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Lu L, Prajna NV, Lalitha P, Rajaraman R, Srinivasan M, Arnold BF, Acharya N, Lietman T, Rose-Nussbaumer J. Association between in vitro susceptibility and clinical outcomes in fungal keratitis. J Ophthalmic Inflamm Infect 2024; 14:42. [PMID: 39222170 PMCID: PMC11368879 DOI: 10.1186/s12348-024-00418-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/19/2024] [Indexed: 09/04/2024] Open
Abstract
PURPOSE The purpose of this study was to assess the association between antifungal susceptibility as measured by minimum inhibitory concentration (MIC) and clinical outcomes in fungal keratitis. METHODS This pre-specified secondary analysis of the Mycotic Ulcer Treatment Trial II (MUTT II) involved patients with filamentous fungal keratitis presenting to Aravind Eye Hospitals in South India. Antifungal susceptibility testing for natamycin and voriconazole was performed on all samples with positive fungal culture results according to Clinical and Laboratory Standards Institute Guidelines. The relationship between MIC and clinical outcomes of best-corrected visual acuity, infiltrate or scar size, corneal perforation, need for therapeutic penetrating keratoplasty, and time to re-epithelialization were assessed. RESULTS We obtained MIC values from 141 patients with fungal keratitis. The most commonly cultured organisms were Aspergillus (46.81%, n = 66) and Fusarium (44.68%, n = 63) species. Overall, there was no association between antifungal MICs and clinical outcomes. Subgroup analysis revealed that among Fusarium-positive cases, higher voriconazole MIC was correlated with worse three-month best-corrected visual acuity (p = 0.03), increased need for therapeutic penetrating keratoplasty (p = 0.04), and time to re-epithelialization (p = 0.03). No significant correlations were found among Aspergillus-positive cases. There were no significant correlations found between natamycin MIC and clinical outcomes among organism subgroups. CONCLUSIONS Decreased susceptibility to voriconazole was associated with increased odds of requiring a therapeutic penetrating keratoplasty in Fusarium-positive cases. Susceptibility to natamycin was not associated with any of the measured outcomes.
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Affiliation(s)
- Louisa Lu
- Department of Ophthalmology, Byers Eye Institute, Stanford University, 2542 Watson Ct, Palo Alto, Stanford, CA, 94303, USA
| | | | | | | | | | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
| | - Nisha Acharya
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Thomas Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Rose-Nussbaumer
- Department of Ophthalmology, Byers Eye Institute, Stanford University, 2542 Watson Ct, Palo Alto, Stanford, CA, 94303, USA.
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
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Gao N, Ju X, Jiao X, Qi Y, Tian Y, Jiang S, Niu Z, Zhao S, Yang R. Breaking Down the Barriers of Drug Resistance and Corneal Permeability with Chitosan-Poly(ethylene glycol)-LK 13 Peptide Conjugate to Combat Fungal Keratitis. ACS Infect Dis 2024; 10:2950-2960. [PMID: 38990785 DOI: 10.1021/acsinfecdis.4c00288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Fungal keratitis (FK) is a leading cause of preventable blindness and eye loss. The poor antifungal activity, increased drug resistance, limited corneal permeability, and unsatisfactory biosafety of conventional antifungal eye drops are among the majority of the challenges that need to be addressed for currently available antifungal drugs. Herein, this study proposes an effective strategy that employs chitosan-poly(ethylene glycol)-LK13 peptide conjugate (CPL) in the treatment of FK. Nanoassembly CPL can permeate the lipophilic corneal epithelium in the transcellular route, and its hydrophilicity surface is a feature to drive its permeability through hydrophilic stroma. When encountering fungal cell membrane, CPL dissembles and exposes the antimicrobial peptide (LK13) to destroy fungal cell membranes, the minimum inhibitory concentration values of CPL against Fusarium solani (F. solani) are always not to exceed 8 μg peptide/mL before and after drug resistance induction. In a rat model of Fusarium keratitis, CPL demonstrates superior therapeutic efficacy than commercially available natamycin ophthalmic suspension. This study provides more theoretical and experimental supports for the application of CPL in the treatment of FK.
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Affiliation(s)
- Ning Gao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Xiaoyan Ju
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing 100190, China
| | - Xiting Jiao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Yuanyuan Qi
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Ye Tian
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing 100190, China
| | - Shidong Jiang
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing 100190, China
| | - Zhongwei Niu
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing 100190, China
- School of Future Technology, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Shaozhen Zhao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Ruibo Yang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
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Kovalchuk B, Auffarth GU, Khoramnia R, Augustin VA. Fusarium Keratitis on the Rise - a Clinical Review. Klin Monbl Augenheilkd 2024; 241:955-963. [PMID: 37673089 DOI: 10.1055/a-2120-7752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Fungal keratitis due to Fusarium species is a rare but serious ocular disease. Due to its rapid progression, often late diagnostic confirmation as well as limited topical treatment options, this is potentially sight threatening. Increasing contact lens use and global climate change have been suggested to be factors leading to an increase in cases of fusarium keratitis, even in regions with moderate climate. Early recognition and initiation of antimycotic treatment, as well as early surgical treatment by penetrating keratoplasty are decisive for the outcome.
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4
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Liu S, Qin T, Zou F, Dong H, Yu L, Wang H, Zhang L. Pseudolaric acid B exerts an antifungal effect and targets SIRT1 to ameliorate inflammation by regulating Nrf2/NF-κB pathways in fungal keratitis. Inflammopharmacology 2024; 32:1133-1146. [PMID: 38150134 DOI: 10.1007/s10787-023-01408-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/30/2023] [Indexed: 12/28/2023]
Abstract
Fungal keratitis (FK) is a vision-threatening infection. We aimed to explore the antifungal and anti-inflammatory effects of pseudolaric acid B (PAB) on FK and the underlying mechanisms involved. Network pharmacology utilized to acquire the potential target genes, and silent information regulator 1 (SIRT1) was consistently downregulated in Gene Expression Omnibus dataset and clinical samples. Molecular docking analysis showed that PAB and SIRT1 had good binding activity. No toxicity was observed in vivo and in vitro with a PAB concentration below 0.3 μM. PAB exerted its antifungal activity by destroying the integrity of hyphae, and alleviated the severity of FK in rats by decreasing clinical scores, fungal burden and inhibiting inflammatory cell infiltration. PAB increased SIRT1 to regulate the crosstalk between nuclear factor erythroid 2-related factor 2 (Nrf2) and nuclear factor kappa-B (NF-κB), decreasing the levels of inflammatory cytokines tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6; and pattern recognition receptors, C-type lectin domain containing 7A (Dectin-1), lectin-like oxidized low-density lipoprotein receptor 1 (LOX-1), toll like receptor (TLR)-2, and TLR4 both in vivo and in vitro. However, this anti-inflammatory effect of PAB was abolished by the SIRT1 inhibitor EX527. This study provides new evidence that PAB has antifungal and anti-inflammatory effects in FK and may provide a novel therapeutic strategy for the treatment of FK.
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Affiliation(s)
- Shuyi Liu
- Dalian Medical University, 9 Lvshun Road South, Dalian, 116044, China
- Department of Ophthalmology, The Third People's Hospital of Dalian, Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Tao Qin
- Dalian Medical University, 9 Lvshun Road South, Dalian, 116044, China
| | - Fengkai Zou
- Dalian Medical University, 9 Lvshun Road South, Dalian, 116044, China
| | - He Dong
- Department of Ophthalmology, The Third People's Hospital of Dalian, Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Liang Yu
- Department of Ophthalmology, The Third People's Hospital of Dalian, Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Hai Wang
- Department of Pathology, The Third People's Hospital of Dalian, Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lijun Zhang
- Dalian Medical University, 9 Lvshun Road South, Dalian, 116044, China.
- Department of Ophthalmology, The Third People's Hospital of Dalian, Affiliated Hospital of Dalian Medical University, Dalian, China.
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5
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Değirmenci C, Palamar M, Ekin Z, Barut Selver Ö, Veral A, Yağcı A. Impression Cytologic Evaluation of the Conjunctiva in Patients Treated with Topical 1% Voriconazole. Turk J Ophthalmol 2024; 54:1-4. [PMID: 38008933 PMCID: PMC10895164 DOI: 10.4274/tjo.galenos.2023.20268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
Objectives The aim of the present study was to evaluate any conjunctival metaplastic changes by impression cytology in patients who underwent topical 1% voriconazole treatment for severe fungal keratitis. Materials and Methods The study was conducted at Ege University Faculty of Medicine, Departments of Ophthalmology and Medical Pathology. Patients who were treated with 1% topical voriconazole for fungal keratitis for at least 3 months were included. The used topical voriconazole treatment was initiated as one drop every hour and was tapered according to clinical improvement in all patients. Treatment was continued 4 times a day for at least 3 months. Impression cytology samples were collected at least 3 months after cessation of topical voriconazole from the affected eyes and from the fellow eyes as a control group. Collected specimens were transferred to the pathology department for evaluation and grading (Nelson’s grading system). Results The mean age of the patients was 57.68±17.32 years (range, 22-87 years). The impression cytology grade of the inferior bulbar conjunctiva was 1.73±0.77 (range, 0-3) in the study group and 1.19±0.98 (range, 0-3) in the control group (p=0.03). The impression cytology grade of the temporal bulbar conjunctiva was 1.69±0.73 (range, 0-3) in the study group and 1.15±0.88 (range, 0-3) in the control group (p=0.02). The impression cytology grades of the nasal and superior bulbar conjunctiva did not differ statistically (p values 0.13 and 0.17, respectively). Conclusion Topical voriconazole is an effective broad-spectrum antifungal drug, but it induces conjunctival squamous metaplasia. Clinicians should be aware of this possible side effect of topical voriconazole and should carefully evaluate the conjunctiva of treated patients at each visit to detect possible metaplastic changes.
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Affiliation(s)
- Cumali Değirmenci
- Ege University Faculty of Medicine, Department of Ophthalmology, İzmir, Türkiye
| | - Melis Palamar
- Ege University Faculty of Medicine, Department of Ophthalmology, İzmir, Türkiye
| | - Zübeyde Ekin
- Ege University Faculty of Medicine, Department of Pathology, İzmir, Türkiye
| | - Özlem Barut Selver
- Ege University Faculty of Medicine, Department of Ophthalmology, İzmir, Türkiye
| | - Ali Veral
- Ege University Faculty of Medicine, Department of Pathology, İzmir, Türkiye
| | - Ayşe Yağcı
- Ege University Faculty of Medicine, Department of Ophthalmology, İzmir, Türkiye
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Tuft S, Stone NRH, Burton MJ, Johnson EM, Borman AM. Antifungal susceptibility profiles for fungal isolates from corneas and contact lenses in the United Kingdom. Eye (Lond) 2024; 38:529-536. [PMID: 37684376 PMCID: PMC10858215 DOI: 10.1038/s41433-023-02719-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/09/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE To report the identification and results of susceptibility testing for fungal isolates from the cornea or contact lens care systems. MATERIALS AND METHODS In this retrospective epidemiological study, we searched the results of fungal cultures from cornea or contact lens systems referred for identification and susceptibility testing to the United Kingdom National Mycology Reference Laboratory between October 2016 and March 2022. For each fungal isolate, we recorded the genus and species of the fungus and the minimum inhibitory concentration (MIC) to six antifungal agents available to treat corneal infection (amphotericin, econazole, itraconazole, natamycin, posaconazole, and voriconazole). RESULTS There were 600 isolates from 585 patients, comprising 374 (62%) from corneal samples and 226 from contact lenses and care systems, of which 414 (69%) isolates were moulds (filamentous fungi) and 186 (31%) were yeasts. The most frequent moulds isolated were Fusarium spp (234 isolates, 39%) and Aspergillus spp (62, 10%). The most frequent yeasts isolated were Candida spp (112, 19%), predominantly Candida parapsilosis (65, 11%) and Candida albicans (33, 6%), with 35 isolates (6%) of Meyerozyma guilliermondii. In vitro susceptibility was greatest for natamycin (347 moulds tested, mode 4 mg/L, range 0.25-64 mg/L; 98 yeasts tested, mode 4 mg/L, range 0.5-32 mg/L), with susceptibility for 94% for moulds and 99% yeasts. Of the 16 isolates interpreted as highly resistant to natamycin (MIC ≥16 mg/L), 13 were Aspergillus flavus complex. CONCLUSIONS In vitro susceptibility supports the use of natamycin for the empiric treatment of fungal keratitis in the UK.
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Affiliation(s)
- Stephen Tuft
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK.
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK.
| | - Neil R H Stone
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Matthew J Burton
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Elizabeth M Johnson
- UK National Mycology Reference Laboratory, UK Health Security Agency South-West, Bristol, and MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Andrew M Borman
- UK National Mycology Reference Laboratory, UK Health Security Agency South-West, Bristol, and MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
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7
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Zhan L, Tian X, Lin J, Zhang Y, Zhao G, Peng X. The Therapeutic Role and Mechanism of Glabridin Under Aspergillus fumigatus Infection. J Ocul Pharmacol Ther 2024; 40:89-99. [PMID: 38346287 DOI: 10.1089/jop.2023.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Purpose: To characterize the efficiency of glabridin alone and in combination with clinical antifungals in Aspergillus fumigatus keratitis. Methods: The broth microdilution method was performed to investigate whether glabridin exerted an antifungal role on planktonic cells and immature and mature biofilm. Antifungal mechanism was evaluated by Sorbitol and Ergosterol Assays. The synergistic effect of glabridin and antifungals was assessed through the checkerboard microdilution method and time-killing test. Regarding anti-inflammatory role, inflammatory substances induced by A. fumigatus were assessed by real-time quantitative polymerase chain reaction, western blot, and enzyme-linked immunosorbent assay. Drug toxicity was assessed by Draize test in vivo. Macrophage phenotypes were examined by flow cytometry. Results: Regarding antifungal activity, glabridin destroyed fungal cell wall and membrane on planktonic cells and suppressed immature and mature biofilm formation. After combining with natamycin or amphotericin B, glabridin possessed a potent synergistic effect against A. fumigatus. Regarding anti-inflammatory aspects, Dectin-1, toll‑like receptor (TLR)-2 and TLR-4 expression of human corneal epithelial cells were significantly elevated after A. fumigatus challenge and reduced by glabridin. The elevated expression of interleukin-1β and tumor necrosis factor-alpha induced by A. fumigatus or corresponding agonists were reversed by glabridin, equivalent to the effect of corresponding inhibitors. Glabridin could also contribute to anti-inflammation by downregulating inflammatory mediator expression to suppress macrophage infiltration. Conclusions: Glabridin contributed to fungal clearance by destroying fungal cell wall and membrane, and disrupting biofilm. Combining glabridin with clinical antifungals was superior in reducing A. fumigatus growth. Glabridin exerted an anti-inflammatory effect by downregulating proinflammatory substance expression and inhibiting macrophage infiltration, which provide a potential agent and treatment strategies for fungal keratitis.
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Affiliation(s)
- Lu Zhan
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xue Tian
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jing Lin
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yingxue Zhang
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Guiqiu Zhao
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xudong Peng
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, Qingdao, China
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
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Gunasekaran R, Chandrasekaran A, Rajarathinam K, Duncan S, Dhaliwal K, Lalitha P, Prajna NV, Mills B. Rapid Point-of-Care Identification of Aspergillus Species in Microbial Keratitis. JAMA Ophthalmol 2023; 141:966-973. [PMID: 37768674 PMCID: PMC10540059 DOI: 10.1001/jamaophthalmol.2023.4214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/30/2023] [Indexed: 09/29/2023]
Abstract
Importance Microbial keratitis (MK) is a common cause of unilateral visual impairment, blindness, and eye loss in low-income and middle-income countries. There is an urgent need to develop and implement rapid and simple point-of-care diagnostics for MK to increase the likelihood of good outcomes. Objective To evaluate the diagnostic performance of the Aspergillus-specific lateral-flow device (AspLFD) to identify Aspergillus species causing MK in corneal scrape and corneal swab samples of patients presenting with microbial keratitis. Design, Setting, and Participants This diagnostic study was conducted between May 2022 and January 2023 at the corneal clinic of Aravind Eye Hospital in Madurai, Tamil Nadu, India. All study participants were recruited during their first presentation to the clinic. Patients aged 15 years or older met the eligibility criteria if they were attending their first appointment, had a corneal ulcer that was suggestive of a bacterial or fungal infection, and were about to undergo diagnostic scrape and culture. Main Outcomes and Measures Sensitivity and specificity of the AspLFD with corneal samples collected from patients with MK. During routine diagnostic scraping, a minimally invasive corneal swab and an additional corneal scrape were collected and transferred to aliquots of sample buffer and analyzed by lateral-flow device (LFD) if the patient met the inclusion criteria. Photographs of devices were taken with a smartphone and analyzed using a ratiometric approach, which was developed for this study. The AspLFD results were compared with culture reports. Results The 198 participants who met the inclusion criteria had a mean (range) age of 51 (15-85) years and included 126 males (63.6%). Overall, 35 of 198 participants with corneal scrape (17.7%) and 17 of 40 participants with swab samples (42.5%) had positive culture results for Aspergillus species. Ratiometric analysis results for the scrape samples found that the AspLFD achieved high sensitivity (0.89; 95% CI, 0.74-0.95), high negative predictive value (0.97; 95% CI, 0.94-0.99), low negative likelihood ratio (0.12; 95% CI, 0.05-0.30), and an accuracy of 0.94 (95% CI, 0.90-0.97). Ratiometric analysis results for the swab samples showed that the AspLFD had high sensitivity (0.94; 95% CI, 0.73-1.00), high negative predictive value (0.95; 95% CI, 0.76-1.00), low negative likelihood ratio (0.07; 95% CI, 0.01-0.48), and an accuracy of 0.88 (95% CI, 0.73-0.96). Conclusions and Relevance Results of this diagnostic study suggest that AspLFD along with the ratiometric analysis of LFDs developed for this study has high diagnostic accuracy in identifying Aspergillus species from corneal scrapes and swabs. This technology is an important step toward the provision of point-of-care diagnostics for MK and could inform the clinical management strategy.
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Affiliation(s)
- Rameshkumar Gunasekaran
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Abinaya Chandrasekaran
- Department of Cornea and Refractive Surgery Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Karpagam Rajarathinam
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Sheelagh Duncan
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
| | - Kevin Dhaliwal
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
| | - Prajna Lalitha
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - N. Venkatesh Prajna
- Department of Cornea and Refractive Surgery Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Bethany Mills
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
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9
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Arimoto S, Inagaki K, Todokoro D, Suzuki T, Makimura K, Ishino T. Antifungal Efficacy of Luliconazole in an Experimental Rabbit Model of Fungal Keratitis Caused by Fusarium solani. Mycopathologia 2023; 188:775-782. [PMID: 37603230 DOI: 10.1007/s11046-023-00783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/31/2023] [Indexed: 08/22/2023]
Abstract
Fungal keratitis is a corneal fungal infection that potentially leads to blindness and is mainly caused by filamentous fungi, such as Fusarium, with limited drug options available, such as natamycin and voriconazole. Therefore, this study aimed to evaluate the therapeutic effects of the imidazole antifungal drug-luliconazole-using a rabbit experimental model of fungal keratitis caused by Fusarium solani, which is the dominant causative agent of fungal keratitis. F. solani was inoculated into rabbit corneas. luliconazole 1% suspension or natamycin 5% eye drops were administered four times a day (N = 6 for each group) 3 days after inoculation. Signs were scored up to 14 days after inoculation to evaluate the efficacy of the drugs. Compared with the peak mean sign scores of the placebo control group, there was a significant decrease in the mean sign scores of both the treatment groups (P < 0.05). Sign score trends were similar between the two treatment groups. In conclusion, luliconazole demonstrated therapeutic efficacy comparable to that of natamycin in treating experimental fungal keratitis. This suggests that luliconazole can be a novel therapeutic agent for human fungal keratitis.
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Affiliation(s)
- Sho Arimoto
- Department of Parasitology and Tropical Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
- Nihon Nohyaku Co., Ltd., Tokyo, Japan.
| | | | - Daisuke Todokoro
- Department of Ophthalmology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takashi Suzuki
- Department of Ophthalmology, School of Medicine, Toho University, Tokyo, Japan
| | - Koichi Makimura
- Institute of Medical Mycology, Teikyo University, Tokyo, Japan
| | - Tomoko Ishino
- Department of Parasitology and Tropical Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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10
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Salah H, Houbraken J, Boekhout T, Almaslamani M, Taj-Aldeen SJ. Molecular epidemiology of clinical filamentous fungi in Qatar beyond Aspergillus and Fusarium with notes on the rare species. Med Mycol 2023; 61:6967136. [PMID: 36592959 PMCID: PMC9874029 DOI: 10.1093/mmy/myac098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/12/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023] Open
Abstract
Due to an increasing number of patients at risk (i.e., those with a highly compromised immune system and/or receiving aggressive chemotherapy treatment), invasive fungal infections (IFI) are increasingly being reported and associated with high mortality rates. Aspergillus spp., particularly A. fumigatus, is the major cause of IFI caused by filamentous fungi around the world followed by Fusarium spp., however, other fungi are emerging as human pathogens. The aim of this study was to explore the epidemiology and prevalence of the non-Aspergillus and non-Fusarium filamentous fungi in human clinical samples over an 11-year period in Qatar using molecular techniques. We recovered 53 filamentous fungal isolates from patients with various clinical conditions. Most patients were males (75.5%), 9.4% were immunocompromised, 20.7% had IFI, and 11.3% died within 30 days of diagnosis. The fungal isolates were recovered from a variety of clinical samples, including the nasal cavity, wounds, respiratory samples, body fluids, eye, ear, tissue, abscess, and blood specimens. Among the fungi isolated, 49% were dematiaceous fungi, followed by Mucorales (30%), with the latter group Mucorales being the major cause of IFI (5/11, 45.5%). The current study highlights the epidemiology and spectrum of filamentous fungal genera, other than Aspergillus and Fusarium, recovered from human clinical samples in Qatar, excluding superficial infections, which can aid in the surveillance of uncommon and emerging mycoses.
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Affiliation(s)
- Husam Salah
- To whom correspondence should be addressed. Husam Salah, M.Sc. Division
of Microbiology, Department of Laboratory Medicine and Pathology, Hamad Medical
Corporation, Doha, Qatar, PO Box 3050. Tel: +97-444-391-047. E-mail: ;
| | - Jos Houbraken
- Applied and Industrial Mycology, Westerdijk Fungal Biodiversity
Institute, Utrecht, Netherlands
| | - Teun Boekhout
- Yeast Research, Westerdijk Fungal Biodiversity Institute,
Utrecht, Netherlands,Institute of Biodiversity and Ecosystem Dynamics (IBED), University of
Amsterdam, Amsterdam, The
Netherlands
| | | | - Saad J Taj-Aldeen
- Division of Microbiology, Department of Laboratory Medicine and
Pathology, Hamad Medical Corporation, Doha,
Qatar,Department of Biology, College of Science, University of
Babylon, Hilla, Iraq
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11
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Ju X, Wu L, Gao N, Tian Y, Lu G, Gao Y, Zhao S, Niu Z, Yang R. Overcoming the Stromal Barrier of the Cornea with a Peptide Conjugate Nano-Assembly to Combat Fungal Keratitis. Adv Healthc Mater 2023; 12:e2202409. [PMID: 36588425 DOI: 10.1002/adhm.202202409] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/22/2022] [Indexed: 01/03/2023]
Abstract
Fungal hyphae deeply invade the cornea in fungal keratitis. The corneal stroma hinders the infiltration of antifungal drugs and reduces their bioavailability. Here, this work reports a peptide conjugate nano-assembly that permeates the stroma and kills the pathogen without irritating the ocular cornea. The hydrophilic surface of the nano-assembly ensures deep permeation into the stroma. When encountering a fungal hyphal cell, the nano-assembly disassembles and exposes the α-helical peptide to destroy the fungal membrane, thus inactivating the pathogen. In a rabbit model of fungal keratitis, the nano-assembly exhibits a better therapeutic effect than commercially available natamycin ophthalmic suspension. Peptide conjugates with a nano-assembled structure and assembly-disassembly behavior could serve as the foundation of a new therapy for fungal keratitis.
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Affiliation(s)
- Xiaoyan Ju
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, No. 29, Zhongguancun East Road, Beijing, 100190, P. R. China
| | - Liping Wu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251, Fu Kang Road, Tianjin, 300384, P. R. China
| | - Ning Gao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251, Fu Kang Road, Tianjin, 300384, P. R. China
| | - Ye Tian
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, No. 29, Zhongguancun East Road, Beijing, 100190, P. R. China
| | - Guojun Lu
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, No. 29, Zhongguancun East Road, Beijing, 100190, P. R. China
| | - Yichen Gao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251, Fu Kang Road, Tianjin, 300384, P. R. China
| | - Shaozhen Zhao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251, Fu Kang Road, Tianjin, 300384, P. R. China
| | - Zhongwei Niu
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, No. 29, Zhongguancun East Road, Beijing, 100190, P. R. China.,School of Future Technology, University of Chinese Academy of Sciences, Beijing, 100049, P. R. China
| | - Ruibo Yang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251, Fu Kang Road, Tianjin, 300384, P. R. China
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12
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Inoue Y, Ohashi Y, Shimomura Y, Sotozono C, Hatano H, Fukuda M, Eguchi H, Araki-Sasaki K, Suzuki T, Hoshi S, Asari S, Sunada A, Kimura K, Yaguchi T, Makimura K. Multicenter prospective observational study of fungal keratitis in Japan: analyses of culture-positive cases. Jpn J Ophthalmol 2022; 66:227-239. [DOI: 10.1007/s10384-022-00904-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022]
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13
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Multicenter prospective observational study of fungal keratitis in Japan: analyses of in vitro susceptibility tests for combinations of drugs. Jpn J Ophthalmol 2022; 66:240-253. [DOI: 10.1007/s10384-022-00907-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/23/2021] [Indexed: 01/03/2023]
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14
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Prajna NV, Lalitha P, Krishnan T, Rajaraman R, Radnakrishnan N, Srinivasan M, Devi L, Das M, Liu Z, Zegans ME, Acharya NR, Porco TC, Lietman TM, Rose-Nussbaumer J. Patterns of Antifungal Resistance in Adult Patients With Fungal Keratitis in South India: A Post Hoc Analysis of 3 Randomized Clinical Trials. JAMA Ophthalmol 2022; 140:179-184. [PMID: 35024776 PMCID: PMC8759027 DOI: 10.1001/jamaophthalmol.2021.5765] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Antifungal resistance has been shown to impact treatment success, but research analyzing antifungal resistance is scarce. OBJECTIVE To evaluate changes in antifungal resistance over time. DESIGN, SETTING, AND PARTICIPANTS Ad hoc analysis of 3 randomized clinical trials including consecutive patients 18 years and older presenting with smear-positive fungal ulcers to Aravind Eye Hospitals in Madurai, Coimbatore, Pondicherry, and Tirunelveli in South India who participated in 1 of 3 clinical trials: the Mycotic Ulcer Treatment Trials (MUTT) I (2010 to 2011) or II (2010 to 2015) or the Cross-Linking Assisted Infection Reduction (CLAIR) trial (2016 to 2018). This post hoc analysis was designed in March 2021 and data were analyzed in May and November 2021. INTERVENTIONS Minimum inhibitory concentration (MIC) of natamycin and voriconazole was determined from corneal cultures obtained using standardized methods outlined in the Clinical and Laboratory Standards Institute. MAIN OUTCOMES AND MEASURES The primary outcome of this post hoc analysis was MIC of natamycin and voriconazole. RESULTS A total of 890 fungal isolates were obtained from 651 patients (mean [SD] age, 49.6 [13.0]; 191 [43.3%] female) from 2010 to 2018. MICs were available for 522 samples in 446 patients. Fungal isolates overall demonstrated a 1.02-fold increase per year in voriconazole resistance as measured by MICs (95% CI, 1.00-1.04; P = .06). In subgroup analyses, Fusarium species demonstrated a 1.04-fold increase in voriconazole resistance per year (95% CI, 1.00-1.06; P = .01). Fungal isolates showed a 1.06-fold increase in natamycin resistance per year overall (95% CI, 1.03-1.09; P < .001). Fusarium species had a 1.06-fold increase in natamycin resistance (95% CI, 1.05-1.08; P < .001), Aspergillus had a 1.09-fold increase in resistance (95% CI, 1.05-1.15; P < .001), and other filamentous fungi had a 1.07-fold increase in resistance to natamycin per year (95% CI, 1.04-1.10; P < .001). CONCLUSIONS AND RELEVANCE This post hoc analysis suggests that susceptibility to both natamycin and voriconazole may be decreasing over the last decade in South India. While a trend of increasing resistance could impact treatment of mycoses in general and infectious fungal keratitis in particular, further study is needed to confirm these findings and determine their generalizability to other regions of the world. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT00996736 and NCT02570321.
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Affiliation(s)
- N. Venkatesh Prajna
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Prajna Lalitha
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Naveen Radnakrishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Lumbini Devi
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Zijun Liu
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco
| | | | - Nisha R. Acharya
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco,Department of Ophthalmology, University of California, San Francisco, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco,Department of Ophthalmology, University of California, San Francisco, San Francisco,UCSF Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco,Department of Ophthalmology, University of California, San Francisco, San Francisco,UCSF Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco,Department of Ophthalmology, University of California, San Francisco, San Francisco,Byers Eye Institute, Stanford University, Palo Alto, California
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15
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Diagnosing Fungal Keratitis and Simultaneously Identifying Fusarium and Aspergillus Keratitis with a Dot Hybridization Array. J Fungi (Basel) 2022; 8:jof8010064. [PMID: 35050004 PMCID: PMC8777873 DOI: 10.3390/jof8010064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 02/05/2023] Open
Abstract
Fungal keratitis (FK) is one of the most common microbial keratitis, which often leads to poor prognosis as a result of delayed diagnosis. Several studies implied that early differentiation of the two major FK, Fusarium and Aspergillus keratitis, could be helpful in selecting effective anti-fungal regimens. Therefore, a novel dot hybridization array (DHA) was developed to diagnose FK and differentiate Fusarium and Aspergillus keratitis in this study. One hundred forty-six corneal scrapes obtained from one hundred forty-six subjects impressed with clinically suspected FK were used to evaluate the performance of the DHA. Among these patients, 107 (73.3%) patients had actual FK confirmed by culture and DNA sequencing. We found that the DHA had 93.5% sensitivity and 97.4% specificity in diagnosing FK. In addition, this array had 93.2% sensitivity and 93.8% specificity in diagnosing Fusarium keratitis, as well as 83.3% sensitivity and 100% specificity in diagnosing Aspergillus keratitis. Furthermore, it had 83.9% sensitivity and 100% specificity in identifying Fusarium solani keratitis. Thus, this newly developed DHA will be beneficial to earlier diagnosis, more precise treatment, and improve prognosis of FK, by minimizing medical refractory events and surgical needs.
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16
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Arunachalam D, Ramanathan SM, Menon A, Madhav L, Ramaswamy G, Namperumalsamy VP, Prajna L, Kuppamuthu D. Expression of immune response genes in human corneal epithelial cells interacting with Aspergillus flavus conidia. BMC Genomics 2022; 23:5. [PMID: 34983375 PMCID: PMC8728928 DOI: 10.1186/s12864-021-08218-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 11/18/2021] [Indexed: 12/19/2022] Open
Abstract
Background Aspergillus flavus, one of the causative agents of human fungal keratitis, can be phagocytosed by human corneal epithelial (HCE) cells and the conidia containing phagosomes mature into phagolysosomes. But the immunological responses of human corneal epithelial cells interacting with A. flavus are not clear. In this study, we report the expression of immune response related genes of HCE cells exposed to A. flavus spores using targeted transcriptomics. Methods Human corneal epithelial cell line and primary cultures were grown in a six-well plate and used for coculture experiments. Internalization of the conidia was confirmed by immunofluorescence microscopy of the colocalized endosomal markers CD71 and LAMP1. Total RNA was isolated, and the quantity and quality of the isolated RNA were assessed using Qubit and Bioanalyzer. NanoString nCounter platform was used for the analysis of mRNA abundance using the Human Immunology panel. R-package and nSolver software were used for data analysis. KEGG and FunRich 3.1.3 tools were used to analyze the differentially expressed genes. Results Different morphotypes of conidia were observed after 6 h of coculture with human corneal epithelial cells and found to be internalized by epithelial cells. NanoString profiling showed more than 20 differentially expressed genes in immortalized human corneal epithelial cell line and more than ten differentially expressed genes in primary corneal epithelial cells. Distinct set of genes were altered in their expression in cell line and primary corneal epithelial cells. KEGG pathway analysis revealed that genes associated with TNF signaling, NF-KB signaling, and Th17 signaling were up-regulated, and genes associated with chemokine signaling and B cell receptor signaling were down regulated. FunRich pathway analysis showed that pathways such as CDC42 signaling, PI3K signaling, and Arf6 trafficking events were activated by the clinical isolates CI1123 and CI1698 in both type of cells. Conclusions Combining the transcript analysis data from cell lines and primary cultures, we showed the up regulation of immune defense genes in A. flavus infected cells. At the same time, chemokine signaling and B cell signaling pathways are downregulated. The variability in the expression levels in the immortalized cell line and the primary cultures is likely due to the variable epigenetic reprogramming in the immortalized cells and primary cultures in the absence of any changes in the genome. It highlights the importance of using both cell types in host-pathogen interaction studies. Supplementary Information The online version contains supplementary material available at 10.1186/s12864-021-08218-5.
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Affiliation(s)
- Divya Arunachalam
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India.,Department of Biotechnology, Alagappa University, Karaikudi, Tamil Nadu, India
| | - Shruthi Mahalakshmi Ramanathan
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Athul Menon
- Theracues Innovations Private Limited, Bangalore, India, Karnataka
| | - Lekshmi Madhav
- Theracues Innovations Private Limited, Bangalore, India, Karnataka
| | | | | | - Lalitha Prajna
- Department of Ocular Microbiology, Aravind Eye Hospital, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Dharmalingam Kuppamuthu
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India. .,Department of Biotechnology, Alagappa University, Karaikudi, Tamil Nadu, India. .,Aravind Medical Research Foundation, Dr. G.Venkataswamy Eye Research Institute, Aravind Eye Care System, No.1 Anna Nagar, Madurai, Tamil Nadu, India.
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17
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Shi L, Li Z, Liang Z, Zhang J, Liu R, Chu D, Han L, Zhu L, Shen J, Li J. A dual-functional chitosan derivative platform for fungal keratitis. Carbohydr Polym 2022; 275:118762. [PMID: 34742450 DOI: 10.1016/j.carbpol.2021.118762] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/15/2021] [Accepted: 10/08/2021] [Indexed: 01/01/2023]
Abstract
Fungal keratitis remains a serious infectious ocular disease, and the traditional administration of eye drops is limited by ocular intrinsic barriers and drug shortages. Herein, we fabricated a chitosan-based dual-functional platform for ocular topical delivery of econazole. The platform can prolong the residence time on the ocular surface due to its strong interaction with the mucin layer by physical adhesion and covalent bonding, and also open corneal epithelial tight junctions for being positively charged, thereby enhancing corneal penetration of drug. Using these strategies, dosing concentration was reduced from 0.3 wt% to 0.1 wt%, dosing frequency was reduced from once-an-hour to twice-daily, in vitro and in vivo antifungal therapeutic effects were achieved and patient compliance could be improved. Given its high structural adaptability, many other ocular anterior segment-related diseases would benefit from this platform.
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Affiliation(s)
- Liuqi Shi
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China; School of Material Science and Engineering, Zhengzhou University, Zhengzhou 450001, China
| | - Zhanrong Li
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China.
| | - Zhen Liang
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Junjie Zhang
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Ruixing Liu
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Dandan Chu
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Lei Han
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Lei Zhu
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Jianliang Shen
- School of Ophthalmology and Optometry, School of Biomedical Engineering, Wenzhou Medical University, Wenzhou 325027, China; Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou 325001, China.
| | - Jingguo Li
- Henan Eye Hospital, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou 450003, China; School of Material Science and Engineering, Zhengzhou University, Zhengzhou 450001, China.
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18
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Raj N, Vanathi M, Ahmed NH, Gupta N, Lomi N, Tandon R. Recent Perspectives in the Management of Fungal Keratitis. J Fungi (Basel) 2021; 7:jof7110907. [PMID: 34829196 PMCID: PMC8621027 DOI: 10.3390/jof7110907] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/28/2022] Open
Abstract
Mycotic keratitis is common in warm, humid regions with a varying profile of pathogenic fungi according to geographical origin, socioeconomic status, and climatic condition. Clinical diagnosis can be challenging in difficult cases and those refractory to treatment. Fungal hyphae on microscopic examination and culture isolation have been the gold standard in the laboratory diagnosis of fungal keratitis. A culture isolate of the aetiological fungus is essential to perform antifungal susceptibility testing. As the culture isolation of fungi is time-consuming, causing delays in the initiation of treatment, newer investigative modalities such as in vivo confocal microscopy and molecular diagnostic methods have recently gained popularity. Molecular diagnostic techniques now help to obtain a rapid diagnosis of fungal keratitis. Genomic approaches are based on detecting amplicons of ribosomal RNA genes, with internal transcribed spacers being increasingly adopted. Metagenomic deep sequencing allows for rapid and accurate diagnosis without the need to wait for the fungus to grow. This is also helpful in identifying new emerging strains of fungi causing mycotic keratitis. A custom-tear proteomic approach will probably play an important diagnostic role in future in the management of mycotic keratitis. Positive repeat cultures are being suggested as an important gauge indicative of a poor prognosis. Positive repeat fungal cultures help to modify a treatment regimen by increasing its frequency, providing the addition of another topical and oral antifungal agent along with close follow-up for perforation and identifying need for early therapeutic keratoplasty. The role of collagen crosslinking in the treatment of fungal keratitis is not convincingly established. Rapid detection by multiplex PCR and antifungal susceptibility testing of the pathogenic fungi, adopted into a routine management protocol of fungal keratitis, will help to improve treatment outcome. Early therapy is essential in minimizing damage to the corneal tissue, thereby providing a better outcome. The role of conventional therapy with polyenes, systemic and targeted therapy of antifungal agents, newer azoles and echinocandins in fungal keratitis has been widely studied in recent times. Combination therapy can be more efficacious in comparison to monotherapy. Given the diversity of fungal aetiology, the emergence of new corneal pathogenic fungi with varying drug susceptibilities, increasing the drug resistance to antifungal agents in some genera and species, it is perhaps time to adopt recent molecular methods for precise identification and incorporate antifungal susceptibility testing as a routine.
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Affiliation(s)
- Nimmy Raj
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Murugesan Vanathi
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
- Correspondence: ; Tel.: +91-11-26593010; Fax: +91-11-26588919
| | - Nishat Hussain Ahmed
- Ocular Microbiology Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India;
| | - Noopur Gupta
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Neiwete Lomi
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Radhika Tandon
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
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19
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Arunga S, Mbarak T, Ebong A, Mwesigye J, Kuguminkiriza D, Mohamed-Ahmed AHA, Hoffman JJ, Leck A, Hu V, Burton M. Chlorhexidine gluconate 0.2% as a treatment for recalcitrant fungal keratitis in Uganda: a pilot study. BMJ Open Ophthalmol 2021; 6:e000698. [PMID: 34368461 PMCID: PMC8258663 DOI: 10.1136/bmjophth-2020-000698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/27/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Fungal keratitis is a major ophthalmic public health problem, particularly in low-income and middle-income countries. The options for treating fungal keratitis are limited. Our study aimed to describe the outcomes of using chlorhexidine 0.2% eye-drops as additional treatment in the management of patients with recalcitrant fungal keratitis. METHODS This study was nested within a large cohort study of people presenting with microbial keratitis in Uganda. We enrolled patients with recalcitrant fungal keratitis not improving with topical natamycin 5% and commenced chlorhexidine 0.2%. Follow-up was scheduled for 3 months and 1 year. The main outcome measures were healing, visual acuity and scar size at final follow-up. RESULTS Thirteen patients were followed in this substudy. The patients were aged 27-73 years (median 43 years). Filamentous fungi were identified by microscopy of corneal scrape samples in all cases. Isolated organisms included Aspergillus spp, Fusarium spp, Candida spp, Bipolaris spp and Acremoninum spp. At the final follow-up, nine patients (75%) had healed; three had vision of better than 6/18. Three patients lost their eyes due to infection. In the remaining nine cases, corneal scarring was variable ranging from 4.6 to 9.4 mm (median 6.6 mm, IQR 5.9-8.0 mm); of these five had dense scars, three had moderate scars and one had a mild scar. None of the patients demonstrated signs of chlorhexidine toxicity during the follow-up. CONCLUSION Chlorhexidine 0.2% was found to be a useful sequential adjunctive topical antifungal in cases of fungal keratitis not responding to natamycin 5%, which warrants further evaluation.
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Affiliation(s)
- Simon Arunga
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Tumu Mbarak
- Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Abel Ebong
- Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - James Mwesigye
- Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Jeremy John Hoffman
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Astrid Leck
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Victor Hu
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- St Paul's Eye Unit, Liverpool, UK
| | - Matthew Burton
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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20
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Abstract
PURPOSE Voriconazole was shown to inhibit ergosterol synthesis in various acanthamoeba species. The purpose of this study was to evaluate the clinical outcome of treatment with supplemental topical voriconazole in patients with acanthamoeba keratitis (AK). METHODS All patients who had been treated for AK with voriconazole 1% drops in conjunction with topical first-line antiacanthamoeba therapy composed of polyhexamethylene biguanide (PHMB) 0.02% and propamidine isethionate 0.1% (Brolene) between November 2014 and August 2017 at the Department of Ophthalmology, University Medical Center Mainz, were included. The main outcomes were treatment failure and recurrence rate. Secondary outcomes were visual acuity, need for keratoplasty, and presence of adverse reactions. RESULTS Twenty-eight eyes of 28 patients with AK, whose treatment had included topical voriconazole, were identified (12 men, 16 women, mean age: 41.7 ± 16.3 years), and 26 of them could be tracked for at least 3 months after cessation of therapy. Resolution of infection under therapy was seen in all eyes, and only one of 26 (3.85%) had a relapse after the therapy had been stopped. Best-corrected visual acuity improved during therapy. Keratoplasty because of central corneal scarring was scheduled in 5 of 26 patients (19.2%) after the pharmacological therapy had been stopped. Five of 26 patients (19.2%) reported on stinging or burning sensation after application of voriconazole 1% drops. CONCLUSIONS Topical voriconazole 1% combined with first-line therapy composed of polyhexamethylene biguanide 0.02% and propamidine isethionate 0.1% appears to be an effective option with minor side effects for the treatment of AK.
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21
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Tendo C, Shahin B, Welch J. Unusual finding of two filamentous fungi in a contact lens-related keratitis. BMJ Case Rep 2021; 14:14/2/e239085. [PMID: 33579798 PMCID: PMC7883852 DOI: 10.1136/bcr-2020-239085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This is a rare case report of two filamentous fungi in a patient with contact lens related keratitis. An early corneal scrape may be useful in detecting multiple causative pathogens and aiding management. The main learning point is to consider fungal infections in patients with atypical ulcer appearances, as prompt diagnosis may reduce the morbidity burden.
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Affiliation(s)
- Chris Tendo
- Ophthalmology, University of Dundee, Dundee, UK .,Ophthalmology, Ninewells Hospital, Dundee, UK
| | | | - James Welch
- Ophthalmology, Ninewells Hospital, Dundee, UK
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22
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Cultrera R, Torelli R, Sarnicola C, Segala D, Mengoli A, Chiaretto G, Perri P, Sanguinetti M. Identification and molecular characterization of Subramaniula asteroides causing human fungal keratitis: a case report. BMC Infect Dis 2021; 21:82. [PMID: 33461505 PMCID: PMC7814578 DOI: 10.1186/s12879-021-05768-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background Keratitis due to by filamentous fungi are not easy to diagnose thus causing a delay in correct therapy. There are many descriptions of keratitis due to Candida, Fusarium and Aspergillus genera. Subramaniula genus has only recently been reported to cause human infections and there are few descriptions of eye infections due to this filamentous fungus. Diagnosis of fungal keratitis is usually based on microscopic and cultural techniques of samples obtained by corneal swabbing or scraping. Considering the amount of time required to obtain culture results it is wise to use other diagnostic methods, such as molecular analyses. Therapeutic options against these fungi are limited by low tissue penetration in the eye due to ocular barriers. We describe the first case of S. asteroides human keratitis treated with isavuconazole. Case presentation We describe a rare case of fungal keratitis unresponsive to antimicrobial treatment in a 65-year-old male patient without a history of diabetes or immunological diseases. He reported that the onset of symptoms occurred during a long holiday in Cape Verde Island. Initial treatment with topical antibiotics associated to steroids were ineffective, allowing a slow clinical progression of disease to corneal perforation. On admission in our Hospital, slit-lamp examination of the left eye showed conjunctival congestion and hyperemia, a large inferior corneal ulceration with brown pigment, corneal edema, about 3 mm of hypopyon and irido-lenticular synechiae. The slow clinical progression of the disease to corneal perforation and the aspect of the ulcer were consistent with a mycotic etiology. Molecular methods used on fungal colonies isolated by Sabouraud’s dextrose agar cultures allowed the identification of Subramaniula asteroids from corneal scraping. Antimicrobial test showed a good susceptibility of this filamentous fungus to voriconazole and isavuconazole. Moreover, this fungal keratitis was successfully treated with isavuconazole, without side effects, observing a progressive clinical improvement. Conclusions Molecular methods may be useful for the identification of filamentous fungal keratitis on scraping samples thus shortening the time of diagnosis. Systemic therapy by isavuconazole could be useful to treat the filamentous fungal keratitis, reducing the possible adverse effects due to the use of voriconazole by systemic administration.
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Affiliation(s)
- Rosario Cultrera
- Department of Morphology, Surgery and Experimental Medicine, Infectious Diseases Unit, University 'S. Anna' Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.
| | - Riccardo Torelli
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Caterina Sarnicola
- Department of Biomedical and Surgical Sciences, Ophthalmology Unit, 'S. Anna' University Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Daniela Segala
- Department of Morphology, Surgery and Experimental Medicine, Infectious Diseases Unit, University 'S. Anna' Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Andrea Mengoli
- Department of Biomedical and Surgical Sciences, Ophthalmology Unit, 'S. Anna' University Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Giuseppina Chiaretto
- Clinical Microbiology, 'S. Anna' University Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Paolo Perri
- Department of Biomedical and Surgical Sciences, Ophthalmology Unit, 'S. Anna' University Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.,Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Verma A, Jain A, Tiwari A, Saraf S, Panda PK, Jain SK. Promising Antifungal Potential of Engineered Non-ionic Surfactant-Based Vesicles: In Vitro and In Vivo Studies. AAPS PharmSciTech 2021; 22:19. [PMID: 33389224 DOI: 10.1208/s12249-020-01900-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/07/2020] [Indexed: 12/19/2022] Open
Abstract
Fungal keratitis (FK) is a corneal infection caused by different fungal species. It is treated by the topical application of natamycin (NAT). Nevertheless, this approach faces many limitations like toxic effects, frequent dosing, resistance, and patient discomfort. The present research reports the development of trimethyl chitosan (TMC) coated mucoadhesive cationic niosomes by a modified thin-film hydration method. TMC was synthesized using a one-step carbodiimide method and characterized by 1H-NMR and degree of quaternization (53.74 ± 1.06%). NAT, cholesterol (CHOL), span 60 (Sp60), and dicetyl phosphate (DCP) were used to prepare niosomes which were incubated with TMC to obtain mucoadhesive cationic NAT loaded niosomes (MCNNs). MCNNs showed a spherical shape with 1031.12 ± 14.18 nm size (PDI below 0.3) and 80.23 ± 5.28% entrapment efficiency. In vitro drug release studies showed gradual drug release from TMC coated niosomes as compared to the uncoated niosomes. MIC assay and disk diffusion assay revealed promising in vitro antifungal potential of MCNNs similar to the marketed formulation. For investigating in vivo performance, ocular retention and pharmacokinetics, ocular irritation, and ulcer healing studies were performed using the rabbit model. Mucoadhesive property and prolonged local drug release improved the safety and efficacy of NAT, suggesting that the developed niosomes could be an emerging system for effective treatment of fungal keratitis.
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24
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Mielech-Łukasiewicz K, Leoniuk M. Voltammetric determination of natamycin using a cathodically pretreated boron-doped diamond electrode in the presence of sodium dodecyl sulfate. Microchem J 2020. [DOI: 10.1016/j.microc.2020.105570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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25
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Huan Y, Peng XD, Lin J, Zhang YX, Zhan L, Gao H, Zhao GQ. Anti-inflammatory effects of astaxanthin against fungal keratitis. Int J Ophthalmol 2020; 13:1681-1688. [PMID: 33214996 DOI: 10.18240/ijo.2020.11.01] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 08/14/2020] [Indexed: 12/31/2022] Open
Abstract
AIM To characterize effect of astaxanthin (ASX) in Aspergillus fumigatus (A. fumigatus) induced keratitis in mouse model. METHODS In vivo, fungal keratitis mouse model was established in C57BL/6 mice using A. fumigatus, followed by ASX or dimethyl sulfoxide (DMSO) treatment. Clinical responses were evaluated by clinical score and myeloperoxidase (MPO) assay. Inflammatory cytokines were assessed by reverse-transcription polymerase chain reaction (RT-PCR), Western blot, immunofluorescence, and enzyme-linked immuno sorbent assay (ELISA). RESULTS In animal model, ASX improved corneal transparency and clinical response, suppressed the expression of inflammatory cytokine like IL-1β, TNF-α, and HMGB-1. Neutrophil levels have been shown to decrease in ASX-treated cornea by immunofluorescence and MPO. TLR2 and TLR4 levels were lower in ASX-treated group than DMSO-treated. CONCLUSION ASX can suppress inflammatory response and reduce inflammatory cytokine production in mice model with A. fumigatus keratitis.
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Affiliation(s)
- Yu Huan
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Xu-Dong Peng
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Jing Lin
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Ying-Xue Zhang
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, MI 48201, USA
| | - Lu Zhan
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Han Gao
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Gui-Qiu Zhao
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
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26
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Seven-Year Analysis of Microbial Keratitis Tendency at an Ophthalmology Department in Poland: A Single-Center Study. J Ophthalmol 2020; 2020:8851570. [PMID: 33489345 PMCID: PMC7803137 DOI: 10.1155/2020/8851570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/03/2020] [Accepted: 10/19/2020] [Indexed: 12/05/2022] Open
Abstract
This study aimed to analyze the frequency, drug susceptibility, and drug resistance of pathogens causing microbial keratitis (a corneal inflammation) in the Clinical Department of Ophthalmology, Medical University of Silesia, Katowice. Despite intensive treatment, severe inflammation causes irreversible blindness in ∼7% of cases and eye loss (evisceration or enucleation of the eyeball) in ∼1% of cases at our hospital. The choice of a targeted drug depends on the culture result and drug resistance of the microorganism. This was a retrospective observation study. Conjunctival swabs and corneal scrapes were collected between January 1, 2013, and December 31, 2019, in the tertiary reference center for keratitis. The collected data included the type of material received, culture result, and antimicrobial susceptibilities. Of the 2482 samples analyzed, 679 were positive and 1803 were negative. Of the total pathogens isolated, 69.9% were Gram-positive bacteria, 20.8% were Gram-negative bacteria, and 7.1% were fungi. A significant increase in the number of Gram-positive methicillin-resistant Staphylococcus aureus and a partial increase in the number of Gram-negative beta-lactams-resistant bacteria were observed. All fungal species were sensitive to amphotericin B, 82.81% were sensitive to voriconazole, and 56.25% were sensitive to fluconazole. Dual drug therapy (levofloxacin and tobramycin) was the first-line treatment. Drug susceptibility testing of the cultured microorganisms is necessary to initiate targeted treatment. Increased drug resistance was observed in this study. In the present study, most bacteria were sensitive to fluoroquinolones. Ciprofloxacin therapy remains the recommended empirical treatment in microbial keratitis. According to our study, voriconazole remains a first-line antifungal drug, when a fungal infection is suspected.
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27
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Natamycin-loaded zein nanoparticles stabilized by carboxymethyl chitosan: Evaluation of colloidal/chemical performance and application in postharvest treatments. Food Hydrocoll 2020. [DOI: 10.1016/j.foodhyd.2020.105871] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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28
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Davletshina NI, Samoylov AN. [Epidemiology and treatment of fungal keratitis]. Vestn Oftalmol 2020; 136:138-145. [PMID: 32779468 DOI: 10.17116/oftalma2020136041138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Infectious keratitis in most cases is caused by bacterial, viral or fungal agents, but their structure is changing. Some researchers have noted a substantial increase in fungal corneal lesions in recent decades, but important local etiological therapy remains unavailable in developing countries. While bacterial keratitis and ophthalmoherpes are controlled by widely available local etiotropic therapy, treatment of keratomycosis in the Russian Federation is carried out with off-label medicine. Lack of skills and availability of diagnostic methods and official etiotropic therapy creates unequal conditions for ophthalmology specialists in the fight against ophthalmomycosis. In part, this causes a reduced level of «myco-caution», which leads to long-term ineffective treatment using antibacterial drops, lasting suffering of patients, and results in the loss of the eye functionally and - in some cases - anatomically. Therefore, the study of fungal keratitis remains relevant. The article provides an overview of research data on current epidemiology in different regions of the world, analyzes available antifungal drugs and the prospects for development of affordable and effective treatment of fungal keratitis.
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Affiliation(s)
- N I Davletshina
- Kazan State Medical University, Kazan, Russia.,Republican Clinical Ophthalmological Hospital, Kazan, Russia
| | - A N Samoylov
- Kazan State Medical University, Kazan, Russia.,Republican Clinical Ophthalmological Hospital, Kazan, Russia
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29
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Mora-Pereira M, Abarca EM, Duran S, Ravis W, McMullen RJ, Fischer BM, Lee YHP, Wooldridge AA. Sustained-release voriconazole-thermogel for subconjunctival injection in horses: ocular toxicity and in-vivo studies. BMC Vet Res 2020; 16:115. [PMID: 32295599 PMCID: PMC7160932 DOI: 10.1186/s12917-020-02331-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 04/05/2020] [Indexed: 12/13/2022] Open
Abstract
Background Keratomycosis is a relatively common, sight threatening condition in horses, where treatment is often prolonged and costly. Subconjunctival (SCo) injections offer less resistance to drug diffusion than the topical route, resulting in better penetration to the ocular anterior segment. Voriconazole, a second generation triazole antifungal, is effective against common fungal organisms causing keratomycosis. If combined with a thermogel biomaterial, voriconazole can be easily injected in the SCo space to provide sustained drug release. The purpose of this study was to evaluate the drug concentrations in the anterior segment and clinical effects after SCo injections of voriconazole-containing thermogel: poly (DL-lactide-co-glycolide-b-ethylene glycol-b-DL-lactide-co-glycolide) (PLGA-PEG-PLGA) in healthy equine eyes. Results Voriconazole aqueous humor (AH) and tear concentrations were compared between 6 horses, receiving 1% voriconazole applied topically (0.2 mL, q4h) (Vori-Top) or 1.7% voriconazole-thermogel (0.3 mL) injected SCo (Vori-Gel). For the Vori-Gel group, voriconazole concentrations were measured in AH and tears at day 2 and then weekly for 23 days, and at day 2 only for the Vori-Top group. Ocular inflammation was assessed weekly (Vori-Gel) using the modified Hackett-McDonald scoring system. Ocular tissue concentrations of voriconazole following SCo 1.7% voriconazole-thermogel (0.3 mL) injections were evaluated post euthanasia in 6 additional horses at 3 different time points. Three horses received bilateral injections at 2 h (n = 3, right eye (OD)) and 48 h (n = 3, left eye (OS)) prior to euthanasia, and 3 horses were injected unilaterally (OS), 7 days prior to euthanasia. Voriconazole-thermogel was easily injected and well tolerated in all cases, with no major adverse effects. On day 2, drug concentrations in tears were higher in the Vori-Top, but not statistically different from Vori-Gel groups. For the Vori-Gel group, voriconazole was non-quantifiable in the AH at any time point. Total voriconazole concentrations in the cornea were above 0.5 μg/g (the target minimum inhibitory concentration (MIC) for Aspergillus sp.) for up to 48 h; however, concentrations were below this MIC at 7 days post treatment. Conclusions Voriconazole-thermogel was easily and safely administered to horses, and provided 48 h of sustained release of voriconazole into the cornea. This drug delivery system warrants further clinical evaluation.
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Affiliation(s)
- Mariano Mora-Pereira
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - Eva M Abarca
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA.
| | - Sue Duran
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - William Ravis
- Department of Drug Discovery and Development, Auburn University, Auburn, AL, USA
| | - Richard J McMullen
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | - Britta M Fischer
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
| | | | - Anne A Wooldridge
- J. T. Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, USA
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30
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Fang S, Peng X, Liang X, Shen J, Wang J, Chen J, Meng Y. Enhancing Water Solubility and Stability of Natamycin by Molecular Encapsulation in Methyl-β-Cyclodextrin and its Mechanisms by Molecular Dynamics Simulations. FOOD BIOPHYS 2019. [DOI: 10.1007/s11483-019-09620-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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31
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The use of in vivo confocal microscopy to track treatment success in fungal keratitis and to differentiate between Fusarium and Aspergillus keratitis. Int Ophthalmol 2019; 40:483-491. [DOI: 10.1007/s10792-019-01209-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
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32
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An Omics Approach to Diagnosing or Investigating Fungal Keratitis. Int J Mol Sci 2019; 20:ijms20153631. [PMID: 31349542 PMCID: PMC6695605 DOI: 10.3390/ijms20153631] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 02/05/2023] Open
Abstract
Fungal keratitis (FK) is one of the most severe corneal infectious diseases. FK often leads to poor visual prognosis and thus requires accurate diagnosis. Conventional approaches, including clinical diagnoses, smears, and cultures, often fail to provide reliable diagnostic value. Omics approaches, such as those using genomic, metagenomic, and tear proteomic data sources, provide promising features for improving the diagnosis and monitoring the progression of FK. Genomic approaches are based mainly on detecting amplicons of ribosomal RNA genes, and internal transcribed spacers are gradually gaining popularity in clinical practices. A metagenomic approach based on 16S rRNA genes may help monitor the dynamic change of conjunctival microbiota associated with an FK event, whereas that based on shot-gun and 18S rRNA target enrichment sequencing could have the potential to diagnose FK using clinical samples. A tear proteomic approach may provide comprehensive information about ocular surface defense and injury during FK. Representative up- and down-regulated proteins during FK could also be used as biomarkers to determine the clinical course and develop a treatment strategy in different stages of FK. Consequently, a personalized tear proteomic approach will soon play a key role in FK management.
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In Vitro Activity of Chlorhexidine Compared with Seven Antifungal Agents against 98 Fusarium Isolates Recovered from Fungal Keratitis Patients. Antimicrob Agents Chemother 2019; 63:AAC.02669-18. [PMID: 31182529 PMCID: PMC6658757 DOI: 10.1128/aac.02669-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/03/2019] [Indexed: 12/17/2022] Open
Abstract
Fungal keratitis is a common but severe eye infection in tropical and subtropical areas of the world. In regions with a temperate climate, the frequency of infection is rising in patients with contact lenses and following trauma. Early and adequate therapy is important to prevent disease progression and loss of vision. The management of Fusarium keratitis is complex, and the optimal treatment is not well defined. We investigated the in vitro activity of chlorhexidine and seven antifungal agents against a well-characterized collection of Fusarium isolates recovered from patients with Fusarium keratitis. The fungus culture collection of the Center of Expertise in Mycology Radboudumc/CWZ was searched for Fusarium isolates that were cultured from cornea scrapings, ocular biopsy specimens, eye swabs, and contact lens fluid containers from patients with suspected keratitis. The Fusarium isolates that were cultured from patients with confirmed keratitis were all identified using conventional and molecular techniques. Antifungal susceptibility testing was performed according to the EUCAST broth microdilution reference method. The antifungal agents tested included amphotericin B, voriconazole, posaconazole, miconazole, natamycin, 5-fluorocytosine, and caspofungin. In addition, the activity of chlorhexidine was determined. The fungal culture collection contained 98 Fusarium isolates of confirmed fungal keratitis cases from 83 Dutch patients and 15 Tanzanian patients. The isolates were collected between 2007 and 2017. Fusarium oxysporum (n = 24, 24.5%) was the most frequently isolated species followed by Fusarium solani sensu stricto (n = 18, 18.4%) and Fusarium petroliphilum (n = 11, 11.2%). Amphotericin B showed the most favorable in vitro inhibition of Fusarium species followed by natamycin, voriconazole, and chlorhexidine, while 5-fluorocytosine, posaconazole, miconazole, and caspofungin showed no relevant inhibiting effect. However, chlorhexidine showed fungicidal activity against 90% of F. oxysporum strains and 100% of the F. solani strains. Our study supports the clinical efficacy of chlorhexidine and therefore warrants its further clinical evaluation for primary therapy of fungal keratitis, particularly in low and middle income countries where fungal keratitis is much more frequent and, currently, antifungal eye drops are often unavailable.
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Rees CA, Bao R, Zegans ME, Cramer RA. Natamycin and Voriconazole Exhibit Synergistic Interactions with Nonantifungal Ophthalmic Agents against Fusarium Species Ocular Isolates. Antimicrob Agents Chemother 2019; 63:e02505-18. [PMID: 31010869 PMCID: PMC6591621 DOI: 10.1128/aac.02505-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/18/2019] [Indexed: 11/20/2022] Open
Abstract
The in vitro activities of two antifungal drugs in combination with four nonantifungal ophthalmic agents were evaluated using a broth microdilution method and a collection of eight Fusarium ocular isolates that exhibited resistance to both natamycin (MICs, 14 to 32 μg/ml) and voriconazole (MICs, 4 to >128 μg/ml). Synergistic and indifferent interactions were observed for natamycin and 5-fluorouracil and natamycin with timolol dependent on the Fusarium isolate tested. Isolate-dependent synergistic and indifferent interactions were also observed for natamycin with EDTA and natamycin with dorzolamide. Synergistic or indifferent interactions were observed for voriconazole with timolol and voriconazole with 5-fluorouracil depending on Fusarium isolate. Taken together, these data suggest that commonly used ophthalmic agents enhance the in vitro activity of antifungal drugs against drug-recalcitrant ocular fungal pathogens.
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Affiliation(s)
- Christiaan A Rees
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Ruina Bao
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Michael E Zegans
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Robert A Cramer
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Chidambaram JD, Prajna NV, Palepu S, Lanjewar S, Shah M, Elakkiya S, Lalitha P, Macleod D, Burton MJ. Cellular morphological changes detected by laser scanning in vivo confocal microscopy associated with clinical outcome in fungal keratitis. Sci Rep 2019; 9:8334. [PMID: 31171825 PMCID: PMC6554396 DOI: 10.1038/s41598-019-44833-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 05/24/2019] [Indexed: 11/10/2022] Open
Abstract
HRT3 in vivo confocal microscopy (IVCM) images may indicate clinical outcome, but few studies have analysed this in fungal keratitis (FK). Adults with FK (diameter ≥3 mm) presenting to Aravind Eye Hospital, India from 2012-3 were enrolled prospectively. IVCM was performed at baseline, days 7, 14 and 21 post-enrolment (+/- 3 days where possible). Specific morphologies were identified in IVCM images by a grader masked to microbiology and clinical outcome (defined as good: healed/improving, or poor: enlarged ulcer, perforation or transplant/glue). Associations with final visit outcome assessed using logistic regression. 143 FK participants were enrolled; 87 had good outcome, 56 had poor outcome. Poor outcomes were associated with stellate interconnected cellular processes with no visible nuclei (OR 2.28, 95% CI: 1.03-5.06, p = 0.043) in baseline IVCM images, and fungal filaments (OR 6.48, 95% CI:2.50-16.78, p < 0.001) or honeycomb distribution of inflammatory cells (OR 5.24, 95% CI: 1.44-19.06, p = 0.012) in final visit images. Fungal filaments (OR 3.61, 95% CI:1.64-7.95, p = 0.001), stromal dendritiform cells (OR 2.88, 95% CI:1.17-7.11, p = 0.022), or stellate cellular processes with no visible nuclei (OR 2.09, 95% CI:1.14-3.82, p = 0.017) were associated with poor outcome if not in baseline but present in final visit images. IVCM can reveal morphological changes associated with clinical outcome.
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Affiliation(s)
- Jaya D Chidambaram
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Namperumalsamy V Prajna
- Aravind Eye Hospital, 1 Anna Nagar, Madurai, 625 020, Tamil Nadu, India.,Aravind Medical Research Foundation, Kuruvikaran Salai, Anna Nagar, Shenoy Nagar, Madurai, 625020, Tamil Nadu, India
| | - Srikanthi Palepu
- Aravind Eye Hospital, 1 Anna Nagar, Madurai, 625 020, Tamil Nadu, India
| | - Shruti Lanjewar
- Aravind Eye Hospital, 1 Anna Nagar, Madurai, 625 020, Tamil Nadu, India
| | - Manisha Shah
- Aravind Eye Hospital, 1 Anna Nagar, Madurai, 625 020, Tamil Nadu, India.,Aravind Medical Research Foundation, Kuruvikaran Salai, Anna Nagar, Shenoy Nagar, Madurai, 625020, Tamil Nadu, India
| | - Shanmugam Elakkiya
- Aravind Medical Research Foundation, Kuruvikaran Salai, Anna Nagar, Shenoy Nagar, Madurai, 625020, Tamil Nadu, India
| | - Prajna Lalitha
- Aravind Eye Hospital, 1 Anna Nagar, Madurai, 625 020, Tamil Nadu, India.,Aravind Medical Research Foundation, Kuruvikaran Salai, Anna Nagar, Shenoy Nagar, Madurai, 625020, Tamil Nadu, India
| | - David Macleod
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Matthew J Burton
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.,Cornea Department, Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK
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Cyclodextrin⁻Amphiphilic Copolymer Supramolecular Assemblies for the Ocular Delivery of Natamycin. NANOMATERIALS 2019; 9:nano9050745. [PMID: 31096569 PMCID: PMC6566826 DOI: 10.3390/nano9050745] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/08/2019] [Accepted: 05/08/2019] [Indexed: 12/25/2022]
Abstract
Natamycin is the only drug approved for fungal keratitis treatment, but its low water solubility and low ocular penetration limit its efficacy. The purpose of this study was to overcome these limitations by encapsulating the drug in single or mixed micelles and poly(pseudo)rotaxanes. Soluplus and Pluronic P103 dispersions were prepared in 0.9% NaCl and pH 6.4 buffer, with or without α-cyclodextrin (αCD; 10% w/v), and characterized through particle size, zeta potential, solubilization efficiency, rheological properties, ocular tolerance, in vitro drug diffusion, and ex vivo permeation studies. Soluplus micelles (90–103 nm) and mixed micelles (150–110 nm) were larger than Pluronic P103 ones (16–20 nm), but all showed zeta potentials close to zero. Soluplus, Pluronic P103, and their mixed micelles increased natamycin solubility up to 6.00-fold, 3.27-fold, and 2.77-fold, respectively. Soluplus dispersions and poly(pseudo)rotaxanes exhibited in situ gelling capability, and they transformed into weak gels above 30 °C. All the formulations were non-irritant according to Hen’s Egg Test on the Chorioallantoic Membrane (HET-CAM) assay. Poly(pseudo)rotaxanes facilitated drug accumulation into the cornea and sclera, but led to lower natamycin permeability through the sclera than the corresponding micelles. Poly(pseudo)rotaxanes made from mixed micelles showed intermediate natamycin diffusion coefficients and permeability values between those of Pluronic P103-based and Soluplus-based poly(pseudo)rotaxanes. Therefore, the preparation of mixed micelles may be a useful tool to regulate drug release and enhance ocular permeability.
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Biofilm testing of microbiota: An essential step during corneal scrap examination in Egyptian acanthamoebic keratitis cases. Parasitol Int 2018; 67:556-564. [PMID: 29730068 DOI: 10.1016/j.parint.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 04/11/2018] [Accepted: 05/01/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE To detect co-infections in the culture-proven acanthamoebic keratitis (AK) cases, and to test the capability of biofilm formation in the isolated microbiota. The clinical findings, habit of wearing contact lens and in-vitro antibiotic resistance were analyzed further according to the biofilm formation capability. METHODS After clinical examination, corneal scraps and swabs were taken from 240 clinically suspected AK cases, for Acanthamoeba and microbiological cultures. In cases of keratoplasty, trimmed corneal tissue was collected and sent for histopathological examination. Scanning electron microscopy was done for some samples. Biofilm formation capability was investigated using a tissue culture plate method. Antibiotic resistance pattern was determined using a modified-Kirby-Bauer disc diffusion method. RESULTS In 102 AK culture proven cases, 11 had no co-infection, 74 had a single co-infection and 17 had double co-infections. Enterobactericae and Aspergillus were the commonest bacterial and fungal isolates, respectively. Regarding the biofilm formation, 64.7% of Enterobactericae, 50% of Pseudomonas aeuroginosa, 43.75% of Staph aureus, 76.92% of Streptococcus pneumoniae, 28.57% of Corynebacterium, 60% of α-haemolytic streptococci, 40% of Acinetobacter, 100% of Candida and 77.8% Aspergillus isolates were biofilm producers. Severe manifestations were more frequently reported in cases co-infected with biofilm producers than with non-biofilm producers. Generally, high percentages of the biofilm forming bacterial isolates were sensitive to antibiotics in-vitro. CONCLUSIONS Routine investigations for co-infection and biofilm formation in addition to Acanthamoeba culture are strongly recommended in suspected AK cases. Co-infection with biofilm producers may precipitate extrinsic in-vivo drug resistance despite of the in-vitro sensitivity. Designing a biofilm-dissolving topical drug is highly recommended to enhance the response to the standard therapeutic regimen especially in the resistant AK cases.
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Sradhanjali S, Yein B, Sharma S, Das S. In vitro synergy of natamycin and voriconazole against clinical isolates of Fusarium, Candida, Aspergillus and Curvularia spp. Br J Ophthalmol 2017; 102:142-145. [DOI: 10.1136/bjophthalmol-2017-310683] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/23/2017] [Accepted: 08/21/2017] [Indexed: 11/04/2022]
Abstract
AimTo determine the minimum inhibitory concentrations (MICs) of voriconazole and natamycin, alone and in combination, against the clinical isolates of Fungus and to evaluate the synergy between the drugs in an experimental in vitro study.MethodsIn an experimental in vitro study, clinical isolates of Fusarium, Aspergillus, Candida and Curvularia spp were maintained on Sabouraud Dextrose Agar and used for the study. The MICs of natamycin and voriconazole, used alone and in combination, were evaluated by checkerboard microdilution technique based on the standard protocol proposed by the Clinical Laboratory Standards Institute. The interactions were assessed using the fractional inhibitory concentration (FIC) Index model.ResultsTested with all the clinical isolates, the MICs ranged between 0.125 and 8 µg/mL both for natamycin and voriconazole. In descending order, maximum synergism (FIC ≤0.5) was observed in Candida spp (33.3%) followed by Curvularia spp and Fusarium spp (23.1%). Synergism was least for Aspergillus spp (22.2%). However, at 61.5% (8/13), maximum additive effect (>0.5–1) was observed in Aspergillus spp and minimum (33.3%, 2/6) in Candida spp. Indifference (FIC value >1 and≤4) was observed in 22.2% (2/9) of Aspergillus spp, 15.4% (2/13) of Fusarium spp, 33.3% (2/6) of Candida spp and 23.1% (3/13) of Curvularia spp. No cases of antagonism (FIC >4) were observed.ConclusionsNatamycin and voriconazole in combination demonstrated more effective antifungal activity than single-use in vitro treatment in all species tested, which implies that these combinations may be helpful in treating fungal keratitis. There was no antagonism between these two drugs.
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Al-Hatmi AMS, Bonifaz A, Ranque S, Sybren de Hoog G, Verweij PE, Meis JF. Current antifungal treatment of fusariosis. Int J Antimicrob Agents 2017; 51:326-332. [PMID: 28705676 DOI: 10.1016/j.ijantimicag.2017.06.017] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/28/2017] [Accepted: 06/24/2017] [Indexed: 12/12/2022]
Abstract
Fungi of the genus Fusarium are well known as major plant pathogens and soil inhabitants, but also cause a broad spectrum of human infections. Fusariosis is the second most common mould infection after aspergillosis, and keratitis is the most encountered implantation infection in immunocompetent individuals. Natamycin is active against Fusarium species both in vitro and in vivo, and is used along with voriconazole as the mainstay of treatment for Fusarium keratitis. Onychomycosis is treated with terbinafine, voriconazole and sometimes itraconazole. Cure is possible despite high in vitro minimum inhibitory concentrations (MICs). Recently, disseminated infections have increased dramatically, mainly affecting severely immunocompromised patients. The remarkable intrinsic resistance of Fusarium species to most antifungal agents results in high mortality rates in this patient population. Recovery of neutropenia is essential for patient survival and treatment should include voriconazole or amphotericin B as first-line and posaconazole as salvage therapy.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Directorate General of Health Services, Ministry of Health, Ibri Hospital, Ibri, Oman; Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands.
| | - Alexandro Bonifaz
- Hospital General de México, 'Dr. Eduardo Liceaga', Mexico City, Mexico
| | - Stephane Ranque
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands; Basic Pathology Department, Federal University of Paraná State, Curitiba, Paraná, Brazil; Biological Sciences Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paul E Verweij
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jacques F Meis
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Acharya Y, Acharya B, Karki P. Fungal keratitis: study of increasing trend and common determinants. Nepal J Epidemiol 2017; 7:685-693. [PMID: 29181230 PMCID: PMC5673246 DOI: 10.3126/nje.v7i2.17975] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 05/20/2017] [Accepted: 05/30/2017] [Indexed: 12/13/2022] Open
Abstract
Fungal keratitis is one of the leading cause of ocular morbidity. Fungal keratitis possesses a clinical challenge due to its slow pathologic process, overlapping features, diagnostic difficulty, and potential complications. Its increasing trend can be attributed to the use of contact lens, non-judiciary corticosteroid, and vegetative trauma. Early diagnosis and treatment is the cornerstone for its effective control. Knowledge of pathological course and clinical characteristics of fungal keratitis will definitely add in early diagnosis and treatment, with reduction in ocular morbidity. This review article explores the risk factor of fungal keratitis, its clinical course and management strategy.
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Affiliation(s)
- Yogesh Acharya
- Assistant professor, Avalon University School of Medicine, Willemstad Curacao, Netherland Antilles
| | - Bhawana Acharya
- Registered nurse, VHA home health care, Toronto Ontario, Canada
| | - Priyanka Karki
- Medical officer, Nobel Medical College and Hospital, Biratnagar Morang, Nepal
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Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Raghavan A, Srinivasan M, O'Brien KS, Zegans M, McLeod SD, Acharya NR, Keenan JD, Lietman TM, Rose-Nussbaumer J. Changing Azole Resistance: A Secondary Analysis of the MUTT I Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:693-6. [PMID: 27054515 DOI: 10.1001/jamaophthalmol.2016.0530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The development of multiple triazole resistance in pathogenic filamentous fungi has become an increasing clinical concern and has been shown to increase the risk for treatment failure. OBJECTIVE To determine whether antifungal resistance increased during the Mycotic Ulcer Treatment Trial I (MUTT I), as measured by minimum inhibitory concentrations (MICs) in baseline cultures. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis of a double-masked, multicenter, randomized clinical trial included patients with culture- or smear-positive filamentous fungal corneal ulcer and a baseline visual acuity of 20/40 to 20/400. Culture-positive samples with susceptibility testing were included in this analysis. The patients were treated at multiple locations of the Aravind Eye Care Hospital system in South India. Data were collected from April 3, 2010, to December 31, 2011, and analyzed from July 15 to September 1, 2015. INTERVENTIONS Corneal smears and cultures were obtained from all study participants at baseline. Susceptibility testing was performed for each culture-positive specimen. MAIN OUTCOMES AND MEASURES Minimum inhibitory concentration of voriconazole and natamycin in baseline cultures. RESULTS Of 323 participants with smear-positive specimens (183 men [56.7%]; 140 women [43.3%]; median [interquartile range] age, 47 [38-56] years), fungal-positive cultures were obtained for 256 (79.3%). The MIC data were available for 221 of 323 participants (68.4%), because 35 samples had no growth during susceptibility testing. A 2.14-fold increase per year (95% CI, 1.13-4.56; P = .02) in voriconazole MICs after controlling for the infectious organism was found. This association was not found when looking at natamycin MICs of baseline cultures after controlling for the infectious organism (1.26; 95% CI, 0.13-12.55; P = .85). CONCLUSIONS AND RELEVANCE Susceptibility to voriconazole appeared to decrease during the relatively short enrollment period of the clinical trial. This decrease may be more related to increased resistance of environmental fungi rather than previous treatment with azoles, because presenting with azole treatment was not a risk factor for resistance. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
| | - Prajna Lalitha
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | | | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | | | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Michael Zegans
- Department of Ophthalmology, Dartmouth Medical School, Hanover, New Hampshire
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco6Department of Optometry, University of California, Berkeley
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Twelve-year analysis of microbial keratitis trends at a UK tertiary hospital. Eye (Lond) 2017; 31:1229-1236. [PMID: 28452995 DOI: 10.1038/eye.2017.55] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/12/2017] [Indexed: 11/08/2022] Open
Abstract
PurposeTo investigate the frequencies, trends, and in vitro drug susceptibilities of the causative pathogens in microbial keratitis in Manchester Royal Eye Hospital.Patients and methodsCorneal scrape results recorded by the microbiology service between 2004 and 2015 were extracted from an established database. A total of 4229 corneal scrape specimens were identified from an established database. First-line antibiotic treatment in our centre during the study period was ofloxacin and second line was cefuroxime and gentamicin.ResultsMean age was 45.9±21.0. A total of 1379 samples (32.6%) were culture positive. One hundred forty-eight (10.7%) specimens cultured multiple organisms. Of the 1539 organisms identified, 63.3% were Gram-positive bacteria, 27.3% Gram-negative bacteria, 7.1% fungi, and 2.3% Acanthamoebae. A decreasing trend in Gram-positive isolates was found together with a stable trend in Gram negatives and an increasing trend in Acanthamoeba and fungi. There appeared to be a significant increasing trend of Moraxella infection (P=0.001). In all, 83.1 and 90.8% of Gram-positive and -negative isolates tested were susceptible to ofloxacin, respectively. Cefuroxime covered 86.6% of Gram-positive and 61.4% of Gram-negative isolates, whereas gentamicin covered 88.8 and 96.5% of Gram-positive and -negative isolates, respectively.ConclusionWe found a change in the type of Gram-negative organisms isolated over time, with the Moraxella species on the rise. Reassuringly, no significant increase in resistance was observed in vitro for any of the commonly used antibiotics. Ofloxacin remains a good first-line antibiotic treatment but duo-therapy does have broader coverage and should be considered in non-responsive cases.
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Chidambaram JD, Prajna NV, Larke N, Macleod D, Srikanthi P, Lanjewar S, Shah M, Lalitha P, Elakkiya S, Burton MJ. In vivo confocal microscopy appearance of Fusarium and Aspergillus species in fungal keratitis. Br J Ophthalmol 2017; 101:1119-1123. [PMID: 28043985 PMCID: PMC5537506 DOI: 10.1136/bjophthalmol-2016-309656] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/07/2016] [Accepted: 11/27/2016] [Indexed: 11/12/2022]
Abstract
Background Clinical outcomes in fungal keratitis vary between Fusarium and Aspergillus spp, therefore distinguishing between species using morphological features such as filament branching angles, sporulation along filaments (adventitious sporulation) or dichotomous branching may be useful. In this study, we assessed these three features within Heidelberg Retina Tomograph 3 in vivo confocal microscopy (IVCM) images from culture-positive Fusarium and Aspergillus spp keratitis participants. Methods Prospective observational cohort study in Aravind Eye Hospital (February 2011–February 2012). Eligibility criteria: age ≥18 years, stromal infiltrate ≥3 mm diameter, Fusarium or Aspergillus spp culture-positive. Exclusion criteria: previous/current herpetic keratitis, visual acuity <6/60 in fellow eye, >80% corneal thinning. IVCM was performed and images analysed for branch angle, presence/absence of adventitious sporulation or dichotomous branching by a grader masked to the microbiological diagnosis. Results 98 participants were included (106 eligible, 8 excluded as no measurable branch angles); 68 were positive for Fusarium spp, 30 for Aspergillus spp. Mean branch angle for Fusarium spp was 59.7° (95% CI 57.7° to 61.8°), and for Aspergillus spp was 63.3° (95% CI 60.8° to 65.8°), p=0.07. No adventitious sporulation was detected in Fusarium spp ulcers. Dichotomous branching was detected in 11 ulcers (7 Aspergillus spp, 4 Fusarium spp). Conclusions There was very little difference in the branching angle of Fusarium and Aspergillus spp. Adventitious sporulation was not detected and dichotomous branching was infrequently seen. Although IVCM remains a valuable tool to detect fungal filaments in fungal keratitis, it cannot be used to distinguish Fusarium from Aspergillus spp and culture remains essential to determine fungal species.
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Affiliation(s)
- Jaya Devi Chidambaram
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Natasha Larke
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Manisha Shah
- Aravind Eye Hospital, Madurai, Tamil Nadu, India.,Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Prajna Lalitha
- Aravind Eye Hospital, Madurai, Tamil Nadu, India.,Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Shanmugam Elakkiya
- Aravind Eye Hospital, Madurai, Tamil Nadu, India.,Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
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Abstract
PURPOSE OF REVIEW This article reviews the literature on past and recent trends in contact lens-related microbial keratitis from bacterial, fungal, and Acanthamoeba infections. RECENT FINDINGS Contact lens wear is the most important risk factor for microbial keratitis. Despite increased use of daily disposable contact lens wear, the incidence of bacterial ulcers related to contact lens wear remains high. Overnight contact lens wear is the leading risk factor in contact lens-related bacterial infections. There may be a trend towards increasing antibiotic resistance of Gram-positive bacteria to fourth-generation fluoroquinolones. The incidence of Acanthamoeba and fungal infections, despite resolution of two outbreaks involving multipurpose solutions, are also on the rise. SUMMARY Contact lens-related microbial keratitis is rising and may be associated with more severe, vision threatening, infections.
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Wu J, Zhang WS, Zhao J, Zhou HY. Review of clinical and basic approaches of fungal keratitis. Int J Ophthalmol 2016; 9:1676-1683. [PMID: 27990375 DOI: 10.18240/ijo.2016.11.23] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 07/20/2016] [Indexed: 02/06/2023] Open
Abstract
Fungal keratitis (FK) is a serious disease which can cause blindness. This review has current information about the pathogenesis, limitations of traditional diagnosis and therapeutic strategies, immune recognition and the diagnosis and therapy of FK. The information of this summary was reviewed regularly and updated as what we need in the diagnosis and therapy of FK nowadays.
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Affiliation(s)
- Jie Wu
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Wen-Song Zhang
- Department of Ophthalmology, the Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Jing Zhao
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Hong-Yan Zhou
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
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Al-Hatmi AMS, Meletiadis J, Curfs-Breuker I, Bonifaz A, Meis JF, De Hoog GS. In vitro combinations of natamycin with voriconazole, itraconazole and micafungin against clinical Fusarium strains causing keratitis. J Antimicrob Chemother 2015; 71:953-5. [PMID: 26702918 DOI: 10.1093/jac/dkv421] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/09/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Fusarium species cause a broad spectrum of infections, from superficial to disseminated disease. Because Fusarium species are intrinsically resistant to most antifungal drugs, new approaches are needed. The aim of the present study was to evaluate the in vitro combination of natamycin with currently used antifungal drugs. METHODS The in vitro interactions of combinations between natamycin and voriconazole, itraconazole and micafungin applied to 20 clinical Fusarium strains (members of Fusarium falciforme, Fusarium napiforme, Fusarium petroliphilum, Fusarium proliferatum, Fusarium pseudensiforme and Fusarium sacchari) were evaluated using a chequerboard microdilution method. The MICs of all drugs alone and in combination were determined visually after 48 h and interactions were assessed using fractional inhibitory concentration index (FICI) analysis. RESULTS MICs of voriconazole and natamycin alone were 4 to >16 and 4-8 mg/L, respectively. Values were reduced 3.5-10-fold to 0.02-0.5 mg/L and 0.5-5-fold to 0.13-2 mg/L in combination, for the currently used antifungals and natamycin, respectively, demonstrating additive to synergistic interactions. The combinations natamycin/voriconazole, natamycin/itraconazole and natamycin/micafungin were synergistic (FICI ≤0.5) for 70%, 15% and 5% of the strains, respectively. No antagonism was found. CONCLUSIONS The combination of natamycin with voriconazole was strongly synergistic at clinically achievable serum concentrations.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- CBS-KNAW Fungal Biodiversity Centre, PO Box 85167, 3508 AD Utrecht, The Netherlands Institutes of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands Directorate General of Health Services, Ibri Hospital, Ministry of Health, Muscat, Oman
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ilse Curfs-Breuker
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - G Sybren De Hoog
- CBS-KNAW Fungal Biodiversity Centre, PO Box 85167, 3508 AD Utrecht, The Netherlands Institutes of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands Basic Pathology Department, Federal University of Paraná State, Curitiba, Paraná, Brazil Biology Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
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Lekhanont K, Nonpassopon M, Nimvorapun N, Santanirand P. Treatment with intrastromal and intracameral voriconazole in 2 eyes with Lasiodiplodia theobromae keratitis: case reports. Medicine (Baltimore) 2015; 94:e541. [PMID: 25674759 PMCID: PMC4602755 DOI: 10.1097/md.0000000000000541] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To report the clinical presentation and the role of intrastromal and intracameral voriconazole injection in the management of rare cases of fungal keratitis caused by Lasiodiplodia theobromae.Two eyes of 2 patients with Lasiodiplodia keratitis unresponsive to topical and oral antifungal medications were included in this study. Diagnosis of Lasiodiplodia keratitis was confirmed by microbiological analysis, including culture-based (case 1 and 2) and DNA sequencing techniques (case 2 only).The first patient presented with multiple satellite lesions and one of these infiltrates spread deeply into the cornea, forming a stromal abscess. Another patient had a large full-thickness corneal infiltrates with several fungal balls in the anterior chamber, requiring a limbus-to-limbus therapeutic penetrating keratoplasty. Despite aggressive topical therapy, the stromal abscess continued to worsen in the first case and recurrent keratitis was observed postoperatively in the second case. Voriconazole 50 μg/0.1 mL was administered intracamerally and intrastromally around the fungal abscess as adjuncts to topical antimycotics in the first case. The second patient who needed therapeutic keratoplasty was treated with an intracameral injection of 50 μg/0.1 mL voriconazole at the end of surgery. Postoperatively, 100 μg/0.1 mL voriconazole was also injected intracamerally after the recurrence of infection was noted in the graft. Reinjections were given 48 hours apart in both cases. After the injections, all corneal and anterior chamber lesions were reduced in size and density and completely resolved within 4 weeks.Intrastromal and intracameral voriconazole injections may offer safe and effective treatment options for L theobromae keratitis.
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Affiliation(s)
- Kaevalin Lekhanont
- From the Department of Ophthalmology (KL, MN, NN); and Department of Pathology (PS), Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Al-Hatmi AMS, van Diepeningen AD, Curfs-Breuker I, de Hoog GS, Meis JF. Specific antifungal susceptibility profiles of opportunists in the Fusarium fujikuroi complex. J Antimicrob Chemother 2014; 70:1068-71. [PMID: 25538167 DOI: 10.1093/jac/dku505] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of the present study was to evaluate and assess the in vitro activity of eight drugs, including the new azole isavuconazole, against 81 strains representing 13 species of the Fusarium fujikuroi species complex. METHODS A total of 81 Fusarium spp. isolates, within the F. fujikuroi species complex, were identified by molecular methods and tested according to CLSI M38-A2. Eight antifungal compounds, including the new azole isavuconazole, were tested. Isolates were selected to represent the widest variety of geographical regions and to include clinical as well as environmental strains. RESULTS Susceptibility profiles differed between and within species, with Fusarium verticillioides showing the lowest MICs and Fusarium nygamai the highest MICs. Amphotericin B was the most active drug, followed by voriconazole, posaconazole, isavuconazole and natamycin. The remaining antifungals (fluconazole, itraconazole and micafungin) showed poor activity with MIC/minimum effective concentration values of ≥ 32, ≥ 16 and >8 mg/L, respectively. CONCLUSIONS Resistance patterns in the F. fujikuroi species complex are species specific and therefore identification down to species level is important for the choice of antifungal treatment.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- CBS-KNAW Fungal Biodiversity Centre, PO Box 85167, 3508 AD Utrecht, The Netherlands Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands Directorate General of Health Services, Ibri Hospital, Ministry of Health, Muscat, Oman
| | | | - Ilse Curfs-Breuker
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - G Sybren de Hoog
- CBS-KNAW Fungal Biodiversity Centre, PO Box 85167, 3508 AD Utrecht, The Netherlands Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands Peking University Health Science Center, Research Center for Medical Mycology, Beijing, China Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China Shanghai Institute of Medical Mycology, Changzheng Hospital, Second Military Medical University, Shanghai, China Basic Pathology Department, Federal University of Paraná State, Curitiba, Paraná, Brazil King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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