Worsening of endogenous Candida albicans endophthalmitis during therapy with intravenous lipid complex amphotericin B

ESCMID* guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients

This part of the EFISG guidelines focuses on non-neutropenic adult patients. Only a few of the numerous recommendations can be summarized in the abstract. Prophylactic usage of fluconazole is supported in patients with recent abdominal surgery and recurrent gastrointestinal perforations or anastomotic leakages. Candida isolation from respiratory secretions alone should never prompt treatment. For the targeted initial treatment of candidaemia, echinocandins are strongly recommended while liposomal amphotericin B and voriconazole are supported with moderate, and fluconazole with marginal strength. Treatment duration for candidaemia should be a minimum of 14 days after the end of candidaemia, which can be determined by one blood culture per day until negativity. Switching to oral treatment after 10 days of intravenous therapy has been safe in stable patients with susceptible Candida species. In candidaemia, removal of indwelling catheters is strongly recommended. If catheters cannot be removed, lipid-based amphotericin B or echinocandins should be preferred over azoles. Transoesophageal echocardiography and fundoscopy should be performed to detect organ involvement. Native valve endocarditis requires surgery within a week, while in prosthetic valve endocarditis, earlier surgery may be beneficial. The antifungal regimen of choice is liposomal amphotericin B +/- flucytosine. In ocular candidiasis, liposomal amphotericin B +/- flucytosine is recommended when the susceptibility of the isolate is unknown, and in susceptible isolates, fluconazole and voriconazole are alternatives. Amphotericin B deoxycholate is not recommended for any indication due to severe side effects.

Fondo de ojo en el paciente crítico no neutropénico: endoftalmitis candidiásica

Invasive Candida (IC) infection is the most common cause of endogenous endophthalmitis. Ocular candidiasis develops within three days and at least two weeks of fungemia. There are two characteristic ocular signs: Candida chorioretinitis defined as retina and choroid lesions without vitreal involvement, and Candida endophthalmitis defined as chorioretinitis with extension into the vitreous with characteristic fluffy balls. The most common initial visual symptoms are blurred vision and floaters. Amphotericin B, fluconazole and voriconazole are effective in the treatment of chorioretinitis; however, when vitreous is involved vitrectomy seems necessary. Early antifungal systemic treatment at first evidence of infection in patients at risk of IC, appears to decrease dramatically the incidence of endogenous fungal endophthalmitis, probably healing minimal chorioretinal infections. Routine ophthalmoscopic examination seems of little value in patients with positive blood culture, with early implementation of antifungal treatment, without symptoms of ocular infection and without impairment of the level of consciousness during the episode. However, periodic ophthalmoscopic examination should be performed in children with candidemia and critically ill patients with documented deep Candida infection.

Antifungal therapy--state of the art at the beginning of the 21st century

The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.

Ocular distribution of intravenously administered lipid formulations of amphotericin B in a rabbit model

Little is known about the ocular penetration of amphotericin B (AMB) and its lipid formulations, the current drug of choice in fungal endophthalmitis. The ocular distribution of AMB lipid complex (ABLC), liposomal AMB (L-AMB), and AMB deoxycholate (D-AMB) was studied in a rabbit model. D-AMB (1 mg/kg of body weight/day), ABLC (5 mg/kg/day), or L-AMB (5 mg/kg/day) was given intravenously to rabbits as a single dose or as repeated daily doses on 7 consecutive days after induction of unilateral uveitis by intravitreal injection of endotoxin. AMB concentrations in aqueous humor, vitreous humor, and plasma were determined by high-pressure liquid chromatography 16 h after administration of a single dose or 24 h after the last of seven doses. After single-dose administration, L-AMB achieved at least eightfold-higher AMB concentrations in the aqueous of inflamed eyes than ABLC or D-AMB (1.21 +/- 0.58 micro g/ml versus 0.14 +/- 0.04 and 0.11 +/- 0.09 micro g/ml, respectively). At that time point no drug was detectable in the vitreous. After 7 days of treatment, the concentration of AMB in the vitreous was higher after treatment with L-AMB (0.47 +/- 0.21 micro g/ml) than after treatment with ABLC (0.27 +/- 0.18 micro g/ml) and D-AMB (0.16 +/- 0.04 micro g/ml). Similarly, AMB concentration in the aqueous was higher after repeated doses of L-AMB (0.73 +/- 0.43 micro g/ml) than after repeated doses of ABLC (0.03 +/- 0.02 micro g/ml) or D-AMB (0.13 +/- 0.06 micro g/ml). No AMB was detected in noninflamed eyes. Following systemic administration, AMB distribution to the eye is inflammation dependent and occurs sequentially, first to the aqueous and then to the vitreous. Compared to D-AMB and ABLC, L-AMB reaches higher drug concentrations in both ocular compartments.

Endogenous endophthalmitis

Endogenous endophthalmitis still presents a diagnostic and therapeutic challenge even with improvements in therapeutic modalities. The main prognostic factor is the virulence of the causative organism: once the organism enters the eye, it rapidly destroys ocular tissues. With the increasing ability to prolong the life of very ill patients, incidence of endogenous endophthalmitis is expected to increase. Ophthalmologists must be ever more vigilant, because prompt treatment offers the best chance of saving the eye.