MSG-15: Super-Bioavailability Itraconazole Versus Conventional Itraconazole in the Treatment of Endemic Mycoses-A Multicenter, Open-Label, Randomized Comparative Trial

Background

Invasive fungal disease caused by dimorphic fungi is associated with significant morbidity and mortality. Super-bioavailability itraconazole (SUBA-itra) is a novel antifungal agent with pharmacokinetic advantages over currently available formulations. In this prospective comparative study, we report the outcomes of patients with endemic fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and sporotrichosis).

Methods

This open-label randomized trial evaluated the efficacy, safety, and pharmacokinetics SUBA-itra compared with conventional itraconazole (c-itra) treatment for endemic fungal infections. An independent data review committee determined responses on treatment days 42 and 180.

Results

Eighty-eight patients were enrolled for IFD (SUBA-itra, n = 42; c-itra, n = 46) caused by Histoplasma (n = 51), Blastomyces (n = 18), Coccidioides (n = 13), or Sporothrix (n = 6). On day 42, clinical success was observed with SUBA-itra and c-itra on day 42 (in 69% and 67%, respectively, and on day 180 (in 60% and 65%). Patients treated with SUBA-itra exhibited less drug-level variability at days 7 (P = .03) and 14 (P = .06) of randomized treatment. The concentrations of itraconazole and hydroxyitraconazole were comparable between the 2 medications (P = .77 and P = .80, respectively). There was a trend for fewer adverse events (AEs; 74% vs 87%, respectively; P = .18) and serious AEs (10% vs 26%; P = .06) in the SUBA-itra-treated patients than in those receiving c-itra. Serious treatment-emergent AEs were less common in SUBA-itra-treated patients (12% vs 50%, respectively; P < .001).

Conclusions

SUBA-itra was bioequivalent, well tolerated, and efficacious in treating endemic fungi, with a more favorable safety profile than c-itra.

Clinical Trials Registration

NCT03572049.

Headaches in a Horseback Rider

An immunocompetent woman presented with headaches. She previouslyworked at a farm in upstate New York. Brain MRI noted pituitary enlargement and neurosurgerypursued trans-sphenoidal pituitary biopsy. Histopathology revealed ill-defined granulomaswith clusters of yeast, consistent with Histoplasma.

144. MSG-15: Pharmacokinetic (PK), Adverse Events (AEs), and Tolerability Data from an Open Label Randomized Clinical Trial (RCT) Comparing Oral Suba-itraconazole (SUBA-ITC) to Conventional Itraconazole (C-ITC) for Treatment of Endemic Mycosis (EM)

Background

C-ITC is a drug of choice for non-life-threatening, non-CNS histoplasmosis, blastomycosis, sporotrichosis, coccidioidomycosis and other EM. Oral C-ITC is problematic due to inconsistent absorption often leading to sub-therapeutic serum levels. SUBA-ITC is an FDA approved formulation which utilizes nanotechnology to provide more consistent absorption when compared to C-ITC. We performed an open-label RCT comparing SUBA-ITC to C-ITC for non-life-threatening non-CNS EM, and is the first US based RCT examining SUBA-ITC. Herein we report the PK during the first 6 wks of study therapy (rx) and drug-related AEs and tolerability throughout the course of rx.

Methods

Subjects with a proven or probable EM, who had received <14 days prior antifungal tx, and were able to take po meds were eligible. Those with life-threatening and CNS disease or prohibited meds were excluded. Subjects were randomized to SUBA-ITC 130 mg or C-ITC 200mg, both PO BID, for up to 6 mo. All subjects received loading doses x 3d. Clinical assessment was performed on d 7, 14, 28, 42, 84, and 180. PK and safety evaluations were performed on d 7, 14 and 42. Serum levels and AUC were calculated and demonstrated using combined ITC and hydroxy-ITC measurements. Tolerability was based on subject ability to remain on rx.

Results

62 subjects are included in this analysis (31 each in SUBA-ITC and C-ITC, respectively). Median serum levels of ITC + hydroxy-ITC at d 7, 14 and 42 were consistently higher in the SUBA-ITC arm (Fig 1, p=0.8, NS). Combined AUC (ITC+hydroxy-ITC) were 2951 and 2845 for SUBA-ITC and C-ITC, respectively (NS). 4 subjects in each arm had sub-therapeutic d 7 levels (< 1000ng/ml). Drug-related AEs and tolerability were similar in both arms (Table 1). Lower extremity edema, hypertension, nausea, and anorexia were the most common AEs. Premature study withdrawal was seen in 12 (19%) subjects overall (5 and 7 subjects, respectively on SUBA-ITC and C-ITC).

Figure 1

Conclusion

SUBA-ITC dosed at 130 mg BID PO is safe, well-tolerated, and consistently leads to combined serum ITC/hydroxy-ITC levels and AUC that are higher (NS) when compared to C-ITC 200 mg BID. Moreover, compared to C-ITC, SUBA-ITC achieves these serum levels when administered at substantially lower daily doses (130mg BID vs 200 mg BID).

Disclosures

Peter G. Pappas, MD, Mayne Pharma (Scientific Research Study Investigator) Andrej Spec, MD, MSCI, Mayne (Consultant, Grant/Research Support) Marisa H. Miceli, MD, FIDSA, SCYNEXIS, Inc. (Advisor or Review Panel member) Laurie Proia, MD, Mayne Pharma (Scientific Research Study Investigator) Ana Belen Arauz, MD, Mayne Pharma (Scientific Research Study Investigator) Justin Hayes, MD, Mayne Pharma (Grant/Research Support) Alisa Peinhardt, MAIS, BSN, Mycoses Study Group Education and Research Consortium (Consultant)

Interaction between Physical Heterogeneity and Microbial Processes in Subsurface Sediments: A Laboratory-Scale Column Experiment

Physical heterogeneity determines interstitial fluxes in porous media. Nutrients and organic matter distribution in depth influence physicochemical and microbial processes occurring in subsurface. Columns 50 cm long were filled with sterile silica sand following five different setups combining fine and coarse sands or a mixture of both mimicking potential water treatment barriers. Water was supplied continuously to all columns during 33 days. Hydraulic conductivity, nutrients and organic matter, biofilm biomass, and activity were analyzed in order to study the effect of spatial grain size heterogeneity on physicochemical and microbial processes and their mutual interaction. Coarse sediments showed higher biomass and activity in deeper areas compared to the others; however, they resulted in incomplete denitrification, large proportion of dead bacteria in depth, and low functional diversity. Treatments with fine sediment in the upper 20 cm of the columns showed high phosphorus retention. However, low hydraulic conductivity values reported in these sediments seemed to constraint biofilm activity and biomass. On the other hand, sudden transition from coarse-to-fine grain sizes promoted a hot-spot of organic matter degradation and biomass growth at the interface. Our results reinforce the idea that grain-size disposition in subsurface sandy sediments drives the interstitial fluxes, influencing microbial processes.

Response of biofilm bacterial communities to antibiotic pollutants in a Mediterranean river

Antibiotics are emerging contaminants, which wing to their bioactivity, may lead to short-term and long-term alterations of natural microbial communities in aquatic environment. We investigated the effects of antibiotics on biofilm bacterial communities in the Llobregat River (Northeast Spain). Three sampling sites were selected: two less polluted sites and one hotspot. River water was collected from each site and used both as inoculum and medium for growing biofilms in independent mesocosms. After 25d of biofilm colonization, we exposed the colonized biofilms to river waters from the downstream sites (progressively contaminated by antibiotics). A control from each site was maintained where the growing biofilm was always exposed to water from the same site. The bacterial community composition, bacterial live/dead ratio and extracellular enzyme activities of the biofilms were measured before and 9d after exposing the biofilms to increasing contaminated waters. Sixteen antibiotic compounds were detected in the water from the three sampling sites. At each site, the antibiotics present in the highest concentrations were sulfonamides, followed by quinolones and macrolides. Bacterial communities of biofilms grown with the three river waters differed markedly in their structure, but less so in terms of functional descriptors. After switching the medium water to increasing pollution, biofilms exhibited increased levels of actinobacteria (HGC), a trend that was associated to the higher antibiotic concentrations in the water. These biofilms also showed increased bacterial mortality, and decreased extracellular leucine-aminopeptidase and alkaline phosphatase. There was a significant correlation between antibiotic concentrations and biofilm responses. Our results indicate that the continuous entrance of antibiotics in running waters cause significant structural and functional changes in microbial attached communities.

Effects of pesticides and pharmaceuticals on biofilms in a highly impacted river

We investigated the effects of pharmaceuticals and pesticides detected in a Mediterranean river, on fluvial biofilms by translocation experiments performed under controlled conditions. Water was sampled from three sites along a pollution gradient. Biofilms grown in mesocosms containing relatively clean water were translocated to heavily polluted water. Several biofilm descriptors were measured before and after translocations. Fifty-seven pharmaceuticals and sixteen pesticides compounds were detected in river waters. The translocation from less to more polluted site was the most effective. Autotrophic biomass and peptidase increased while phosphatase and photosynthetic efficiency decreased. Multivariate analysis revealed that analgesics and anti-inflammatories significantly affected biofilm responses. Ibuprofen and paracetamol were associated with negative effects on photosynthesis, and with the decrease of the green algae/cyanobacteria ratio, while diclofenac was associated with phosphatase activity. The effects of these emerging compounds on biofilms structure and function may cause important alterations in river ecosystem functioning.

Drought episode modulates the response of river biofilms to triclosan

The consequences of global change on rivers include altered flow regime, and entrance of compounds that may be toxic to biota. When water is scarce, a reduced dilution capacity may amplify the effects of chemical pollution. Therefore, studying the response of natural communities to compromised water flow and to toxicants is critical for assessing how global change may affect river ecosystems. This work aims to investigate how an episode of drought might influence the response of river biofilms to pulses of triclosan (TCS). The objectives were to assess the separate and combined effects of simulated drought (achieved through drastic flow alteration) and of TCS exposure on biofilms growing in artificial channels. Thus, three-week-old biofilms were studied under four conditions: Control (normal water flow); Simulated Drought (1 week reduced flow+2 days interrupted flow); TCS only (normal water flow plus a 48-h pulse of TCS); and Simulated Drought+TCS. All channels were then left for 2 weeks under steady flow conditions, and their responses and recovery were studied. Several descriptors of biofilms were analyzed before and after each step. Flow reduction and subsequent interruption were found to provoke an increase in extracellular phosphatase activity, bacterial mortality and green algae biomass. The TCS pulses severely affected biofilms: they drastically reduced photosynthetic efficiency, the viability of bacteria and diatoms, and phosphate uptake. Latent consequences evidenced significant combined effects caused by the two stressors. The biofilms exposed only to TCS recovered far better than those subjected to both altered flow and subsequent TCS exposure: the latter suffered more persistent consequences, indicating that simulated drought amplified the toxicity of this compound. This finding has implications for river ecosystems, as it suggests that the toxicity of pollutants to biofilms may be exacerbated following a drought.

Resistance and recovery of river biofilms receiving short pulses of Triclosan and Diuron

The effects of the herbicide Diuron (DIU) and the bactericide Triclosan (TCS) were assessed on laboratory-grown stream biofilms. Four week-old biofilms were exposed in mesocosms to 48-hours of short pulses of either DIU or TCS. The direct and indirect effects of each toxicant on the biofilms, and the subsequent recovery of the biofilms, were evaluated according to structural and functional biomarkers. These parameters were analyzed immediately before exposure, immediately after exposure, and 9 and 16days post-exposure. DIU caused an increase in diatom mortality (+79%), which persisted until the end of the experiment. TCS also affected diatom mortality (+41%), although the effect did not appear until 1week post-exposure. TCS caused an increase in bacterial mortality (+45%); however, this parameter returned to normal values 1week post-exposure. TCS compromised the cellular integrity of the green alga Spirogyra sp., whereas DIU did not. TCS also strongly inhibited phosphate uptake (-71%), which did not return to normal values until 2weeks post-exposure. DIU directly affected algae, but barely affected the heterotrophs, whereas TCS seriously impaired bacteria (direct effect) as well as autotrophs (indirect effect). However, the biofilms recovered their normal structure and function within only a few days to a few weeks. These findings demonstrate the capacity of biofilms to cope with periodic inputs of toxicants, but also the risks associated to repeated exposure or multi-contamination in aquatic ecosystems.

A multicenter study of histoplasmosis and blastomycosis after solid organ transplantation

AIM

A review of the clinical presentation, diagnosis, treatment and outcomes of 30 solid organ transplant recipients (SOTRs) with histoplasmosis or blastomycosis from 3 Midwestern academic medical centers.

BACKGROUND

The endemic fungal pathogens, Histoplasma capsulatum and Blastomyces dermatitidis, may cause severe infection in SOTRs. In this report, we describe the clinical presentation, diagnosis, treatment, and outcomes of these endemic fungal infections (EFIs) among SOTRs at 3 academic transplant centers.

METHODS

A retrospective review was conducted of SOTRs with histoplasmosis or blastomycosis from 3 Midwestern medical centers in the United States. Data collected included demographics, immunosuppression, clinical presentation, method of diagnosis, antifungal treatment, response to therapy, and patient and graft survival.

RESULTS

Between 1996 and 2008, 30 transplant recipients with histoplasmosis or blastomycosis were identified, giving a cumulative incidence of infection of 0.50% (30/5989); 73% of the study patients were renal transplant recipients, and the median time to disease onset after transplantation was 10.5 months. The lungs were the most common site of infection (83%), and 60% had disseminated disease. Urine antigen testing was positive in all patients in whom it was performed (23/23). Initial antifungal therapy consisted of amphotericin B in 70%, and 87% received azoles, typically itraconazole (83%). Two patients developed relapsed infection and 7 patients had graft failure after EFI. Overall mortality was 30%, with an attributable mortality of 13%.

CONCLUSIONS

As in several previous single-center studies, the incidence of post-transplant histoplasmosis and blastomycosis was <1%, but often resulted in disseminated infection. In this cohort, EFI was associated with a high rate of allograft loss and overall mortality.

The major genetic determinants of HIV-1 control affect HLA class I peptide presentation

Infectious and inflammatory diseases have repeatedly shown strong genetic associations within the major histocompatibility complex (MHC); however, the basis for these associations remains elusive. To define host genetic effects on the outcome of a chronic viral infection, we performed genome-wide association analysis in a multiethnic cohort of HIV-1 controllers and progressors, and we analyzed the effects of individual amino acids within the classical human leukocyte antigen (HLA) proteins. We identified >300 genome-wide significant single-nucleotide polymorphisms (SNPs) within the MHC and none elsewhere. Specific amino acids in the HLA-B peptide binding groove, as well as an independent HLA-C effect, explain the SNP associations and reconcile both protective and risk HLA alleles. These results implicate the nature of the HLA-viral peptide interaction as the major factor modulating durable control of HIV infection.

Progressive Disseminated Histoplasmosis Presenting as Cellulitis in a Renal Transplant Recipient

With the advent of potent immunosuppressive therapies used in solid organ transplantation, patients are more susceptible to a variety of infectious organisms. Infections may result from atypical pathogens and present in an unusual manner. We describe a case of progressive disseminated histoplasmosis presenting as cellulitis in a renal transplant recipient and review this disease.

The epidemiology of blastomycosis in Illinois and factors associated with death

BACKGROUND

Blastomycosis is a systemic fungal disease that may be asymptomatic or progressive and may lead to death.

METHODS

In response to a reported increase in the number of cases of blastomycosis in Illinois, surveillance data reported to the Illinois Department of Public Health from January 1993 to August 2003 were analyzed and the medical records of 4 patients who died were reviewed.

RESULTS

Among the 500 cases reported, the median age of the patients was 43 years (range, 4-87 years), and 34 patients (7%) died. Higher rates of mortality were observed among persons who were black, who were > or =65 years of age, and who were male. The median time from onset of illness to diagnosis was 128 days (range, 12-489 days). Death was associated with a time from onset of illness to diagnosis of > or =128 days (OR, 2.1; 95% CI, 1.0-4.8). During the period from 1993 through 2002, the number of cases reported per year increased from 24 to 87 (P<.05).

CONCLUSIONS

The incidence of blastomycosis has been increasing in Illinois. To reduce mortality related to delay in diagnosis and treatment, medical providers need to be educated about blastomycosis, with an emphasis on symptom recognition, methods of diagnosis, and appropriate antifungal treatment.

Interlaboratory comparison of results of susceptibility testing with caspofungin against Candida and Aspergillus species

Seventeen laboratories participated in a study of interlaboratory reproducibility with caspofungin microdilution susceptibility testing against panels comprising 30 isolates of Candida spp. and 20 isolates of Aspergillus spp. The laboratories used materials supplied from a single source to determine the influence of growth medium (RPMI 1640 with or without glucose additions and antibiotic medium 3 [AM3]), the same incubation times (24 h and 48 h), and the same end point definition (partial or complete inhibition of growth) for the MIC of caspofungin. All tests were run in duplicate, and end points were determined both spectrophotometrically and visually. The results from almost all of the laboratories for quality control and reference Candida and Aspergillus isolates tested with fluconazole and itraconazole matched the NCCLS published values. However, considerable interlaboratory variability was seen in the results of the caspofungin tests. For Candida spp. the most consistent MIC data were generated with visual "prominent growth reduction" (MIC(2)) end points measured at 24 h in RPMI 1640, where 73.3% of results for the 30 isolates tested fell within a mode +/- one dilution range across all 17 laboratories. MIC(2) at 24 h in RPMI 1640 or AM3 also gave the best interlaboratory separation of Candida isolates of known high and low susceptibility to caspofungin. Reproducibility of MIC data was problematic for caspofungin tests with Aspergillus spp. under all conditions, but the minimal effective concentration end point, defined as the lowest caspofungin concentration yielding conspicuously aberrant hyphal growth, gave excellent reproducibility for data from 14 of the 17 participating laboratories.

Trichosporon inkin peritonitis treated with caspofungin

Trichosporon inkin is one of six pathogenic species of the genus Trichosporon and the etiologic agent of pubic white piedra. Trichosporon species have been reported as a cause of disseminated infections, particularly among immunosuppressed patients. We describe the third reported case of T. inkin peritonitis associated with peritoneal dialysis and the first to be treated with caspofungin.

[Review on renal calculosis in pregnancy]

By the analysis of the series reported by many authors, urolithiasis in pregnancy seems to be a rare, but significant pathology. The disease, potentially dramatic for the mother and fetus, appearing into a such particular physiological state like is pregnancy, suggests a reevaluation of diagnostic and therapeutic methods and better control of maternal and fetal risk. Furthermore, urolithiasis must be considered as cause of premature birth, a very severe complication of pregnancy the incidence and predisposing factors of urinary tract stones are generally the same in nonpregnant women. But any metabolic effects and the anatomical changes happen in pregnancy can have a important role on stone's formation. Signs and symptoms in urinary stone disease are: colic, flank pain, hematuria, urinary tract infection; irritative voiding, fever. The initial evaluation and treatment are again similar to those used for the non pregnant population. Radiographic studies any way must be used with caution for the risks of the ionizing radiations for the fetus. All forms of treatment with the exception of extracorporeal shock ware lithotripsy, are appropriate in the pregnant patients but naturally very useful, for the appropriate care of these patients is the coordination by the urologist, the obstetrician, the pediatrician, the radiologist and the anesthesiologist.

[A case of difficult diagnosis of primary tubal carcinoma]

Primary Fallopian tube cancer is a very un common cancer that appears between 40 and 65 years old, highly aggressive associate to a poor survival. In this work the authors explain a clinic case of primary Fallopian tube cancer in a woman of 57 years old operated for endometrial cancer. The authors display that the definitive diagnosis was possible only after the histological examination of the operating piece.

[Authors' experience with transvaginal administration of progestagens]

The authors, after a short introducing on the most used kinds of progestins in Hormonal Replacement Therapy (HRT), report this own clinical experience on the efficacy of a micronized progestin treatment given by the vaginal route in comparison with oral somministration, studying in details the protective effects on endometrial hyperplasia and cancer. The role of danazolo on the hormonal balance during HRT has been also evaluated. The results suggest a positive effects of the vaginal somministration of micronized HRT progesterone or danazolo.