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Gabrielle Haeusler
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- The Victorian Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Victoria, Australia
| | - Theresa Cole
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amanda Gwee
- Department of Pharmacy, Children's Cancer Centre, General Medicine and Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials and Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Kunvarjee B, Siver M, Mathew S, Steiger S, Lee YJ, Spitzer B. Characterization of the Use and Efficacy of Isavuconazonium Sulfate in a Pediatric Oncology and Stem Cell Transplant Population: A Single Institution Retrospective Review. J Pediatr Hematol Oncol 2024; 46:e143-e146. [PMID: 38237014 DOI: 10.1097/mph.0000000000002812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/22/2023] [Indexed: 02/28/2024]
Abstract
Isavuconazonium sulfate (ISA) is a triazole antifungal approved for the treatment of invasive aspergillosis and mucormycosis in adults. This single-center, retrospective review of pediatric oncology and stem cell transplant patients receiving ISA for prophylaxis (n=20) or treatment (n=6) of invasive fungal disease (IFD) aims to characterize real-world clinical efficacy and toxicity of ISA in patients <18 years of age. Of 20 patients receiving ISA for prophylaxis, three patients had presumed breakthrough IFD (1 proven, 2 probable/possible). No adverse effects were attributed to ISA use or led to the discontinuation of therapy.
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Affiliation(s)
| | | | | | | | - Yeon Joo Lee
- Department of Medicine, Infectious Diseases Service
| | - Barbara Spitzer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, NY
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Bio LL, Hiroshima L, Schwenk HT, Green S. Successful enteral administration of crushed posaconazole delayed-release tablets in children. Pediatr Blood Cancer 2024; 71:e30782. [PMID: 37990039 DOI: 10.1002/pbc.30782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/06/2023] [Accepted: 11/11/2023] [Indexed: 11/23/2023]
Abstract
Erratic absorption of posaconazole oral suspension necessitates frequent dosing and administration with meals or supplements. Alternative enteral formulations are desirable for patients intolerant to enteral nutrition. Crushed posaconazole delayed-release tablets (POS-DRT) show promise in adults; limited evidence exists in children. We used crushed POS-DRT in 10 encounters with nine pediatric patients, achieving target POS concentrations in 90% of encounters. This highlights crushed POS-DRT as a potential enteral option for pediatric antifungal prophylaxis and treatment.
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Affiliation(s)
- Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Lyndsie Hiroshima
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Hayden T Schwenk
- Division of Pediatric Infectious Diseases, Stanford School of Medicine, Stanford, California, USA
| | - Sean Green
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
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Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
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Ferdjallah A, Nelson KM, Meyer K, Jennissen CA, Ebens CL. Isavuconazonium Sulfate Use in Multi-Modal Management of Invasive Mucormycosis in Four Pediatric Allogeneic Hematopoietic Cell Transplant Patients. J Pediatr Pharmacol Ther 2021; 26:863-867. [PMID: 34790078 DOI: 10.5863/1551-6776-26.8.863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/04/2021] [Indexed: 11/11/2022]
Abstract
Prolonged neutropenia increases the risk for lethal invasive fungal infections (IFIs) such as those caused by Rhizopus species. Isavuconazonium sulfate is a new triazole that lacks pediatric dosing recommendations. Clinical courses of 4 pediatric patients with IFIs in the peri-allogeneic hematopoietic cell transplantation (alloHCT) period between 2015 and 2017 were reviewed. The reviews included previously unreported pharmacokinetic and safety data, and the IFIs included Rhizopus. Isavuconazonium sulfate was initiated with a loading dose followed by daily dosing, adjusted to a goal trough concentration of >3 mg/L based on adult literature. This target was achieved at a median of 7 days, demonstrating varying rates of metabolism. Renal insufficiency, electrolyte disturbances, and transaminitis were noted, although attribution was confounded by other alloHCT complications. One patient survived infection-free to hospital discharge and 1 of 3 deceased patients had evidence of an unresolved IFI (case 2). Case 2 was subtherapeutic for 39% of the duration of treatment, compared with others at an average of 29%, suggesting this target trough to be clinically relevant because case 2 demonstrated positive sinus and nasal cultures for Rhizopus on autopsy. We recommend initiation of isavuconazonium 10 mg/kg with a maximum dose of 372 mg. A loading dose of 10 mg/kg is used every 8 hours for 6 doses followed by 10 mg/kg dosing every 24 hours. Monitoring must continue beyond steady state. If early monitoring is not possible, we recommend a first drug level at week 3. If dose increases are required, a partial reload has been more successful instead of increasing daily doses. Further larger studies are needed to demonstrate optimum dosing in pediatric patients.
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Garner LM, Ngo S, Kaplan JB, Wilson WS, McKinzie CJ. Evaluation of Posaconazole Dosing in Children and Young Adults: A Single-Center Review. J Pediatr Pharmacol Ther 2021; 26:834-840. [PMID: 34790074 DOI: 10.5863/1551-6776-26.8.834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/08/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Initial posaconazole dosing regimens in children often do not achieve target concentrations, and data continue to support the need for higher initial dosing regimens. The objective of this study is to contribute to the current data regarding suboptimal posaconazole dosing in pediatric patients by retrospectively observing dosing strategies and subsequent drug concentrations. METHODS This study was conducted at a single institution in 27 patients aged 1 to 21 years. Patients who were initiated on any formulation of posaconazole for prophylaxis or treatment while admitted to the hospital were included. The primary outcome was to determine the percentage of pediatric patients who achieved the targeted trough concentration using their initial posaconazole dosing regimen. Secondary outcomes included percentage of patients who experienced a breakthrough invasive fungal infection (IFI), percentage of patients with elevated liver function tests (LFTs), and discontinuation for any reason. RESULTS There were 15 patients (55.5%) who reached desired trough serum concentration after the initial dosing regimen. The number of dose modifications to achieve the desired trough ranged from 1 to 3. Most patients received delayed-release tablets (n = 17), and the average doses for reaching prophylactic and treatment trough concentrations were 6.1 mg/kg/day and 11 mg/kg/day, respectively. There were 2 patients (7.4%) who experienced breakthrough IFI. Overall, 5 patients developed elevated LFTs and 7 patients discontinued treatment early. CONCLUSIONS The results describe a single population of pediatric patients, of whom 55% were able to achieve target trough concentrations of posaconazole with the initial dosing strategy used.
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Panagopoulou P, Roilides E. Evaluating posaconazole, its pharmacology, efficacy and safety for the prophylaxis and treatment of fungal infections. Expert Opin Pharmacother 2021; 23:175-199. [PMID: 34758695 DOI: 10.1080/14656566.2021.1996562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal diseases (IFDs) are a significant cause of morbidity and mortality among immunocompromised patients. Safe and effective antifungal medications used for prophylaxis and treatment are pivotal in their management. Posaconazole is a promising triazole antifungal agent. AREAS COVERED The authors discuss the pharmacological properties of posaconazole, including pharmacokinetics/pharmacodynamics, safety and tolerability profile, together with efficacy data for prophylaxis and treatment as well as its use in special populations based on current literature. EXPERT OPINION Posaconazole has a favorable safety and tolerability profile; however, caution is advised when co-administered with agents that are CYP3A4 inhibitors, because their concentration may significantly increase, and their levels should be closely monitored. It has an extended spectrum of activity against yeasts and filamentous fungi. It is successfully used as prophylaxis for patients with acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) and post-hematopoietic cell transplantation (HCT) with graft-versus-host disease (GVHD). It is the first line treatment for oropharyngeal candidiasis and is also used as a salvage treatment for refractory IFDs. Currently available formulations include the oral suspension, delayed-release tablets and solution for intravenous infusion, all with different PK/PD properties and indications. Its use in children and adolescents is currently being examined in Phase-II clinical trials.
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Affiliation(s)
- Paraskevi Panagopoulou
- 4th Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Papageorgiou General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece.,Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Vu CA, Riollano-Cruz M, Kowalsky SR. Supratherapeutic Posaconazole Concentration in a Pediatric Transplant Patient With Confirmed Rhizopus Infection. J Pediatr Pharmacol Ther 2021; 26:753-757. [PMID: 34588941 PMCID: PMC8475801 DOI: 10.5863/1551-6776-26.7.753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/19/2021] [Indexed: 11/11/2022]
Abstract
There are a limited number of studies that guide dosing of posaconazole delayed-release (DR) tablets for the pediatric population. Current FDA-approved doses are only recommended for patients 13 years and older. For younger patients, providers are faced with the challenge of recommending posaconazole doses extrapolated from adult studies or choosing an alternative agent. We report on a case of a 10-year-old patient who experienced a supratherapeutic trough serum concentration and transaminitis after receiving the extrapolated adult dosage of posaconazole DR tablets (300 mg twice daily for the first day, followed by 300 mg daily) for 7 days. In the end, the patient required a smaller dose of 200 mg daily to achieve the desired trough target concentration for the treatment of a Rhizopus neck infection. Our findings highlight the need for additional studies to determine the optimal dosing of posaconazole DR tablets for children.
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Elkayal O, Spriet I, Uyttebroeck A, Colita A, Annaert P, Allegaert K, Smits A, Van Daele R, Dreesen E. A Population Pharmacokinetic Modeling and Simulation Study of Posaconazole Oral Suspension in Immunocompromised Pediatric Patients: A Short Communication. Ther Drug Monit 2021; 43:512-518. [PMID: 33560094 DOI: 10.1097/ftd.0000000000000877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Posaconazole oral suspension emerged as a promising candidate for prophylaxis of invasive fungal infections in immunocompromised children. Its pharmacodynamic advantages include a broad-spectrum activity and a favorable safety profile; however, they are overshadowed by its large pharmacokinetic (PK) variability, which might cause subtherapeutic exposure. The aim of this study was to develop a population (pop) PK model based on rich sampling data to better understand the PK of posaconazole oral suspension in pediatric patients. METHODS Data were obtained from a prospective interventional study involving hospitalized pediatric patients with a hematologic malignancy and prophylactically treated with posaconazole oral suspension. After constructing the popPK model, the probability of target attainment (PTA; 100% T ≥ 0.7 mg/L) for prophylaxis under fixed, body weight-based, and body surface area-based dosing was evaluated using Monte Carlo simulation. RESULTS Fourteen patients contributed 112 posaconazole plasma concentrations. The PK of posaconazole was adequately described by a 1-compartment model with lag time 2.71 hours [13%]; nonlinear bioavailability ED50 99.1 mg/m2 (fixed); first-order absorption rate constant 0.325 hour-1 [27%]; apparent volume of distribution 1150 L [34%]; and apparent clearance 15.4 L/h [24%] (∼70-kg individual). The bioavailability decreased in the presence of diarrhea and co-treatment with a proton pump inhibitor (PPI). The unexplained interindividual variability in posaconazole PK remained large. The PTA was <85%, irrespective of the simulated dosing strategy. Patients without diarrhea and not administered a PPI had the highest PTA (85% under the fixed 300-mg dosing 4 times per day). CONCLUSIONS Therapeutic drug monitoring is recommended during prophylactic posaconazole therapy in immunocompromised pediatric patients. Large-scale comparative studies are needed to characterize the PK variability between different posaconazole formulations in this cohort.
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Affiliation(s)
- Omar Elkayal
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacy Department, University Hospitals Leuven
| | - Anne Uyttebroeck
- Paediatric Oncology Unit, Department of Oncology, KU Leuven
- Pediatric Oncology and Hematology Department, University Hospitals Leuven, Leuven, Belgium
| | - Anca Colita
- Department of Pediatrics, Fundeni Clinical Institute
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Pieter Annaert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Woman and Child Unit, Department of Development and Regeneration, KU Leuven
| | - Anne Smits
- Woman and Child Unit, Department of Development and Regeneration, KU Leuven
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium ; and
| | - Ruth Van Daele
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacy Department, University Hospitals Leuven
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven
- Pharmacometrics Research Group, Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Is Posaconazole Really Effective in Adolescent patients as a Prophylactic Agent: Experience of a Tertiary Care Center. J Pediatr Hematol Oncol 2021; 43:e613-e618. [PMID: 33560081 DOI: 10.1097/mph.0000000000002080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 12/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Invasive fungal infections (IFIs) are a leading cause of morbidity and death in immunocompromised patients. Data on efficacy and pharmacokinetics of posaconazole in pediatric patients are rare (1 to 5). Herein, we retrospectively analyzed adolescent patients who had received posaconazole as antifungal prophylaxis. METHODS We retrospectively analyzed patients who received posaconazole as primary or secondary antifungal prophylaxis. RESULTS A total of 34 adolescent patients, 19 men (55.9%) and 15 women (44.1%) with a mean age of 15.8±2.1 years were included. Twenty-five of 34 (73.5%) patients were on primary and nine of 34 (26.5%) patients were on secondary antifungal prophylaxis. Diagnosis of the patients receiving posaconazole as primary antifungal prophylaxis were acute myeloid leukemia (n=12, 48%), hematopoietic stem cell transplantation (n=7, 28%), acute lymphoblastic leukemia (n=5, 20%), and Fanconi aplastic anemia (n=1, 4%). Five patients (55.6%) with hematopoietic stem cell transplantation, 1 patient with acute myeloid leukemia (11.1%), 1 patient with Fanconi aplastic anemia (11.1%), and 2 (22.2%) patients with chronic granulomatous disease received posaconazole as secondary antifungal prophylaxis. Twelve of 25 (48%) patients receiving posaconazole as primary antifungal prophylaxis were complicated by IFI; 4 of them were proven, 6 probable, and 2 with possible IFI. Three of 9 patients (33.3%) receiving posaconazole as secondary antifungal prophylaxis was complicated by IFI (P=0.29), 2 of them were probable and 1 was possible IFI. Five of 25 patients (20%) receiving posaconazole as primary prophylaxis died because of IFI. CONCLUSION Improvement of antifungal prophylaxis in patients with high risk of invasive infections seems clearly necessary, and analyzing serum posaconazole levels and individualizing dosing may be 1 approach to improve outcomes.
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Lambrix AA, Swanson HD, Pauley JL, Bragg AW, Carias DC, Bourque MS, Zhou Y, Cheng C, Greene WL, Maron G. Experience using intravenous posaconazole in paediatric and young adult oncology patients. J Antimicrob Chemother 2021; 75:3682-3687. [PMID: 32929484 DOI: 10.1093/jac/dkaa377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Posaconazole exhibits broad-spectrum antifungal activity. An IV formulation became available in 2014. Few studies describing the use of this formulation exist in patients under the age of 18 years. This study describes our experience using IV posaconazole in paediatric and young adult cancer patients. METHODS This single-centre retrospective chart review evaluated patients who received IV posaconazole and had at least one posaconazole plasma concentration obtained after five or more days with a consistent dosage. Relationships between doses required to achieve a plasma concentration of ≥1 µg/mL and patient age, weight and body surface area (BSA) were evaluated. The clinical record was reviewed to identify descriptions of any adverse events. RESULTS Twenty-five patients were analysed, with a median age of 10.5 years (range 1.9-22.9 years; 92% were <18 years). All patients were able to achieve a posaconazole plasma concentration ≥1 µg/mL during their treatment course. The daily mg/kg/day dose required to achieve the target concentration decreased significantly with increasing age of the patient (P = 0.018). Assessment of dosage based on BSA suggested a requirement of 225 mg/m2/day across all age groups <18 years. Adverse events documented in the clinical record were consistent with those described with the oral formulations. No CNS toxicities were observed with use of IV posaconazole. CONCLUSIONS Concentrations ≥1 µg/mL are achievable and a BSA-based dosing approach may allow a consistent empirical dose for patients <18 years of age. Therapeutic drug monitoring is recommended to ensure patients achieve therapeutic concentrations.
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Affiliation(s)
- Arathi A Lambrix
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Hope D Swanson
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer L Pauley
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Allison W Bragg
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Delia C Carias
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa S Bourque
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yinmei Zhou
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - William L Greene
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
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Liang Y, Chen X, Wang J, Guo C, Liu F, Yang J. Oral posaconazole and bronchoscopy as a treatment for pulmonary mucormycosis in pediatric acute lymphoblastic leukemia patient: A case report. Medicine (Baltimore) 2021; 100:e24630. [PMID: 33578579 PMCID: PMC7886464 DOI: 10.1097/md.0000000000024630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/15/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Mucormycosis is a rare fungal infection that typically occurs in immunosuppressed patients following chemotherapy or hematopoietic stem cell transplantation. PATIENT CONCERNS An 11-year-old child with newly developed acute lymphoblastic leukemia suffered from the paroxysmal left chest pain, fever, and hemoptysis. DIAGNOSES We made a histopathologic diagnosis aided by bronchoscopy techniques, which indicated invasive fungal hyphae that are characteristic of mucormycosis. INTERVENTIONS The patient was treated with oral posaconazole and repeated bronchoscopy interventions for 4 months. OUTCOMES The patient's clinical signs and symptoms and signs were no longer present. The prior lung lesions were also no longer observable using radiologic methods, and a 3-month follow-up with the patient showed no signs of mucormycosis recurrence. Finally, the patient was cured, when the cancer chemotherapy was stopped. Close follow-up for another 2 years showed no evidence of recurrence. LESSONS Mucormycosis diagnosis is difficult as clinical and imaging findings vary. This case demonstrates that posaconazole monotherapy combined with bronchoscopy interventions may be a safe and effective treatment option for pediatric pulmonary mucormycosis.
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Abstract
Posaconazole is typically used for preventing invasive yeast and mold infections such as invasive aspergillosis in high-risk immunocompromised patients. The oral suspension was the first released formulation and many pharmacokinetic and pharmacodynamic studies of this formulation have been published. Erratic absorption profiles associated with this formulation were widely reported. Posaconazole exposure was found to be significantly influenced by food and many gastrointestinal conditions, including pH and motility. As a result, low posaconazole plasma concentrations were obtained in large groups of patients. These issues of erratic absorption urged the development of the subsequently marketed delayed-release tablet, which proved to be associated with higher and more stable exposure profiles. Shortly thereafter, an intravenous formulation was released for patients who are not able to take oral formulations. Both new formulations require a loading dose on day 1 to achieve high posaconazole concentrations more quickly, which was not possible with the oral suspension. So far, there appears to be no evidence of increased toxicity correlated to the higher posaconazole exposure achieved with the regimen for these formulations. The higher systemic availability of posaconazole for the delayed-release tablet and intravenous formulation have resulted in these two formulations being preferable for both prophylaxis and treatment of invasive fungal disease. This review aimed to integrate the current knowledge on posaconazole pharmacokinetics, pharmacodynamics, major toxicity, existing resistance, clinical experience in special populations, and new therapeutic strategies in order to get a clear understanding of the clinical use of this drug.
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Tragiannidis A, Herbrüggen H, Ahlmann M, Vasileiou E, Gastine S, Thorer H, Fröhlich B, Müller C, Groll AH. Plasma exposures following posaconazole delayed-release tablets in immunocompromised children and adolescents. J Antimicrob Chemother 2020; 74:3573-3578. [PMID: 31504563 DOI: 10.1093/jac/dkz359] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Posaconazole is a recommended option for antifungal prophylaxis in paediatric patients >12 years of age. However, little is known about plasma exposures and safety following administration of the delayed-release tablets (DRTs) in children and adolescents. METHODS In a retrospective observational study, we analysed steady-state trough concentrations of posaconazole in all paediatric patients who had received the DRT formulation between May 2015 and December 2018 for antifungal prophylaxis. Dosing was guided by a published population pharmacokinetic model with weight-based dosing. Drug concentrations in plasma were measured by a validated tandem MS method. Liver function and drug discontinuations due to adverse effects were also assessed. RESULTS A total of 34 patients (21 male, 13 female; median age 12 years, range 5-17 years; median body weight 43.5 kg, range 16-84 kg) undergoing treatment for haemato-oncological disorders (n=23) or immunosuppression for polyarthritis (n=1) or post-allogeneic HSCT (n=11) received posaconazole DRTs for a median of 70 days (range 9-391 days). The median first steady-state trough plasma concentration following model-derived dosing was 1607 ng/mL (range 501-8485 ng/mL) with trough concentrations being above the dosing target of ≥700 ng/mL in 32/34 patients (94%). Considering all (first and subsequent) trough concentrations, target attainment was 90% (63/70 samples). Posaconazole was well tolerated without adverse event-related discontinuations or breakthrough infections. CONCLUSIONS Administration of posaconazole DRTs to paediatric patients guided by a population pharmacokinetic-derived dosing algorithm resulted in predictable and potentially effective exposures and was well tolerated over prolonged time periods.
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Affiliation(s)
- Athanasios Tragiannidis
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany.,Hematology Oncology Unit, 2nd Department of Pediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Heidrun Herbrüggen
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Martina Ahlmann
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Eleni Vasileiou
- Hematology Oncology Unit, 2nd Department of Pediatrics, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Silke Gastine
- Department of Pharmaceutical and Medical Chemistry, University of Münster, Münster, Germany
| | - Heike Thorer
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Birgit Fröhlich
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Carsten Müller
- Department of Pharmacology, University of Cologne, Cologne, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Dept. of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
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15
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Patel D, Popple S, Claydon A, Modha DE, Gaillard EA. Posaconazole therapy in children with cystic fibrosis and Aspergillus-related lung disease. Med Mycol 2020; 58:11-21. [PMID: 30877757 DOI: 10.1093/mmy/myz015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/30/2019] [Accepted: 02/16/2019] [Indexed: 01/08/2023] Open
Abstract
There is emerging evidence for the role of posaconazole in the management of Aspergillus-related cystic fibrosis (CF) lung disease. The tolerability and efficacy of posaconazole in paediatric CF is not well established. We report a prospective study over a fifty-three month period evaluating the safety, tolerability, and efficacy of posaconazole in pediatric CF. Fourteen children (seven males, median age 13 years, range 3-17 years) received a total of twenty-three courses of posaconazole (13 oral suspension and 10 tablet formulation). Of these patient episodes, nine received posaconazole for emerging or active allergic bronchopulmonary aspergillosis (ABPA) and two required a combination of posaconazole and systemic corticosteroids for difficult-to-treat ABPA. A subgroup of patients (n = 12) with persistent isolates of Aspergillus fumigatus, in the absence of serological markers of ABPA, received posaconazole monotherapy for pulmonary exacerbations not responding to conventional broad-spectrum antibiotic treatment. Posaconazole levels, full blood count, electrolytes, and liver function were monitored on day 7 of treatment and then monthly. Posaconazole was well tolerated in all but three patients. Therapeutic plasma levels >1 mg/l were achieved in all receiving the tablet formulation in comparison to 60% on the liquid preparation. There was a modest but significant improvement in FEV1 (% predicted) demonstrated for the cohort as a whole (p = 0.015) following posaconazole therapy. Posaconazole is well tolerated in children as young as six years old, improvements in lung function are observed, and therapeutic plasma levels are readily achieved in patients taking the tablet formulation and in adherent patients taking the liquid formulation.
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Affiliation(s)
- Deepa Patel
- Department of Respiratory Sciences, NIHR Biomedical Research Centre (Respiratory theme) and Institute for Lung Health, University of Leicester, Leicester, United Kingdom.,Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Sarah Popple
- Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Alison Claydon
- Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Deborah E Modha
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Erol A Gaillard
- Department of Respiratory Sciences, NIHR Biomedical Research Centre (Respiratory theme) and Institute for Lung Health, University of Leicester, Leicester, United Kingdom.,Department of Paediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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16
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Antifungal Triazole Posaconazole Targets an Early Stage of the Parechovirus A3 Life Cycle. Antimicrob Agents Chemother 2020; 64:AAC.02372-19. [PMID: 31818821 DOI: 10.1128/aac.02372-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/18/2022] Open
Abstract
Viruses in species Parechovirus A (Picornaviridae) are associated with a wide variety of clinical manifestations. Parechovirus A3 (PeV-A3) is known to cause sepsis-like illness, meningitis, and encephalitis in infants and young children. To date, no specific therapies are available to treat PeV-A3-infected children. We had previously identified two FDA-cleared antifungal drugs, itraconazole (ITC) and posaconazole (POS), with potent and specific antiviral activity against PeV-A3. Time-of-addition and synchronized infection assays revealed that POS targets an early stage of the PeV-A3 life cycle. POS exerts an antiviral effect, evidenced by a reduction in viral titer following the addition of POS to Vero-P cells before infection, coaddition of POS and PeV-A3 to Vero-P cells, incubation of POS and PeV-A3 prior to Vero-P infection, and at attachment. POS exerts less of an effect on virus entry. A PeV-A3 enzyme-linked immunosorbent assay inhibition experiment, using an anti-PeV-A3 monoclonal antibody, suggested that POS binds directly to the PeV-A3 capsid. POS-resistant PeV-A3 strains developed by serial passage in the presence of POS acquired substitutions in multiple regions of the genome, including the capsid. Reverse genetics confirmed substitutions in capsid proteins VP0, VP3, and VP1 and nonstructural proteins 2A and 3A. Single mutants VP0_K66R, VP0_A124T, VP3_N88S, VP1_Y224C, 2A_S78L, and 3A_T1I were 4-, 9-, 12-, 34-, 51-, and 119-fold more resistant to POS, respectively, than the susceptible prototype strain. Our studies demonstrate that POS may be a valuable tool in developing an antiviral therapy for PeV-A3.
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17
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Wass EN, Hernandez EA, Sierra CM. Comparison of the Efficacy of Posaconazole Delayed Release Tablets and Suspension in Pediatric Hematology/Oncology Patients. J Pediatr Pharmacol Ther 2020; 25:47-52. [PMID: 31897075 DOI: 10.5863/1551-6776-25.1.47] [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] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Posaconazole is effective in preventing invasive fungal infections in neutropenic pediatric patients. The oral suspension has challenges in administration and absorption that are theorized to be minimized with delayed release tablets. However, this has not been validated in the pediatric population. This study was conducted to compare the efficacy and safety of posaconazole suspension and delayed release tablets in pediatric hematology/oncology patients. METHODS A retrospective chart review in pediatric hematology/oncology patients was conducted from February 2013 to February 2017. Data collected include patient demographic data; posaconazole formulation, dose, and serum concentrations; and adverse events. RESULTS Sixty-five patients with 353 serum posaconazole concentrations were included; 51.6% of concentrations drawn while patients were receiving posaconazole suspension were therapeutic, whereas 62.5% of concentrations drawn while patients were receiving posaconazole delayed release tablets were therapeutic (p = 0.035). Serum concentrations drawn while taking acid suppression (histamine receptor antagonists or proton pump inhibitors) and posaconazole suspension were less likely to be therapeutic (p < 0.0001) compared with those taken while receiving delayed release tablets. Adverse event profiles were similar between both formulations. CONCLUSIONS Delayed release tablets proved more effective in achieving therapeutic serum posaconazole concentrations than posaconazole suspension, with minimal difference in adverse events, in pediatric hematology/oncology patients.
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18
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Lavigne S, Fisher BT, Ellis D, Zaoutis TE, Downes KJ. Posaconazole Administration in Hospitalized Children in the United States. J Pediatric Infect Dis Soc 2019; 8:481-484. [PMID: 30445549 DOI: 10.1093/jpids/piy119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 10/26/2018] [Indexed: 11/12/2022]
Abstract
In this study, we evaluated posaconazole use among hospitalized children between October 2006 and September 2015 using data from the Pediatric Health Information System. A total of 878 children (in 1949 admissions) received posaconazole, and administration increased 22% per year overall and 27% per year in children aged <13 years for whom the drug was not approved.
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Affiliation(s)
- Sondra Lavigne
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,School of Veterinary Medicine, University of Pennsylvania, Philadelphia
| | - Brian T Fisher
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
| | - Darcy Ellis
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania
| | - Theoklis E Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
| | - Kevin J Downes
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
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19
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Ojeda-Diezbarroso K, Aguilar-Rascón J, Jiménez-Juárez RN, Moreno-Espinosa S, Reséndiz-Sánchez J, Romero-Zamora JL. Successful posaconazole salvage therapy for rhinocerebral mucormycosis in a child with leukemia. Review of the literature. Rev Iberoam Micol 2019; 36:160-164. [PMID: 31563327 DOI: 10.1016/j.riam.2018.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/20/2018] [Accepted: 07/30/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Mucormycosis is a fungal infection caused by species of the Mucorales order. These microorganisms are angioinvasive, with rapid disease progression and potentially lethal in its rhinocerebral form. CASE REPORT We present the case of a 12-year-old female with trisomy 21, acute lymphoblastic leukemia and diabetes, with fever and neutropenia who developed rhinocerebral mucormicosis. After treatment with amphotericin B lipid complex and extensive surgery, disease progressed and posaconazole was added as salvage treatment with full remission of the infection. Four years after diagnosis the patient continues without relapse of mucormycosis or leukemia. CONCLUSIONS This case highlights the use of posaconazole as either monotherapy or combined therapy. Although it is still debated, it can be considered an option for salvage treatment in children with non-responding mucormycosis, despite lack of standard dosage in pediatric patients.
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Affiliation(s)
- Karla Ojeda-Diezbarroso
- Pediatric Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico; Otorhinolaryngology Department, Hospital Infantil de México Federico Gómez, Mexico
| | - Juan Aguilar-Rascón
- Otorhinolaryngology Department, Hospital Infantil de México Federico Gómez, Mexico
| | - Rodolfo Norberto Jiménez-Juárez
- Pediatric Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico; Department of Pediatrics, Infectious Diseases Hospital, National Medical Center La Raza, Mexican Institute of Social Security, Mexico City, Mexico.
| | | | - Jesús Reséndiz-Sánchez
- Pediatric Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico
| | - José Luis Romero-Zamora
- Pediatric Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico
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20
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Otto WR, Pahud BA, Yin DE. Pediatric Mucormycosis: A 10-Year Systematic Review of Reported Cases and Review of the Literature. J Pediatric Infect Dis Soc 2019; 8:342-350. [PMID: 31181136 DOI: 10.1093/jpids/piz007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 05/28/2019] [Indexed: 12/29/2022]
Abstract
Mucormycosis is a severe infection that affects a variety of patients, including immunocompromised children and neonates. Given improved survival rates from advances in the treatment of malignancies, the population at risk for mucormycosis is increasing. We conducted a systematic review of cases of mucormycosis in children in the English-language literature reported between August 2008 and June 2017 and analyzed the clinical characteristics, diagnosis, management, and outcome of those infections. The most common underlying diagnoses included neutropenia (41%), hematologic malignancy (39%), prematurity (13%), and hematopoietic stem cell transplant (11%). Sinus disease (28%) and disseminated disease (24%) were the most common presentations. Rhizopus spp were the most common organisms isolated (22%). Amphotericin B remains the backbone of treatment and was prescribed in 86% of these cases. The resulting mortality rate remains high (32%). We provide here the results of a literature review of mucormycosis in children, including its epidemiology and clinical manifestations, and describe current advances in its diagnosis and treatment.
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Affiliation(s)
- William R Otto
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
| | - Barbara A Pahud
- Department of Pediatrics, Division of Infectious Diseases, Children's Mercy, Kansas City, Missouri.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Missouri
| | - Dwight E Yin
- Department of Pediatrics, Division of Infectious Diseases, Children's Mercy, Kansas City, Missouri.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Missouri
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21
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Shearin S, Bell T. Treatment of Aspergillus fumigatus infection with posaconazole delayed-release tablets. Am J Health Syst Pharm 2019; 75:958-961. [PMID: 29941535 DOI: 10.2146/ajhp170534] [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] [Indexed: 01/14/2023] Open
Abstract
PURPOSE A pediatric patient with cystic fibrosis (CF) was successfully treated for Aspergillus fumigatus infection with posaconazole delayed-release tablets. SUMMARY A 13-year-old, 29-kg, Caucasian boy with CF was admitted to the hospital for a pulmonary exacerbation. The patient had a history of multiple hospital admissions and was colonized with methicillin-sensitive Staphylococcus aureus, Stenotrophomonas maltophilia, and A. fumigatus. The patient was started on piperacillin-tazobactam 2.8 g (piperacillin 2 g and tazobactam 0.8 g) i.v. every 6 hours (400 mg/kg/day) and tobramycin 400 mg i.v. every 24 hours (13.7 mg/kg/day). After 2 weeks of therapy and therapeutic tobramycin concentrations, doxycycline 75 mg given orally twice daily was continued due to lack of clinical improvement. After 2 additional weeks of therapy, the patient was started on posaconazole delayed-release tablets 300 mg given orally daily with the evening meal due to concern about A. fumigatus colonization and a further decline in forced expiratory volume in 1 second to 37%. The posaconazole trough concentration was 1,500 ng/mL after 5 days of therapy. As this level was within the goal range, posaconazole was continued, with a plan to periodically check the trough level, pulmonary function, and liver function. The patient's liver function values remained stable throughout therapy. The patient's appetite improved and weight increased. Once the patient's weight exceeded 35 kg, his dosage of posaconazole delayed-release tablets was increased to 400 mg daily. His pulmonary function improved during posaconazole therapy, and A. fumigatus was eradicated. Posaconazole was discontinued after 9 months of therapy. CONCLUSION A 13-year old patient with CF was successfully treated for an A. fumigatus infection with posaconazole delayed-release tablets.
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Affiliation(s)
- Suzanne Shearin
- Department of Pharmacy, Carolinas Medical Center, Charlotte, NC
| | - Tara Bell
- Duke Children's Hospital and Health Center, Durham, NC.,College of Pharmacy and Health Sciences, Campbell University, Durham, NC
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22
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Agnihotri S, Mansouri S, Burrell K, Li M, Mamatjan Y, Liu J, Nejad R, Kumar S, Jalali S, Singh SK, Vartanian A, Chen EX, Karimi S, Singh O, Bunda S, Mansouri A, Aldape KD, Zadeh G. Ketoconazole and Posaconazole Selectively Target HK2-expressing Glioblastoma Cells. Clin Cancer Res 2018; 25:844-855. [PMID: 30322879 DOI: 10.1158/1078-0432.ccr-18-1854] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/14/2018] [Accepted: 10/10/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Hexokinase II (HK2) protein expression is elevated in glioblastoma (GBM), and we have shown that HK2 could serve as an effective therapeutic target for GBM. Here, we interrogated compounds that target HK2 effectively and restrict tumor growth in cell lines, patient-derived glioma stem cells (GSCs), and mouse models of GBM.Experimental Design: We performed a screen using a set of 15 drugs that were predicted to inhibit the HK2-associated gene signature. We next determined the EC50 of the compounds by treating glioma cell lines and GSCs. Selected compounds showing significant impact in vitro were used to treat mice and examine their effect on survival and tumor characteristics. The effect of compounds on the metabolic activity in glioma cells was also assessed in vitro. RESULTS This screen identified the azole class of antifungals as inhibitors of tumor metabolism. Among the compounds tested, ketoconazole and posaconazole displayed the greatest inhibitory effect on GBM both in vitro and in vivo. Treatment of mice bearing GBM with ketoconazole and posaconazole increased their survival, reduced tumor cell proliferation, and decreased tumor metabolism. In addition, treatment with azoles resulted in increased proportion of apoptotic cells. CONCLUSIONS Overall, we provide evidence that azoles exert their effect by targeting genes and pathways regulated by HK2. These findings shed light on the action of azoles in GBM. Combined with existing literature and preclinical results, these data support the value of repurposing azoles in GBM clinical trials.
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Affiliation(s)
- Sameer Agnihotri
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Sheila Mansouri
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Kelly Burrell
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Mira Li
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Yasin Mamatjan
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Jeff Liu
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada.,Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, Ontario, Canada
| | - Romina Nejad
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Sushil Kumar
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Shahrzad Jalali
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Sanjay K Singh
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Alenoush Vartanian
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada.,MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Eric Xueyu Chen
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shirin Karimi
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Olivia Singh
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Severa Bunda
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | | | - Kenneth D Aldape
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada.,Laboratory of Pathology, NCI, Bethesda, Massachusetts
| | - Gelareh Zadeh
- MacFeeters-Hamilton Center for Neuro-Oncology Research, Princess Margaret Cancer Center, Toronto, Ontario, Canada. .,Toronto Western Hospital, Toronto, Ontario, Canada
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23
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Vicenzi EB, Cesaro S. Posaconazole in immunocompromised pediatric patients. Expert Rev Anti Infect Ther 2018; 16:543-553. [DOI: 10.1080/14787210.2018.1490177] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Edoardo Bruno Vicenzi
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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24
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Francis JR, Villanueva P, Bryant P, Blyth CC. Mucormycosis in Children: Review and Recommendations for Management. J Pediatric Infect Dis Soc 2018; 7:159-164. [PMID: 29294067 DOI: 10.1093/jpids/pix107] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/17/2017] [Indexed: 12/14/2022]
Abstract
Mucormycosis represents the third most common invasive fungal infection in children, and recent studies have suggested a rising incidence. Its case fatality rate is high, especially for neonates. Clinical presentation is influenced by underlying risk factors; associations with immunosuppression, neutropenia, diabetes, and prematurity have been described. It has been implicated in several hospital outbreaks. Diagnosis requires a high index of suspicion and evaluation with histopathology, culture, and, increasingly, molecular identification. Surgical debridement and antifungal therapies are the cornerstone for combatting invasive mucormycosis. However, the severity and relative rarity of this disease make comparative clinical trials for evaluating antifungal therapies in children difficult to conduct. Hence, therapeutic decisions are derived mainly from retrospective case series, in vitro data, and animal models. In this review, we summarize the literature on the epidemiology and diagnosis of this invasive fungal infection and provide suggestions on the management of mucormycosis in children.
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Affiliation(s)
- Joshua R Francis
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Paola Villanueva
- Department of General Medicine, Royal Children's Hospital, Melbourne, Australia
| | - Penelope Bryant
- Infectious Diseases Unit, Royal Children's Hospital, Melbourne, Australia
| | - Christopher C Blyth
- Department of Paediatric Infectious Diseases, Princess Margaret Hospital for Children, Perth, Australia.,School of Medicine, University of Western Australia, Perth.,Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth
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25
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Abstract
BACKGROUND Posaconazole is a broad-spectrum antifungal used for prophylaxis and treatment of invasive fungal infections. There is no published data to inform prescribers on dosing of the intravenous (IV) formulation in the pediatric population. We describe our experience including dosing, serum concentrations, and tolerability. OBSERVATIONS Four patients (3 to 9 y) received IV posaconazole for treatment of documented/suspected invasive fungal infections. Patients achieved therapeutic concentrations on daily doses of 8.4 to 12.2 mg/kg and adverse effects were minimal. CONCLUSIONS Higher dosing per body weight of IV posaconazole may be required in the pediatric population compared with adults to consistently achieve therapeutic concentrations.
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26
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Döring M, Cabanillas Stanchi KM, Klinker H, Eikemeier M, Feucht J, Blaeschke F, Schwarze CP, Ebinger M, Feuchtinger T, Handgretinger R, Heinz WJ. Posaconazole plasma concentrations in pediatric patients receiving antifungal prophylaxis during neutropenia. Med Mycol 2018; 55:375-384. [PMID: 27703016 DOI: 10.1093/mmy/myw091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/15/2016] [Indexed: 02/03/2023] Open
Abstract
Invasive fungal infections are one of the major complications in pediatric patients during prolonged neutropenia after chemotherapy. Evaluation of the efficacy and safety of the triazole posaconazole in these patients is missing. This multicenter survey analyzed trough concentrations of 33 pediatric patients with a median age of 8 years during 108 neutropenic episodes who received prophylactic posaconazole oral suspension. A total of 172 posaconazole trough levels were determined to median 438 ng/ml (range 111-2011 ng/ml; mean 468 ± 244 ng/ml). Age and gender had no influence on posaconazole plasma levels. Posaconazole was not discontinued due to adverse events in any of the patients. Only hepatic parameters significantly increased beyond the upper normal limit to median values of ALT of 87 U/l (P < .0001), and AST of 67 U/l (P < .0001). One patient with a median posaconazole trough concentration of 306 ng/ml experienced an invasive fungal infection. In conclusion, posaconazole was effective, safe and feasible in 33 pediatric patients with neutropenia ≥5 days after chemotherapy. Median posaconazole plasma concentrations were approximately 1.6-fold lower than the recommended plasma level of 700 ng/ml. Larger patient cohorts are needed to evaluate these findings.
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Affiliation(s)
- Michaela Döring
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Karin Melanie Cabanillas Stanchi
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Hartwig Klinker
- University Medical Center, Würzburg, Department of Infectiology, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Melinda Eikemeier
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Judith Feucht
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Franziska Blaeschke
- Ludwig-Maximilians-University München, Dr. von Hauner'sches Kinderspital, Pediatric Hematology, Oncology and Stem Cell Transplantation, Lindwurmstrasse 4, 80337 Munich, Germany
| | - Carl-Philipp Schwarze
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Martin Ebinger
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Tobias Feuchtinger
- Ludwig-Maximilians-University München, Dr. von Hauner'sches Kinderspital, Pediatric Hematology, Oncology and Stem Cell Transplantation, Lindwurmstrasse 4, 80337 Munich, Germany
| | - Rupert Handgretinger
- University Hospital Tübingen, Children's Hospital, Department I - General Paediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Werner J Heinz
- University Medical Center, Würzburg, Department of Infectiology, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
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27
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Vicenzi EB, Calore E, Decembrino N, Berger M, Perruccio K, Carraro F, Rossin S, Putti MC, Molinaro M, Tridello G, Cesaro S. Posaconazole oral dose and plasma levels in pediatric hematology-oncology patients. Eur J Haematol 2018; 100:315-322. [PMID: 29240266 DOI: 10.1111/ejh.13017] [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] [Accepted: 12/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Posaconazole is a triazole with limited pharmacokinetic information in children. This study assessed the correlation between posaconazole oral solution daily dosage/kg/body weight and trough plasma level. METHODS A total of 97 hematology-oncology pediatric patients with ≥1 posaconazole plasma concentration level (PPC) assessment in the first 6 weeks after the start of posaconazole treatment were included. RESULTS Posaconazole was used as prophylaxis in 84 of 97 (87%) patients and as therapy in 13 of 97 (13%). The median daily dose/kg/bw ranged from 10 to 12 mg in the prophylaxis group and 12.5 to 16.5 mg in the therapy group. The median value of PPC for the prophylaxis group was 0.9 and 0.8 μg/mL at the first and second/third determinations, respectively. Posaconazole prophylaxis failed in 4 of 84 patients (5%). The median value of PPC for the therapy group was 1.5 and 1.4 μg/mL at the first/second and the third determination, respectively. Posaconazole-related side effects were reported in 6 patients and all regressed with the suspension of the drug. In the prophylaxis group, the use of proton-pump inhibitors was significantly associated with a lower PPC, P = 0.04. CONCLUSIONS Posaconazole may be a valuable antifungal agent in children despite the incomplete knowledge of its pharmacokinetic characteristics.
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Affiliation(s)
- Edoardo Bruno Vicenzi
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Elisabetta Calore
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Nunzia Decembrino
- Pediatric Hematology Oncology, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Massimo Berger
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, AOU Città della Salute e della Scienza, Regina Margherita Childrens Hospital, Turin, Italy
| | - Katia Perruccio
- Pediatric Hematology-Oncology, Azienda Ospedaliera Universitaria, Perugia, Italy
| | - Francesca Carraro
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, AOU Città della Salute e della Scienza, Regina Margherita Childrens Hospital, Turin, Italy
| | - Sara Rossin
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Maria Caterina Putti
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Mariadelfina Molinaro
- Clinical and Experimental Pharmacokinetics Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gloria Tridello
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Rhoden E, Nix WA, Weldon WC, Selvarangan R. Antifungal azoles itraconazole and posaconazole exhibit potent in vitro antiviral activity against clinical isolates of parechovirus A3 (Picornaviridae). Antiviral Res 2018; 149:75-77. [PMID: 29155163 PMCID: PMC9169550 DOI: 10.1016/j.antiviral.2017.11.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/19/2017] [Accepted: 11/14/2017] [Indexed: 11/16/2022]
Abstract
Parechovirus A3 (Par-A3, formerly human parechovirus 3) is an emerging viral infection of the central nervous system in children. We used an automated, homogeneous, cell based assay to identify itraconazole and posaconazole as inhibitors of Par-A3, with antiviral activity below concentrations clinically attainable in pediatric patients. Currently, there is no approved antiviral treatment for Par-A3 infection, despite numerous reports of serious Par-A3 disease in neonates and infants.
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Affiliation(s)
- Eric Rhoden
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - W Allan Nix
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
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McMahon J, Théorêt Y, Autmizguine J, Bittencourt H, Tapiéro B, Ovetchkine P. Posaconazole Plasma Monitoring in Immunocompromised Children. J Pediatric Infect Dis Soc 2017; 6:389-392. [PMID: 28186550 DOI: 10.1093/jpids/piw087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/06/2016] [Indexed: 11/12/2022]
Abstract
Plasma posaconazole exposure was assessed in 13 children who underwent a hematopoietic stem cell transplant. The median dosage was 12.5 mg/kg per day, divided into 3 doses. Of these 13 patients, 46.2% (6) and 30.8% (4) achieved concentrations higher than 0.7 and 1.25 mg/L, respectively. In children at high risk, a higher dosage might be needed to achieve target concentrations.
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Affiliation(s)
| | - Yves Théorêt
- Research Centre.,Infectious Diseases Division, Department of Pediatrics.,Hemato-Oncology Division, Department of Pediatrics, CHU Sainte-Justine-Université de Montréal, Québec, Canada
| | - Julie Autmizguine
- Research Centre.,Infectious Diseases Division, Department of Pediatrics.,Hemato-Oncology Division, Department of Pediatrics, CHU Sainte-Justine-Université de Montréal, Québec, Canada.,Clinical Pharmacology Unit, CHU Sainte-Justine, Montréal, Québec, Canada
| | | | - Bruce Tapiéro
- Clinical Pharmacology Unit, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Philippe Ovetchkine
- Research Centre.,Clinical Pharmacology Unit, CHU Sainte-Justine, Montréal, Québec, Canada
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30
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Mathew S, Kussin ML, Liu D, Pozotrigo M, Seyboth B, Thackray J, Yan SQ, Hsu M, Cohen N, Seo SK. Retrospective Analysis of Posaconazole Suspension Dosing Strategies in a Pediatric Oncology Population: Single-Center Experience. J Pediatric Infect Dis Soc 2017; 6:e149-e151. [PMID: 28903522 PMCID: PMC5907872 DOI: 10.1093/jpids/pix058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/28/2017] [Indexed: 11/13/2022]
Abstract
Limited data on optimal posaconazole dosing strategies for pediatric patients exist. In this study, we found that the median initial dose in patients who achieved a posaconazole plasma concentration of 0.7 μg/mL was 22.8 mg/kg per day whereas the median initial dose in those who did not reach the target concentration was 15.8 mg/kg per day; this result suggests that higher initial doses might be warranted.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Susan K Seo
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
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32
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Döring M, Cabanillas Stanchi KM, Queudeville M, Feucht J, Blaeschke F, Schlegel P, Feuchtinger T, Lang P, Müller I, Handgretinger R, Heinz WJ. Efficacy, safety and feasibility of antifungal prophylaxis with posaconazole tablet in paediatric patients after haematopoietic stem cell transplantation. J Cancer Res Clin Oncol 2017; 143:1281-1292. [PMID: 28258343 DOI: 10.1007/s00432-017-2369-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Paediatric recipients of haematopoietic stem cell transplantation (HSCT) have a high risk for invasive fungal infections. Posaconazole oral suspension has proven to be effective in antifungal prophylaxis in adult and paediatric patients. A new posaconazole tablet formulation with absorption independent of the gastric conditions was approved by the FDA in 2013. This is the first report on the use of posaconazole tablets in paediatric patients. METHODS This single-centre study included 63 paediatric patients with haemato-oncological malignancies who received posaconazole for antifungal prophylaxis after HSCT. They were analysed for efficacy, feasibility and the safety of posaconazole. Out of 63 patients, 31 received posaconazole oral suspension and 32 received posaconazole tablets up to 200 days after transplantation. Analyses of the posaconazole trough levels were determined. RESULTS No possible, probable or proven invasive fungal infection was observed in either group. Posaconazole trough levels were significantly higher in the tablet group than in the suspension group at all analysed time points. Drug-related adverse events were similarly low in both groups. CONCLUSIONS Posaconazole tablets are effective in preventing invasive fungal infections in paediatric patients. As early as day 3 after starting posaconazole tablets, over 50% of the posaconazole trough levels were >500 ng/mL, while this was observed on day 14 after start with posaconazole suspension. The administration of posaconazole tablets was safe, effective and feasible as antifungal prophylaxis in paediatric patients after HSCT.
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Affiliation(s)
- Michaela Döring
- Department I - General Paediatrics, Haematology/Oncology, Children's Hospital, University Hospital Tübingen, Hoppe-Seyler-Str.1, 72076, Tübingen, Germany.
| | - Karin Melanie Cabanillas Stanchi
- Department I - General Paediatrics, Haematology/Oncology, Children's Hospital, University Hospital Tübingen, Hoppe-Seyler-Str.1, 72076, Tübingen, Germany
| | - Manon Queudeville
- Department I - General Paediatrics, Haematology/Oncology, Children's Hospital, University Hospital Tübingen, Hoppe-Seyler-Str.1, 72076, Tübingen, Germany
| | - Judith Feucht
- Department I - General Paediatrics, Haematology/Oncology, Children's Hospital, University Hospital Tübingen, Hoppe-Seyler-Str.1, 72076, Tübingen, Germany
| | - Franziska Blaeschke
- Ludwig-Maximilians-University München, Dr. von Hauner'sches Kinderspital, Paediatric Haematology, Oncology and Stem Cell Transplantation, Lindwurmstrasse 4, 80337, Munich, Germany
| | - Patrick Schlegel
- Department I - General Paediatrics, Haematology/Oncology, Children's Hospital, University Hospital Tübingen, Hoppe-Seyler-Str.1, 72076, Tübingen, Germany
| | - Tobias Feuchtinger
- Ludwig-Maximilians-University München, Dr. von Hauner'sches Kinderspital, Paediatric Haematology, Oncology and Stem Cell Transplantation, Lindwurmstrasse 4, 80337, Munich, Germany
| | - Peter Lang
- Department I - General Paediatrics, Haematology/Oncology, Children's Hospital, University Hospital Tübingen, Hoppe-Seyler-Str.1, 72076, Tübingen, Germany
| | - Ingo Müller
- Department of Paediatrics Haematology and Oncology, University Hospital Hamburg-Eppendorf, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rupert Handgretinger
- Department I - General Paediatrics, Haematology/Oncology, Children's Hospital, University Hospital Tübingen, Hoppe-Seyler-Str.1, 72076, Tübingen, Germany
| | - Werner J Heinz
- Division of Infectious Diseases, Department of Internal Medicine II, University Medical Centre Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
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Jancel T, Shaw PA, Hallahan CW, Kim T, Freeman AF, Holland SM, Penzak SR. Therapeutic drug monitoring of posaconazole oral suspension in paediatric patients younger than 13 years of age: a retrospective analysis and literature review. J Clin Pharm Ther 2016; 42:75-79. [PMID: 27982447 DOI: 10.1111/jcpt.12483] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/25/2016] [Indexed: 02/04/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Posaconazole is an extended-spectrum triazole antifungal with activity against a variety of clinically significant yeasts and moulds. Posaconazole is not currently approved by the U.S. Food and Drug Administration for use in children younger than 13 years of age. Our primary objective was to describe the dosing and observed trough concentrations with posaconazole oral suspension in paediatric patients at the National Institutes of Health Clinical Center (Bethesda, MD). METHODS This retrospective single-centre study reviewed paediatric patients younger than 13 years of age initiated on posaconazole oral suspension. Patients were included if they were initiated on posaconazole for prophylaxis or treatment for fungal infections from September 2006 through March 2013 with at least one trough concentration collected after at least 7 days of therapy. RESULTS AND DISCUSSION A total of 20 male patients were included, of whom 15 (75%) had chronic granulomatous disease. The median age of patients was 6·5 years (range: 2·8-10·7). A total of 79 posaconazole trough concentrations were measured in patients receiving posaconazole as prophylaxis (n = 8) or treatment (n = 12). Posaconazole dose referenced to total body weight ranged from 10·0 to 49·2 mg/kg/day. Posaconazole trough concentrations ranged from undetectable (<50 ng/mL) up to 3620 ng/mL and were ≥500, ≥700 and ≥1250 ng/mL in 95%, 60% and 25% of patients, respectively. WHAT IS NEW AND CONCLUSIONS Patients younger than 13 years of age had highly variable trough concentrations, and recommendations for the appropriate dosing of posaconazole oral suspension remain challenging. Until studies are conducted to determine the appropriate dosing of posaconazole in this patient population, therapeutic drug monitoring should be considered to ensure adequate posaconazole exposure.
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Affiliation(s)
- T Jancel
- Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - P A Shaw
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - C W Hallahan
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - T Kim
- Clinical Center Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
| | - A F Freeman
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - S M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - S R Penzak
- Department of Pharmacotherapy, University of North Texas System College of Pharmacy, Fort Worth, TX, USA
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Dauchy FA, Bonhivers M, Landrein N, Dacheux D, Courtois P, Lauruol F, Daulouède S, Vincendeau P, Robinson DR. Trypanosoma brucei CYP51: Essentiality and Targeting Therapy in an Experimental Model. PLoS Negl Trop Dis 2016; 10:e0005125. [PMID: 27855164 PMCID: PMC5113867 DOI: 10.1371/journal.pntd.0005125] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 10/24/2016] [Indexed: 01/03/2023] Open
Abstract
Trypanosoma brucei gambiense is the main causative agent of Human African Trypanosomiasis (HAT), also known as sleeping sickness. Because of limited alternatives and treatment toxicities, new therapeutic options are urgently needed for patients with HAT. Sterol 14alpha-demethylase (CYP51) is a potential drug target but its essentiality has not been determined in T. brucei. We used a tetracycline-inducible RNAi system to assess the essentiality of CYP51 in T. brucei bloodstream form (BSF) cells and we evaluated the effect of posaconazole, a well-tolerated triazole drug, within a panel of virulent strains in vitro and in a murine model. Expression of CYP51 in several T. brucei cell lines was demonstrated by western blot and its essentiality was demonstrated by RNA interference (CYP51RNAi) in vitro. Following reduction of TbCYP51 expression by RNAi, cell growth was reduced and eventually stopped compared to WT or non-induced cells, showing the requirement of CYP51 in T. brucei. These phenotypes were rescued by addition of ergosterol. Additionally, CYP51RNAi induction caused morphological defects with multiflagellated cells (p<0.05), suggesting cytokinesis dysfunction. The survival of CYP51RNAi Doxycycline-treated mice (p = 0.053) and of CYP51RNAi 5-day pre-induced Doxycycline-treated mice (p = 0.008) were improved compared to WT showing a CYP51 RNAi effect on trypanosomal virulence in mice. The posaconazole concentrations that inhibited parasite growth by 50% (IC50) were 8.5, 2.7, 1.6 and 0.12 μM for T. b. brucei 427 90-13, T. b. brucei Antat 1.1, T. b. gambiense Feo (Feo/ITMAP/1893) and T. b. gambiense Biyamina (MHOM/SD/82), respectively. During infection with these last three virulent strains, posaconazole-eflornithine and nifurtimox-eflornithine combinations showed similar improvement in mice survival (p≤0.001). Our results provide support for a CYP51 targeting based treatment in HAT. Thus posaconazole used in combination may represent a therapeutic alternative for trypanosomiasis.
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Affiliation(s)
- Frédéric-Antoine Dauchy
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
- University Hospital of Bordeaux, Department of infectious and tropical diseases, Hôpital Pellegrin, France
- * E-mail:
| | - Mélanie Bonhivers
- University of Bordeaux, Microbiologie Fondamentale et Pathogénicité, France
- CNRS, Microbiologie Fondamentale et Pathogénicité, France
| | - Nicolas Landrein
- University of Bordeaux, Microbiologie Fondamentale et Pathogénicité, France
- CNRS, Microbiologie Fondamentale et Pathogénicité, France
| | - Denis Dacheux
- University of Bordeaux, Microbiologie Fondamentale et Pathogénicité, France
- CNRS, Microbiologie Fondamentale et Pathogénicité, France
- Bordeaux INP, ENSTBB, Microbiologie Fondamentale et Pathogénicité, France
| | - Pierrette Courtois
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
| | - Florian Lauruol
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
| | - Sylvie Daulouède
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
| | - Philippe Vincendeau
- University of Bordeaux, laboratoire de parasitologie, France
- IRD-CIRAD-University of Bordeaux, France
- University Hospital of Bordeaux, laboratoire de parasitologie, Hôpital Pellegrin, France
| | - Derrick R. Robinson
- University of Bordeaux, Microbiologie Fondamentale et Pathogénicité, France
- CNRS, Microbiologie Fondamentale et Pathogénicité, France
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Wattier RL, Ramirez-Avila L. Pediatric Invasive Aspergillosis. J Fungi (Basel) 2016; 2:jof2020019. [PMID: 29376936 PMCID: PMC5753081 DOI: 10.3390/jof2020019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 06/06/2016] [Accepted: 06/08/2016] [Indexed: 02/06/2023] Open
Abstract
Invasive aspergillosis (IA) is a disease of increasing importance in pediatrics due to growth of the immunocompromised populations at risk and improvements in long-term survival for many of these groups. While general principles of diagnosis and therapy apply similarly across the age spectrum, there are unique considerations for clinicians who care for children and adolescents with IA. This review will highlight important differences in the epidemiology, clinical manifestations, diagnosis, and therapy of pediatric IA.
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Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California-San Francisco, 550 16th St, 4th Floor, Box 0434, San Francisco, CA 94143, USA.
| | - Lynn Ramirez-Avila
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California-San Francisco, 550 16th St, 4th Floor, Box 0434, San Francisco, CA 94143, USA.
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King J, Henriet SSV, Warris A. Aspergillosis in Chronic Granulomatous Disease. J Fungi (Basel) 2016; 2:jof2020015. [PMID: 29376932 PMCID: PMC5753077 DOI: 10.3390/jof2020015] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/19/2016] [Accepted: 05/24/2016] [Indexed: 12/20/2022] Open
Abstract
Patients with chronic granulomatous disease (CGD) have the highest life-time incidence of invasive aspergillosis and despite the availability of antifungal prophylaxis, infections by Aspergillus species remain the single most common infectious cause of death in CGD. Recent developments in curative treatment options, such as haematopoietic stem cell transplantation, will change the prevalence of infectious complications including invasive aspergillosis in CGD patients. However, invasive aspergillosis in a previously healthy host is often the first presenting feature of this primary immunodeficiency. Recognizing the characteristic clinical presentation and understanding how to diagnose and treat invasive aspergillosis in CGD is of utmost relevance to improve clinical outcomes. Significant differences exist in fungal epidemiology, clinical signs and symptoms, and the usefulness of non-culture based diagnostic tools between the CGD host and neutropenic patients, reflecting underlying differences in the pathogenesis of invasive aspergillosis shaped by the nicotinamide adenine dinucleotide phosphate (NADPH)-oxidase deficiency.
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Affiliation(s)
- Jill King
- Aberdeen Fungal Group, MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| | - Stefanie S V Henriet
- Radboud University Medical Center, Amalia Children's Hospital, Nijmegen 6500 HB, The Netherlands.
| | - Adilia Warris
- Aberdeen Fungal Group, MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK.
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Abstract
BACKGROUND Antifungal prophylaxis remains challenging in immunocompromised children as no clear consensus has yet been reached about which drug to be used. Posaconazole has a broad spectrum of activity, a favorable safety profile and excellent prophylactic activity in adults. However, a lack of pharmacokinetic studies in pediatric patients hampers routine implementation. This study investigates the pharmacokinetics of a newly introduced posaconazole dosing regimen based on the body surface area in pediatric hematologic patients. METHODS In this prospective pharmacokinetic study, 8 blood samples were taken during 1 dosing interval at steady state in children aged 13 years or younger with hematologic malignancy, who were treated prophylactically with posaconazole oral suspension at a dose of 120 mg/m 3 times daily. Posaconazole plasma concentrations were determined using high-performance liquid chromatography fluorescence detection. RESULTS One hundred twelve samples were taken from 14 patients with a mean age of 6.7 ± 2.8 years. A median posaconazole daily dose of 100.0 mg (77.3-100.0) 3 times daily (tid), corresponding to a median of 117.9 mg/m (112.2-120.4) tid, resulted in mean trough posaconazole plasma concentrations of 0.85 ± 0.56 mg/L. Pharmacokinetic analysis revealed a clearance of 0.8 L/(h kg) (0.5-1.4). No invasive fungal infections or adverse events were encountered during treatment. CONCLUSIONS Posaconazole is a promising antifungal agent to be used prophylactically in hematologic patients aged 13 years or younger. Administering posaconazole oral suspension in a dosage of 120 mg/m tid results in adequate posaconazole plasma exposure, without significant adverse events.
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38
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Molinelli AR, Rose CH. Quantification of the Triazole Antifungal Compounds Voriconazole and Posaconazole in Human Serum or Plasma Using Liquid Chromatography Electrospray Tandem Mass Spectrometry (HPLC-ESI-MS/MS). Methods Mol Biol 2016; 1383:39-47. [PMID: 26660172 DOI: 10.1007/978-1-4939-3252-8_5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Voriconazole and posaconazole are triazole antifungal compounds used in the treatment of fungal infections. Therapeutic drug monitoring of both compounds is recommended in order to guide drug dosing to achieve optimal blood concentrations. In this chapter we describe an HPLC-ESI-MS/MS method for the quantification of both compounds in human plasma or serum following a simple specimen preparation procedure. Specimen preparation consists of protein precipitation using methanol and acetonitrile followed by a cleanup step that involves filtration through a cellulose acetate membrane. The specimen is then injected into an HPLC-ESI-MS/MS equipped with a C18 column and separated over an acetonitrile gradient. Quantification of the drugs in the specimen is achieved by comparing the response of the unknown specimen to that of the calibrators in the standard curve using multiple reaction monitoring.
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Affiliation(s)
- Alejandro R Molinelli
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 313, Memphis, TN, 38105, USA.
| | - Charles H Rose
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 313, Memphis, TN, 38105, USA
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Heinz WJ, Cabanillas Stanchi KM, Klinker H, Blume O, Feucht J, Hartmann U, Feuchtinger T, Lang P, Handgretinger R, Döring M. Posaconazole plasma concentration in pediatric patients receiving antifungal prophylaxis after allogeneic hematopoietic stem cell transplantation. Med Mycol 2015; 54:128-37. [PMID: 26483433 DOI: 10.1093/mmy/myv087] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/08/2015] [Indexed: 11/14/2022] Open
Abstract
Posaconazole has been proven to be effective for antifungal prophylaxis in adults after hematopoietic stem cell transplantation (HSCT). Due to low gastrointestinal resorption of posaconazole suspension, bioavailability is impaired. Fatty food improves the uptake of posaconazole, but insufficient data on the pharmacokinetics of posaconazole in pediatric patients are available so far. The single-center analysis investigated 161 posaconazole serum concentrations in 27 pediatric patients after HSCT receiving 12 mg·kg BW(-1)·d(-1) posaconazole suspension depending on age, gender, and intestinal graft-versus-host (iGvHD) disease, and the influence of posaconazole on cyclosporine A plasma concentrations. To improve the uptake of posaconazole, one patient cohort received higher fat nutrition with the drug administration. A comparison of the regular nutrition and higher-fat nutrition groups revealed the following values: 31 (27.4%) versus 8 (16.7%) < 500 ng/ml; 12 (10.6%) versus 7 (14.6%) 500-700 ng/ml; 8 (7.1%) versus 6 (12.5%) 700-1000 ng/ml; 51 (45.1%) versus 21 (43.8%) 1000-2000 ng/ml; and 11 (9.7%) versus 6 (12.5%) > 2000 ng/ml. The mean posaconazole concentrations in patients with regular nutrition was 1123 ± 811 ng/ml and with higher-fat nutrition was 1191 ± 673 ng/ml. Posaconazole levels in patients with iGvHD were significantly lower (P = 0.0003) than in patients without GvHD. The majority of samples showed a sufficient posaconazole concentration above 700 ng/ml. Posaconazole levels were slightly higher in patients with higher-fat nutrition and significantly lower in patients with iGvHD. Cyclosporine A levels were not significantly higher during posaconazole administration.
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Affiliation(s)
- Werner J Heinz
- University of Würzburg Medical Center, Department of Internal Medicine II, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Karin M Cabanillas Stanchi
- University Hospital Tübingen, Children's Hospital, Department I - General Pediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Hartwig Klinker
- University of Würzburg Medical Center, Department of Internal Medicine II, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Olivia Blume
- University Hospital Tübingen, Children's Hospital, Department I - General Pediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Judith Feucht
- University Hospital Tübingen, Children's Hospital, Department I - General Pediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Ulrike Hartmann
- University Hospital Tübingen, University Pharmacy, Röntgenweg 9, 72076 Tübingen, Germany
| | - Tobias Feuchtinger
- Ludwig-Maximilians-University München, Dr. von Hauner'sches Kinderspital, Pediatric Hematology, Oncology and Stem Cell Transplantation, Lindwurmstrasse 4, 80337 Munich
| | - Peter Lang
- University Hospital Tübingen, Children's Hospital, Department I - General Pediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Rupert Handgretinger
- University Hospital Tübingen, Children's Hospital, Department I - General Pediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Michaela Döring
- University Hospital Tübingen, Children's Hospital, Department I - General Pediatrics, Hematology/Oncology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany Ludwig-Maximilians-University München, Dr. von Hauner'sches Kinderspital, Pediatric Hematology, Oncology and Stem Cell Transplantation, Lindwurmstrasse 4, 80337 Munich
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Ramos-Martín V, O’Connor O, Hope W. Clinical pharmacology of antifungal agents in pediatrics: children are not small adults. Curr Opin Pharmacol 2015; 24:128-34. [DOI: 10.1016/j.coph.2015.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/14/2015] [Accepted: 08/25/2015] [Indexed: 10/23/2022]
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Abstract
Posaconazole is a broad-spectrum antifungal agent used for the prevention and treatment of invasive fungal infections. It is currently only licensed for use in children greater than 12 years of age. Absorption of the oral formulation is unpredictable and affected by mucositis and concomitant medications. We reviewed studies of posaconazole use in children younger than 12 years in relation to attainment of target serum concentrations.
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Infectious Prophylaxis in Paediatric Oncology and Stem Cell Transplantation. CURRENT PEDIATRICS REPORTS 2015. [DOI: 10.1007/s40124-015-0076-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Osowicki J, Blyth CC, Britton PN, Clark J, Cooper CM, Haeusler GM, McMullan B, Bryant PA. Ahead of consensus: a paediatric antifungal prophylaxis census. Intern Med J 2015; 45:364-5. [DOI: 10.1111/imj.12690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/21/2014] [Indexed: 11/26/2022]
Affiliation(s)
- J. Osowicki
- Infectious Diseases Unit; The Royal Children's Hospital Melbourne; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
| | - C. C. Blyth
- Department of General Paediatrics; Princess Margaret Hospital for Children; Perth Western Australia Australia
- School of Paediatrics and Child Health; University of Western Australia; Perth Western Australia Australia
- PathWest Laboratory Medicine WA; Princess Margaret Hospital; Perth Western Australia Australia
- Telethon Kids Institute; University of Western Australia; Perth Western Australia Australia
| | - P. N. Britton
- Department of Infectious Diseases and Microbiology; The Children's Hospital at Sydney; Westmead Australia
- Discipline of Paediatrics and Child Health; Sydney Medical School; University of Sydney; Sydney New South Wales Australia
| | - J. Clark
- Infection Management and Prevention Service; Lady Cilento Children's Hospital; Brisbane Queensland Australia
| | - C. M. Cooper
- SA Pathology; Women's and Children's Hospital; Adelaide South Australia Australia
| | - G. M. Haeusler
- Department of Paediatric Infectious Diseases; Monash Children's Hospital; Melbourne Victoria Australia
- Department of Infectious Diseases; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - B. McMullan
- Department of Immunology and Infectious Diseases; Sydney Children's Hospital; Sydney New South Wales Australia
- School of Women's and Children's Health; University of New South Wales; Sydney New South Wales Australia
| | - P. A. Bryant
- Infectious Diseases Unit; The Royal Children's Hospital Melbourne; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- Department of Paediatrics; The University of Melbourne; Melbourne Victoria Australia
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Azanza JR, Sádaba B, Gómez-Guíu A. Farmacología de los antifúngicos en el tratamiento de la aspergilosis. Rev Iberoam Micol 2014; 31:255-61. [DOI: 10.1016/j.riam.2014.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 05/15/2014] [Indexed: 11/26/2022] Open
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45
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Cornely O, Arikan-Akdagli S, Dannaoui E, Groll A, Lagrou K, Chakrabarti A, Lanternier F, Pagano L, Skiada A, Akova M, Arendrup M, Boekhout T, Chowdhary A, Cuenca-Estrella M, Freiberger T, Guinea J, Guarro J, de Hoog S, Hope W, Johnson E, Kathuria S, Lackner M, Lass-Flörl C, Lortholary O, Meis J, Meletiadis J, Muñoz P, Richardson M, Roilides E, Tortorano A, Ullmann A, van Diepeningen A, Verweij P, Petrikkos G. ESCMID† and ECMM‡ joint clinical guidelines for the diagnosis and management of mucormycosis 2013. Clin Microbiol Infect 2014; 20 Suppl 3:5-26. [DOI: 10.1111/1469-0691.12371] [Citation(s) in RCA: 465] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/09/2013] [Accepted: 08/12/2013] [Indexed: 12/22/2022]
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