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Sharma V, Madia VN, Tudino V, Nguyen JV, Debnath A, Messore A, Ialongo D, Patacchini E, Palenca I, Basili Franzin S, Seguella L, Esposito G, Petrucci R, Di Matteo P, Bortolami M, Saccoliti F, Di Santo R, Scipione L, Costi R, Podust LM. Miconazole-like Scaffold is a Promising Lead for Naegleria fowleri-Specific CYP51 Inhibitors. J Med Chem 2023; 66:17059-17073. [PMID: 38085955 PMCID: PMC10758121 DOI: 10.1021/acs.jmedchem.3c01898] [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: 10/10/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023]
Abstract
Developing drugs for brain infection by Naegleria fowleri is an unmet medical need. We used a combination of cheminformatics, target-, and phenotypic-based drug discovery methods to identify inhibitors that target an essential N. fowleri enzyme, sterol 14-demethylase (NfCYP51). A total of 124 compounds preselected in silico were tested against N. fowleri. Nine primary hits with EC50 ≤ 10 μM were phenotypically identified. Cocrystallization with NfCYP51 focused attention on one primary hit, miconazole-like compound 2a. The S-enantiomer of 2a produced a 1.74 Å cocrystal structure. A set of analogues was then synthesized and evaluated to confirm the superiority of the S-configuration over the R-configuration and the advantage of an ether linkage over an ester linkage. The two compounds, S-8b and S-9b, had an improved EC50 and KD compared to 2a. Importantly, both were readily taken up into the brain. The brain-to-plasma distribution coefficient of S-9b was 1.02 ± 0.12, suggesting further evaluation as a lead for primary amoebic meningoencephalitis.
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Affiliation(s)
- Vandna Sharma
- Skaggs
School of Pharmacy and Pharmaceutical Sciences, Center for Discovery
and Innovation in Parasitic Diseases, University
of California San Diego, La Jolla, California 92093, United States
| | - Valentina Noemi Madia
- Dipartimento
di Chimica e Tecnologie del Farmaco, Istituto Pasteur-Fondazione Cenci
Bolognetti, “Sapienza” Università
di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Valeria Tudino
- Dipartimento
di Biotecnologie, Università degli
Studi di Siena, Chimica e Farmacia via Aldo Moro 2, Siena 53100, Italy
| | - Jennifer V. Nguyen
- Skaggs
School of Pharmacy and Pharmaceutical Sciences, Center for Discovery
and Innovation in Parasitic Diseases, University
of California San Diego, La Jolla, California 92093, United States
| | - Anjan Debnath
- Skaggs
School of Pharmacy and Pharmaceutical Sciences, Center for Discovery
and Innovation in Parasitic Diseases, University
of California San Diego, La Jolla, California 92093, United States
| | - Antonella Messore
- Dipartimento
di Chimica e Tecnologie del Farmaco, Istituto Pasteur-Fondazione Cenci
Bolognetti, “Sapienza” Università
di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Davide Ialongo
- Dipartimento
di Chimica e Tecnologie del Farmaco, Istituto Pasteur-Fondazione Cenci
Bolognetti, “Sapienza” Università
di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Elisa Patacchini
- Dipartimento
di Chimica e Tecnologie del Farmaco, Istituto Pasteur-Fondazione Cenci
Bolognetti, “Sapienza” Università
di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Irene Palenca
- Department
of Physiology and Pharmacology “V. Erspamer”, “Sapienza″ Università di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Silvia Basili Franzin
- Department
of Physiology and Pharmacology “V. Erspamer”, “Sapienza″ Università di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Luisa Seguella
- Department
of Physiology and Pharmacology “V. Erspamer”, “Sapienza″ Università di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Giuseppe Esposito
- Department
of Physiology and Pharmacology “V. Erspamer”, “Sapienza″ Università di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Rita Petrucci
- Dipartimento
di Scienze di Base e Applicate per l’Ingegneria, “Sapienza” Università di Roma, Via Castro Laurenziano 7, Rome 00161, Italy
| | - Paola Di Matteo
- Dipartimento
di Scienze di Base e Applicate per l’Ingegneria, “Sapienza” Università di Roma, Via Castro Laurenziano 7, Rome 00161, Italy
| | - Martina Bortolami
- Dipartimento
di Scienze di Base e Applicate per l’Ingegneria, “Sapienza” Università di Roma, Via Castro Laurenziano 7, Rome 00161, Italy
| | - Francesco Saccoliti
- D3 PharmaChemistry, Italian
Institute of Technology, Via Morego 30, Genova 16163, Italy
| | - Roberto Di Santo
- Dipartimento
di Chimica e Tecnologie del Farmaco, Istituto Pasteur-Fondazione Cenci
Bolognetti, “Sapienza” Università
di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Luigi Scipione
- Dipartimento
di Chimica e Tecnologie del Farmaco, Istituto Pasteur-Fondazione Cenci
Bolognetti, “Sapienza” Università
di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Roberta Costi
- Dipartimento
di Chimica e Tecnologie del Farmaco, Istituto Pasteur-Fondazione Cenci
Bolognetti, “Sapienza” Università
di Roma, p.le Aldo Moro 5, Rome I-00185, Italy
| | - Larissa M. Podust
- Skaggs
School of Pharmacy and Pharmaceutical Sciences, Center for Discovery
and Innovation in Parasitic Diseases, University
of California San Diego, La Jolla, California 92093, United States
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2
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Kelly L, Walsh J, Skally M, Dinesh B, Burns K, O'Connell K, MacNally S, Humphreys H, Fitzpatrick F. Candida meningitis/ventriculitis over a decade. Increased morbidity and length of stay a concern. Br J Neurosurg 2023; 37:227-230. [PMID: 35361033 DOI: 10.1080/02688697.2022.2054947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
AIM The primary aim of this study was to review the diagnosis, management and outcome of Candida meningitis/ventriculitis in our hospital over a ten-year period. MATERIALS AND METHODS We retrospectively reviewed all culture and 18s rRNA nucleic acid positive CSF specimens processed between 1st January 2010 and 31st December 2020. Patient records were subsequently reviewed to assess the significance of the isolate. RESULTS Of 851 culture-positive cerebrospinal fluid (CSF) specimens, Candida spp. were isolated from 29 (3.4%), representing infection in 12 patients. One culture-negative specimen was positive for Candida on 18s rRNA testing. Of the 13 patients, eight were male; 61.5% and the median age was 47 years; range: 20-70. The median interval from admission to onset of infection and culture positivity was 24 days (range: 1-63 days). All patients had a central nervous system (CNS) device in situ (external ventricular drain: 11; ventriculoperitoneal shunt: 1; lumbar drain: 1). Four were colonised with Candida spp. before meningitis/ventriculitis diagnosis, from wounds (n = 3), respiratory (n = 3), and urine (n = 1) specimens. On culture, the most common species was Candida albicans (n = 8), followed by C. parapsilosis (n = 2), C. tropicalis (n = 1), and C. dubliniensis (n = 1). The median number of follow-up CSFs per patient was nine (range; 3-22), with a median of 6 days to CSF sterility (range 3-10 days). Treatment included; liposomal amphotericin B (n = 5), fluconazole (n = 2), liposomal amphotericin B, and flucytosine (n = 2), liposomal amphotericin B, fluconazole and flucytosine (n = 3), and intra-ventricular amphotericin B (n = 1). Median treatment duration was 25 days (range 11-76) and CNS device removal occurred in 12 patients. The median length-of-stay (LOS) was 58 days (range 24-406). On discharge, moderate to severe disability (Modified Rankin Scale [mRS] 3-5) was evident in eight patients. Two patients died and one was lost to follow-up. CONCLUSION Meningitis/ventriculitis due to Candida spp. is an uncommon but challenging infection, usually associated with a device, increased morbidity, LOS, and necessitating prolonged treatment. Neurosurgeons need to be aware of these issues in managing and in communicating with such complex patients.
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Affiliation(s)
- Louise Kelly
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Jennifer Walsh
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Mairead Skally
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Binu Dinesh
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Karina O'Connell
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stephen MacNally
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Hilary Humphreys
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
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3
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Wirth F, Staudt KJ, Araújo BV, Ishida K. Experimental models for pharmacokinetic and pharmacodynamic studies of antifungals used in cryptococcosis treatment. Future Microbiol 2022; 17:969-982. [PMID: 35694892 DOI: 10.2217/fmb-2021-0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Studies on cryptococcosis in the mammal animal model have demonstrated the occurrence of central nervous system infection and similarities in fungal pathogenicity with clinical and immunological features of the human infection. Although there is still a lack of studies involving pharmacokinetics (PK) and pharmacodynamics (PD) in animal models of cryptococcosis in the literature, these experimental models are useful for understanding this mycosis and antifungal effectiveness in improving the therapeutic schemes. The scope of this review is to describe and discuss the main mammal animal models for PK and PD studies of antifungals used in cryptococcosis treatment. Alternative models and computational methods are also addressed. All approaches for PK/PD studies are relevant to investigating drug-infection interaction and improving cryptococcosis therapy.
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Affiliation(s)
- Fernanda Wirth
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, 05508-000, Brazil
| | - Keli J Staudt
- Faculty of Pharmacy, Pharmaceutical Sciences Post-Graduation Program, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, 90610-000, Brazil
| | - Bibiana V Araújo
- Faculty of Pharmacy, Pharmaceutical Sciences Post-Graduation Program, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, 90610-000, Brazil
| | - Kelly Ishida
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, 05508-000, Brazil
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4
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Chau MM, Daveson K, Alffenaar JWC, Gwee A, Ho SA, Marriott DJE, Trubiano JA, Zhao J, Roberts JA. Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy and haemopoietic stem cell transplant recipients, 2021. Intern Med J 2021; 51 Suppl 7:37-66. [PMID: 34937141 DOI: 10.1111/imj.15587] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Antifungal agents can have complex dosing and the potential for drug interaction, both of which can lead to subtherapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy and haemopoietic stem cell transplant recipients. Antifungal agents can also be associated with significant toxicities when drug concentrations are too high. Suboptimal dosing can be minimised by clinical assessment, laboratory monitoring, avoidance of interacting drugs, and dose modification. Therapeutic drug monitoring (TDM) plays an increasingly important role in antifungal therapy, particularly for antifungal agents that have an established exposure-response relationship with either a narrow therapeutic window, large dose-exposure variability, cytochrome P450 gene polymorphism affecting drug metabolism, the presence of antifungal drug interactions or unexpected toxicity, and/or concerns for non-compliance or inadequate absorption of oral antifungals. These guidelines provide recommendations on antifungal drug monitoring and TDM-guided dosing adjustment for selected antifungal agents, and include suggested resources for identifying and analysing antifungal drug interactions. Recommended competencies for optimal interpretation of antifungal TDM and dose recommendations are also provided.
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Affiliation(s)
- Maggie M Chau
- Pharmacy Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases and Microbiology, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Jan-Willem C Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Camperdown, New South Wales, Australia.,Pharmacy Department, Westmead Hospital, Westmead, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Camperdown, New South Wales, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Su Ann Ho
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Faculty of Science, University of Technology, Ultimo, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Kensington, New South Wales, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Jessie Zhao
- Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason A Roberts
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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5
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Keighley C, Cooley L, Morris AJ, Ritchie D, Clark JE, Boan P, Worth LJ. Consensus guidelines for the diagnosis and management of invasive candidiasis in haematology, oncology and intensive care settings, 2021. Intern Med J 2021; 51 Suppl 7:89-117. [DOI: 10.1111/imj.15589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Caitlin Keighley
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney Camperdown New South Wales Australia
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology Westmead New South Wales Australia
- Southern IML Pathology, Sonic Healthcare Coniston New South Wales Australia
| | - Louise Cooley
- Department of Microbiology and Infectious Diseases Royal Hobart Hospital Hobart Tasmania Australia
- University of Tasmania Hobart Tasmania Australia
| | - Arthur J. Morris
- LabPLUS, Clinical Microbiology Laboratory Auckland City Hospital Auckland New Zealand
| | - David Ritchie
- Department of Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne Victoria Australia
| | - Julia E. Clark
- Department of Infection Management Queensland Children's Hospital, Children's Health Queensland Brisbane Queensland Australia
- Child Health Research Centre The University of Queensland Brisbane Queensland Australia
| | - Peter Boan
- PathWest Laboratory Medicine WA, Department of Microbiology Fiona Stanley Fremantle Hospitals Group Murdoch Western Australia Australia
- Department of Infectious Diseases Fiona Stanley Fremantle Hospitals Group Murdoch Western Australia Australia
| | - Leon J. Worth
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
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6
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Chintalacharuvu KR, Matolek ZA, Pacheco B, Carriera EM, Beenhouwer DO. Complexing amphotericin B with gold nanoparticles improves fungal clearance from the brains of mice infected with Cryptococcal neoformans. Med Mycol 2021; 59:1085-1091. [PMID: 34332505 DOI: 10.1093/mmy/myab042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/25/2021] [Indexed: 12/31/2022] Open
Abstract
Amphotericin B (AmB) is used to treat cryptococcal meningoencephalitis. However, the mortality rate remains high. Higher doses of AmB in deoxycholate buffer (AmBd) are toxic to human red blood cells (hRBC) and have no effect on brain organism load in mice. Here we show that while AmBd lysed 96% of hRBC, AmB complexed with gold nanoparticles (AuNP-SA-AmB) lysed only 27% of hRBC. In vitro growth of C. neoformans was inhibited by 0.25 μg/ml AmBd and 0.04 μg/ml of AuNP-SA-AmB. In mice infected with C. neoformans, five daily treatments with AuNP-SA-AmB containing 0.25 mg/kg AmB significantly lowered the fungal burden in the brain tissue compared to either untreated or treatment with 0.25 mg/kg of AmBd. When a single dose of AmBd was injected intravenously into BALB/c mice, 81.61% of AmB cleared in the α-phase and 18.39% cleared in the β-phase at a rate of 0.34% per hour. In contrast, when AuNP-SA-AmB was injected, 49.19% of AmB cleared in the α-phase and 50.81% of AmB cleared in the β-phase at a rate of 0.27% per hour. These results suggest that AmB complexed with gold nanoparticles is less toxic to hRBC, is more effective against C. neoformans and persists longer in blood when injected into mice resulting in more effective clearing of C. neoformans from the brain tissue. LAY SUMMARY Amphotericin B (AmB) was complexed with gold nanoparticles (AuNP-SA-AmB) to improve brain delivery. AuNP-SA-AmB was more effective than AmB alone in clearing of Cryptococcus neoformans from the brain tissue of infected mice. This may be due to longer plasma half-life of AmB as AuNP-SA-AmB.
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Affiliation(s)
| | - Zlatko A Matolek
- Division of Infectious Diseases, VA Greater Los Angeles Health Care System, Los Angeles, CA 90073, USA
| | - Benny Pacheco
- Cytodiagnostics Inc., 919 Fraser Dr. Unit 11, Burlington, ON L7L 4×8, Canada
| | - Erick M Carriera
- ETH-Zürich, Department of Chemistry and Applied Biosciences, Laboratory of Organic Chemistry, Vladimir Prelog Weg 3, HCI H335, Zürich 8093, Switzerland
| | - David O Beenhouwer
- Division of Infectious Diseases, VA Greater Los Angeles Health Care System, Los Angeles, CA 90073, USA
- Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA 90025, USA
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7
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Dong L, Bai N, Wang T, Cai Y. Development and validation of a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantification of voriconazole in human cerebrospinal fluid. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2021; 13:4585-4593. [PMID: 34532726 DOI: 10.1039/d1ay01103k] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Background: A liquid chromatography-tandem mass spectrometry (LC-MS/MS). Method: For the quantification of voriconazole in human cerebrospinal fluid (CSF) was developed and validated, to guide the clinical use of voriconazole in the treatment of central nervous system infections. CSF samples were treated by protein precipitation with methanol containing fluconazole as the internal standard (IS). The supernatant was analyzed by LC-MS/MS using an Agilent EclipsePlus C18 column eluted with a methanol and water mobile phase at a flow rate of 0.4 mL min-1. Quantification was performed by multiple-reaction monitoring using the precursor and product ion pair 350/280.9 for voriconazole and 307/219.9 for fluconazole. Results: The calibration curve was linear over the range of 0.1-10.0 μg mL-1 (R2 = 0.9991). The inter-day and intra-day precisions were <4.20% and <9.97%, respectively. The recoveries for the three concentrations (0.2, 1.0, and 8.0 μg mL-1) were 99.96%, 107.00%, and 99.85%, and the matrix effects were 99.35%, 103.41%, and 99.64%, respectively. The stability under various conditions was also acceptable. The study also demonstrated that the CSF matrix could be replaced by plasma and artificial CSF. Conclusion: A simple and accurate method for the determination of voriconazole concentrations in human CSF was developed and validated, which can be used for drug monitoring in the treatment of central nervous system infections.
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Affiliation(s)
- Liuhan Dong
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, 28 Fu Xing Road, Beijing 100853, China.
- Medical School of Chinese PLA, Beijing 100853, China
| | - Nan Bai
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, 28 Fu Xing Road, Beijing 100853, China.
| | - Tianlin Wang
- Office of Clinical Pharmacy, Department of Pharmacy, Chinese PLA General Hospital, 28 Fu Xing Road, Beijing 100853, China.
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, Chinese PLA General Hospital, 28 Fu Xing Road, Beijing 100853, China.
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8
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[AmBisome, three challenges: Candida auris infection, central nervous system infection, and biofilm-associated infection]. Rev Iberoam Micol 2021; 38:84-90. [PMID: 34144836 DOI: 10.1016/j.riam.2021.03.004] [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] [Received: 02/04/2021] [Revised: 03/21/2021] [Accepted: 03/31/2021] [Indexed: 12/17/2022] Open
Abstract
The treatment of invasive fungal infections remains a challenge, both for the diagnosis and for the need of providing the appropriate antifungal therapy. Candida auris is a pathogenic yeast that is responsible for hospital outbreaks, especially in intensive care units; it is characterized by a high resistance to the antifungal agents and can become multidrug-resistant. At present, the recommended antifungal agents for the invasive infections with this pathogen are echinocandins, always after carrying out an antifungal susceptibility testing. In case of no clinical response or persistent candidemia, the addition of liposomal amphotericin B or isavuconazole may be considered. Both fungal infection of the central nervous system and that associated with biomedical devices remain rare entities affecting mainly immunocompromised patients. However, an increase in their incidence in recent years, along with high morbidity and mortality, has been shown. The treatment of these infections is conditioned by the limited knowledge of the pharmacokinetic properties of antifungals. A better understanding of the pharmacokinetic and pharmacodynamic parameters of the different antifungals is essential to determine the efficacy of the antifungal agents in the treatment of these infections.
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9
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Meyerowitz EA, Sanchez S, Mansour MK, Triant VA, Goldberg MB. Isolated Cerebral Mucormycosis in Immunocompetent Adults who Inject Drugs: Case Reports and Systematic Review of the Literature. Open Forum Infect Dis 2020; 7:ofaa552. [PMID: 33409328 PMCID: PMC7765436 DOI: 10.1093/ofid/ofaa552] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/05/2020] [Indexed: 01/16/2023] Open
Abstract
Background Mucormycosis involves life-threatening rapidly progressive angioinvasion with infiltration across tissue planes, resulting in necrosis and thrombosis, most commonly seen in the setting of immunocompromised states. We describe 2 cases of isolated cerebral mucormycosis in immunocompetent adults and describe this syndrome in detail in the context of a systemic literature review. Methods Using the criteria (1) isolated cerebral disease, (2) mucormycosis (by polymerase chain reaction, culture, or pathology), and (3) affected an immunocompetent individual, we identified 53 additional cases from 1969 to 2020. Results Of these 55 cases, ~60% occurred in men, >70% were in patients under age 35, 92% were associated with intravenous drug use, and >85% had infection centered in the basal ganglia. Many presented with cranial nerve deficits, headache, focal weakness, or altered mental status. Conclusions No patient survived without amphotericin, and steroid administration was associated with worse outcomes. Given the current opioid crisis, this syndrome may be seen more frequently.
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Affiliation(s)
- Eric A Meyerowitz
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarimer Sanchez
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael K Mansour
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Virginia A Triant
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marcia B Goldberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Microbiology, Harvard Medical School, Boston, Massachusetts, USA
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10
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McCreary EK, Byers KE, Fernandes C, Kline EG, Nicolau DP, Shields RK. Plasma and Cerebrospinal Fluid Therapeutic Drug Monitoring of Ceftolozane and Tazobactam During Treatment of Multidrug-Resistant Pseudomonas aeruginosa Meningitis. Open Forum Infect Dis 2020; 7:ofaa549. [PMID: 33409327 PMCID: PMC7751399 DOI: 10.1093/ofid/ofaa549] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/03/2020] [Indexed: 11/13/2022] Open
Abstract
We report a case of multidrug-resistant Pseudomonas aeruginosa meningitis treated with ceftolozane-tazobactam with concomitant therapeutic drug monitoring of plasma and cerebral spinal fluid. The data suggest that ceftolozane-tazobactam may be an option for select central nervous system infections; however, treatment decisions should be interpreted on a case-by-case basis.
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Affiliation(s)
- Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karin E Byers
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carolyn Fernandes
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ellen G Kline
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford, Connecticut, USA
| | - Ryan K Shields
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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11
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Wirth F, Ishida K. Antifungal drugs: An updated review of central nervous system pharmacokinetics. Mycoses 2020; 63:1047-1059. [PMID: 32772402 DOI: 10.1111/myc.13157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 01/06/2023]
Abstract
Invasive fungal infections (IFIs) in the central nervous system (CNS) are particularly hard to treat and are associated with high morbidity and mortality rates. Four chemical classes of systemic antifungal agents are used for the treatment of IFIs (eg meningitis), including polyenes, triazoles, pyrimidine analogues and echinocandins. This review will address all of these classes and discuss their penetration and accumulation in the CNS. Treatment of fungal meningitis is based on the antifungal that shows good penetration and accumulation in the CNS. Pharmacokinetic data concerning the entry of antifungal agents into the intracranial compartments are faulty. This review will provide an overview of the ability of systemic antifungals to penetrate the CNS, based on previously published drug physicochemical properties and pharmacokinetic data, for evaluation of the most promising antifungal drugs for the treatment of fungal CNS infections. The studies selected and discussed in this review are from 1990 to 2019.
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Affiliation(s)
- Fernanda Wirth
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Kelly Ishida
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
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12
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Abstract
Candida meningitis in neurosurgical patients is relatively unusual but is associated with a high mortality rate. We present our experience with this infection and discuss the clinical characteristics, treatment options and outcomes. We retrospectively reviewed neurosurgical patients with multiple positive cerebrospinal fluid (CSF) culture results in our hospital from January 2013 to December 2019. Nine patients were available for review according to our inclusion and exclusion criteria. Four species of Candida were isolated from the CSF samples and Candida albicans accounted for half of all infections. Eight infections were associated with ventricle peritoneal shunt, lumbar cistern peritoneal shunt or external ventricular drain. All of these foreign intracranial materials were removed or changed and all the patients received antifungal treatment, including fluconazole and/or voriconazole. It is associated with severe long-term outcomes in survivors and a mortality rate that reaches 11.1%. Prior treatments with broad-spectrum and high-grade antibiotics and anaemia are possible risk factors for Candida meningitis. We advise that foreign intracranial material should be removed or changed as early as possible and the timing of re-shunt operation can be 1 month after control of Candida meningitis has been achieved, with several negative CSF culture results.
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13
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Spadari CDC, Wirth F, Lopes LB, Ishida K. New Approaches for Cryptococcosis Treatment. Microorganisms 2020; 8:E613. [PMID: 32340403 PMCID: PMC7232457 DOI: 10.3390/microorganisms8040613] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 02/06/2023] Open
Abstract
Cryptococcosis is an important opportunistic infection and a leading cause of meningitis in patients with HIV infection. The antifungal pharmacological treatment is limited to amphotericin B, fluconazole and 5- flucytosine. In addition to the limited pharmacological options, the high toxicity, increased resistance rate and difficulty of the currently available antifungal molecules to cross the blood-brain barrier hamper the treatment. Thus, the search for new alternatives for the treatment of cryptococcal meningitis is extremely necessary. In this review, we describe the therapeutic strategies currently available, discuss new molecules with antifungal potential in different phases of clinical trials and in advanced pre-clinical phase, and examine drug nanocarriers to improve delivery to the central nervous system.
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Affiliation(s)
- Cristina de Castro Spadari
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.d.C.S.); (F.W.)
| | - Fernanda Wirth
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.d.C.S.); (F.W.)
| | - Luciana Biagini Lopes
- Laboratory of Nanomedicine and Drug Delivery Systems, Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil;
| | - Kelly Ishida
- Laboratory of Antifungal Chemotherapy, Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil; (C.d.C.S.); (F.W.)
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14
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Colon BL, Rice CA, Guy RK, Kyle DE. Phenotypic Screens Reveal Posaconazole as a Rapidly Acting Amebicidal Combination Partner for Treatment of Primary Amoebic Meningoencephalitis. J Infect Dis 2020; 219:1095-1103. [PMID: 30358879 DOI: 10.1093/infdis/jiy622] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 10/23/2018] [Indexed: 11/13/2022] Open
Abstract
Naegleria fowleri is the causative agent of primary amoebic meningoencephalitis (PAM), which is fatal in >97% of cases. In this study, we aimed to identify new, rapidly acting drugs to increase survival rates. We conducted phenotypic screens of libraries of Food and Drug Administration-approved compounds and the Medicines for Malaria Venture Pathogen Box and validated 14 hits (defined as a 50% inhibitory concentration of <1 μM). The hits were then prioritized by assessing the rate of action and efficacy in combination with current drugs used to treat PAM. Posaconazole was found to inhibit amoeba growth within the first 12 hours of exposure, which was faster than any currently used drug. In addition, posaconazole cured 33% of N. fowleri-infected mice at a dose of 20 mg/kg and, in combination with azithromycin, increased survival by an additional 20%. Fluconazole, which is currently used for PAM therapy, was ineffective in vitro and vivo. Our results suggest posaconazole could replace fluconazole in the treatment of PAM.
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Affiliation(s)
- Beatrice L Colon
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa.,Center for Tropical and Emerging Global Diseases, University of Georgia, Athens
| | - Christopher A Rice
- Department of Global Health, College of Public Health, University of South Florida, Tampa.,Center for Tropical and Emerging Global Diseases, University of Georgia, Athens
| | - R Kiplin Guy
- Department of Chemical Biology and Therapeutics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Dennis E Kyle
- Department of Global Health, College of Public Health, University of South Florida, Tampa.,Center for Tropical and Emerging Global Diseases, University of Georgia, Athens
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15
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Shi D, Chahal KK, Oto P, Nothias LF, Debnath A, McKerrow JH, Podust LM, Abagyan R. Identification of Four Amoebicidal Nontoxic Compounds by a Molecular Docking Screen of Naegleria fowleri Sterol Δ8-Δ7-Isomerase and Phenotypic Assays. ACS Infect Dis 2019; 5:2029-2038. [PMID: 31583882 PMCID: PMC7085920 DOI: 10.1021/acsinfecdis.9b00227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Naegleria fowleri is a free-living amoeba causing primary amoebic meningoencephalitis, a rapid-onset brain infection in humans with over 97% mortality rate. Despite some progress in the treatment of the disease, there is no single, proven, evidence-based treatment with a high probability of cure. Here we report the chemical library screening and experimental identification of four new compounds with amoebicidal effects against N. fowleri. The chemical library was screened by molecular docking against a homology model of sterol Δ8-Δ7 isomerase (NfERG2). Thirty top-ranking hits were then tested in a cell-based assay for antiproliferative/amoebicidal activities. Eight chemicals exhibited nearly 100% inhibition of N. fowleri at 50 μM, with the EC50 values ranging from 6 to 25 μM. A cell toxicity assay using human HEK-293 cells was also performed. Four of the compounds preferentially kill amoeba cells with no apparent human cell toxicities. These compounds fall into two distinct chemical scaffolds with druglike properties.
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Affiliation(s)
- Da Shi
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego,9500 Gilman Drive, La Jolla, California, 92093, United States of America
| | - Kirti Kandhwal Chahal
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego,9500 Gilman Drive, La Jolla, California, 92093, United States of America
- Department of Pharmaceutical Sciences, Guru Jambheshwar University of Science and Technology, Hisar-Delhi Bypass Road, Hisar, Haryana 125001, India
| | - Patricia Oto
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego,9500 Gilman Drive, La Jolla, California, 92093, United States of America
| | - Louis-Felix Nothias
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego,9500 Gilman Drive, La Jolla, California, 92093, United States of America
| | - Anjan Debnath
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego,9500 Gilman Drive, La Jolla, California, 92093, United States of America
| | - James H. McKerrow
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego,9500 Gilman Drive, La Jolla, California, 92093, United States of America
| | - Larissa M. Podust
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego,9500 Gilman Drive, La Jolla, California, 92093, United States of America
| | - Ruben Abagyan
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California San Diego,9500 Gilman Drive, La Jolla, California, 92093, United States of America
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16
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Ashley ED. Antifungal Drugs: Special Problems Treating Central Nervous System Infections. J Fungi (Basel) 2019; 5:E97. [PMID: 31614505 PMCID: PMC6958367 DOI: 10.3390/jof5040097] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 02/07/2023] Open
Abstract
Treating fungal infections in the central nervous system (CNS) remains a challenge despite the availability of new antifungal agents. Therapy is limited by poor understanding of the kinetic properties of antifungal drugs in the CNS compounded by lack of data for many agents. In some cases, clinical response rates do not correspond to data on drug concentrations in the cerebral spinal fluid and/or brain parenchyma. In order to better characterize the use of antifungal agents in treating CNS infections, a review of the essential principles of neuroPK are reviewed. Specific data regarding antifungal drug concentrations in the cerebral spinal fluid and brain tissue are described from human data where available. Alternative dosing regimens and the role of antifungal drug concentration monitoring in treating fungal infections in the CNS are also discussed. Having a better understanding of these key concepts will help guide clinicians in determining the best treatment courses for patients with these devastating infections.
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Affiliation(s)
- Elizabeth Dodds Ashley
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, NC 27710, USA.
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17
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Ryan D, Lippert WC, Fenwick AJ, Bhatt M, Jones CR. Central Nervous System Blastomycosis With Multiple Brain Abscesses Presenting as Right Upper Extremity Weakness. Neurohospitalist 2019; 9:230-234. [PMID: 31534614 DOI: 10.1177/1941874419829276] [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: 11/16/2022] Open
Abstract
Blastomycosis is a mycotic infection that typically affects the lung, but that can have dermatologic, orthopedic, genitourinary, and central nervous system manifestations. Blastomyces dermatitidis is a true human pathogen, which can produce disease in immunocompetent hosts. Risk factors for infection include residence in or travel to endemic areas and outdoor occupation, particularly those activities near open bodies of water and that disrupt soil. Immunosuppressed patients are also at increased risk for severe and disseminated disease. We present a case of a 79-year-old male who presented with a 2-week history of progressive right upper extremity weakness and severe odontogenic disease. He was found to have multiple brain abscesses with positive cultures from a cerebral abscess incision and drainage for B dermatitidis. He underwent an incision and drainage of the largest cerebral abscess and was treated with intravenous liposomal amphotericin B, which he tolerated poorly. He was subsequently switched to voriconazole, which was well tolerated, and his neurological deficits improved throughout his hospitalization.
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Affiliation(s)
- Dylan Ryan
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - William C Lippert
- Department of Internal Medicine, Section of Hospital Medicine, Wake Forest Baptist Medical Center, NC, USA
| | - Alexander J Fenwick
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahesh Bhatt
- Division of Infectious Diseases, University of Kentucky Medical Center, Lexington, KY, USA
| | - Charles R Jones
- Division of Hospital Medicine, University of Kentucky Medical Center, Lexington, KY, USA
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18
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Xu L, Tao R, Wu J, Dai X, Hu C, Huang Y, Chen Y, Zhu B, He J. Short-Course Rather Than Low-Dose Amphotericin B May Exert Potential Influence on Mortality in Cryptococcal Meningitis Patients Treated With Amphotericin B Plus Flucytosine Alone or in Combination With Fluconazole. Front Microbiol 2019; 10:2082. [PMID: 31551999 PMCID: PMC6747010 DOI: 10.3389/fmicb.2019.02082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/23/2019] [Indexed: 12/20/2022] Open
Abstract
Background The influence of Amphotericin B (AmB) dose and the addition of fluconazole (Flu) on the AmB + 5-flucytosine (5FC) regimen for cryptococcal meningitis (CM) treatment remain debatable. Methods A retrospective study was conducted to compare 44 CM patients treated with AmB + 5FC and 78 CM patients treated with AmB + 5FC + Flu using the propensity score matching method. The effects of AmB dosage, AmB course and Flu addition on the cerebrospinal fluid (CSF) chemical profile recovery, adverse effects, and 90-day mortality were compared between the groups. Results No differences in adverse effects, the rate of the 14-day CSF chemical profile recovery and 90-day cumulative survival rate (91.2% vs. 87.5%, P = 0.637) were observed between the AmB + 5FC group and the AmB + 5FC + Flu group. However, the incidence rates of hypokalemia (33.9%) and creatinine elevation (7.1%) in patients treated with an AmB dosage of 0.4–0.5 mg/kg/d were less than those (53.0 and 22.7%, respectively) treated with an AmB dosage of 0.6–0.7 mg/kg/d (P = 0.034 and P = 0.018, respectively). The 90-day cumulative survival rate was 70.1% for patients treated with AmB for <14 days and 96.4% for patients treated with AmB for ≥14 days (log-rank P < 0.001). Multivariate Cox proportional hazards models suggested the hazard ratio was 26.8 (95% CI: 3.9–183.2) for patients treated with AmB < 14 days than those treated with AmB ≥ 14 days (P = 0.001). Conclusion Treatment with AmB less than 14 days was associated with a higher 90-day mortality in CM patients. A relative lower dosage but prolonged course of AmB in the +5FC ± Flu regimen led to favorable trends of fewer adverse effects and comparable clinical efficacy.
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Affiliation(s)
- Lijun Xu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ran Tao
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jingjing Wu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiahong Dai
- Department of Infectious Diseases, Shulan Hospital, Hangzhou, China
| | - Caiqin Hu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ying Huang
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - YaoKai Chen
- Chongqing Public Health Medical Center, Chongqing, China
| | - Biao Zhu
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianqin He
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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19
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Chorlton SD. Adjunctive bradyzoite-directed therapy for reducing complications of congenital toxoplasmosis. Med Hypotheses 2019; 133:109376. [PMID: 31472369 DOI: 10.1016/j.mehy.2019.109376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/18/2019] [Indexed: 11/25/2022]
Abstract
Congenital toxoplasmosis is caused by in utero infection of the fetus with the intracellular parasite Toxoplasma gondii. Upon infection, the parasite forms life-long cysts in fetal brain and eyes which are resistant to the currently accepted therapy of pyrimethamine and sulfadiazine. These cysts commonly reactivate later in life causing chorioretinitis and visual impairment, and rarely cause neurological complications. I hypothesize that adjunctive, bradyzoite-directed therapies have the potential to alleviate a significant burden of disease by reducing cyst burden in neonatal brain and eyes. Atovaquone is perhaps the most promising drug for further evaluation given its low side-effect profile, established safety, and efficacy in animal models reducing cyst burden. Very limited observational data in humans suggests atovaquone may prevent Toxoplasma-associated chorioretinitis recurrence. Clinical trials are needed to evaluate it and other potential drugs as adjunctive treatment in congenital toxoplasmosis.
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Affiliation(s)
- Samuel D Chorlton
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.
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20
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Gerhart JG, Watt KM, Edginton A, Wade KC, Salerno SN, Benjamin DK, Smith PB, Hornik CP, Cohen-Wolkowiez M, Duara S, Ross A, Shattuck K, Stewart DL, Neu N, Gonzalez D. Physiologically-Based Pharmacokinetic Modeling of Fluconazole Using Plasma and Cerebrospinal Fluid Samples From Preterm and Term Infants. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:500-510. [PMID: 31087536 PMCID: PMC6656941 DOI: 10.1002/psp4.12414] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 12/16/2022]
Abstract
Fluconazole is used to treat hematogenous Candida meningoencephalitis in preterm and term infants. To characterize plasma and central nervous system exposure, an adult fluconazole physiologically‐based pharmacokinetic (PBPK) model was scaled to infants, accounting for age dependencies in glomerular filtration and metabolism. The model was optimized using 760 plasma samples from 166 infants (median postmenstrual age (range) 28 weeks (24–50)) and 27 cerebrospinal fluid (CSF) samples from 22 infants (postmenstrual age 28 weeks (24–33)). Simulations evaluated achievement of the surrogate efficacy target of area under the unbound concentration‐time curve ≥ 400 mg • hour/L over the dosing interval in plasma and CSF using dosing guidelines. Average fold error of predicted concentrations was 0.73 and 1.14 for plasma and CSF, respectively. Target attainment in plasma and CSF was reached faster after incorporating a loading dose of 25 mg/kg. PBPK modeling can be useful in exploring CNS kinetics of drugs in children.
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Affiliation(s)
- Jacqueline G Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kevin M Watt
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Kelly C Wade
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sara N Salerno
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Shahnaz Duara
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Ashley Ross
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Karen Shattuck
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, USA
| | - Dan L Stewart
- Department of Pediatrics, University of Louisville, Louisville, Kentucky, USA
| | - Natalie Neu
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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21
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Wirth F, de Azevedo MI, Pilla C, Aquino VR, Neto GW, Goldani LZ. Relationship between intracranial pressure and antifungal agents levels in the CSF of patients with cryptococcal meningitis. Med Mycol 2019; 56:257-262. [PMID: 28992308 DOI: 10.1093/mmy/myx054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/29/2017] [Indexed: 11/13/2022] Open
Abstract
The purpose of this study was to evaluate the influence of intracranial hypertension in the cerebrospinal fluid (CSF) levels of amphotericin B and fluconazole levels of patients with cryptococcal meningitis. CSF samples and intracranial pressure were obtained by means of routine punctures performed at days 1, 7, and 14 of therapy, respectively. Amphotericin B and fluconazole CSF levels were measured by HPLC method as previously described. The minimum inhibitory concentration for amphotericin B, fluconazole, 5΄flucytosine, and voriconazole of each Cryptococcus isolate was performed according to CLSI. The predominant Cryptococcus species found was C. neoformans, and the major underlying condition was AIDS. Only one CSF sample had a detectable level for amphotericin B during the 14 days of therapy. Fluconazole CSF levels progressively increased from day 1 to day 14 of therapy for most cases. Fluconazole levels in the CSF were above the minimum inhibitory concentrations (MICs) for Cryptococcus during the initial 14 days of antifungal therapy. Variations of intracranial pressure did not affect amphotericin B and fluconazole levels in the CSF. The generalized estimating correlation (GEE) and Spearman correlation test (SCT) showed no significant correlation between the amphotericin B or fluconazole concentrations in the CSF and intracranial pressure (P = .953 and P = .093, respectively for GEE test and P = .477 and P = .847, respectively, for SCT). Combination therapy of amphotericin B with fluconazole was effective in 60% of the patients considering CSF cultures were negative in 9 of 15 patients after 14 days of therapy. Further studies are necessary to evaluate the role of intracranial hypertension on the therapeutic efficacy of different antifungal agents in patients with cryptococcal meningitis.
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Affiliation(s)
- Fernanda Wirth
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Ramiro Barcelos, 2400. Porto Alegre, RS, Brazil.,Hospital de Clínicas de Porto Alegre (HCPA), Section of Infectious Diseases. Ramiro Barcelos, 2350. Porto Alegre, RS, Brazil
| | - Maria Isabel de Azevedo
- Universidade Federal de Santa Maria. Laboratório de Pesquisas Micológicas. Departamento de Microbiologia e Parasitologia. Avenida Roraima, 1000. Santa Maria, RS, Brazil
| | - Carmen Pilla
- Hospital de Clínicas de Porto Alegre (HCPA). Serviço de Patologia Clínica. Ramiro Barcelos, 2350. Porto Alegre, RS, Brazil
| | - Valério Rodrigues Aquino
- Hospital de Clínicas de Porto Alegre (HCPA). Serviço de Patologia Clínica. Ramiro Barcelos, 2350. Porto Alegre, RS, Brazil
| | - Gustavo Wissmann Neto
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Ramiro Barcelos, 2400. Porto Alegre, RS, Brazil.,Hospital de Clínicas de Porto Alegre (HCPA), Section of Infectious Diseases. Ramiro Barcelos, 2350. Porto Alegre, RS, Brazil
| | - Luciano Zubaran Goldani
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Ramiro Barcelos, 2400. Porto Alegre, RS, Brazil.,Hospital de Clínicas de Porto Alegre (HCPA), Section of Infectious Diseases. Ramiro Barcelos, 2350. Porto Alegre, RS, Brazil
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22
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Nwafor DC, Brichacek AL, Mohammad AS, Griffith J, Lucke-Wold BP, Benkovic SA, Geldenhuys WJ, Lockman PR, Brown CM. Targeting the Blood-Brain Barrier to Prevent Sepsis-Associated Cognitive Impairment. J Cent Nerv Syst Dis 2019; 11:1179573519840652. [PMID: 31007531 PMCID: PMC6456845 DOI: 10.1177/1179573519840652] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 01/21/2019] [Indexed: 12/17/2022] Open
Abstract
Sepsis is a systemic inflammatory disease resulting from an infection. This disorder affects 750 000 people annually in the United States and has a 62% rehospitalization rate. Septic symptoms range from typical flu-like symptoms (eg, headache, fever) to a multifactorial syndrome known as sepsis-associated encephalopathy (SAE). Patients with SAE exhibit an acute altered mental status and often have higher mortality and morbidity. In addition, many sepsis survivors are also burdened with long-term cognitive impairment. The mechanisms through which sepsis initiates SAE and promotes long-term cognitive impairment in septic survivors are poorly understood. Due to its unique role as an interface between the brain and the periphery, numerous studies support a regulatory role for the blood-brain barrier (BBB) in the progression of acute and chronic brain dysfunction. In this review, we discuss the current body of literature which supports the BBB as a nexus which integrates signals from the brain and the periphery in sepsis. We highlight key insights on the mechanisms that contribute to the BBB's role in sepsis which include neuroinflammation, increased barrier permeability, immune cell infiltration, mitochondrial dysfunction, and a potential barrier role for tissue non-specific alkaline phosphatase (TNAP). Finally, we address current drug treatments (eg, antimicrobials and intravenous immunoglobulins) for sepsis and their potential outcomes on brain function. A comprehensive understanding of these mechanisms may enable clinicians to target specific aspects of BBB function as a therapeutic tool to limit long-term cognitive impairment in sepsis survivors.
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Affiliation(s)
- Divine C Nwafor
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Allison L Brichacek
- Immunology and Microbial Pathogenesis, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Afroz S Mohammad
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Jessica Griffith
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Brandon P Lucke-Wold
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Stanley A Benkovic
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Werner J Geldenhuys
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Paul R Lockman
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Pharmaceutical Sciences, School of Pharmacy, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Candice M Brown
- Graduate Programs in Neuroscience, Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Neuroscience, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Immunology and Microbial Pathogenesis, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, Health Sciences Center, West Virginia University, Morgantown, WV, USA
- Center for Basic and Translational Stroke Research, Rockefeller Neuroscience Institute, Health Sciences Center, West Virginia University, Morgantown, WV, USA
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Nel JS, Bartelt LA, van Duin D, Lachiewicz AM. Endemic Mycoses in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:667-685. [PMID: 30146029 DOI: 10.1016/j.idc.2018.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The endemic mycoses are a group of thermally dimorphic fungal pathogens occupying a specific geographic range. In North America, the chief endemic mycoses are histoplasmosis, coccidioidomycosis, and blastomycosis. Endemic fungi can cause serious infections in solid organ transplant recipients from primary infection, reactivation of latent disease, or donor-derived infection.
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Affiliation(s)
- Jeremy S Nel
- Division of Infectious Diseases, University of North Carolina, CB 7030, 130 Mason Farm Road, Chapel Hill, NC 27599, USA
| | - Luther A Bartelt
- Division of Infectious Diseases, University of North Carolina, CB 7030, 130 Mason Farm Road, Chapel Hill, NC 27599, USA
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, CB 7030, 130 Mason Farm Road, Chapel Hill, NC 27599, USA
| | - Anne M Lachiewicz
- Division of Infectious Diseases, University of North Carolina, CB 7030, 130 Mason Farm Road, Chapel Hill, NC 27599, USA.
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Population Pharmacokinetics and Cerebrospinal Fluid Penetration of Fluconazole in Adults with Cryptococcal Meningitis. Antimicrob Agents Chemother 2018; 62:AAC.00885-18. [PMID: 29914943 PMCID: PMC6125572 DOI: 10.1128/aac.00885-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/08/2018] [Indexed: 01/26/2023] Open
Abstract
Robust population pharmacokinetic (PK) data for fluconazole are scarce. The variability of fluconazole penetration into the central nervous system (CNS) is not known. Robust population pharmacokinetic (PK) data for fluconazole are scarce. The variability of fluconazole penetration into the central nervous system (CNS) is not known. A fluconazole PK study was conducted in 43 patients receiving oral fluconazole (usually 800 mg every 24 h [q24h]) in combination with amphotericin B deoxycholate (1 mg/kg q24h) for cryptococcal meningitis (CM). A four-compartment PK model was developed, and Monte Carlo simulations were performed for a range of fluconazole dosages. A meta-analysis of trials reporting outcomes of CM patients treated with fluconazole monotherapy was performed. Adjusted for bioavailability, the PK parameter means (standard deviation) were the following: clearance, 0.72 (0.24) liters/h; volume of the central compartment, 18.07 (6.31) liters; volume of the CNS compartment, 32.07 (17.60) liters; first-order rate constant from the central to peripheral compartment, 12.20 (11.17) h−1, from the peripheral to central compartment, 18.10 (8.25) h−1, from the central to CNS compartment, 35.43 (13.74) h−1, and from the CNS to central the compartment, 28.63 (10.03) h−1. Simulations of the area under concentration-time curve resulted in median (interquartile range) values of 1,143.2 (range, 988.4 to 1,378.0) mg · h/liter in plasma (AUCplasma) and 982.9 (range, 781.0 to 1,185.9) mg · h/liter in cerebrospinal fluid (AUCCSF) after a dosage of 1,200 mg q24h. The mean simulated ratio of AUCCSF/AUCplasma was 0.89 (standard deviation [SD], 0.44). The recommended dosage of fluconazole for CM induction therapy fails to attain the pharmacodynamic (PD) target in respect to the wild-type MIC distribution for C. neoformans. The meta-analysis suggested modest improvements in both CSF sterility and mortality outcomes with escalating dosage. This study provides the pharmacodynamic rationale for the long-recognized fact that fluconazole monotherapy is an inadequate induction regimen for CM.
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Beardsley J, Halliday CL, Chen SCA, Sorrell TC. Responding to the emergence of antifungal drug resistance: perspectives from the bench and the bedside. Future Microbiol 2018; 13:1175-1191. [PMID: 30113223 PMCID: PMC6190174 DOI: 10.2217/fmb-2018-0059] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/01/2018] [Indexed: 12/15/2022] Open
Abstract
The incidence of serious fungal infections is increasing rapidly, and yet the rate of new drugs becoming available to treat them is slow. The limited therapeutic armamentarium is a challenge for clinicians, because the available drugs are often toxic, expensive, difficult to administer, ineffective or a combination of all four. Given this setting, the emergence of resistance is especially concerning, and a review of the topic is timely. Here we discuss antifungal drug resistance in Candida spp. and Aspergillus spp. with reference to the most commonly used first-line antifungal agents - azoles and echinocandins. We review the resistance mechanisms of the leading pathogens, how resistance can be identified in the diagnostic lab and the clinical implications of resistance once detected.
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Affiliation(s)
- Justin Beardsley
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney & Westmead Institute for Medical Research, Westmead, NSW, Australia
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Catriona L Halliday
- The Center for Infectious Diseases & Microbiology Laboratory Services, ICPMR Pathology West, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Sharon C-A Chen
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney & Westmead Institute for Medical Research, Westmead, NSW, Australia
- The Center for Infectious Diseases & Microbiology Laboratory Services, ICPMR Pathology West, New South Wales Health Pathology, Westmead, NSW, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney & Westmead Institute for Medical Research, Westmead, NSW, Australia
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Stott KE, Hope W. Pharmacokinetics–pharmacodynamics of antifungal agents in the central nervous system. Expert Opin Drug Metab Toxicol 2018; 14:803-815. [DOI: 10.1080/17425255.2018.1492551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Katharine E Stott
- Antimicrobial Pharmacodynamics and Therapeutics Laboratory, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics Laboratory, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Bodilsen J, Brouwer MC, Nielsen H, Van De Beek D. Anti-infective treatment of brain abscess. Expert Rev Anti Infect Ther 2018; 16:565-578. [PMID: 29909695 DOI: 10.1080/14787210.2018.1489722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Brain abscess is an uncommon and potentially life-threatening infection of the CNS that can be caused by a range of different pathogens including bacteria, fungi, and parasites. A multidisciplinary approach is important and anti-infective treatment remains crucial. Here, we review anti-infective treatment of brain abscess. Areas covered: We used the terms '(Brain abscess[ti] AND (antibiotic* OR treatment)) NOT case report'), to conduct a search in the PubMed. Additional papers were identified by cross-reference checking and by browsing textbooks of infectious diseases and neurology. COMMENTARY Empiric treatment of bacterial brain abscess consists of cefotaxime and metronidazole with the addition of vancomycin if meticilline-resistant Staphylococcus aureus is suspected. For severely immuno-suppressed patients, for example transplant recipients, voriconazole and trimethoprim-sulfamethoxazole or sulfadiazine should be added. Increased knowledge of the pharmacokinetic profile of anti-infective treatments may help to improve the treatment of brain abscess. Future studies should address efficacy and safety of continuous abscess drainage, mode of anti-infective administration (continuous vs. bolus), and anti-infective treatments in immuno-suppressed patients.
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Affiliation(s)
- Jacob Bodilsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Matthijs C Brouwer
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Henrik Nielsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Diederik Van De Beek
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
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Population Pharmacokinetic Model and Meta-analysis of Outcomes of Amphotericin B Deoxycholate Use in Adults with Cryptococcal Meningitis. Antimicrob Agents Chemother 2018; 62:AAC.02526-17. [PMID: 29735567 PMCID: PMC6021666 DOI: 10.1128/aac.02526-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/27/2018] [Indexed: 02/02/2023] Open
Abstract
There is a limited understanding of the population pharmacokinetics (PK) and pharmacodynamics (PD) of amphotericin B deoxycholate (DAmB) for cryptococcal meningitis. A PK study was conducted in n = 42 patients receiving DAmB (1 mg/kg of body weight every 24 h [q24h]). A 2-compartment PK model was developed. Patient weight influenced clearance and volume in the final structural model. Monte Carlo simulations estimated drug exposure associated with various DAmB dosages. A search was conducted for trials reporting outcomes of treatment of cryptococcal meningitis patients with DAmB monotherapy, and a meta-analysis was performed. The PK parameter means (standard deviations) were as follows: clearance, 0.03 (0.01) × weight + 0.67 (0.01) liters/h; volume, 0.82 (0.80) × weight + 1.76 (1.29) liters; first-order rate constant from central compartment to peripheral compartment, 5.36 (6.67) h-1; first-order rate constant from peripheral compartment to central compartment, 9.92 (12.27) h-1 The meta-analysis suggested that the DAmB dosage explained most of the heterogeneity in cerebrospinal fluid (CSF) sterility outcomes but not in mortality outcomes. Simulations of values corresponding to the area under concentration-time curve from h 144 to h 168 (AUC144-168) resulted in median (interquartile range) values of 5.83 mg · h/liter (4.66 to 8.55), 10.16 mg · h/liter (8.07 to 14.55), and 14.51 mg · h/liter (11.48 to 20.42) with dosages of 0.4, 0.7, and 1.0 mg/kg q24h, respectively. DAmB PK is described adequately by a linear model that incorporates weight with clearance and volume. Interpatient PK variability is modest and unlikely to be responsible for variability in clinical outcomes. There is discordance between the impact that drug exposure has on CSF sterility and its impact on mortality outcomes, which may be due to cerebral pathology not reflected in CSF fungal burden, in addition to clinical variables.
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Alvarez-Uria G, Midde M, Battula J, Pujari HNB. Safety and tolerability of intrathecal liposomal amphotericin B ( AmBisome) for cryptococcal meningitis: a retrospective study in HIV-infected patients. Ther Adv Infect Dis 2018; 5:77-81. [PMID: 30224950 DOI: 10.1177/2049936118782846] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/24/2018] [Indexed: 11/16/2022] Open
Abstract
Background While mortality of HIV-related cryptococcal meningitis (CM) in developed countries is relatively low, in developing countries over half of patients die within 10 weeks. Current recommended therapies are often not suitable for resource-poor settings, and new shorter regimens are urgently needed. Intrathecal administration of liposomal amphotericin B (lAmB) has shown promising results in animal models. However, the safety and tolerability of intrathecal lAmB in humans are not well known. Methods In this retrospective observational study, we report the tolerability and safety of intrathecal lAmB in patients with CM from an HIV cohort study in India. Results In all, 18 patients were included in the analysis. Six were female and the median age was 40 years [interquartile range (IQR): 35-45]. The median CD4 count was 42 cells/µl (IQR: 19-127). Compared with a historical control group, the hazard ratio for mortality was 0.59 (95% confidence interval: 0.26-1.29). Two patients complained of transient lumbar pain in single occasion. One patient had a skin reaction to chlorhexidine, which was used as skin disinfectant. After initial improvement, one patient requested to stop lumbar punctures for the last 2 days of treatment. Conclusion Intrathecal lAmB was safe and well tolerated in HIV-infected patients with CM.
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Affiliation(s)
- Gerardo Alvarez-Uria
- Department of Infectious Diseases, Bathalapalli Rural Development Trust Hospital, Kadiri Road, Bathalapalli 515661, Anantapur District, Andhra Pradesh, India
| | - Manoranjan Midde
- Department of Infectious Diseases, Bathalapalli Rural Development Trust Hospital, Bathalapalli, India
| | - Jayaram Battula
- Department of Infectious Diseases, Bathalapalli Rural Development Trust Hospital, Bathalapalli, India
| | - Himachandra N B Pujari
- Department of Infectious Diseases, Bathalapalli Rural Development Trust Hospital, Bathalapalli, India
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Alves IA, Staudt KJ, Carreño FO, de Araujo Lock G, de Miranda Silva C, Rates SMK, Dalla Costa T, De Araujo BV. Population Pharmacokinetic Modeling to Describe the Total Plasma and Free Brain Levels of Fluconazole in Healthy and Cryptococcus neoformans Infected Rats: How Does the Infection Impact the Drug's Levels on Biophase? Pharm Res 2018; 35:132. [PMID: 29704215 DOI: 10.1007/s11095-018-2402-9] [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: 10/31/2017] [Accepted: 04/05/2018] [Indexed: 01/04/2023]
Abstract
PURPOSE The present work aimed to evaluate the influence of experimental meningitis caused by C. neoformans on total plasma and free brain concentrations of fluconazole (FLC) in Wistar rats. METHOD The infection was induced by the administration of 100 μL of inoculum (1.105 CFU) through the tail vein. Free drug in the brain was assessed by microdialisys (μD). Blood and μD samples were collected at pre-determined time points up to 12 h after intravenous administration of FLC (20 mg/kg) to healthy and infected rats. The concentration-time profiles were analyzed by non-compartmental and population pharmacokinetics approaches. RESULTS A two-compartmental popPK model was able to simultaneously describe plasma and free drug concentrations in the brain for both groups investigated. Analysis of plasma and μD samples showed a better FLC distribution on the brain of infected than healthy animals (1.04 ± 0.31 vs 0.69 ± 0.14, respectively). The probability of target attainment was calculated by Monte Carlo simulations based on the developed popPK model for 125 mg/kg dose for rats and 400-2000 mg for humans. CONCLUSIONS FLC showed a limited use in monotherapy to the treatment of criptoccocosis in rats and humans to value of MIC >8 μg/mL.
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Affiliation(s)
- Izabel Almeida Alves
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Keli Jaqueline Staudt
- Medical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga 2752, office 407, Porto Alegre, RS, 90610-000, Brazil
| | - Fernando Olinto Carreño
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Graziela de Araujo Lock
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Carolina de Miranda Silva
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Stela Maris Kuze Rates
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Teresa Dalla Costa
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Bibiana Verlindo De Araujo
- Pharmaceutical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil. .,Medical Sciences Graduate Program of Federal University of Rio Grande do Sul, Av. Ipiranga 2752, office 407, Porto Alegre, RS, 90610-000, Brazil.
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Shah H, Honeybul S, Tang S, Arthur I, McLaren S, Boan P. Mould meningitis associated with intravenous drug use. Med Mycol Case Rep 2018; 20:18-20. [PMID: 30148056 PMCID: PMC6105917 DOI: 10.1016/j.mmcr.2018.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 12/27/2017] [Accepted: 01/09/2018] [Indexed: 10/31/2022] Open
Abstract
Fungal meningitis is most commonly causes by Cryptococcus species and dimorphic fungi. We present a rare case of mould meningitis, ventriculitis and subependymal nodules in an immunocompetent patient, having likely seeded the meninges and ventricular system through intravenous drug use. The causative mould remains undetermined. The case highlights the poor sensitivity of CSF culture and the need to consider surgical biopsy where there is diagnostic difficulty and fungal infection is being considered.
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Affiliation(s)
- Hassan Shah
- Department of Rehabilitation Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Stephanie Tang
- Department of Rehabilitation Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Ian Arthur
- PathWest Laboratory Medicine WA, Department of Microbiology, QEII Medical Centre, Perth, Western Australia, Australia
| | - Sally McLaren
- PathWest Laboratory Medicine WA, Department of Anatomical Pathology, QEII Medical Centre, Perth, Western Australia, Australia
| | - Peter Boan
- Departments of Infectious Diseases and Microbiology, Fiona Stanley Hospital and PathWest Laboratory Medicine WA, Perth, Western Australia, Australia
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Debnath A, Calvet CM, Jennings G, Zhou W, Aksenov A, Luth MR, Abagyan R, Nes WD, McKerrow JH, Podust LM. CYP51 is an essential drug target for the treatment of primary amoebic meningoencephalitis (PAM). PLoS Negl Trop Dis 2017; 11:e0006104. [PMID: 29284029 PMCID: PMC5746216 DOI: 10.1371/journal.pntd.0006104] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 11/08/2017] [Indexed: 11/24/2022] Open
Abstract
Primary Amoebic Meningoencephalitis (PAM) is caused by Naegleria fowleri, a free-living amoeba that occasionally infects humans. While considered "rare" (but likely underreported) the high mortality rate and lack of established success in treatment makes PAM a particularly devastating infection. In the absence of economic inducements to invest in development of anti-PAM drugs by the pharmaceutical industry, anti-PAM drug discovery largely relies on drug 'repurposing'-a cost effective strategy to apply known drugs for treatment of rare or neglected diseases. Similar to fungi, N. fowleri has an essential requirement for ergosterol, a building block of plasma and cell membranes. Disruption of sterol biosynthesis by small-molecule inhibitors is a validated interventional strategy against fungal pathogens of medical and agricultural importance. The N. fowleri genome encodes the sterol 14-demethylase (CYP51) target sharing ~35% sequence identity to fungal orthologues. The similarity of targets raises the possibility of repurposing anti-mycotic drugs and optimization of their usage for the treatment of PAM. In this work, we (i) systematically assessed the impact of anti-fungal azole drugs, known as conazoles, on sterol biosynthesis and viability of cultured N. fowleri trophozotes, (ii) identified the endogenous CYP51 substrate by mass spectrometry analysis of N. fowleri lipids, and (iii) analyzed the interactions between the recombinant CYP51 target and conazoles by UV-vis spectroscopy and x-ray crystallography. Collectively, the target-based and parasite-based data obtained in these studies validated CYP51 as a potentially 'druggable' target in N. fowleri, and conazole drugs as the candidates for assessment in the animal model of PAM.
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Affiliation(s)
- Anjan Debnath
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Claudia M. Calvet
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
- Cellular Ultrastructure Laboratory, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | - Gareth Jennings
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Wenxu Zhou
- Department of Chemistry & Biochemistry, Texas Tech University, Lubbock, Texas, United States of America
| | - Alexander Aksenov
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Madeline R. Luth
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Ruben Abagyan
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - W. David Nes
- Department of Chemistry & Biochemistry, Texas Tech University, Lubbock, Texas, United States of America
| | - James H. McKerrow
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Larissa M. Podust
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
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Abstract
Invasive fungal infections are a significant cause of morbidity and mortality in infants and children. Early diagnosis is critical, and treatment with the appropriate drug and dose should be initiated promptly. Although an increasing number of studies have examined dosing of antifungals in this population, pediatric safety and efficacy data are lacking.
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Affiliation(s)
- Mihai Puia-Dumitrescu
- Department of Pediatrics, Division of Neonatal Medicine, Duke University Medical Center, 2424 Erwin Road, Suite 504, Durham, NC 27705, USA; Department of Pediatrics, Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715, USA
| | - P Brian Smith
- Department of Pediatrics, Division of Neonatal Medicine, Duke University Medical Center, 2424 Erwin Road, Suite 504, Durham, NC 27705, USA; Department of Pediatrics, Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715, USA.
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Tissue Distribution and Elimination of Isavuconazole following Single and Repeat Oral-Dose Administration of Isavuconazonium Sulfate to Rats. Antimicrob Agents Chemother 2017; 61:AAC.01292-17. [PMID: 28971866 PMCID: PMC5700325 DOI: 10.1128/aac.01292-17] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/23/2017] [Indexed: 12/18/2022] Open
Abstract
Quantitative whole-body autoradiography was used to assess the distribution and tissue penetration of isavuconazole in rats following single and repeated oral-dose administration of radiolabeled isavuconazonium sulfate, the prodrug of isavuconazole. Following a single-dose administration of radiolabeled isavuconazonium sulfate (labeled on the active moiety), radioactivity was detectable within 1 h postdose in 56 of 65 tissue/fluid specimens. The highest maximum concentrations (Cmax) were observed in bile and liver (66.6 and 24.7 μg eq/g, respectively). The lowest Cmax values were in bone and eye lens (0.070 and 0.077 μg eq/g, respectively). By 144 h postdose, radioactivity was undetectable in all tissues/fluids except liver (undetectable at 336 h) and adrenal gland tissues (undetectable at 672 h). Following daily administration for up to 21 days, 1-h-postdose Cmax values were the highest on or before day 14 in all except seven tissues/fluids, of which only rectum mucosa and small intestine mucosa had Cmax values >25% higher than all other 1-h-postdose values. For 24-h-postdose Cmax values, only large intestine, large intestine mucosa, and urine had the highest Cmax values at day 21. The penetration of single oral doses of unlabeled isavuconazole (25 mg/kg of body weight isavuconazonium sulfate) and voriconazole (50 mg/kg) into rat brain (assessed using liquid chromatography-tandem mass spectrometry) was also compared. Brain concentration/plasma concentration ratios reached approximately 1.8:1 and 2:1, respectively. These data suggest that isavuconazole penetrates most tissues rapidly, reaches a steady state in most or all tissues/fluids within 14 days, does not accumulate in tissues/fluids over time, and achieves potentially efficacious concentrations in the brain.
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Wang W, Zheng N, Zhang J, Huang X, Yu S. Effect of Efflux Transporter Inhibition on the Distribution of Fluconazole in the Rat Brain. Neurochem Res 2017; 42:2274-2281. [PMID: 28337665 DOI: 10.1007/s11064-017-2240-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/23/2017] [Accepted: 03/17/2017] [Indexed: 11/30/2022]
Abstract
Multidrug resistance-associated proteins (MRPs) and organic anion transporters (OATs) are expressed on the blood-brain barrier (BBB) and blood-cerebrospinal fluid barrier (BCSFB), preventing the entry of or the pumping out of numerous molecules. Fluconazole is widely used to treat fungal meningoencephalitis. The effect of these transporters on the distribution of fluconazole in the brain is unclear. We used microdialysis to compare the distribution of fluconazole in the rat brain with and without co-administration of probenecid, a MRP and OAT inhibitor. Additionally, we also observed the difference in fluconazole distribution between the two barriers. The results showed that probenecid increased the penetration of fluconazole into the BBB but did not alter the penetration of fluconazole into the BCSFB of rats. The penetration of the BBB and BCSFB by fluconazole did not statistically differ according to physiological condition. These results demonstrate that transporters that can be inhibited by probenecid may be involved in fluconazole resistance at the BBB and provide a laboratory basis for predicting brain extracellular fluid (ECF) concentration using the cerebrospinal fluid (CSF) concentration of fluconazole.
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Affiliation(s)
- Wei Wang
- Department of Neurology, General Hospital of People's Liberation Army, No. 28, Fuxing Road, Haidian District, Beijing, 100853, China
| | - Na Zheng
- Department of Neurology, General Hospital of People's Liberation Army, No. 28, Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jiatang Zhang
- Department of Neurology, General Hospital of People's Liberation Army, No. 28, Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Xusheng Huang
- Department of Neurology, General Hospital of People's Liberation Army, No. 28, Fuxing Road, Haidian District, Beijing, 100853, China
| | - Shengyuan Yu
- Department of Neurology, General Hospital of People's Liberation Army, No. 28, Fuxing Road, Haidian District, Beijing, 100853, China
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Panda PK, Mavidi SK, Wig N, Garg A, Nalwa A, Sharma MC. Intracranial Aspergillosis in an Immunocompetent Young Woman. Mycopathologia 2017; 182:527-538. [PMID: 28054219 DOI: 10.1007/s11046-016-0106-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/16/2016] [Indexed: 02/07/2023]
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Gonzalez JM, Rodriguez CA, Agudelo M, Zuluaga AF, Vesga O. Antifungal pharmacodynamics: Latin America's perspective. Braz J Infect Dis 2016; 21:79-87. [PMID: 27821250 PMCID: PMC9425464 DOI: 10.1016/j.bjid.2016.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/14/2016] [Accepted: 09/19/2016] [Indexed: 11/23/2022] Open
Abstract
The current increment of invasive fungal infections and the availability of new broad-spectrum antifungal agents has increased the use of these agents by non-expert practitioners, without an impact on mortality. To improve efficacy while minimizing prescription errors and to reduce the high monetary cost to the health systems, the principles of pharmacokinetics (PK) and pharmacodynamics (PD) are necessary. A systematic review of the PD of antifungals agents was performed aiming at the practicing physician without expertise in this field. The initial section of this review focuses on the general concepts of antimicrobial PD. In vitro studies, fungal susceptibility and antifungal serum concentrations are related with different doses and dosing schedules, determining the PD indices and the magnitude required to obtain a specific outcome. Herein the PD of the most used antifungal drug classes in Latin America (polyenes, azoles, and echinocandins) is discussed.
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Affiliation(s)
- Javier M Gonzalez
- Clinica CARDIO VID, Medellín, Colombia; Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia
| | - Carlos A Rodriguez
- Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia
| | - Maria Agudelo
- Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia; Hospital Universitario San Vicente Fundación, Unidad de Enfermedades Infecciosas, Medellín, Colombia
| | - Andres F Zuluaga
- Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia
| | - Omar Vesga
- Universidad de Antioquia, Facultad de Medicina, Grupo Investigador de Problemas en Enfermedades Infecciosas (GRIPE), Medellín, Colombia; Hospital Universitario San Vicente Fundación, Unidad de Enfermedades Infecciosas, Medellín, Colombia.
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HIV Immune Recovery Inflammatory Syndrome and Central Nervous System Paracoccidioidomycosis. Mycopathologia 2016; 182:393-396. [PMID: 27718161 DOI: 10.1007/s11046-016-0076-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/02/2016] [Indexed: 10/20/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a deregulated inflammatory response to invading microorganisms. It is manifested when there is an abrupt change in host immunity from an anti-inflammatory and immunosuppressive state to a pro-inflammatory state as a result of rapid depletion or removal of factors that promote immune suppression or inhibition of inflammation. The aim of this paper is to discuss and re-interpret the possibility of association of paracoccidioidomycosis (PCM) with IRIS in the central nervous system (CNS) in a case from Brazil published by Silva-Vergara ML. et al. (Mycopathologia 177:137-141, 6). An AIDS patient who was not receiving medical care developed pulmonary PCM successfully treated with itraconazole. The patient developed central nervous system PCM (NPCM) after starting the ARV therapy with recovery of immunity and control of HIV viral load, although it was not interpreted as IRIS by the authors, it fulfills the criteria for CNS IRIS. This could be the first case of NPCM associated with IRIS described. Although not frequent, IRIS must be considered in PCM patients and HIV, from endemic areas or patients that traveled to endemic areas, receiving ARV treatment and with worsening symptoms.
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Thompson GR, Rendon A, Ribeiro Dos Santos R, Queiroz-Telles F, Ostrosky-Zeichner L, Azie N, Maher R, Lee M, Kovanda L, Engelhardt M, Vazquez JA, Cornely OA, Perfect JR. Isavuconazole Treatment of Cryptococcosis and Dimorphic Mycoses. Clin Infect Dis 2016; 63:356-62. [PMID: 27169478 PMCID: PMC4946023 DOI: 10.1093/cid/ciw305] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/28/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Invasive fungal diseases (IFD) caused by Cryptococcus and dimorphic fungi are associated with significant morbidity and mortality. Isavuconazole (ISAV) is a novel, broad-spectrum, triazole antifungal agent (IV and by mouth [PO]) developed for the treatment of IFD. It displays potent activity in vitro against these pathogens and in this report we examine outcomes of patients with cryptococcosis or dimorphic fungal infections treated with ISAV. METHODS The VITAL study was an open-label nonrandomized phase 3 trial conducted to evaluate the efficacy and safety of ISAV treatment in management of rare IFD. Patients received ISAV 200 mg 3 times daily for 2 days followed by 200 mg once-daily (IV or PO). Proven IFD and overall response at end of treatment (EOT) were determined by an independent, data-review committee. Mortality and safety were also assessed. RESULTS Thirty-eight patients received ISAV for IFD caused by Cryptococcus spp. (n = 9), Paracoccidioides spp. (n = 10), Coccidioides spp. (n = 9), Histoplasma spp. (n = 7) and Blastomyces spp. (n = 3). The median length of therapy was 180 days (range 2-331 days). At EOT 24/38 (63%) patients exhibited a successful overall response. Furthermore, 8 of 38 (21%) had stable IFD at the end of therapy without progression of disease, and 6 (16%) patients had progressive IFD despite this antifungal therapy. Thirty-three (87%) patients experienced adverse events. CONCLUSIONS ISAV was well tolerated and demonstrated clinical activity against these endemic fungi with a safety profile similar to that observed in larger studies, validating its broad-spectrum in vitro activity and suggesting it may be a valuable alternative to currently available agents. CLINICAL TRIALS REGISTRATION NCT00634049.
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Affiliation(s)
- George R Thompson
- Department of Medicine/Division of Infectious Diseases, University of California-Davis Medical Center, Sacramento
| | - Adrian Rendon
- CIPTIR, Universidad Autónoma de Nuevo León, Monterrey, México
| | | | - Flavio Queiroz-Telles
- Department of Public Health Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | | | - Nkechi Azie
- Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - Rochelle Maher
- Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - Misun Lee
- Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - Laura Kovanda
- Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | | | - Jose A Vazquez
- Department of Medicine, Division of Infectious Diseases, Medical College of Georgia/Georgia Regents University, Augusta
| | - Oliver A Cornely
- Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Germany
| | - John R Perfect
- Department of Medicine/Division of Infectious Diseases, Duke University, Durham, North Carolina
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Kathwate GH, Shinde RB, Karuppayil SM. Antiepileptic Drugs Inhibit Growth, Dimorphism, and Biofilm Mode of Growth in Human Pathogen Candida albicans. Assay Drug Dev Technol 2016; 13:307-12. [PMID: 26241210 DOI: 10.1089/adt.2015.29007.ghkdrrr] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Exploring the potential of existing drugs for their unknown properties may offer advantages over conventional drug development by saving time and money. Candida albicans, an important human opportunist, shares many genetic properties with humans. This has encouraged us to study drugs that are not originally antifungals against C. albicans. In the present study, we have tested six antiepileptic drugs for their activities against C. albicans. Their effects on growth, time-dependent killing, yeast-to-hyphal form switching, and biofilms formation by C. albicans were studied. Out of the drugs studied, four drugs, which are γ-aminobutyric acid (GABA) receptor agonists in humans, inhibited growth, yeast-to-hyphal form switching, and biofilm formation in C. albicans. Lorazepam inhibited growth of C. albicans at 25 μg/ml, followed by midazolam and diazepam (minimum inhibitory concentrations 100 and 400 μg/ml, respectively). Members from other group voltage-gated sodium channel blockers failed to inhibit C. albicans. Our study has identified GABA receptor agonists used in epileptic therapy as potential candidates for antifungal drug development against the human pathogen C. albicans.
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Affiliation(s)
- Gunderao H Kathwate
- DST-FIST- and UGC-SAP-Sponsored School of Life Sciences, Swami Ramanand Teerth Marathwada University , Nanded, Maharashtra, India
| | - Ravikumar B Shinde
- DST-FIST- and UGC-SAP-Sponsored School of Life Sciences, Swami Ramanand Teerth Marathwada University , Nanded, Maharashtra, India
| | - S Mohan Karuppayil
- DST-FIST- and UGC-SAP-Sponsored School of Life Sciences, Swami Ramanand Teerth Marathwada University , Nanded, Maharashtra, India
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Shirey K, Stover KR, Cleary J, Hoang N, Hosler J. Membrane-Anchored Cyclic Peptides as Effectors of Mitochondrial Oxidative Phosphorylation. Biochemistry 2016; 55:2100-11. [PMID: 26985698 DOI: 10.1021/acs.biochem.5b01368] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The echinocandins are membrane-anchored, cyclic lipopeptides (CLPs) with antifungal activity due to their ability to inhibit a glucan synthase located in the plasma membrane of fungi such as Candida albicans. A hydrophobic tail of an echinocandin CLP inserts into a membrane, placing a six-amino acid cyclic peptide near the membrane surface. Because processes critical for the function of the electron transfer complexes of mitochondria, such as proton uptake and release, take place near the surface of the membrane, we have tested the ability of two echinocandin CLPs, caspofungin and micafungin, to affect the activity of electron transfer complexes in isolated mammalian mitochondria. Indeed, caspofungin and micafungin both inhibit whole chain electron transfer in isolated mitochondria at low micromolar concentrations. The effects of the CLPs are fully reversible, in some cases simply via the addition of bovine serum albumin to bind the CLPs via their hydrophobic tails. Each CLP affects more than one complex, but they still exhibit specificity of action. Only caspofungin inhibits complex I, and the CLP inhibits liver but not heart complex I. Both CLPs inhibit heart and liver complex III. Caspofungin inhibits complex IV activity, while, remarkably, micafungin stimulates complex IV activity nearly 3-fold. Using a variety of assays, we have developed initial hypotheses for the mechanisms by which caspofungin and micafungin alter the activities of complexes IV and III. The dication caspofungin partially inhibits cytochrome c binding at the low-affinity binding site of complex IV, while it also appears to inhibit the release of protons from the outer surface of the complex, similar to Zn(2+). Anionic micafungin appears to stimulate complex IV activity by enhancing the transfer of protons to the O2 reduction site. For complex III, we hypothesize that each CLP binds to the cytochrome b subunit and the Fe-S subunit to inhibit the required rotational movement of the latter.
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Affiliation(s)
- Kristin Shirey
- Department of Biochemistry and ‡School of Pharmacy, University of Mississippi Medical Center , 2500 North State Street, Jackson, Mississippi 39216, United States
| | - Kayla R Stover
- Department of Biochemistry and ‡School of Pharmacy, University of Mississippi Medical Center , 2500 North State Street, Jackson, Mississippi 39216, United States
| | - John Cleary
- Department of Biochemistry and ‡School of Pharmacy, University of Mississippi Medical Center , 2500 North State Street, Jackson, Mississippi 39216, United States
| | - Ngoc Hoang
- Department of Biochemistry and ‡School of Pharmacy, University of Mississippi Medical Center , 2500 North State Street, Jackson, Mississippi 39216, United States
| | - Jonathan Hosler
- Department of Biochemistry and ‡School of Pharmacy, University of Mississippi Medical Center , 2500 North State Street, Jackson, Mississippi 39216, United States
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Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1-50. [PMID: 26679628 PMCID: PMC4725385 DOI: 10.1093/cid/civ933] [Citation(s) in RCA: 1836] [Impact Index Per Article: 229.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor
| | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Thomas J Walsh
- Weill Cornell Medical Center and Cornell University, New York, New York
| | | | - Jack D Sobel
- Harper University Hospital and Wayne State University, Detroit, Michigan
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Preclinical pharmacokinetics, tissue distribution and excretion studies of a novel anti-candidal agent-thiosemicarbazide derivative of isoniazid (TSC-INH) by validated UPLC–MS/MS assay. J Pharm Biomed Anal 2016; 117:109-17. [DOI: 10.1016/j.jpba.2015.08.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/20/2015] [Accepted: 08/21/2015] [Indexed: 11/21/2022]
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da Silva D, Magalhães T, dos Santos J, de Paula T, Modolo L, de Fátima A, Buzanello Martins C, Santos D, de Resende-Stoianoff M. Curcumin enhances the activity of fluconazole against Cryptococcus gattii
-induced cryptococcosis infection in mice. J Appl Microbiol 2015; 120:41-8. [DOI: 10.1111/jam.12966] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/01/2015] [Accepted: 09/29/2015] [Indexed: 01/10/2023]
Affiliation(s)
- D.L. da Silva
- Departamento de Microbiologia; ICB; Universidade Federal de Minas Gerais; Belo Horizonte MG Brazil
| | - T.F.F. Magalhães
- Departamento de Microbiologia; ICB; Universidade Federal de Minas Gerais; Belo Horizonte MG Brazil
| | - J.R.A. dos Santos
- Departamento de Microbiologia; ICB; Universidade Federal de Minas Gerais; Belo Horizonte MG Brazil
| | - T.P. de Paula
- Departamento de Microbiologia; ICB; Universidade Federal de Minas Gerais; Belo Horizonte MG Brazil
| | - L.V. Modolo
- Departamento de Botânica; ICB; Universidade Federal de Minas Gerais; Belo Horizonte MG Brazil
| | - A. de Fátima
- Departamento de Química; ICEx; Universidade Federal de Minas Gerais; Belo Horizonte MG Brazil
| | - C.V. Buzanello Martins
- Centro de Engenharias e Ciências Exatas; Universidade Estadual do Oeste do Paraná; Toledo PR Brazil
| | - D.A. Santos
- Departamento de Microbiologia; ICB; Universidade Federal de Minas Gerais; Belo Horizonte MG Brazil
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Noguchi KK, Cabrera OH, Swiney BS, Salinas-Contreras P, Smith JK, Farber NB. Hedgehog regulates cerebellar progenitor cell and medulloblastoma apoptosis. Neurobiol Dis 2015; 83:35-43. [PMID: 26319366 DOI: 10.1016/j.nbd.2015.08.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/12/2015] [Accepted: 08/19/2015] [Indexed: 12/12/2022] Open
Abstract
The external granule layer (EGL) is a proliferative region that produces over 90% of the neurons in the cerebellum but can also malignantly transform into a cerebellar tumor called the medulloblastoma (the most common malignant brain tumor in children). Current dogma considers Hedgehog stimulation a potent proliferative signal for EGL neural progenitor cells (NPCs) and medulloblastomas. However, the Hedgehog pathway also acts as a survival signal in the neural tube where it regulates dorsoventral patterning by controlling NPC apoptosis. Here we show that Hedgehog stimulation is also a potent survival signal in the EGL and medulloblastomas that produces a massive apoptotic response within hours of signal loss in mice. This toxicity can be produced by numerous Hedgehog antagonists (vismodegib, cyclopamine, and jervine) and is Bax/Bak dependent but p53 independent. Finally, since glucocorticoids can also induce EGL and medulloblastoma apoptosis, we show that Hedgehog's effects on apoptosis can occur independent of glucocorticoid stimulation. This effect may play a major role in cerebellar development by directing where EGL proliferation occurs thereby morphologically sculpting growth. It may also be a previously unknown major therapeutic effect of Hedgehog antagonists during medulloblastoma therapy. Results are discussed in terms of their implications for both cerebellar development and medulloblastoma treatment.
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Affiliation(s)
- Kevin Kiyoshi Noguchi
- Washington University in St. Louis, Department of Psychiatry, 660 South Euclid, St. Louis, MO 63110, USA.
| | - Omar Hoseá Cabrera
- University of Missouri-St. Louis, Department of Psychological Sciences, One University Boulevard, 325 Stadler Hall, St. Louis, MO 63121, USA.
| | - Brant S Swiney
- Washington University in St. Louis, Department of Psychiatry, 660 South Euclid, St. Louis, MO 63110, USA.
| | - Patricia Salinas-Contreras
- Washington University in St. Louis, Department of Psychiatry, 660 South Euclid, St. Louis, MO 63110, USA.
| | - Julie Kathryn Smith
- Washington University in St. Louis, Department of Psychiatry, 660 South Euclid, St. Louis, MO 63110, USA.
| | - Nuri B Farber
- Washington University in St. Louis, Department of Psychiatry, 660 South Euclid, St. Louis, MO 63110, USA.
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Analysis of cerebrospinal fluid protein concentrations of patients with cryptococcal meningitis treated with antifungal agents. BMC Infect Dis 2015; 15:333. [PMID: 26268786 PMCID: PMC4535692 DOI: 10.1186/s12879-015-1063-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/28/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Many neurological diseases are accompanied by an increase in the cerebrospinal fluid (CSF) protein concentration, which indicates dysfunction of the blood-CSF/blood-brain barrier. However, the significance CSF protein concentration of patients with cryptococcal meningitis (CM) is not fully understood. The aim of the present was to determine whether CSF protein concentrations correlated with the responses of patients to treatment with antifungal drugs. METHODS We conducted a retrospective study of the analytical data of 623 lumbar punctures of 46 patients with CM who were treated at West China Hospital. We divided the patients into groups with good or poor responses to antifungal treatment. We used a generalized linear mixed model (GLMM) to evaluate the significance of the differences between the two groups. RESULTS The baseline CSF protein concentrations of the good antifungal response group (GR-group) (median = 0.97 g/L) were higher compared with those of the poor antifungal response group (PR-group) (median = 0.72 g/L). Analysis using the GLMM indicated that the CSF protein concentration of the GR-group decreased at a rate of 1.8 mg/L per day after antifungal treatment started and was 2.1 mg/L higher compared with that of the PR-group. CONCLUSIONS Compared with poor responders, we found that the baseline CSF protein concentrations of good responders were higher and decreased at faster rate after the initiation of antifungal treatment.
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International expert opinion on the management of infection caused by azole-resistant Aspergillus fumigatus. Drug Resist Updat 2015; 21-22:30-40. [PMID: 26282594 DOI: 10.1016/j.drup.2015.08.001] [Citation(s) in RCA: 230] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An international expert panel was convened to deliberate the management of azole-resistant aspergillosis. In culture-positive cases, in vitro susceptibility testing should always be performed if antifungal therapy is intended. Different patterns of resistance are seen, with multi-azole and pan-azole resistance more common than resistance to a single triazole. In confirmed invasive pulmonary aspergillosis due to an azole-resistant Aspergillus, the experts recommended a switch from voriconazole to liposomal amphotericin B (L-AmB; Ambisome(®)). In regions with environmental resistance rates of ≥10%, a voriconazole-echinocandin combination or L-AmB were favoured as initial therapy. All experts recommended L-AmB as core therapy for central nervous system aspergillosis suspected to be due to an azole-resistant Aspergillus, and considered the addition of a second agent with the majority favouring flucytosine. Intravenous therapy with either micafungin or L-AmB given as either intermittent or continuous therapy was recommended for chronic pulmonary aspergillosis due to a pan-azole-resistant Aspergillus. Local and national surveillance with identification of clinical and environmental resistance patterns, rapid diagnostics, better quality clinical outcome data, and a greater understanding of the factors driving or minimising environmental resistance are areas where research is urgently needed, as well as the development of new oral agents outside the azole drug class.
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Muilwijk EW, Lempers VJC, Burger DM, Warris A, Pickkers P, Aarnoutse RE, Brüggemann RJM. Impact of special patient populations on the pharmacokinetics of echinocandins. Expert Rev Anti Infect Ther 2015; 13:799-815. [PMID: 25947367 DOI: 10.1586/14787210.2015.1028366] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Echinocandins belong to the class of antifungal agents. Currently, three echinocandin drugs are licensed for intravenous treatment of invasive fungal infections: anidulafungin, caspofungin and micafungin. While their antifungal activity overlaps, there are substantial differences in pharmacokinetics (PK). Numerous factors may account for variability in PK of echinocandins including age (pediatrics vs adults), body surface area and body composition (normal weight vs obesity), disease status (e.g., critically ill and burn patients) and organ dysfunction (kidney and liver impairment). Subsequent effects of altered exposure might impact efficacy and safety. Knowledge of PK behavior is crucial in optimal clinical utilization of echinocandin in a specific patient or patient population. This review provides up-to-date information on PK data of anidulafungin, caspofungin and micafungin in special patient populations. Patient populations addressed are neonates, children and adolescents, obese patients, patients with hepatic or renal impairment, critically ill patients (including burn patients) and patients with hematological diseases.
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Affiliation(s)
- Eline W Muilwijk
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
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Moss DM, Marzolini C, Rajoli RKR, Siccardi M. Applications of physiologically based pharmacokinetic modeling for the optimization of anti-infective therapies. Expert Opin Drug Metab Toxicol 2015; 11:1203-17. [PMID: 25872900 DOI: 10.1517/17425255.2015.1037278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The pharmacokinetic properties of anti-infective drugs are a determinant part of treatment success. Pathogen replication is inhibited if adequate drug levels are achieved in target sites, whereas excessive drug concentrations linked to toxicity are to be avoided. Anti-infective distribution can be predicted by integrating in vitro drug properties and mathematical descriptions of human anatomy in physiologically based pharmacokinetic models. This method reduces the need for animal and human studies and is used increasingly in drug development and simulation of clinical scenario such as, for instance, drug-drug interactions, dose optimization, novel formulations and pharmacokinetics in special populations. AREAS COVERED We have assessed the relevance of physiologically based pharmacokinetic modeling in the anti-infective research field, giving an overview of mechanisms involved in model design and have suggested strategies for future applications of physiologically based pharmacokinetic models. EXPERT OPINION Physiologically based pharmacokinetic modeling provides a powerful tool in anti-infective optimization, and there is now no doubt that both industry and regulatory bodies have recognized the importance of this technology. It should be acknowledged, however, that major challenges remain to be addressed and that information detailing disease group physiology and anti-infective pharmacodynamics is required if a personalized medicine approach is to be achieved.
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Affiliation(s)
- Darren Michael Moss
- University of Liverpool, Institute of Translational Medicine, Molecular and Clinical Pharmacology , Liverpool , UK +44 0 151 794 8211 ; +44 0 151 794 5656 ;
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50
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Lemetayer JD, Dowling PM, Taylor SM, Papich MG. Pharmacokinetics and distribution of voriconazole in body fluids of dogs after repeated oral dosing. J Vet Pharmacol Ther 2015; 38:451-6. [DOI: 10.1111/jvp.12208] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 01/16/2015] [Indexed: 01/21/2023]
Affiliation(s)
- J. D. Lemetayer
- Small Animal Clinical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - P. M. Dowling
- Veterinary Biomedical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - S. M. Taylor
- Small Animal Clinical Sciences; Western College of Veterinary Medicine; University of Saskatchewan; Saskatoon SK Canada
| | - M. G. Papich
- Department of Molecular Biomedical Sciences; College of Veterinary Medicine; North Carolina State University; Raleigh NC USA
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