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Sobel JD. Automated microscopy and pH test for diagnosis of vaginitis - the end of empiricism? NPJ Digit Med 2023; 6:167. [PMID: 37673955 PMCID: PMC10482843 DOI: 10.1038/s41746-023-00850-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/19/2023] [Indexed: 09/08/2023] Open
Affiliation(s)
- J D Sobel
- Wayne State University School of Medicine, Detroit, MI, USA.
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Sobel JD. Resistance to Fluconazole of Candida albicans in Vaginal Isolates: a 10-Year Study in a Clinical Referral Center. Antimicrob Agents Chemother 2023; 67:e0018123. [PMID: 37093005 PMCID: PMC10190554 DOI: 10.1128/aac.00181-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/23/2023] [Indexed: 04/25/2023] Open
Abstract
Review of vaginal isolates of Candida albicans that caused clinical failure in a 10-year collection of vaginal C. albicans specimens obtained in a university vaginitis referral clinic indicated an increase in fluconazole resistance. Factors contributing to azole resistance are discussed, including treatment choice associated with fluconazole-resistant C. albicans vaginal infection.
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Affiliation(s)
- J. D. Sobel
- Department of Internal Medicine, Wayne State University, Detroit, Michigan, USA
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Sobel JD. Role of Antifungal Susceptibility Tests in the Treatment of Vulvovaginal Candidiasis. Curr Infect Dis Rep 2023. [DOI: 10.1007/s11908-023-00797-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Sobel R, Nyirjesy P, Ghannoum MA, Delchev DA, Azie NE, Angulo D, Harriott IA, Borroto-Esoda K, Sobel JD. Efficacy and safety of oral ibrexafungerp for the treatment of acute vulvovaginal candidiasis: a global phase 3, randomised, placebo-controlled superiority study (VANISH 306). BJOG 2021; 129:412-420. [PMID: 34676663 PMCID: PMC9299454 DOI: 10.1111/1471-0528.16972] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 01/25/2023]
Abstract
Objective To evaluate the efficacy and safety of ibrexafungerp versus placebo for acute vulvovaginal candidiasis (VVC) treatment. Design Global phase 3, randomised, placebo‐controlled superiority study. Setting Study sites in the USA (n = 19) and Bulgaria (n = 18). Population Female patients aged ≥12 years with acute VVC and a vulvovaginal signs and symptoms (VSS) score ≥4 at baseline. Methods Patients were randomly assigned 2:1 to ibrexafungerp (300 mg twice for 1 day) or placebo. Main outcome measures The primary endpoint was the percentage of patients with a clinical cure (VSS = 0) at the test‐of‐cure visit (day 11 ± 3). Secondary endpoints included percentages of patients with mycological eradication, clinical cure and mycological eradication (overall success), clinical improvement (VSS ≤1) at test‐of‐cure visit, and complete resolution of symptoms at follow‐up visit (day 25 ± 4). Results At the test‐of‐cure visit, patients receiving ibrexafungerp had significantly higher rates of clinical cure (63.3% [119/188] versus 44.0% [37/84]; P = 0.007), mycological eradication (58.5% [110/188] versus 29.8% [25/84]; P < 0.001), overall success (46.1% [82/188] versus 28.4% [23/84]; P = 0.022) and clinical improvement (72.3% [136/188] versus 54.8% [46/84]; P = 0.01) versus those receiving placebo. Symptom resolution was sustained and further increased with ibrexafungerp (73.9%) versus placebo (52.4%) at follow‐up (P = 0.001). Ibrexafungerp was generally well tolerated. Adverse events were primarily gastrointestinal and were mild to moderate in severity. Conclusions Ibrexafungerp demonstrated statistical superiority over placebo for the primary and secondary endpoints. Ibrexafungerp is a promising novel, well‐tolerated and effective oral 1‐day treatment for acute VVC. Tweetable abstract Ibrexafungerp is statistically superior to placebo for the treatment of vulvovaginal candidiasis. Ibrexafungerp is statistically superior to placebo for the treatment of vulvovaginal candidiasis. Linked article This article is commented on by KSJ Olah, p. 421–422 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.17000.
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Affiliation(s)
- R Sobel
- Department of Obstetrics and Gynecology, Jefferson Vulvovaginal Health Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - P Nyirjesy
- Department of Obstetrics and Gynecology, Jefferson Vulvovaginal Health Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - M A Ghannoum
- Department of Dermatology, Center for Medical Mycology, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - D A Delchev
- Department of Gynaecology, MHAT Dr. Bratan Shukerov AD, Smolyan, Bulgaria
| | - N E Azie
- Departments of Clinical Development and Medical Affairs, SCYNEXIS, Inc., Jersey City, NJ, USA
| | - D Angulo
- Department of Clinical Research, SCYNEXIS, Inc., Jersey City, NJ, USA
| | - I A Harriott
- Department of Medical Affairs, SCYNEXIS, Inc., Jersey City, NJ, USA
| | | | - J D Sobel
- Infectious Diseases, Department of Internal Medicine, Wayne State University, Detroit, MI, USA
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Affiliation(s)
- J D Sobel
- Department of Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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Abstract
PURPOSE OF REVIEW Goal was to review epidemiology, pathophysiology, and prevention of post-antibiotic Candida vulvovaginitis (VVC). RECENT FINDINGS Antibacterial therapy, whether systemic or locally applied to the vagina, represents the single most frequent and predictable cause or triggering mechanism of symptomatic vulvovaginal candidiasis (VVC). Such initiating mechanisms may precipitate sporadic or recurrent episodes of VVC. In spite of this widely recognized association, the exact mechanism whereby antibiotics of all classes cause acute exacerbation of symptomatic vaginal disease remains largely unstudied and therefore largely unknown. Pathophysiology is hypothesized to be reduction or alteration of vaginal microbiome restraints of yeast colonization, proliferation, and expression of virulence characteristics. The predictable link between antibiotic use and post-antibiotic VVC affords practitioners an opportunity for timely intervention using selective, convenient antimycotics usually drugs but possibly probiotic measures. Indications and limitation of these steps are discussed.
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Affiliation(s)
- Asmita Shukla
- Department of Internal Medicine, Wayne State University School of Medicine, 540 E. Canfield St., 1241 Scott Hall, Detroit, MI, 48021, USA
| | - J D Sobel
- Department of Internal Medicine, Wayne State University School of Medicine, 540 E. Canfield St., 1241 Scott Hall, Detroit, MI, 48021, USA.
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Abstract
PURPOSE OF REVIEW Evaluation of pathogenicity of an uncommon vaginal Candida species, Candida parapsilosis with particular references to susceptibility to conventional antifungal agents. RECENT FINDINGS C. parapsilosis vaginal isolates usually present in asymptomatic women as commensals but may induce vulvovaginal symptoms indistinguishable from C. albicans requiring antifungal therapy; however, recent experience reveals clinically relevant resistance to the azole class of antimycotics. CONCLUSION Clinicians are required to determine a causal relationship between vaginal isolates of C. parapsilosis before prescribing antifungal agents, recognizing the possibility of fluconazole resistance to explain refractory symptomatology.
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Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Wayne State University School of Medicine, 540 E. Canfield St., 1241 Scott Hall, Detroit, MI, 48201, USA.
| | - S Suprapaneni
- Division of Infectious Diseases, Wayne State University School of Medicine, 540 E. Canfield St., 1241 Scott Hall, Detroit, MI, 48201, USA
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Abstract
INTRODUCTION Clinicians are increasingly challenged by patients with refractory vulvovaginal candidiasis (VVC) caused by azole-resistant Candida species. Fluconazole resistant C.albicans is a growing and perplexing problem following years of indiscriminate drug prescription and unnecessary drug exposure and for which there are few therapeutic alternatives. Regrettably, although the azole class of drugs has expanded, new classes of antifungal drugs have not been forthcoming, limiting effective treatment options in patients with azole resistant Candida vaginitis. AREAS COVERED This review covers published data on epidemiology, pathophysiology and treatment options for women with azole-resistant refractory VVC. EXPERT OPINION Fluconazole resistant C.albicans adds to the challenge of azole resistant non-albicans Candida spp. Both issues follow years of indiscriminate drug prescription and unnecessary fluconazole exposure. Although an understanding of azole resistance in yeast has been established, this knowledge has not translated into useful therapeutic advantage. Treatment options for such women with refractory symptoms are extremely limited. New therapeutic options and strategies are urgently needed to meet this challenge of azole drug resistance.
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Affiliation(s)
- J D Sobel
- a Department of Internal Medicine , Wayne State University School of Medicine , Detroit , MI , USA
| | - R Sobel
- b Department of Obstetrics & Gynecology , Jefferson Medical College , Philadelphia , PA , USA
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Hilbert DW, Schuyler JA, Adelson ME, Mordechai E, Sobel JD, Gygax SE. Gardnerella vaginalis population dynamics in bacterial vaginosis. Eur J Clin Microbiol Infect Dis 2017; 36:1269-1278. [PMID: 28197729 DOI: 10.1007/s10096-017-2933-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/31/2017] [Indexed: 01/08/2023]
Abstract
Bacterial vaginosis (BV) is the leading cause of vaginal discharge and is associated with the facultative Gram-variable bacterium Gardnerella vaginalis, whose population structure consists of four clades. Our goal was to determine if these clades differ with regard to abundance during BV. We performed a short-term longitudinal study of BV. Patients were evaluated according to the Amsel criteria and Nugent scoring at initial diagnosis, immediately after treatment and at a 40- to 45-day follow-up visit. G. vaginalis clade abundance was determined by quantitative real-time polymerase chain reactions (qPCRs). Among all specimens, the abundance of clades 1 and 4 were higher than that of clades 2 and 3 (P < 0.001). In general, the abundance of each clade increased with the degree of vaginal dysbiosis, as determined by the Nugent score and was greater in women with Amsel 4 compared with those with Amsel 0. Only clade 1 abundance was greater when Amsel 0 or 1 specimens were compared with Amsel 2 or 3 specimens (P < 0.01). Following antimicrobial treatment, abundance of clades 1 (P < 0.001) and 4 (P < 0.05) decreased regardless of the clinical and microbiological outcome, whereas clade 2 only decreased in women who had a sustained treatment response for 40-45 days (P < 0.01). Recurrent BV was characterized by post-treatment increases of clade 1 and 2 (P < 0.01). Clades 1 and 4 predominate in vaginal specimens. Clade abundance differs with regard to the Nugent score, the Amsel criteria, and response to therapy and BV recurrence.
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Affiliation(s)
- D W Hilbert
- Femeris Women's Health Research Center, Medical Diagnostic Laboratories, Genesis Biotechnology Group, 2439 Kuser Road, Hamilton, NJ, USA.
| | - J A Schuyler
- Femeris Women's Health Research Center, Medical Diagnostic Laboratories, Genesis Biotechnology Group, 2439 Kuser Road, Hamilton, NJ, USA
| | - M E Adelson
- Femeris Women's Health Research Center, Medical Diagnostic Laboratories, Genesis Biotechnology Group, 2439 Kuser Road, Hamilton, NJ, USA
| | - E Mordechai
- Femeris Women's Health Research Center, Medical Diagnostic Laboratories, Genesis Biotechnology Group, 2439 Kuser Road, Hamilton, NJ, USA
| | - J D Sobel
- Division of Infectious Diseases, Wayne State University School of Medicine, 540 E. Canfield Street, Detroit, MI, USA
| | - S E Gygax
- Femeris Women's Health Research Center, Medical Diagnostic Laboratories, Genesis Biotechnology Group, 2439 Kuser Road, Hamilton, NJ, USA
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Jaeger M, Carvalho A, Cunha C, Plantinga TS, van de Veerdonk F, Puccetti M, Galosi C, Joosten LAB, Dupont B, Kullberg BJ, Sobel JD, Romani L, Netea MG. Association of a variable number tandem repeat in the NLRP3 gene in women with susceptibility to RVVC. Eur J Clin Microbiol Infect Dis 2016; 35:797-801. [PMID: 26951262 PMCID: PMC4840230 DOI: 10.1007/s10096-016-2600-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 02/01/2016] [Indexed: 12/21/2022]
Abstract
Vaginal infections with Candida spp. frequently occur in women of childbearing age. A small proportion of these women experience recurrent vulvovaginal candidosis (RVVC), which is characterized by at least three episodes of infection in one year. In addition to known risk factors such as antibiotics, diabetes, or pregnancy, host genetic variation and inflammatory pathways such as the IL-1/Th17 axis have been reported to play a substantial role in the pathogenesis of RVVC. In this study, we assessed a variable number tandem repeat (VNTR) polymorphism in the NLRP3 gene that encodes a component of the inflammasome, processing the proinflammatory cytokines IL-1β and IL-18. A total of 270 RVVC patients and 583 healthy controls were analyzed, and increased diseases susceptibility was associated with the presence of the 12/9 genotype. Furthermore, functional studies demonstrate that IL-1β production at the vaginal surface is higher in RVVC patients bearing the 12/9 genotype compared to controls, whereas IL-1Ra levels were decreased and IL-18 levels remained unchanged. These findings suggest that IL-1β-mediated hyperinflammation conveyed by the NLRP3 gene plays a causal role in the pathogenesis of RVVC and may identify this pathway as a potential therapeutic target in the disease.
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Affiliation(s)
- M Jaeger
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - A Carvalho
- Department of Experimental Medicine, University of Perugia, Polo Unico Sant'Andrea delle Fratte, 06132, Perugia, Italy
| | - C Cunha
- Department of Experimental Medicine, University of Perugia, Polo Unico Sant'Andrea delle Fratte, 06132, Perugia, Italy
| | - T S Plantinga
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - F van de Veerdonk
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - M Puccetti
- Department of Experimental Medicine, University of Perugia, Polo Unico Sant'Andrea delle Fratte, 06132, Perugia, Italy
| | - C Galosi
- Department of Experimental Medicine, University of Perugia, Polo Unico Sant'Andrea delle Fratte, 06132, Perugia, Italy
| | - L A B Joosten
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | | | - B J Kullberg
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - J D Sobel
- Department of Medicine, Infectious Diseases, Wayne State University School of Medicine, Detroit, MI, USA
| | - L Romani
- Department of Experimental Medicine, University of Perugia, Polo Unico Sant'Andrea delle Fratte, 06132, Perugia, Italy
| | - M G Netea
- Department of Internal Medicine and Radboudumc Center for Infectious Diseases, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Abstract
PCR is recognized as a reliable technique for detection of all types of microorganisms. Being highly objective and reproducible also sensitive and specific, PCR is now widely used for sexually transmitted infection (STI) diagnosis. Potential, however, exists for detecting non-pathogens, and not identifying a pathogenic state decreases specificity or clinical significance. PCR Candida tests of vaginal specimens are now widely available and frequently used offering a modest to moderate increase in sensitivity and are likely to replace traditional culture and DNA homology testing. Nevertheless, there remain considerable gaps in our knowledge regarding the usefulness and applications of these expensive tests.
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Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA,
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Andes DR, Safdar N, Baddley JW, Playford G, Reboli AC, Rex JH, Sobel JD, Pappas PG, Kullberg BJ. Impact of Treatment Strategy on Outcomes in Patients with Candidemia and Other Forms of Invasive Candidiasis: A Patient-Level Quantitative Review of Randomized Trials. Clin Infect Dis 2012; 54:1110-22. [DOI: 10.1093/cid/cis021] [Citation(s) in RCA: 556] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Sobel JD. S5.1 The other vaginitides: update on desquammative inflammatory vaginitis and refractory Candida vaginitis. Br J Vener Dis 2011. [DOI: 10.1136/sextrans-2011-050102.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Fisher JF, Kavanagh K, Sobel JD, Kauffman CA, Newman CA. Candida Urinary Tract Infection: Pathogenesis. Clin Infect Dis 2011; 52 Suppl 6:S437-51. [DOI: 10.1093/cid/cir110] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Lamont RF, Sobel JD, Akins RA, Hassan SS, Chaiworapongsa T, Kusanovic JP, Romero R. The vaginal microbiome: new information about genital tract flora using molecular based techniques. BJOG 2011; 118:533-49. [PMID: 21251190 DOI: 10.1111/j.1471-0528.2010.02840.x] [Citation(s) in RCA: 280] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Vaginal microbiome studies provide information that may change the way we define vaginal flora. Normal flora appears dominated by one or two species of Lactobacillus. Significant numbers of healthy women lack appreciable numbers of vaginal lactobacilli. Bacterial vaginosis (BV) is not a single entity, but instead consists of different bacterial communities or profiles of greater microbial diversity than is evident from cultivation-dependent studies. BV should be considered a syndrome of variable composition that results in different symptoms, phenotypical outcomes, and responses to different antibiotic regimens. This information may help to elucidate the link between BV and infection-related adverse outcomes of pregnancy.
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Affiliation(s)
- R F Lamont
- Perinatology Research Branch, National Institute of Child Health and Human Development, NIH/DHHS, Bethesda, MD 20892, USA
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Bulik CC, Sobel JD, Nailor MD. Susceptibility profile of vaginal isolates of Candida albicans prior to and following fluconazole introduction - impact of two decades. Mycoses 2010; 54:34-8. [DOI: 10.1111/j.1439-0507.2009.01752.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Micafungin, a potent inhibitor of 1,3-beta-D-glucan synthase, has become the second available agent in the echinocandins class that is approved for use in clinical practice. This agent shares with caspofungin an identical spectrum of in vitro activity against Candida albicans, non-albicans species of Candida, and Aspergillus species, as well as several but not all pathogenic molds. If anything, its in vitro activity appears to be superior to that of caspofungin, although the clinical relevance of this observation is unclear. The clinical role of micafungin appears to be similar to that of caspofungin, although clinical data are still lacking at this stage, with initial approval only for treatment of esophageal candidiasis and prophylaxis in subjects with neutropenia. Pharmacokinetic and pharmacodynamic studies and reports of adverse effects and safety have reported similar but not identical results to those of other agents in the echinocandin class. Factors such as acquisition costs and the potential for resistance development may be more relevant to its widespread use than in vitro and in vivo data comparisons with caspofungin.
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Affiliation(s)
- P H Chandrasekar
- Division of Infectious Diseases, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Michigan, USA
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Kullberg BJ, Sobel JD, Ruhnke M, Pappas PG, Viscoli C, Rex JH, Cleary JD, Rubinstein E, Church LWP, Brown JM, Schlamm HT, Oborska IT, Hilton F, Hodges MR. Voriconazole versus a regimen of amphotericin B followed by fluconazole for candidaemia in non-neutropenic patients: a randomised non-inferiority trial. Lancet 2005; 366:1435-42. [PMID: 16243088 DOI: 10.1016/s0140-6736(05)67490-9] [Citation(s) in RCA: 372] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Voriconazole has proven efficacy against invasive aspergillosis and oesophageal candidiasis. This multicentre, randomised, non-inferiority study compared voriconazole with a regimen of amphotericin B followed by fluconazole for the treatment of candidaemia in non-neutropenic patients. METHODS Non-neutropenic patients with a positive blood culture for a species of candida and clinical evidence of infection were enrolled. Patients were randomly assigned, in a 2:1 ratio, either voriconazole (n=283) or amphotericin B followed by fluconazole (n=139). The primary efficacy analysis was based on clinical and mycological response 12 weeks after the end of treatment, assessed by an independent data-review committee unaware of treatment assignment. FINDINGS Of 422 patients randomised, 370 were included in the modified intention-to-treat population. Voriconazole was non-inferior to amphotericin B/fluconazole in the primary efficacy analysis, with successful outcomes in 41% of patients in both treatment groups (95% CI for difference -10.6% to 10.6%). At the last evaluable assessment, outcome was successful in 162 (65%) patients assigned voriconazole and 87 (71%) assigned amphotericin B/fluconazole (p=0.25). Voriconazole cleared blood cultures as quickly as amphotericin B/fluconazole (median time to negative blood culture, 2.0 days). Treatment discontinuations due to all-cause adverse events were more frequent in the voriconazole group, although most discontinuations were due to non-drug-related events and there were significantly fewer serious adverse events and cases of renal toxicity than in the amphotericin B/fluconazole group. INTERPRETATION Voriconazole was as effective as the regimen of amphotericin B followed by fluconazole in the treatment of candidaemia in non-neutropenic patients, and with fewer toxic effects. RELEVANCE TO PRACTICE There are several options for treatment of candidaemia in non-neutropenic patients, including amphotericin B, fluconazole, voriconazole, and echinocandins. Voriconazole can be given both as initial intravenous treatment and as an oral stepdown agent.
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Affiliation(s)
- B J Kullberg
- Nijmegen University Centre for Infectious Diseases, Department of Internal Medicine (484), Radboud University Nijmegen Medical Centre (541), PO Box 9101, 6500 HB Nijmegen, Netherlands.
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Abstract
Distinguishing between re-infection and relapse of trichomonas infections is often a difficult task in the clinical setting. The chronicity of trichomonas infections and the ongoing sexual activity are two confounding factors. We present a patient with recurrent resistant vaginal trichomoniasis shortly following a sexual contact with an untreated partner after a complete response to treatment with tinidazole for nine months. We hypothesise that re-infection occurred from the asymptomatic partner who was an untreated chronic carrier of resistant trichomonas in the urogenital tract.
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Affiliation(s)
- M Kanno
- Division of Infectious Diseases, Department of Medicine, Detroit Medical Center, Harper Hospital, Detroit, Michigan, USA
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Sobel JD, Zervos M, Reed BD, Hooton T, Soper D, Nyirjesy P, Heine MW, Willems J, Panzer H. Fluconazole susceptibility of vaginal isolates obtained from women with complicated Candida vaginitis: clinical implications. Antimicrob Agents Chemother 2003; 47:34-8. [PMID: 12499165 PMCID: PMC148960 DOI: 10.1128/aac.47.1.34-38.2003] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Despite considerable evidence of azole resistance in oral candidiasis due to Candida species, little is known about the azole susceptibilities of the genital tract isolates responsible for vaginitis. The fluconazole susceptibilities of vaginal isolates obtained during a multicenter study of 556 women with complicated Candida vaginitis were determined by evaluating two fluconazole treatment regimens. Of 393 baseline isolates of Candida albicans, 377 (96%) were highly susceptible to fluconazole (MICs, <8 microg/ml) and 14 (3.6%) were resistant (MICs, >or=64 microg/ml). Following fluconazole therapy, one case of in vitro resistance developed during 6 weeks of monitoring. In accordance with the NCCLS definition, in vitro fluconazole resistance correlated poorly with the clinical response, although a trend of a higher mycological failure rate was found (41 versus 19.6% on day 14). By using an alternative breakpoint of 1 micro g/ml, based upon the concentrations of fluconazole achievable in vaginal tissue, no significant differences in the clinical and mycological responses were observed when isolates (n = 250) for which MICs were <or=1 microg/ml were compared with isolates (n = 30) for which MICs were >1 microg/ml, although a trend toward an improved clinical outcome was noted on day 14 (odds ratio, >2.7; 95% confidence interval, 0.91, 8.30). Although clinical failure was uncommon, symptomatic recurrence or mycological relapse almost invariably occurred with highly sensitive strains (MICs, <1.0 microg/ml). In vitro fluconazole resistance developed in 2 of 18 initially susceptible C. glabrata isolates following fluconazole exposure. Susceptibility testing for women with complicated Candida vaginitis appears to be unjustified.
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Affiliation(s)
- J D Sobel
- Department of Internal Medicine, Wayne State University, Detroit, Michigan, USA.
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Abstract
In the last 2 decades, Candida species have progressed from infrequent pathogens to among the most important and frequent opportunistic microorganisms causing nosocomial infection in intensive care unit (ICU) patients. Medical and surgical ICUs have become the epicenter of the Candida epidemic. Superficial infections causing oropharyngeal and esophageal candidiasis are common, and, although non-life threatening, may be refractory to conventional antifungals. In contrast, invasive candidiasis, candidemia, and hematogenous disseminated infections are associated with considerable attributable mortality. Although blood isolates of C. albicans remain susceptible to fluconazole, the increasing incidence of non- albicans Candida species with intrinsic reduced susceptibility to azoles creates new therapeutic challenges. Fortunately, lipid formulations of amphotericin B and the recently introduced echinocandin group represent new and strategic treatment responses to the challenge of invasive candidiasis.
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Affiliation(s)
- J D Sobel
- Department of Internal Medicine, Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan, USA.
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Barousse MM, Steele C, Dunlap K, Espinosa T, Boikov D, Sobel JD, Fidel PL. Growth inhibition of Candida albicans by human vaginal epithelial cells. J Infect Dis 2001; 184:1489-93. [PMID: 11709796 DOI: 10.1086/324532] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Vulvovaginal candidiasis (VVC) is a common mucosal infection caused by Candida species in women of childbearing age. Although acute VVC affects a large number of women and is often precipitated by hormonal fluctuations involving high estrogen levels, recurrent VVC (RVVC) affects another 5%-10% of women without any known predisposing factors. We have recently reported that vaginal epithelial cells from nonhuman primates and mice inhibit the growth of Candida albicans in vitro, which may represent an innate host defense mechanism against C. albicans at the vaginal mucosa. In the present study, we show that vaginal epithelial cells collected from healthy women with no history of VVC also exhibit anti-Candida activity, with no differences in activity at various stages of the menstrual cycle. Women diagnosed with RVVC, on the other hand, have reduced epithelial cell anti-Candida activity. These results are further evidence that vaginal epithelial cells provide an innate host resistance mechanism against Candida and that reduced activity may contribute to RVVC.
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Affiliation(s)
- M M Barousse
- Department of Microbiology, Immunology, and Parasitology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA.
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Sobel JD, Nyirjesy P, Brown W. Tinidazole therapy for metronidazole-resistant vaginal trichomoniasis. Clin Infect Dis 2001; 33:1341-6. [PMID: 11565074 DOI: 10.1086/323034] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2001] [Revised: 04/27/2001] [Indexed: 11/03/2022] Open
Abstract
Treatment of patients with metronidazole-refractory vaginal trichomoniasis constitutes a major therapeutic challenge, and treatment options are extremely limited. Although the majority of patients infected with trichomonads, who demonstrate reduced in vitro susceptibility to metronidazole, respond to high-dose but poorly tolerated regimens of metronidazole, clinical failure is by no means uncommon. We report a cure rate of 22 (92%) of 24 patients with refractory trichomoniasis treated with high doses of oral and vaginal tinidazole. This series included 15 cases with increased in vitro minimal lethal concentration values of metronidazole. Tinidazole, despite the high doses used, was extremely well tolerated, with few side effects. Topical paromomycin was effective in 7 (58%) of 12 patients treated, but frequent local vulvovaginal adverse reactions precluded extensive use. Widespread reports of metronidazole resistance and limited treatment options emphasize the need for additional trichomonacidal agents.
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Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Harper Hospital, Detroit, MI 48201, USA.
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24
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Vazquez JA, Peng G, Sobel JD, Steele-Moore L, Schuman P, Holloway W, Neaton JD. Evolution of antifungal susceptibility among Candida species isolates recovered from human immunodeficiency virus-infected women receiving fluconazole prophylaxis. Clin Infect Dis 2001; 33:1069-75. [PMID: 11528582 DOI: 10.1086/322641] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2000] [Revised: 03/20/2001] [Indexed: 11/04/2022] Open
Abstract
The effect of fluconazole on the susceptibility of Candida isolates recovered from women infected with human immunodeficiency virus (HIV) was evaluated in a randomized, double-blind, placebo-controlled trial. Women with CD4(+) cell counts of < or =300 cells/mm(3) received either fluconazole (200 mg/week) or placebo as prophylaxis. The antifungal susceptibility of specimens was evaluated. One patient who received fluconazole and 2 patients assigned to placebo had Candida albicans isolates recovered that were resistant to fluconazole (MIC, > or =64 microg/mL). Eleven patients assigned fluconazole and 4 patients assigned placebo had non-albicans Candida strains (all Candida glabrata) recovered that were resistant to fluconazole. There was significant azole cross-resistance among the non-albicans Candida species isolates. Although the rate of azole resistance did not significantly increase after fluconazole prophylaxis, there was a trend toward more in vitro azole resistance in C. glabrata isolates from patients assigned fluconazole. Moreover, the majority of resistant vaginal isolates of Candida species were recovered after initiation of open-label fluconazole use.
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Affiliation(s)
- J A Vazquez
- Wayne State University School of Medicine, Detroit, MI, USA.
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25
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Abstract
The distinction between Candida colonization of the urinary tract and infection is often blurred. Asymptomatic candiduria is particularly common in catheterized intensive care unit patients. To date, few studies have addressed the appropriate treatment regimens for candiduria. Fluconazole has become a mainstay of therapy; however, when to treat, whom to treat, and how long to treat are still largely unanswered questions. Asymptomatic nosocomial candiduria infrequently requires treatment intervention because morbidity is low and ascending infection and candidemia are rare complications. An understanding of the anatomic site of infection drives treatment decisions. More research is needed to define diagnostic criteria and therapeutic pathways. This review attempts to summarize the diagnosis and management of candiduria.
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Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Wayne State University School of Medicine, Harper Hospital, Detroit, MI 48201, USA.
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26
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Sobel JD, Kapernick PS, Zervos M, Reed BD, Hooton T, Soper D, Nyirjesy P, Heine MW, Willems J, Panzer H, Wittes H. Treatment of complicated Candida vaginitis: comparison of single and sequential doses of fluconazole. Am J Obstet Gynecol 2001; 185:363-9. [PMID: 11518893 DOI: 10.1067/mob.2001.115116] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE An attempt was made to validate recent recommendations that women with complicated Candida vaginitis (severe or recurrent, non-albicans Candida spp or abnormal host) require longer-duration antifungal therapy to achieve clinical cure and mycologic eradication. STUDY DESIGN A prospective, multicenter, randomized, double-blind study was performed comparing a single dose of 150 mg of fluconazole with 2 sequential 150-mg doses of fluconazole given 3 days apart. RESULTS Five hundred fifty-six women with severe or recurrent Candida vaginitis were enrolled, and 398 had at least one postbaseline evaluation (intent to treat) and of these 309 were fully evaluable (efficacy-valid). At baseline, 92% of vaginal isolates were Candida albicans. The 2-dose fluconazole regimen achieved significantly higher clinical cure rates in women with severe vaginitis when evaluated on day 14 (P =.015) and higher clinical and mycologic responses persisted at day 35. Women with recurrent but not severe vaginitis did not benefit clinically short term by the additional fluconazole dose. Multivariate logistic regression analysis showed that being infected with non-albicans Candida predicted significantly reduced clinical and mycologic response regardless of duration of therapy. Fluconazole therapy was well tolerated and free of serious adverse effects. CONCLUSION Treatment of Candida vaginitis requires individualization, and women with severe Candida vaginitis achieve superior clinical and mycologic eradication with a 2-dose fluconazole regimen.
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Affiliation(s)
- J D Sobel
- Department of Internal Medicine, Wayne State University, Detroit, MI 48201, USA.
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Foxman B, Somsel P, Tallman P, Gillespie B, Raz R, Colodner R, Kandula D, Sobel JD. Urinary tract infection among women aged 40 to 65: behavioral and sexual risk factors. J Clin Epidemiol 2001; 54:710-8. [PMID: 11438412 DOI: 10.1016/s0895-4356(00)00352-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We conducted a case-control study to explore the role of health behavior and sexual and medical history on urinary tract infection (UTI) risk among otherwise healthy women aged 40-65. Cases and controls were recruited from nine practices and clinics in Michigan and a single clinic in Israel. In both countries, several factors were reported significantly more frequently among UTI cases than controls: a previous UTI within 12 months, incontinence symptoms, a recent episode of 30-plus minutes of cold hands, feet, back or buttocks, and recent antibiotic use. Cases were less likely than controls to report recent estrogen use, but the results were only statistically significant in Michigan. Sexual activity during the previous 2 weeks and having ceased menses were modestly, but not statistically significantly, protective at both study sites. Risk factors for UTI among women 40-65 differ from those for younger women and these differences cannot be attributed solely to changes in menopausal status.
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Affiliation(s)
- B Foxman
- Department of Epidemiology, University of Michigan School of Public Health, 109 Observatory St., Ann Arbor, MI 48109, USA.
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29
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Rex JH, Walsh TJ, Nettleman M, Anaissie EJ, Bennett JE, Bow EJ, Carillo-Munoz AJ, Chavanet P, Cloud GA, Denning DW, de Pauw BE, Edwards JE, Hiemenz JW, Kauffman CA, Lopez-Berestein G, Martino P, Sobel JD, Stevens DA, Sylvester R, Tollemar J, Viscoli C, Viviani MA, Wu T. Need for alternative trial designs and evaluation strategies for therapeutic studies of invasive mycoses. Clin Infect Dis 2001; 33:95-106. [PMID: 11389501 DOI: 10.1086/320876] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2000] [Revised: 11/07/2000] [Indexed: 11/03/2022] Open
Abstract
Studies of invasive fungal infections have been and remain difficult to implement. Randomized clinical trials of fungal infections are especially slow and expensive to perform because it is difficult to identify eligible patients in a timely fashion, to prove the presence of the fungal infection in an unequivocal fashion, and to evaluate outcome in a convincing fashion. Because of these challenges, licensing decisions for antifungal agents have to date depended heavily on historical control comparisons and secondary advantages of the new agent. Although the availability of newer and potentially more effective agents makes these approaches less desirable, the fundamental difficulties of trials of invasive fungal infections have not changed. Therefore, there is a need for alternative trial designs and evaluation strategies for therapeutic studies of invasive mycoses, and this article summarizes the possible strategies in this area.
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Affiliation(s)
- J H Rex
- Division of Infectious Diseases, Department of Internal Medicine, Center for the Study of Emerging and Reemerging Pathogens, University of Texas Medical School, Houston, TX, USA.
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Tiraboschi IN, Bennett JE, Kauffman CA, Rex JH, Girmenia C, Sobel JD, Menichetti F. Deep Candida infections in the neutropenic and non-neutropenic host: an ISHAM symposium. Med Mycol 2001; 38 Suppl 1:199-204. [PMID: 11204146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
A symposium was held on May 8, 2000 to discuss the management of deep infections with Candida species. Among the findings discussed were the following. Candiduria is most often benign, though it occurs in patients with serious underlying diseases. Candida species are now the fourth most common cause of nosocomial bloodstream infections, usually arising from an intravenous catheter. Candida albicans represents only 50-60% of the isolates. There has been no change in the frequency of fluconazole resistance in C. albicans but some of the other species now being isolated from blood are constitutively more resistant to this drug. Nevertheless, for most non-neutropenic patients with candidemia, fluconazole is a reasonable choice for initial therapy. In the neutropenic patient, candidemia is now uncommon. Deep candida infections in neutropenic patients are usually being treated empirically with an amphotericin B formulation. Hepatosplenic candidiasis is usually detected only after recovery from neutropenia but can be suspected by imaging techniques. Improved diagnostic techniques for deep candidiasis in the neutropenic patient remain a critical requirement.
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Affiliation(s)
- I N Tiraboschi
- Division of Infectious Diseases Hospital de Clínicas, University of Buenos Aires, Argentina
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31
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Ormerod LD, Puklin JE, Sobel JD. Syphilitic Posterior Uveitis: Correlative Findings and Significance. Clin Infect Dis 2001; 32:1661-73. [PMID: 11360205 DOI: 10.1086/320766] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/1999] [Revised: 08/16/2000] [Indexed: 11/03/2022] Open
Abstract
Twenty-one patients with syphilitic posterior uveitis were investigated retrospectively to study the disease spectrum, associations with neurosyphilis, and therapeutic implications. Ophthalmologic manifestations of syphilitic posterior uveitis are differentiated into acute and chronic uveitides. The several distinct acute uveitic syndromes are usually florid and are associated with early syphilis, with VDRL-positive syphilitic meningitis, and frequently with human immunodeficiency virus coinfection. The chronic posterior uveitides are often insidious, a manifestation of late syphilis, and associated commonly with subclinical neurosyphilis. All patients with acute cases and 54% of patients with chronic cases in our study received penicillin therapy appropriate for neurosyphilis. The frequent association of syphilitic posterior uveitis with neurosyphilis and the analogous spirochetal sequestration beyond the blood-brain and the blood-ocular barriers suggest that all patients with syphilitic posterior uveitis, irrespective of ocular disease intensity, should undergo evaluation of cerebrospinal fluid and be treated with penicillin regimens appropriate for neurosyphilis.
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Affiliation(s)
- L D Ormerod
- Mason Eye Institute, University of Missouri-Columbia, Columbia, MO 65212, USA
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32
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Abstract
Antifungal prophylaxis is regularly used during treatment of patients with some cancers, as subgroups with high rates of invasive fungal infections are readily identified; for these patients, prophylaxis has been shown to be of value. High-risk liver transplant recipients also benefit from antifungal prophylaxis. Although the idea of extending this concept to the prevention of candidal infections in the larger population of critically ill patients who are seen in the intensive care unit (ICU) and who do not have neutropenia is attractive, implementation of this strategy is difficult because of the widely varying characteristics of patients in the ICU. Two studies have shown the benefit of such prophylaxis, but the benefit was shown only in selected groups of patients who had an unusually high risk for invasive candidiasis. Although the concept is sound, broad-scale implementation of antifungal prophylaxis would be premature and costly, both financially and with regard to resistance and toxicity. Investigations are needed to define and prove the utility of predictive tools for the identification of patients in the ICU who would benefit from prophylaxis.
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Affiliation(s)
- J H Rex
- Division of Infectious Diseases, Department of Internal Medicine, Center for the Study of Emerging and Re-Emerging Pathogens, University of Texas Medical School, Houston, TX 77030, USA.
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33
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Rex JH, Walsh TJ, Sobel JD, Filler SG, Pappas PG, Dismukes WE, Edwards JE. Reply to Dr. Chandrasekar (Clin Infect Dis 2001; 32:320-1) and Drs. Marr and Boeckh (Clin Infect Dis 2001; 32:321). Clin Infect Dis 2001; 32:518-9. [PMID: 11170965 DOI: 10.1086/318517] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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34
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Nyirjesy P, Sobel JD, Weitz MV, Leaman DJ, Small MJ, Gelone SP. Cromolyn cream for recalcitrant idiopathic vulvar vestibulitis: results of a placebo controlled study. Sex Transm Infect 2001; 77:53-7. [PMID: 11158692 PMCID: PMC1758319 DOI: 10.1136/sti.77.1.53] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Patients with chronic idiopathic vulvar vestibulitis have increased mast cells when biopsied, and cromolyn has been suggested as a treatment. The purpose of this study was to assess the efficacy of 4% cromolyn cream in women with vulvar vestibulitis. METHODS A prospective, double blind, randomised, placebo controlled study was initiated at two centres. Patients with vulvar vestibulitis were assigned to apply cromolyn or placebo cream to the vestibule. Symptoms (burning, irritation) and signs (erythema, extent of erythema, tenderness) were recorded on a 0-3 scale. In the sexually active patient subgroup, dyspareunia was also evaluated. RESULTS 13 of the 26 evaluable patients received cromolyn. Patients in the cromolyn arm were more likely to have failed therapy with amitriptyline (p = 0.05), but the two groups were otherwise similar upon study entry. Overall, scores decreased from a median of 9 to 5 (p = 0.001) during the study, but the level of improvement was similar between both groups. Improvement was unrelated to duration of symptoms, fluconazole use, or sexual activity. Five patients (38%) taking cromolyn and six (46%) taking placebo felt they had a 50% or greater reduction in symptoms. In the 21 sexually active patients, the total score decreased from a mean of 12 to 8 (p = 0.005), but there was no statistically significant difference between study arms. CONCLUSIONS Cromolyn cream did not confer a significant benefit in patients with vulvar vestibulitis. The large placebo response suggests the need for large well controlled studies of other treatment modalities.
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Affiliation(s)
- P Nyirjesy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University School of Medicine, Philadelphia, Pennsylvania, USA.
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35
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Sobel JD, Ohmit SE, Schuman P, Klein RS, Mayer K, Duerr A, Vazquez JA, Rampalo A. The evolution of Candida species and fluconazole susceptibility among oral and vaginal isolates recovered from human immunodeficiency virus (HIV)-seropositive and at-risk HIV-seronegative women. J Infect Dis 2001; 183:286-93. [PMID: 11204125 DOI: 10.1086/317936] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Antifungal agents can effectively treat mucosal candidiasis; however, their use can lead to colonization with less susceptible species and to resistance among normally susceptible strains. Oral and vaginal Candida isolates obtained at 3 points over 2 years from human immunodeficiency virus (HIV)-seropositive and at-risk HIV-seronegative women were identified by species and were evaluated for in vitro fluconazole susceptibility. Prevalence of non-C. albicans strains increased over time, and these strains were more likely among women reporting current antifungal use. Among C. albicans isolates, resistance was rare, with no evidence for progressive reduction in susceptibility over time. Among non-C. albicans isolates, reduced susceptibility occurred frequently and increased with time. HIV-seropositive women were more likely to have non-C. albicans isolates with reduced susceptibility as were women reporting current antifungal use. This evolution and section of mucosa-colonizing Candida species with reduced susceptibility could play a critical early role in the development of antifungal resistance among C. albicans isolates responsible for refractory candidiasis.
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Affiliation(s)
- J D Sobel
- Wayne State University School of Medicine, Detroit, Michigan, USA.
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36
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Leigh JE, Barousse M, Swoboda RK, Myers T, Hager S, Wolf NA, Cutright JL, Thompson J, Sobel JD, Fidel PL. Candida-specific systemic cell-mediated immune reactivities in human immunodeficiency virus-positive persons with mucosal candidiasis. J Infect Dis 2001; 183:277-285. [PMID: 11120933 DOI: 10.1086/317944] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2000] [Revised: 10/09/2000] [Indexed: 11/04/2022] Open
Abstract
Oropharyngeal candidiasis (OPC), as opposed to vulvovaginal candidiasis (VVC), is a common opportunistic infection in human immunodeficiency virus (HIV)-positive persons that correlates with reduced CD4 T cell counts. Although cell-mediated immunity (CMI) by CD4 Th1-type cells is considered to be the predominant host defense against mucosal candidiasis, the immune factors associated with susceptibility to OPC in HIV-positive persons are not well understood. This study investigated Candida-specific systemic CMI in HIV-positive persons with OPC and/or VVC. Reductions in delayed skin test reactivity to Candida antigen were observed in HIV-positive persons with CD4 cell counts <200 cells/microL, irrespective of the presence of mucosal infection. Likewise, despite the correlate of OPC with reduced CD4 cell counts in HIV-positive persons, differences in Candida-specific peripheral blood mononuclear cell proliferation and Th1/Th2 cytokine production between HIV-positive and HIV-negative persons were not consistent in a manner to suggest that deficiencies in Candida-specific systemic CMI account solely for the susceptibility to OPC.
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Affiliation(s)
- J E Leigh
- Department of General Dentistry, Louisiana State University School of Dentistry, New Orleans, LA, USA
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37
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Abstract
Although Zygomycetes cause life-threatening, opportunistic infections in immunocompromised hosts, the first case of vaginitis caused by Mucor species in a healthy woman is reported. Mucor vaginitis, which caused mild symptoms only, was refractory to conventional azole therapy and resistant to flucytosine. Cure was achieved with topical amphotericin B.
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Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Detroit Medical Center, Wayne State University School of Medicine, MI, USA.
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38
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Tiraboschi IN, Bennett JE, Kauffman CA, Rex JH, Girmenia C, Sobel JD, Menichetti F. Deep Candida infections in the neutropenic and non-neutropenic host: an ISHAM symposium. Med Mycol 2000. [DOI: 10.1080/744118734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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39
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Sobel JD. Clinical Trials Report. Curr Infect Dis Rep 2000; 2:499-500. [PMID: 11095898 DOI: 10.1007/s11908-000-0050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- JD Sobel
- Division of Infectious Diseases, Harper Hospital, 4 Brush Center, Room 411, 3990 John R, Detroit, MI 48201, USA
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Abstract
The maturation of the acquired immunodeficiency syndrome epidemic has now claimed more than 12 million women worldwide, the majority in undeveloped countries where human immunodeficiency virus (HIV) and sexually transmitted infections coexist and interact synergistically. Among HIV-infected women, there is excessive morbidity due to sexually transmitted diseases (STDs) and gynecologic disorders. This review summarizes the expanding understanding of vaginal flora, vaginitis, cervicitis, pelvic inflammatory disease, and genital ulcer disease in HIV-infected women. In addition to the altered clinical course, complications, and management difficulties of STDs, some gynecologic infections may influence HIV transmission as well as the vertical transmission of HIV to the newborn. Finally, severe immunodeficiency allows unusual opportunistic pathogens to invade the upper and lower genital tract. Control and prevention of gynecologic infections in HIV-positive and HIV-negative women are key components to preventing further HIV transmission.
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Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Department of Internal Medicine, Wayne State University School of Medicine, Detroit Medical Center, Detroit, MI 48201, USA.
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Abstract
PURPOSE To estimate the annual incidence, cumulative probability of presumed urinary tract infection (UTI) by age, and the social costs. METHODS Analysis of a random digit dialing survey of 2000 women in the United States. RESULTS 10.8 percent (95% CI: 9.4, 12.1%) of women aged 18 and older reported at least one presumed UTI during the past 12 months, with the majority of the cases occurring among women with a history of two or more UTI episodes in their life. We estimate that by age 24, one-third of women will have at least one physician-diagnosed UTI that was treated with prescription medication. Overall, an estimated 11.3 million women in the United States had at least one presumed UTI treated with antibiotics in 1995. We estimate the annual cost of UTI cases with prescriptions to be $1.6 billion in 1995. If the costs occurring after 1995 are discounted at 5% annually, the total cost over 20 years has a present value of $25.5 billion. CONCLUSION If a vaccine were developed that would prevent either initial or recurrent UTI the net benefits to society would be substantial, even at a developmental cost of one billion dollars.
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Affiliation(s)
- B Foxman
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
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42
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Abstract
Candida glabrata infections undoubtedly have become more frequent, and are now common. They appear to be the consequence of widespread and often indiscriminate use of azoles, especially fluconazole. This species constitutes the Achilles heel of all available azoles, including newer ones in the pipeline. Even when amphotericin B is used, higher dosages are now required. Little is known about the epidemiology of and risk factors for this troublesome species; even less about its virulence factors. However, studying the resistance mechanisms of this haploid organism may provide answers in developing new fungicidal agents.
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Affiliation(s)
- JD Sobel
- Department of Internal Medicine, Wayne State University School of Medicine and Harper Hospital, 4 Brush, Room 4811, 3990 John R, Detroit, MI 48201, USA.
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43
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Abstract
The use of antifungals in pregnancy requires special consideration for the safety of the developing fetus. Clinicians now have an increased repertoire of both topical and systemic antimycotics available to treat superficial or mucotaneous fungal infections including Candida vaginitis. The ability of many nontopical antifungals to penetrate the placenta and achieve measurable, often therapeutic, concentrations in cord blood, fetal tissue and amniotic fluid means that evidence exists of successful treatment of all varieties of systemic fungal disease in pregnant women, even with placental involvement. However, for the same reasons, safety considerations remain a concern. Although the use of azoles as topical agents for superficial infections is both efficacious and well tolerated, especially when used for short periods, systemic azole therapy is not recommended in pregnancy. Accordingly, amphotericin B remains the drug of choice for systemic, invasive mycotic infections, whether life-threatening or less severe. Unfortunately little if any information is available regarding the safety of the newer lipid formulations of amphotericin B. There is a general reluctance to perform randomised, comparative studies involving antifungal agents in pregnancy, hence cumulative anecdotal reports form much of the available data; animal studies, although useful, have several drawbacks. There is a need for additional safe and effective new antifungal agents for widespread use in pregnant women.
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Affiliation(s)
- J D Sobel
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit Medical Center, USA.
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Foxman B, Gillespie B, Koopman J, Zhang L, Palin K, Tallman P, Marsh JV, Spear S, Sobel JD, Marty MJ, Marrs CF. Risk factors for second urinary tract infection among college women. Am J Epidemiol 2000; 151:1194-205. [PMID: 10905532 DOI: 10.1093/oxfordjournals.aje.a010170] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
To better understand the etiology of recurrent urinary tract infection (UTI), the authors followed a cohort of 285 female college students with first UTI for 6 months or until second UTI. A first UTI due to Escherichia coli was followed by a second UTI three times more often than was a non-E. coli first UTI (24 vs. 8%; p = 0.02). In a logistic regression analysis limited to the 224 women from the University of Michigan Health Service and the University of Texas at Austin Health Service from September 1992 to December 1994, with a first UTI due to E. coli, vaginal intercourse increased the risk of a second UTI with both a different (odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.19, 2.15) and the same (OR = 1.37, 95% CI: 0.91, 2.07) uropathogen, as did using a diaphragm, cervical cap, and/or spermicide (same uropathogen: OR = 1.53, 95% CI: 0.95, 2.47; different uropathogen: OR = 1.77, 95% CI: 1.22, 2.58). Condom use decreased the risk of a second UTI caused by a different uropathogen (OR = 0.68, 95% CI: 0.48, 0.99) but had no effect on a second UTI caused by the same E. coli (OR = 0.99; 95% CI: 0.66, 1.50). Type or duration of treatment was not associated with a second UTI. Although the risk of second UTI is strongly influenced by sexual behavior, women with a first UTI caused by E. coli are more likely than are those with a non-E. coli first UTI to have a second UTI within 6 months.
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Affiliation(s)
- B Foxman
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA.
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Abstract
Bacterial vaginosis represents a unique upheaval of the complex vaginal bacterial flora with disappearance of lactobacilli and overgrowth of Gardnerella vaginalis and resident anaerobic vaginal bacteria. Little progress has occurred in identifying causal factors, although the pathophysiology of this syndrome is better understood. Although symptoms are easily recognizable, obstetric and gynecologic complications continue to increase in number. Bacterial vaginosis is far more than a nuisance infection. Problems with diagnosis continue to dominate clinical practice, although new tests have been introduced. Therapeutic options have increased, although recurrent disease remains common, and management of this common complication constitutes a major challenge.
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Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit Medical Center, Michigan 48201, USA.
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Lundstrom TS, Sobel JD. Antibiotics for gram-positive bacterial infections. Vancomycin, teicoplanin, quinupristin/dalfopristin, and linezolid. Infect Dis Clin North Am 2000; 14:463-74. [PMID: 10829266 DOI: 10.1016/s0891-5520(05)70258-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Vancomycin is a safe, effective antibiotic for a variety of serious gram-positive infections. Because of emerging resistance in enterococci and staphylococci and the emerging threat of spread of vancomycin-resistant genes to other gram-positive organisms, judicious use of vancomycin should be promoted. Quinupristin/dalfopristin, a streptogramin antibiotic, and linezolid, an oxazolidinone, show promise against some strains of gram-positive bacteria that are resistant to vancomycin.
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Affiliation(s)
- T S Lundstrom
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
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Abstract
BACKGROUND AND OBJECTIVES Incidence of Candida vaginitis by age and racial or ethnic group is poorly described. GOAL Estimate incidence, cumulative probability of presumed C vaginitis by age, racial or ethnic group, and associated costs. STUDY DESIGN Random digit-dialing survey of 2000 US women. RESULTS A total of 6.5 percent (95% CI, 5.4-7.5%) of women older than 18 years reported a least one episode of presumed C vaginitis during the previous 2 months. Women reporting a 1-year period with four or more episodes comprised 8.0% of the sample but accounted for 37.2% of women reporting episodes. Black women reported approximately three times more yeast infections in the previous 2 months (17.4%; 95% CI, 11.2-23.5%) than white women (5.8%; 95% CI, 4.7-6.9%). CONCLUSION The high incidence and the propensity for recurrence underscore the need for a better understanding of the epidemiology and pathogenesis, and stress the need for the development of more accurate, rapid diagnostics and effective treatments.
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Affiliation(s)
- B Foxman
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor 48109-2029, USA.
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Saag MS, Graybill RJ, Larsen RA, Pappas PG, Perfect JR, Powderly WG, Sobel JD, Dismukes WE. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society of America. Clin Infect Dis 2000; 30:710-8. [PMID: 10770733 DOI: 10.1086/313757] [Citation(s) in RCA: 788] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/1999] [Indexed: 12/19/2022] Open
Abstract
An 8-person subcommittee of the National Institute of Allergy and Infectious Diseases (NIAID) Mycoses Study Group evaluated available data on the treatment of cryptococcal disease. Opinion regarding optimal treatment was based on personal experience and information in the literature. The relative strength of each recommendation was graded according to the type and degree of evidence available to support the recommendation, in keeping with previously published guidelines by the Infectious Diseases Society of America (IDSA). The panel conferred in person (on 2 occasions), by conference call, and through written reviews of each draft of the manuscript. The choice of treatment for disease caused by Cryptococcus neoformans depends on both the anatomic sites of involvement and the host's immune status. For immunocompetent hosts with isolated pulmonary disease, careful observation may be warranted; in the case of symptomatic infection, indicated treatment is fluconazole, 200-400 mg/day for 36 months. For those individuals with non-CNS-isolated cryptococcemia, a positive serum cryptococcal antigen titer >1:8, or urinary tract or cutaneous disease, recommended treatment is oral azole therapy (fluconazole) for 36 months. In each case, careful assessment of the CNS is required to rule out occult meningitis. For those individuals who are unable to tolerate fluconazole, itraconazole (200-400 mg/day for 6-12 months) is an acceptable alternative. For patients with more severe disease, treatment with amphotericin B (0.5-1 mg/kg/d) may be necessary for 6-10 weeks. For otherwise healthy hosts with CNS disease, standard therapy consists of amphotericin B, 0.7-1 mg/kg/d, plus flucytosine, 100 mg/kg/d, for 6-10 weeks. An alternative to this regimen is amphotericin B (0.7-1 mg/kg/d) plus 5-flucytosine (100 mg/kg/d) for 2 weeks, followed by fluconazole (400 mg/day) for a minimum of 10 weeks. Fluconazole "consolidation" therapy may be continued for as along as 6-12 months, depending on the clinical status of the patient. HIV-negative, immunocompromised hosts should be treated in the same fashion as those with CNS disease, regardless of the site of involvement. Cryptococcal disease that develops in patients with HIV infection always warrants therapy. For those patients with HIV who present with isolated pulmonary or urinary tract disease, fluconazole at 200-400 mg/d is indicated. Although the ultimate impact from highly active antiretroviral therapy (HAART) is currently unclear, it is recommended that all HIV-infected individuals continue maintenance therapy for life. Among those individuals who are unable to tolerate fluconazole, itraconazole (200-400 mg/d) is an acceptable alternative. For patients with more severe disease, a combination of fluconazole (400 mg/d) plus flucytosine (100-150 mg/d) may be used for 10 weeks, followed by fluconazole maintenance therapy. Among patients with HIV infection and cryptococcal meningitis, induction therapy with amphotericin B (0.7-1 mg/kg/d) plus flucytosine (100 mg/kg/d for 2 weeks) followed by fluconazole (400 mg/d) for a minimum of 10 weeks is the treatment of choice. After 10 weeks of therapy, the fluconazole dosage may be reduced to 200 mg/d, depending on the patient's clinical status. Fluconazole should be continued for life. An alternative regimen for AIDS-associated cryptococcal meningitis is amphotericin B (0.7-1 mg/kg/d) plus 5-flucytosine (100 mg/kg/d) for 6-10 weeks, followed by fluconazole maintenance therapy. Induction therapy beginning with an azole alone is generally discouraged. Lipid formulations of amphotericin B can be substituted for amphotericin B for patients whose renal function is impaired. Fluconazole (400-800 mg/d) plus flucytosine (100-150 mg/kg/d) for 6 weeks is an alternative to the use of amphotericin B, although toxicity with this regimen is high. In all cases of cryptococcal meningitis, careful attention to the management of intracranial pressure is imperative to assure optimal c
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Affiliation(s)
- M S Saag
- University of Alabama at Birmingham, 35294-2050, USA. For the Mycoses Study Group Cryptococcal Subproject
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Sobel JD. Practice guidelines for the treatment of fungal infections. For the Mycoses Study Group. Infectious Diseases Society of America. Clin Infect Dis 2000; 30:652. [PMID: 10770725 DOI: 10.1086/313746] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/1999] [Revised: 06/18/1999] [Indexed: 11/04/2022] Open
Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Harper Hospital, Detroit, MI 48201, USA.
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Rex JH, Walsh TJ, Sobel JD, Filler SG, Pappas PG, Dismukes WE, Edwards JE. Practice guidelines for the treatment of candidiasis. Infectious Diseases Society of America. Clin Infect Dis 2000; 30:662-78. [PMID: 10770728 DOI: 10.1086/313749] [Citation(s) in RCA: 534] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/1999] [Revised: 06/10/1999] [Indexed: 11/03/2022] Open
Abstract
Infections due to Candida species are the most common of the fungal infections. Candida species produce a broad range of infections, ranging from nonlife-threatening mucocutaneous illnesses to invasive process that may involve virtually any organ. Such a broad range of infections requires an equally broad range of diagnostic and therapeutic strategies. This document summarizes current knowledge about treatment of multiple forms of candidiasis and is the guideline of the Infectious Diseases Society of America (IDSA) for the treatment of candidiasis. Throughout this document, treatment recommendations are scored according to the standard scoring scheme used in other IDSA guidelines to illustrate the strength of the underlying data. The document covers 4 major topical areas. The role of the microbiology laboratory. To a greater extent than for other fungi, treatment of candidiasis can now be guided by in vitro susceptibility testing. The guidelines review the available information supporting current testing procedures and interpretive breakpoints and place these data into clinical context. Susceptibility testing is most helpful in dealing with infection due to non-albicans species of Candida. In this setting, especially if the patient has been treated previously with an azole antifungal agent, the possibility of microbiological resistance must be considered. Treatment of invasive candidiasis. In addition to acute hematogenous candidiasis, the guidelines review strategies for treatment of 15 other forms of invasive candidiasis. Extensive data from randomized trials are really available only for therapy of acute hematogenous candidiasis in the nonneutropenic adult. Choice of therapy for other forms of candidiasis is based on case series and anecdotal reports. In general, both amphotericin B and the azoles have a role to play in treatment. Choice of therapy is guided by weighing the greater activity of amphotericin B for some non-albicans species (e.g., Candida krusei) against the lesser toxicity and ease of administration of the azole antifungal agents. Flucytosine has activity against many isolates of Candida but is not often used. Treatment of mucocutaneous candidiasis. Therapy for mucosal infections is dominated by the azole antifungal agents. These drugs may be used topically or systemically and have been proven safe and efficacious. A significant problem with mucosal disease is the propensity for a small proportion of patients to suffer repeated relapses. In some situations, the explanation for such a relapse is obvious (e.g., relapsing oropharyngeal candidiasis in an individual with advanced and uncontrolled HIV infection), but in other patients the cause is cryptic (e.g., relapsing vaginitis in a healthy woman). Rational strategies for these situations are discussed in the guidelines and must consider the possibility of induction of resistance over time. Prevention of invasive candidiasis. Prophylactic strategies are useful if the risk of a target disease is sharply elevated in a readily identified group of patients. Selected patient groups undergoing therapy that produces prolonged neutropenia (e.g., some bone-marrow transplant recipients) or who receive a solid-organ transplant (e.g., some liver transplant recipients) have a sufficient risk of invasive candidiasis to warrant prophylaxis.
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Affiliation(s)
- J H Rex
- Dept. of Internal Medicine, Center for the Study of Emerging and Re-emerging Pathogens, University of Texas Medical School, Houston, TX 77030, USA.
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