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Hoenigl M, Arastehfar A, Arendrup MC, Brüggemann R, Carvalho A, Chiller T, Chen S, Egger M, Feys S, Gangneux JP, Gold JAW, Groll AH, Heylen J, Jenks JD, Krause R, Lagrou K, Lamoth F, Prattes J, Sedik S, Wauters J, Wiederhold NP, Thompson GR. Novel antifungals and treatment approaches to tackle resistance and improve outcomes of invasive fungal disease. Clin Microbiol Rev 2024; 37:e0007423. [PMID: 38602408 PMCID: PMC11237431 DOI: 10.1128/cmr.00074-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
SUMMARYFungal infections are on the rise, driven by a growing population at risk and climate change. Currently available antifungals include only five classes, and their utility and efficacy in antifungal treatment are limited by one or more of innate or acquired resistance in some fungi, poor penetration into "sequestered" sites, and agent-specific side effect which require frequent patient reassessment and monitoring. Agents with novel mechanisms, favorable pharmacokinetic (PK) profiles including good oral bioavailability, and fungicidal mechanism(s) are urgently needed. Here, we provide a comprehensive review of novel antifungal agents, with both improved known mechanisms of actions and new antifungal classes, currently in clinical development for treating invasive yeast, mold (filamentous fungi), Pneumocystis jirovecii infections, and dimorphic fungi (endemic mycoses). We further focus on inhaled antifungals and the role of immunotherapy in tackling fungal infections, and the specific PK/pharmacodynamic profiles, tissue distributions as well as drug-drug interactions of novel antifungals. Finally, we review antifungal resistance mechanisms, the role of use of antifungal pesticides in agriculture as drivers of drug resistance, and detail detection methods for antifungal resistance.
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Affiliation(s)
- Martin Hoenigl
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Amir Arastehfar
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Roger Brüggemann
- Department of Pharmacy and Radboudumc Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc-CWZ Center of Expertise in Mycology, Nijmegen, The Netherlands
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW South Wales Health Pathology, Westmead Hospital, Westmead, Australia
- The University of Sydney, Sydney, Australia
| | - Matthias Egger
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Simon Feys
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Jean-Pierre Gangneux
- Centre National de Référence des Mycoses et Antifongiques LA-AspC Aspergilloses chroniques, European Excellence Center for Medical Mycology (ECMM EC), Centre hospitalier Universitaire de Rennes, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) UMR_S 1085, Rennes, France
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andreas H. Groll
- Department of Pediatric Hematology/Oncology and Infectious Disease Research Program, Center for Bone Marrow Transplantation, University Children’s Hospital, Muenster, Germany
| | - Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Jeffrey D. Jenks
- Department of Public Health, Durham County, Durham, North Carolina, USA
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Robert Krause
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Frédéric Lamoth
- Department of Laboratory Medicine and Pathology, Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Medicine, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Juergen Prattes
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
- BiotechMed-Graz, Graz, Austria
| | - Sarah Sedik
- Department of Internal Medicine, Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Medical University of Graz, Graz, Austria
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Nathan P. Wiederhold
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - George R. Thompson
- Department of Internal Medicine, Division of Infectious Diseases University of California-Davis Medical Center, Sacramento, California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
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de Carvalho Patricio BF, da Silva Lopes Pereira JO, Sarcinelli MA, de Moraes BPT, Rocha HVA, Gonçalves-de-Albuquerque CF. Could the Lung Be a Gateway for Amphotericin B to Attack the Army of Fungi? Pharmaceutics 2022; 14:2707. [PMID: 36559201 PMCID: PMC9784761 DOI: 10.3390/pharmaceutics14122707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/07/2022] Open
Abstract
Fungal diseases are a significant cause of morbidity and mortality worldwide, primarily affecting immunocompromised patients. Aspergillus, Pneumocystis, and Cryptococcus are opportunistic fungi and may cause severe lung disease. They can develop mechanisms to evade the host immune system and colonize or cause lung disease. Current fungal infection treatments constitute a few classes of antifungal drugs with significant fungi resistance development. Amphotericin B (AmB) has a broad-spectrum antifungal effect with a low incidence of resistance. However, AmB is a highly lipophilic antifungal with low solubility and permeability and is unstable in light, heat, and oxygen. Due to the difficulty of achieving adequate concentrations of AmB in the lung by intravenous administration and seeking to minimize adverse effects, nebulized AmB has been used. The pulmonary pathway has advantages such as its rapid onset of action, low metabolic activity at the site of action, ability to avoid first-pass hepatic metabolism, lower risk of adverse effects, and thin thickness of the alveolar epithelium. This paper presented different strategies for pulmonary AmB delivery, detailing the potential of nanoformulation and hoping to foster research in the field. Our finds indicate that despite an optimistic scenario for the pulmonary formulation of AmB based on the encouraging results discussed here, there is still no product registration on the FDA nor any clinical trial undergoing ClinicalTrial.gov.
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Affiliation(s)
- Beatriz Ferreira de Carvalho Patricio
- Pharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
- Postgraduate Program in Molecular and Cell Biology, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
| | | | - Michelle Alvares Sarcinelli
- Laboratory of Micro and Nanotechnology, Institute of Technology of Drugs, Oswaldo Cruz Foundation, Brazil Av., 4036, Rio de Janeiro 213040-361, Brazil
| | - Bianca Portugal Tavares de Moraes
- Postgraduate Program in Biotechnology, Biology Institute, Federal Fluminense University, Rua Prof. Marcos Waldemar de Freitas Reis, Niterói 24210-201, Brazil
- Immunopharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
| | - Helvécio Vinicius Antunes Rocha
- Laboratory of Micro and Nanotechnology, Institute of Technology of Drugs, Oswaldo Cruz Foundation, Brazil Av., 4036, Rio de Janeiro 213040-361, Brazil
| | - Cassiano Felippe Gonçalves-de-Albuquerque
- Postgraduate Program in Molecular and Cell Biology, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
- Postgraduate Program in Biotechnology, Biology Institute, Federal Fluminense University, Rua Prof. Marcos Waldemar de Freitas Reis, Niterói 24210-201, Brazil
- Immunopharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
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Marinelli T, Davoudi S, Foroutan F, Orchanian-Cheff A, Husain S. Antifungal prophylaxis in adult lung transplant recipients: Uncertainty despite 30 years of experience. A systematic review of the literature and network meta-analysis. Transpl Infect Dis 2022; 24:e13832. [PMID: 35388588 DOI: 10.1111/tid.13832] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/17/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Invasive fungal infections (IFI), particularly invasive aspergillosis (IA), cause significant morbidity and mortality in lung transplant (LTx) recipients. The optimum strategy and antifungal agents for prevention are unclear. METHODS We performed a comprehensive literature search, systematic review, and network meta-analysis using a frequentist framework to compare the efficacy of various antifungal drugs on the incidence of IA/IFI in the setting of universal prophylaxis or no prophylaxis following lung transplantation. RESULTS We included 13 eligible studies comprising of 1515 LTx recipients and 12 different prophylaxis strategies/antifungal combinations. The greatest number of direct comparisons were between the inhaled amphotericin formulations. The top three ranked treatments were inhaled liposomal amphotericin B (L-AmB), inhaled amphotericin deoxycholate (AmBd), and itraconazole plus inhaled amphotericin B (AmB). Among the azoles, isavuconazole ranked highest. The certainty of the evidence, assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, was very low. CONCLUSION Although universal antifungal prophylaxis post lung transplantation is commonly used, robust data from randomized controlled trials (RCTs) to inform the choice of antifungal agent and prophylaxis strategy are lacking. This exploratory network meta-analysis provides insight into the probable relative effectiveness of various antifungal agents in preventing IA, and this analysis should serve as a guide when selecting antifungals to be assessed in a RCT.
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Affiliation(s)
- Tina Marinelli
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada.,Department of Infectious Diseases, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Setareh Davoudi
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Farid Foroutan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Victoria, Canada.,Ted Rogers Center for Heart Research, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Brunet K, Martellosio JP, Tewes F, Marchand S, Rammaert B. Inhaled Antifungal Agents for Treatment and Prophylaxis of Bronchopulmonary Invasive Mold Infections. Pharmaceutics 2022; 14:pharmaceutics14030641. [PMID: 35336015 PMCID: PMC8949245 DOI: 10.3390/pharmaceutics14030641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Pulmonary mold infections are life-threatening diseases with high morbi-mortalities. Treatment is based on systemic antifungal agents belonging to the families of polyenes (amphotericin B) and triazoles. Despite this treatment, mortality remains high and the doses of systemic antifungals cannot be increased as they often lead to toxicity. The pulmonary aerosolization of antifungal agents can theoretically increase their concentration at the infectious site, which could improve their efficacy while limiting their systemic exposure and toxicity. However, clinical experience is poor and thus inhaled agent utilization remains unclear in term of indications, drugs, and devices. This comprehensive literature review aims to describe the pharmacokinetic behavior and the efficacy of inhaled antifungal drugs as prophylaxes and curative treatments both in animal models and humans.
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Affiliation(s)
- Kévin Brunet
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Laboratoire de Mycologie-Parasitologie, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
- Correspondence: (K.B.); (B.R.)
| | - Jean-Philippe Martellosio
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
| | - Frédéric Tewes
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
| | - Sandrine Marchand
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
| | - Blandine Rammaert
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
- Correspondence: (K.B.); (B.R.)
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5
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Drew RH, Perfect JR. Conventional Antifungals for Invasive Infections Delivered by Unconventional Methods; Aerosols, Irrigants, Directed Injections and Impregnated Cement. J Fungi (Basel) 2022; 8:jof8020212. [PMID: 35205966 PMCID: PMC8879564 DOI: 10.3390/jof8020212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 12/10/2022] Open
Abstract
The administration of approved antifungals via unapproved formulations or administration routes (such as aerosol, direct injection, irrigation, topical formulation and antifungal-impregnated orthopedic beads or cement) may be resorted to in an attempt to optimize drug exposure while minimizing toxicities and/or drug interactions associated with conventional (systemic) administrations. Existing data regarding such administrations are mostly restricted to uncontrolled case reports of patients with diseases refractory to conventional therapies. Attribution of efficacy and tolerability is most often problematic. This review updates prior published summaries, reflecting the most recent data and its application by available prevention and treatment guidelines for invasive fungal infections. Of the various dosage forms and antifungals, perhaps none is more widely reported than the application of amphotericin B-containing aerosols for the prevention of invasive mold infections (notably Aspergillus spp.).
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Affiliation(s)
- Richard H. Drew
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC 27710, USA;
- College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA
- Correspondence: ; Tel.: +1-(919)681-6793; Fax: +1-(919)681-7494
| | - John R. Perfect
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC 27710, USA;
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Ray A, Manikanta J, Singh K, Gabra P, Vyas S, Singh G, Xess I, Sethi P, Meena VP, Soneja M, Sinha S, Wig N, Kabra SK. An open-label non-inferiority randomised control trial comparing nebulised amphotericin B with oral itraconazole in patients with pulmonary aspergilloma. Mycoses 2021; 64:1038-1044. [PMID: 34058036 DOI: 10.1111/myc.13329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary aspergilloma (PA) is a common complication seen in patients with pulmonary tuberculosis sequelae. Antifungal therapy, including oral azoles, is commonly used though only surgical resection offers curative benefit. Local administration of amphotericin B, like intracavitary instillation, has been effective in aspergilloma patients though nebulised amphotericin B (nAB) has never been formally assessed. OBJECTIVE The aim of this prospective, non-inferior, open-label, randomised control trial is to evaluate the efficacy and safety of nebulised amphotericin B compared to oral itraconazole therapy in the treatment of PA. PATIENTS/METHODS Diagnosed cases of PA (n=33) were randomised into the control group receiving oral itraconazole (n=18) and intervention group receiving nebulised amphotericin B (n = 15). Response to treatment was assessed both clinically and radiologically at the end 6 months. RESULTS AND CONCLUSION The number of patients showing overall improvement at the end of 6 months in the control arm(oral itraconazole) vs intervention arm(nebulised amphotericin B) was 65% (95% CI 38.3-85.8) and 67%(95% CI 38.4%-88.2%), respectively, in the intention-to-treat and 79% (95% CI 49.2%-95.3%), and 65% (95% CI 38.4%-88.2%), respectively, in the per-protocol analysis. While there was no statistically significant difference between the intervention and control arm in both the analyses, non-inferiority was shown in the per-protocol but not in the intention-to-treat analysis. No major adverse events were noted in either group; however, a significant proportion of patients receiving nAB reported minor cough (40%), which, however, did not lead to discontinuation of therapy in any patients. Nebulised amphotericin B can be an effective therapeutic option for pulmonary aspergilloma patients.
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Affiliation(s)
- Animesh Ray
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jagdeesh Manikanta
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Komal Singh
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Pavan Gabra
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Surabhi Vyas
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Gagandeep Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Immaculata Xess
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Prayas Sethi
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ved Prakash Meena
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Sinha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
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Strategies for the Prevention of Invasive Fungal Infections after Lung Transplant. J Fungi (Basel) 2021; 7:jof7020122. [PMID: 33562370 PMCID: PMC7914704 DOI: 10.3390/jof7020122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/31/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022] Open
Abstract
Long-term survival after lung transplantation is lower than that associated with other transplanted organs. Infectious complications, most importantly invasive fungal infections, have detrimental effects and are a major cause of morbidity and mortality in this population. Candida infections predominate in the early post-transplant period, whereas invasive mold infections, usually those related to Aspergillus, are most common later on. This review summarizes the epidemiology and risk factors for invasive fungal diseases in lung transplant recipients, as well as the current evidence on preventive measures. These measures include universal prophylaxis, targeted prophylaxis, and preemptive treatment. Although there is consensus that a preventive strategy should be implemented, current data show no superiority of one preventive measure over another. Data are also lacking regarding the optimal antifungal regimen and the duration of treatment. As all current recommendations are based on observational, single-center, single-arm studies, it is necessary that this longstanding debate is settled with a multicenter randomized controlled trial.
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8
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Husain S, Camargo JF. Invasive Aspergillosis in solid-organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13544. [PMID: 30900296 DOI: 10.1111/ctr.13544] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/18/2019] [Indexed: 12/13/2022]
Abstract
These updated AST-IDCOP guidelines provide information on epidemiology, diagnosis, and management of Aspergillus after organ transplantation. Aspergillus is the most common invasive mold infection in solid-organ transplant (SOT) recipients, and it is the most common invasive fungal infection among lung transplant recipients. Time from transplant to diagnosis of invasive aspergillosis (IA) is variable, but most cases present within the first year post-transplant, with shortest time to onset among liver and heart transplant recipients. The overall 12-week mortality of IA in SOT exceeds 20%; prognosis is worse among those with central nervous system involvement or disseminated disease. Bronchoalveolar lavage galactomannan is preferred for the diagnosis of IA in lung and non-lung transplant recipients, in combination with other diagnostic modalities (eg, chest CT scan, culture). Voriconazole remains the drug of choice to treat IA, with isavuconazole and lipid formulations of amphotericin B regarded as alternative agents. The role of combination antifungals for primary therapy of IA remains controversial. Either universal prophylaxis or preemptive therapy is recommended in lung transplant recipients, whereas targeted prophylaxis is favored in liver and heart transplant recipients. In these guidelines, we also discuss newer antifungals and diagnostic tests, antifungal susceptibility testing, and special patient populations.
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Affiliation(s)
- Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Unit, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
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9
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Pilarczyk K, Haake N, Heckmann J, Carstens H, Haneya A, Cremer J, Jakob H, Pizanis N, Kamler M. Is universal antifungal prophylaxis mandatory in adults after lung transplantation? A review and meta-analysis of observational studies. Clin Transplant 2016; 30:1522-1531. [PMID: 27653443 DOI: 10.1111/ctr.12854] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Kevin Pilarczyk
- Department of Intensive Care Medicine; imland Klinik Rendsburg; Rendsburg Germany
- Department of Thoracic and Cardiovascular Surgery; West German Heart and Vascular Center Essen; University Hospital Essen; Essen Germany
| | - Nils Haake
- Department of Intensive Care Medicine; imland Klinik Rendsburg; Rendsburg Germany
| | - Jens Heckmann
- Department of Thoracic and Cardiovascular Surgery; West German Heart and Vascular Center Essen; University Hospital Essen; Essen Germany
| | - Henning Carstens
- Department of Thoracic and Cardiovascular Surgery; West German Heart and Vascular Center Essen; University Hospital Essen; Essen Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery; University of Schleswig-Holstein; Kiel Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery; University of Schleswig-Holstein; Kiel Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery; West German Heart and Vascular Center Essen; University Hospital Essen; Essen Germany
| | - Nikolaus Pizanis
- Department of Thoracic and Cardiovascular Surgery; West German Heart and Vascular Center Essen; University Hospital Essen; Essen Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery; West German Heart and Vascular Center Essen; University Hospital Essen; Essen Germany
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11
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Husain S, Sole A, Alexander BD, Aslam S, Avery R, Benden C, Billaud EM, Chambers D, Danziger-Isakov L, Fedson S, Gould K, Gregson A, Grossi P, Hadjiliadis D, Hopkins P, Luong ML, Marriott DJ, Monforte V, Muñoz P, Pasqualotto AC, Roman A, Silveira FP, Teuteberg J, Weigt S, Zaas AK, Zuckerman A, Morrissey O. The 2015 International Society for Heart and Lung Transplantation Guidelines for the management of fungal infections in mechanical circulatory support and cardiothoracic organ transplant recipients: Executive summary. J Heart Lung Transplant 2016; 35:261-282. [DOI: 10.1016/j.healun.2016.01.007] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/10/2016] [Indexed: 01/10/2023] Open
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12
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The Effectiveness of Culture-Directed Preemptive Anti-Aspergillus Treatment in Lung Transplant Recipients at One Year After Transplant. Transplantation 2015; 99:2387-93. [DOI: 10.1097/tp.0000000000000743] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Immunosuppressive therapy in allograft transplantation: from novel insights and strategies to tolerance and challenges. Cent Eur J Immunol 2014; 39:400-9. [PMID: 26155155 PMCID: PMC4440012 DOI: 10.5114/ceji.2014.45955] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 07/03/2014] [Indexed: 01/07/2023] Open
Abstract
Immunosuppression therapy is the key to successful post-transplantation outcomes. The need for ideal immunosuppression became durable maintenance of long-term graft survival. In spite of current immunosuppressive therapy regimens advances, surgical procedures, and preservation methods, organ transplantation is associated with a long-term poor survival and significant mortality. This has led to an increased interest to optimize outcomes while minimizing associated toxicity by using alternative methods for maintenance immunosuppression, organ rejection treatment, and monitoring of immunosuppression. T regulatory (Treg) cells, which have immunosuppressive functions and cytokine profiles, have been studied during the last decades. Treg cells are able to inhibit the development of allergen-specific cell responses and consequently play a key role in a healthy immune response to allergens. Mature dendritic cells (DCs) play a crucial role in the differentiation of Tregs, which are known to regulate allergic inflammatory responses. Advance in long-standing allograft outcomes may depend on new drugs with novel mechanisms of action with minimal toxicity. Newer treatment techniques have been developed, including using novel stem cell-based therapies such as mesenchymal stem cells, phagosomes and exosomes. Immunoisolation techniques and salvage therapies, including photopheresis and total lymphoid irradiation have emerged as alternative therapeutic choices. The present review evaluates the recent clinical advances in immunosuppressive therapies for organ transplantation.
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Neoh CF, Snell G, Levvey B, Morrissey CO, Stewart K, Kong DC. Antifungal prophylaxis in lung transplantation. Int J Antimicrob Agents 2014; 44:194-202. [DOI: 10.1016/j.ijantimicag.2014.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 05/12/2014] [Indexed: 10/25/2022]
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[Mold infections in lung transplants]. Rev Iberoam Micol 2014; 31:229-36. [PMID: 25442380 DOI: 10.1016/j.riam.2014.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/11/2014] [Indexed: 11/23/2022] Open
Abstract
Invasive infections by molds, mainly Aspergillus infections, account for more than 10% of infectious complications in lung transplant recipients. These infections have a bimodal presentation: an early one, mainly invading bronchial airways, and a late one, mostly focused on lung or disseminated. The Aspergillus colonization at any time in the post-transplant period is one of the major risk factors. Late colonization, together with chronic rejection, is one of the main causes of late invasive forms. A galactomannan value of 0.5 in bronchoalveolar lavage is currently considered a predictive factor of pulmonary invasive infection. There is no universal strategy in terms of prophylaxis. Targeted prophylaxis and preemptive treatment instead of universal prophylaxis, are gaining more followers. The therapeutic drug monitoring level of azoles is highly recommended in the treatment. Monotherapy with voriconazole is the treatment of choice in invasive aspergillosis; combined antifungal therapies are only recommended in severe, disseminated, and other infections due to non-Aspergillus molds.
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Sacanell J, Rey T, López E, Vicente R, Ballesteros M, Iranzo R, Robles J, Restrepo M, Rello J. Profilaxis antifúngica en el postoperatorio de trasplante de pulmón en España. Med Intensiva 2013; 37:201-5. [DOI: 10.1016/j.medin.2012.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 09/26/2012] [Accepted: 10/01/2012] [Indexed: 11/25/2022]
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Singh N, Singh NM, Husain S. Aspergillosis in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:228-41. [PMID: 23465016 DOI: 10.1111/ajt.12115] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- N Singh
- VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA.
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Kim SY, Shin JA, Cho EN, Byun MK, Kim HJ, Ahn CM, Haam SJ, Lee DY, Paik HC, Chang YS. Late respiratory infection after lung transplantation. Tuberc Respir Dis (Seoul) 2013; 74:63-9. [PMID: 23483760 PMCID: PMC3591540 DOI: 10.4046/trd.2013.74.2.63] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 01/03/2013] [Accepted: 01/17/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Aiming to improve outcome of lung transplantation (LTx) patients, we reviewed risk factors and treatment practices for the LTx recipients who experienced respiratory infection in the late post-LTx period (>1 month after LTx). METHODS We analyzed the clinical data of 48 recipients and donors from 61 LTx, who experienced late respiratory infections. Late respiratory infections were classified according to the etiology, time of occurrence, and frequency of donor-to-host transmission or colonization of the recipient prior to transplantation. RESULTS During the period of observation, 42 episodes of respiratory infections occurred. The organisms most frequently involved were gram (-) bacteria: Acinetobacter baumannii (n=13, 31.0%), Pseudomonas aeruginosa (n=7, 16.7%), and Klebsiella pneumoniae (n=4, 10.0%). Among the 42 episodes recorded, 14 occurred in the late post-LTx period. These were bacterial (n=6, 42.9%), fungal (n=2, 14.3%), viral (n=4, 28.5%), and mycobacterial (n=2, 14.3%) infections. Of 6 bacterial infections, 2 were from multidrug-resistant (MDR) A. baumannii and one from each of MDR P. aeruginosa, extended spectrum β-lactamase (+) K. pneumoniae, methicillin-resistant Staphylococcus aureus and Streptococcus pneumoniae. Infection-related death occurred in 6 of the 14 episodes (43%). CONCLUSION Although the frequency of respiratory infection decreased sharply in the late post-LTx period, respiratory infection was still a major cause of mortality. Gram (-) MDR bacteria were the agents most commonly identified in these infections.
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Affiliation(s)
- Sang Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Pinney MF, Rosenberg AF, Hampp C, Schain D, Akindipe O, Baz M. Invasive fungal infections in lung transplant recipients not receiving routine systemic antifungal prophylaxis: 12-year experience at a university lung transplant center. Pharmacotherapy 2012; 31:537-45. [PMID: 21923437 DOI: 10.1592/phco.31.6.537] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To determine the rate of invasive fungal infection among the lung transplant population at a center that does not provide routine systemic antifungal prophylaxis, and to compare that rate with rates currently reported in the literature. DESIGN Retrospective medical record review. SETTING University-affiliated lung transplant center. PATIENTS Two hundred forty-two adults without cystic fibrosis who underwent lung transplantation between March 1, 1994, and June 30, 2006. MEASUREMENTS AND MAIN RESULTS Patients were followed by the adult lung transplant service. Twenty-three cases of invasive fungal infections were identified in 22 patients, resulting in a 9.1% overall invasive fungal infection rate in our study population. Aspergillus infections were the most common type of fungal infection identified, occurring in 11 (47.8%) of the 23 cases, with an overall rate of 4.5% (11/242 patients). Invasive fungal infections in lung transplant recipients have been reported in the literature at a rate 15-35%, with rates of Aspergillus infections reported as 3-15%. CONCLUSION Despite the absence of routine systemic antifungal prophylaxis, the overall invasive fungal infection rate and the Aspergillus infection rate in these lung transplant recipients do not appear to be higher than the rates reported in the literature.
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Affiliation(s)
- Marlena F Pinney
- Department of Pharmacy Services, Orlando Regional Medical Center, Orlando, Florida, USA.
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Zaragoza R, Pemán J, Salavert M, Viudes A, Solé A, Jarque I, Monte E, Romá E, Cantón E. Multidisciplinary approach to the treatment of invasive fungal infections in adult patients. Prophylaxis, empirical, preemptive or targeted therapy, which is the best in the different hosts? Ther Clin Risk Manag 2011; 4:1261-80. [PMID: 19337433 PMCID: PMC2643107 DOI: 10.2147/tcrm.s3994] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The high morbidity, mortality, and health care costs associated with invasive fungal infections, especially in the critical care setting and immunocompromised host, have made it an excellent target for prophylactic, empiric, and preemptive therapy interventions principally based on early identification of risk factors. Early diagnosis and treatment are associated with a better prognosis. In the last years there have been important developments in antifungal pharmacotherapy. An approach to the new diagnosis tools in the clinical mycology laboratory and an analysis of the use new antifungal agents and its application in different clinical situations has been made. Furthermore, an attempt of developing a state of the art in each clinical scenario (critically ill, hematological, and solid organ transplant patients) has been performed, trying to choose the best strategy for each clinical situation (prophylaxis, pre-emptive, empirical, or targeted therapy). The high mortality rates in these settings make mandatory the application of early de-escalation therapy in critically ill patients with fungal infection. In addition, the possibility of antifungal combination therapy might be considered in solid organ transplant and hematological patients.
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Affiliation(s)
- Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr Peset, Valencia, Spain.
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Abstract
No official guidelines exist for perioperative antibiotic use in noncardiac thoracic surgery. Despite some conflicting data and few randomized clinical trials there exists strong evidence supporting the use of perioperative antibiotic prophylaxis in pulmonary resection. This article discusses the evidence-based indications for antibiotic prophylaxis after lung resection, esophageal surgery, and lung transplantation.
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Affiliation(s)
- Stephanie H Chang
- Division of Cardiothoracic Surgery, Washington University in St Louis School of Medicine, 660 South Euclid, Campus Box 8234, St Louis, MO 63110-1013, USA
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Fortún J, Carratalá J, Gavaldá J, Lizasoain M, Salavert M, de la Cámara R, Borges M, Cervera C, Garnacho J, Lassaleta Á, Lumbreras C, Sanz MÁ, Ramos JT, Torre-Cisneros J, Aguado JM, Cuenca-Estrella M. [Guidelines for the treatment of invasive fungal disease by Aspergillus spp. and other fungi issued by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). 2011 Update]. Enferm Infecc Microbiol Clin 2011; 29:435-54. [PMID: 21474210 DOI: 10.1016/j.eimc.2011.01.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 01/20/2011] [Accepted: 01/24/2011] [Indexed: 01/17/2023]
Abstract
The guidelines on the treatment of invasive fungal disease by Aspergillus spp. and other fungi issued by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) are presented. These recommendations are focused on four clinical categories: oncology-haematology patients, solid organ transplant recipients, patients admitted to intensive care units, and children. An extensive review is made of therapeutical advances and scientific evidence in these settings. These guidelines have been prepared according the SEIMC consensus rules by a working group composed of specialists in infectious diseases, clinical microbiology, critical care medicine, paediatrics and oncology-haematology. Specific recommendations on the prevention of fungal infections in these patients are included.
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Affiliation(s)
- Jesús Fortún
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, Madrid, Spain.
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Pound MW, Townsend ML, Dimondi V, Wilson D, Drew RH. Overview of treatment options for invasive fungal infections. Med Mycol 2011; 49:561-80. [PMID: 21366509 DOI: 10.3109/13693786.2011.560197] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The introduction of several new antifungals has significantly expanded both prophylaxis and treatment options for invasive fungal infections (IFIs). Relative to amphotericin B deoxycholate, lipid-based formulations of amphotericin B have significantly reduced the incidence of nephrotoxicity, but at a significant increase in drug acquisition cost. Newer, broad-spectrum triazoles (notably voriconazole and posaconazole) have added significantly to both the prevention and treatment of IFIs, most notably Aspergillus spp. (with voriconazole) and the treatment of some emerging fungal pathogens. Finally, a new class of parenteral antifungals, the echinocandins, is employed most frequently against invasive candidal infections. While the role of these newer agents continues to evolve, this review summarizes the activity, safety and clinical applications of agents most commonly employed in the treatment of IFIs.
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Affiliation(s)
- Melanie W Pound
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC 27506, USA.
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Gompelmann D, Heussel CP, Schuhmann M, Herth FJF. The role of diagnostic imaging in the management of invasive fungal diseases - report from an interactive workshop. Mycoses 2010; 54 Suppl 1:27-31. [DOI: 10.1111/j.1439-0507.2010.01983.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Monforte V, Ussetti P, Gavaldà J, Bravo C, Laporta R, Len O, García-Gallo CL, Tenorio L, Solé J, Román A. Feasibility, tolerability, and outcomes of nebulized liposomal amphotericin B for Aspergillus infection prevention in lung transplantation. J Heart Lung Transplant 2010; 29:523-30. [DOI: 10.1016/j.healun.2009.11.603] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 11/26/2009] [Accepted: 11/27/2009] [Indexed: 10/20/2022] Open
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Marino E, Gallagher JC. Prophylactic Antifungal Agents Used After Lung Transplantation. Ann Pharmacother 2010; 44:546-56. [DOI: 10.1345/aph.1m377] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To review the data supporting available antifungal agents and compare regimens utilized to prevent fungal infection in lung transplant recipients. Data Sources: Literature retrieval was accessed through MEDLINE (1950 through October 2009) and United Network for Organ Sharing online database (available data through October 2009), using the terms lung transplantation, prophylaxis, and fungal infection. In addition, reference citations from publications identified were reviewed. Study Selection And Data Extraction: All articles or related abstracts in English identified from the data sources above were evaluated. Literature including adult lung transplant recipients who received systemic antifungal prophylaxis to prevent invasive fungal infections (IFIs) was included in the review. Data Synthesis: IFIs after lung transplantation remain a common postoperative problem and are associated with high mortality. The lung is the most vulnerable solid organ to be transplanted, as it is the main organ responsible for gas exchange and therefore the high risk for pulmonary-related IFIs. It is most susceptible to developing an IFI, as it serves as a medium for organisms traveling from air to human tissue, potentially causing life-threatening infections. Such infections typically involve Candida and Aspergillus spp. and tend to occur within the first 12 months after transplant. Although there has been an increase in lung transplants performed over the past decade, no standard antifungal prophylactic regimen exists. Literature describing antifungals used to prevent IFI after transplant is scarce, which may be due to a lack of consistency in regimens used between transplant centers. Several regimens have been described utilizing different antifungal agents as both monotherapy and combination therapy. The majority of the literature reviewed here describes aerosolized amphotericin B formulations and azole antifungals demonstrating an overall decreased risk of fungal infection after lung transplantation. It has become the standard of practice to initiate some form of antifungal prophylaxis in these patients. Conclusions: The risk of fungal infection after lung transplant is multifactorial and optimal prophylactic regimens should include agents with adequate activity against the most pathogenic fungi.
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Affiliation(s)
| | - Jason C Gallagher
- Clinical Specialist, Infectious Diseases, Department of Pharmacy Practice, School of Pharmacy, Temple University, Philadelphia, PA
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Singh N, Husain S. Invasive aspergillosis in solid organ transplant recipients. Am J Transplant 2009; 9 Suppl 4:S180-91. [PMID: 20070679 DOI: 10.1111/j.1600-6143.2009.02910.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- N Singh
- VA Pittsburgh Healthcare System and University of Pittsburgh,Pittsburgh, PA, USA. nis5+@pitt.edu
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Kuiper L, Ruijgrok EJ. A review on the clinical use of inhaled amphotericin B. J Aerosol Med Pulm Drug Deliv 2009; 22:213-27. [PMID: 19466905 DOI: 10.1089/jamp.2008.0715] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Despite the systemic toxicity of amphotericin B (AMB), it still has a place in treatment or prophylactic regimes of fungal infections. METHODS A strategy for minimizing the potential of systemic side effects is to bring it in direct contact with the body site most likely to be infected, such as the administration of AMB as an aerosol. Nebulized amphotericin has been used in humans since 1959. However, due to a lack of sufficient data regarding efficacy, its use is still not established. Little is known about the optimal dose, frequency, duration of administration, and the pharmacokinetics of inhaled AMB in humans. RESULTS AND CONCLUSIONS In this review, published data regarding inhaled AMB are summarized, including available descriptions regarding preparation, dose, efficacy, and toxicity, and its place in therapy is discussed. The results from the studies that were reviewed in this article indicate that inhaled AMB may have a place in the prophylactic regimens of patients with prolonged neutropenia and in lung transplant recipients. Furthermore, nebulized (liposomal) AMB may have a place in the treatment of allergic bronchopulmonary aspergillosis (ABPA) in patients with corticosteroid-dependent ABPA.
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Affiliation(s)
- Laura Kuiper
- Department of Pharmacy, Ikazia Hospital Rotterdam, The Netherlands.
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Cadena J, Levine DJ, Angel LF, Maxwell PR, Brady R, Sanchez JF, Michalek JE, Levine SM, Restrepo MI. Antifungal prophylaxis with voriconazole or itraconazole in lung transplant recipients: hepatotoxicity and effectiveness. Am J Transplant 2009; 9:2085-91. [PMID: 19645709 DOI: 10.1111/j.1600-6143.2009.02734.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Invasive fungal infections (IFI) are common after lung transplantation and there are limited data for the use of antifungal prophylaxis in these patients. Our aim was to compare the safety and describe the effectiveness of universal prophylaxis with two azole regimens in lung transplant recipients. This is a retrospective study in lung transplant recipients from July 2003 to July 2006 who received antifungal prophylaxis with itraconazole or voriconazole plus inhaled amphotericin B to compare the incidence of hepatotoxicity. Secondary outcomes include describing the incidence of IFI, clinical outcomes after IFI and mortality. Sixty-seven consecutive lung transplants received antifungal prophylaxis, 32 itraconazole and 35 voriconazole and inhaled amphotericin B. There were no significant differences between groups in the acute physiology and chronic health evaluation (APACHE) score at the time of transplantation, demographic characteristics, comorbidities and concomitant use of hepatotoxic medications. Hepatotoxicity occurred in 12 patients receiving voriconazole and inhaled amphotericin B and in no patients receiving itraconazole (p < 0.001). There was no significant difference between groups with regard to the percentage of transplants with IFI, but one case of zygomycosis occurred in a transplant treated with voriconazole. Voriconazole prophylaxis after lung transplantation was associated with a higher incidence of hepatotoxicity and similar clinical effectiveness when compared to itraconazole.
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Affiliation(s)
- J Cadena
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center at San Antonio (UTHSCSA), TX, USA.
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SanMartín E, Morales P, Monte E, Vicente R. A Comparision of Several Formats of Amphotericin B as an Inhaled Antifungal Prophylaxis. Transplant Proc 2009; 41:2225-6. [DOI: 10.1016/j.transproceed.2009.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW Lung transplant's Achilles heel is chronic rejection. This is the reason why high immunosuppression is used, which leads to the development of infections. Fungal infections are a great obstacle in lung transplant patients' progress, not only because of their impact on patient survival, but also because fungal infections indirectly have an influence on the graft's progress. This review highlights the changing spectrum of invasive fungal infections as well as the most recent developments in diagnosis, prophylaxis, treatment and monitoring of lung transplantation. RECENT FINDINGS Fungal infections have a bimodal presentation: early onset, in relation to difficult postsurgeries and prior colonizations, and late onset, primarily in relation to chronic rejection and terminal renal insufficiency. The clinical impact of non-Aspergillus moulds is still unknown. Recent efforts have focused on nonculture-based methods to establish a rapid diagnosis. However, multicentre studies are needed to establish the diagnostic value of galactomannan antigen assay in invasive aspergillosis in lung transplantation. In addition, studies of the sensitivity and specificity of PCR assays are required to establish their diagnostic value. Unfortunately, only some advances in the diagnosis of aspergillosis have been achieved. SUMMARY Prophylaxis should be tailored according to the different individual patient's risk status. Combined treatments, including surgical therapy, may be useful in some patients.
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Efficiency and safety of inhaled amphotericin B lipid complex (Abelcet) in the prophylaxis of invasive fungal infections following lung transplantation. Transplant Proc 2009; 40:3090-3. [PMID: 19010204 DOI: 10.1016/j.transproceed.2008.09.020] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Invasive fungal infections (IFIs) in patients undergoing lung transplantation (LT) are associated with significant mortality. Previous studies have shown the efficacy of aerosolized amphotericin B deoxycholate and oral fluconazole for antifungal prophylaxis. Evolving data show a potential advantage of prophylaxis with lipid-based formulations of amphotericin B in the prevention of IFIs. We reviewed the incidence of IFIs among patients receiving aerosolized amphotericin B lipid complex (ABLC) in LT. METHODS We undertook a retrospective review of the results of our antifungal protocol in a cohort of 60 LT patients. We analyzed the efficiency, safety, and tolerability of 50 mg of aerosolized ABLC administered postoperatively for IFI prophylaxis once every 2 days for 2 weeks and then once per week for at least 13 weeks. In addition, these transplanted patients received fluconazole (200 mg/d) during the first 21 days posttransplant. The prophylaxis-related efficiency and safety were quantified for IFIs and adverse events (AEs) for 6 months after study drug initiation. RESULTS Prophylaxis was efficient in 59 (98.3%) patients. Only one patient developed a possible IFI, due to Aspergillus fumigatus. Four patients presented nausea and vomiting as an AE, although aerosolized amphotericin B was ongoing. CONCLUSIONS Nebulized ABLC was effective, safe, and well tolerated for the prophylaxis of aspergillosis in lung transplant patients during the early posttransplant period.
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Monforte V, Ussetti P, López R, Gavaldà J, Bravo C, de Pablo A, Pou L, Pahissa A, Morell F, Román A. Nebulized Liposomal Amphotericin B Prophylaxis for Aspergillus Infection in Lung Transplantation: Pharmacokinetics and Safety. J Heart Lung Transplant 2009; 28:170-5. [DOI: 10.1016/j.healun.2008.11.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 10/27/2008] [Accepted: 11/06/2008] [Indexed: 10/21/2022] Open
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Tong KB, Lau CJ, Murtagh K, Layton AJ, Seifeldin R. The economic impact of aspergillosis: analysis of hospital expenditures across patient subgroups. Int J Infect Dis 2009; 13:24-36. [DOI: 10.1016/j.ijid.2008.02.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Revised: 11/20/2007] [Accepted: 02/16/2008] [Indexed: 11/26/2022] Open
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Drew RH. Aerosol and other novel administrations for prevention and treatment of invasive aspergillosis. Med Mycol 2009; 47 Suppl 1:S355-61. [DOI: 10.1080/13693780802247710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Solé A. Invasive fungal infections in lung transplantation: role of aerosolised amphotericin B. Int J Antimicrob Agents 2008; 32 Suppl 2:S161-5. [DOI: 10.1016/s0924-8579(08)70019-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lung Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Aguilar-Guisado M, Givaldá J, Ussetti P, Ramos A, Morales P, Blanes M, Bou G, de la Torre-Cisneros J, Román A, Borro JM, Lama R, Cisneros JM. Pneumonia after lung transplantation in the RESITRA Cohort: a multicenter prospective study. Am J Transplant 2007; 7:1989-96. [PMID: 17617864 DOI: 10.1111/j.1600-6143.2007.01882.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The aim of the present study is to evaluate the epidemiology, etiology and prognosis of pneumonia in lung transplant (LT) recipients. This is a prospective, multicenter study of a consecutive cohort of LT recipients in Spain. From September 2003 to November 2005, 85 episodes of pneumonia in 236 LT recipients were included (incidence 72 episodes per 100 LT/year). Bacterial pneumonia (82.7%) was more frequent than fungal (14%) and viral pneumonia (10.4%). The most frequent microorganisms in each etiological group were Pseudomonas aeruginosa (n = 14, 24.6%), CMV (n = 6, 10.4%) and Aspergillus spp. (n = 5, 8.8%). Incidence of Aspergillus spp. and CMV pneumonia is lower than previously reported, probably due to the spread of universal prophylaxis. Pneumonia caused by viruses appeared significantly later than pneumonia due to gram-negative bacilli, fungi and those without known etiology (p < 0.01, p = 0.03 and p = 0.02, respectively). The routine use of ganciclovir has changed the natural history of CMV infection, so that pneumonia appears later, once prophylaxis is suspended. The probability of survival during the first year of follow-up was significantly higher in the multivariate analysis in LT recipients who did not have a pneumonia episode compared with those that had at least one episode (p < 0.01).
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Lowry CM, Marty FM, Vargas SO, Lee JT, Fiumara K, Deykin A, Baden LR. Safety of aerosolized liposomal versus deoxycholate amphotericin B formulations for prevention of invasive fungal infections following lung transplantation: a retrospective study. Transpl Infect Dis 2007; 9:121-5. [PMID: 17461997 DOI: 10.1111/j.1399-3062.2007.00209.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nebulized amphotericin B deoxycholate (AmBd) has been used to prevent invasive pulmonary aspergillosis after lung transplantation. METHODS In this retrospective study we compared the safety and tolerability of nebulized AmBd and nebulized liposomal amphotericin B (L-AmB) in 38 consecutive lung transplant recipients. Progress notes, medication administration records, microbiology, and pulmonary function reports were reviewed. Histologic sections from lung tissue were examined. Plasma amphotericin B levels were measured. RESULTS A total of 1206 doses of AmBd and 1149 doses of L-AmB were administered. Eighteen patients received AmBd only, 11 received L-AmB only, and 9 received the medications sequentially. The total number of complaints vs. the number of doses administered was 1.0% for AmBd-treated patients and 1.2% for L-AmB-treated patients. No differences were observed between the treatment groups on lung biopsy specimens. Plasma amphotericin B levels were <0.2-0.9 microg/mL in AmBd-treated patients and <0.2 microg/mL in L-AmB-treated patients. CONCLUSIONS In lung transplant recipients, both inhaled AmBd and L-AmB were safe and well tolerated over a large number of medication exposures.
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Affiliation(s)
- C M Lowry
- Department of Pharmacy, Brigham & Women's Hospital, Boston, MA 02115, USA
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Abstract
Fungal infections in solid organ transplant recipients continue to be a significant cause of morbidity and mortality. Candida spp. and Aspergillus spp. account for most invasive fungal infections. The incidence of fungal infection varies with type of solid organ transplant. Liver transplant recipients have highest reported incidence of candida infections while lung transplant recipients have highest rate of Aspergillus infections. Recent epidemiological studies suggest the emergence of resistant strains of candida as well as mycelial fungi other than Aspergillus in these patients. The current review incorporates the recent changes in the epidemiology of fungal infections in solid organ transplant recipients and highlights the newer data on the diagnosis, prophylaxis and treatment of fungal infections in these patients.
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Affiliation(s)
- Fernanda P Silveira
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Castón JJ, Linares MJ, Gallego C, Rivero A, Font P, Solís F, Casal M, Torre-Cisneros J. Risk Factors for Pulmonary Aspergillus terreus Infection in Patients With Positive Culture for Filamentous Fungi. Chest 2007; 131:230-6. [PMID: 17218581 DOI: 10.1378/chest.06-0767] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Invasive aspergillosis (IA) is a common fungal infection in immunocompromised patients and has a high mortality rate. Among patients with IA, Aspergillus terreus infections have become a growing concern in the past few years. OBJECTIVE To determine the clinical risk factors for isolation of and respiratory infection by A terreus in patients with culture findings positive for filamentous fungi. METHODS Cohort study of 505 consecutive isolates of filamentous fungi in 332 patients from one center. A terreus was present in 46 isolates from 40 patients (9.1%). Clinical histories were reviewed to identify the risk factors related to isolation of and infection by A terreus, which were grouped into three categories (ie, host factors, factors related to immunosuppression, and factors related to hospitalization), and were analyzed using a multiple logistic regression model. RESULTS A total of 192 of 505 isolates studied (38%) were due to invasive respiratory infection. A total of 27 of 46 cultures (58.7%) that were positive for A terreus were due to invasive infection (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.37 to 4.69; p = 0.034). The factors associated with invasive A terreus infection were prophylactic use of amphotericin B aerosols (OR, 27.8; 95% CI, 6.7 to 109.7; p = 0.001) and mechanical ventilation (OR, 3.3; 95% CI, 1.02 to 10.9; p = 0.04). Transplantation was associated with a lower risk of A terreus infection (OR, 0.2; 95% CI, 0.046 to 0.789; p = 0.02). CONCLUSIONS In patients with culture findings positive for filamentous fungi, the prophylactic use of amphotericin B aerosols and mechanical ventilation are associated with a higher risk of A terreus infections. In these patients, transplantation is associated with a lower risk of isolation and respiratory infection by A terreus.
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Affiliation(s)
- Juan José Castón
- Unit of Infectious Diseases, Reina Sofía University Hospital, Córdoba, Spain
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Mohammad RA, Klein KC. Inhaled amphotericin B for prophylaxis against invasive Aspergillus infections. Ann Pharmacother 2006; 40:2148-54. [PMID: 17148653 DOI: 10.1345/aph.1g477] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the available literature describing the use of inhaled amphotericin B for prophylaxis of invasive Aspergillus spp. infections. DATA SOURCES A MEDLINE search was conducted (1966-July 2006) using the key terms amphotericin B, inhaled amphotericin B, Aspergillus spp., invasive aspergillosis, solid-organ transplant, neutropenia, and inhalation. Review of the reference lists of the identified articles was also performed. STUDY SELECTION AND DATA EXTRACTION Study selection included published trials, case reports, and case series of humans with hematologic disease and solid-organ transplant who used inhaled amphotericin B in the prevention of invasive Aspergillus infections. DATA SYNTHESIS Inhaled amphotericin B has been evaluated for the prevention of invasive aspergillosis (IA) infections in neutropenic patients and certain solid-organ transplant recipients. Use of inhaled amphotericin B seems to reduce the incidence of IA in these patients; however, some of the clinical evidence was limited by factors such as small sample sizes, lack of statistical analyses, and lack of power to detect a difference between prophylaxis and control groups. Although the clinical evidence supporting the use of inhaled amphotericin B has some limitations, its use still may be beneficial for the prophylaxis of invasive Aspergillus infections, especially in solid-organ transplant recipients where the evidence is strongest. CONCLUSIONS Invasive Aspergillus infections are becoming more prevalent in high-risk populations (eg, patients with malignancies, following bone marrow transplantation, or following solid-organ transplantation). The mortality rates associated with IA are great in these populations, making prophylaxis an important consideration. Inhaled amphotericin B has recently come into vogue as an option for prophylaxis against IA. Some of the data available supports the use of inhaled amphotericin B for the prevention of IA while providing evidence of fewer drug interactions and toxicities associated with other antifungal agents.
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Affiliation(s)
- Rima A Mohammad
- Department of Pharmacy Services, College of Pharmacy, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, USA.
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Husain S, Paterson DL, Studer S, Pilewski J, Crespo M, Zaldonis D, Shutt K, Pakstis DL, Zeevi A, Johnson B, Kwak EJ, McCurry KR. Voriconazole prophylaxis in lung transplant recipients. Am J Transplant 2006; 6:3008-16. [PMID: 17062003 DOI: 10.1111/j.1600-6143.2006.01548.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Lung transplant recipients have one of the highest rates of invasive aspergillosis (IA) in solid organ transplantation. We used a single center, nonrandomized, retrospective, sequential study design to evaluate fungal infection rates in lung transplant recipients who were managed with either universal prophylaxis with voriconazole (n = 65) or targeted prophylaxis (n = 30) with itraconazole +/- inhaled amphotericin in patients at high risk (pre- or posttransplant Aspergillus colonization [except Aspergillus niger]). The rate of IA at 1 year was better in lung transplant recipients receiving voriconazole prophylaxis as compared to the cohort managed with targeted prophylaxis (1.5% vs. 23%; p = 0.001). Twenty-nine percent of cases in the targeted prophylaxis group were in patients colonized with A. niger who did not receive itraconazole. A three-fold or higher increase in liver enzymes was noted in 37-60% of patients receiving voriconazole prophylaxis as compared to 15-41% of patients in the targeted prophylaxis cohort. Fourteen percent in the voriconazole group as compared to 8% in the targeted prophylaxis group had to discontinue antifungal medications due to side effects. Voriconazole prophylaxis can be used in preventing IA in lung transplant recipients. Regular monitoring of liver enzymes and serum concentrations of calcineurin inhibitors are required to avoid hepatotoxicity and nephrotoxicity.
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Affiliation(s)
- S Husain
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pennsylvania, USA
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Husain S, Zaldonis D, Kusne S, Kwak EJ, Paterson DL, McCurry KR. Variation in antifungal prophylaxis strategies in lung transplantation. Transpl Infect Dis 2006; 8:213-8. [PMID: 17116134 DOI: 10.1111/j.1399-3062.2006.00156.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We conducted a survey of 50 lung transplant centers across the world to evaluate the variation in antifungal prophylaxis practices. These 50 centers performed 63% of the world's lung transplants reported in 2001. Eighty-six percent (43/50) of the centers responded to the survey. Sixty-nine percent (30/43) of centers used universal antifungal prophylaxis. Aerosolized amphotericin B deoxycholate (AmBd) alone or in combination with itraconazole was used at 56% (24/43) of centers. The median duration of prophylaxis with aerosolized AmBd and itraconazole was 30 and 90 days, respectively. Seventy-four percent of the centers surveyed agreed to participate in future research prophylaxis protocols, which they felt should include both diagnostic and therapeutic arms. Our survey is the first documentation of the international variation in antifungal prophylactic strategies in lung transplant recipients, and underscores the need for multicenter, randomized trials of antifungal prophylaxis in lung transplant recipients.
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Affiliation(s)
- S Husain
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Corcoran TE, Venkataramanan R, Mihelc KM, Marcinkowski AL, Ou J, McCook BM, Weber L, Carey ME, Paterson DL, Pilewski JM, McCurry KR, Husain S. Aerosol deposition of lipid complex amphotericin-B (Abelcet) in lung transplant recipients. Am J Transplant 2006; 6:2765-73. [PMID: 17049064 DOI: 10.1111/j.1600-6143.2006.01529.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Lung transplant recipients exhibit a high incidence of invasive aspergillosis. The inhalation of lipid complex amphotericin-B (Abelcet; ABLC) offers a possible prophylactic strategy. The goals of this study were to select the optimal nebulizer delivery system for ABLC and to measure deposited aerosol dose in 12 lung transplant recipients. In vitro testing was performed to select a nebulizer delivery system, and an empirical model was used to estimate lung deposition. Estimated pulmonary doses varied by as much as 2-fold between different nebulizers. Aerosol deposition testing was performed in six single and six double lung recipients, each of whom received one 7 mL (35 mg) nebulized dose of Technetium-labeled ABLC using the selected nebulizer. In single lung recipients, the average deposited doses were 3.9 +/- 1.6 mg (mean +/- S.D.) in the allograft versus 2.1 +/- 1.1 mg in the native lung. Double lung recipients deposited on average 2.8 +/- 0.8 mg (left lung) and 4.0 +/- 1.3 mg (right lung). The drug was well distributed throughout the lungs, but delivery to the native lung was in some cases suboptimal. These studies provide an important precursor to studies of the efficacy of inhaled ABLC as a prophylaxis of invasive aspergillosis after lung transplant.
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Affiliation(s)
- T E Corcoran
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Gibbs WJ, Drew RH, Perfect JR. Liposomal amphotericin B: clinical experience and perspectives. Expert Rev Anti Infect Ther 2006; 3:167-81. [PMID: 15918775 DOI: 10.1586/14787210.3.2.167] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While amphotericin B deoxycholate (Fungizone, Apothecon Pharmaceuticals) has been considered by many to be the gold standard for the treatment for numerous invasive fungal infections for over 45 years, toxicities associated with its use often necessitate treatment modification or discontinuation. Lipid-based formulations, including liposomal amphotericin B (AmBisome, Fujisawa Healthcare, Inc.), were developed to decrease many of these toxicities while retaining broad antifungal spectrum and potency of amphotericin B. In clinical trials, liposomal amphotericin B has demonstrated efficacy comparable to that of amphotericin B deoxycholate while reducing the incidence of treatment-related nephrotoxicity, electrolyte-wasting, and infusion-related reactions. In addition, recent clinical trials have also compared liposomal amphotericin B with other antifungal classes. Acquisition costs of liposomal amphotericin B are substantially higher than those of amphotericin B deoxycholate and other antifungals. While pharmacoeconomic analyses consider outcomes and other treatment-related costs, they have yet to clearly demonstrate the cost-effectiveness of liposomal amphotericin B when compared with amphotericin B deoxycholate or other antifungal agents. This review will focus primarily on recent liposomal amphotericin B experience and attempt to put its use into perspective considering other available antifungal agents.
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Affiliation(s)
- Winter J Gibbs
- Department of Pharmacy practice, Campbell University School of Pharmacy, Buies Creek.
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