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Strong N, Ostrosky-Zeichner L. Fusarium species central nervous system infection. Curr Opin Infect Dis 2024; 37:185-191. [PMID: 38518108 DOI: 10.1097/qco.0000000000001009] [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: 03/24/2024]
Abstract
PURPOSE OF REVIEW Fusarium species are an increasingly important cause of meningitis and invasive disease in immunocompromised patients as well as in otherwise healthy patients as observed in two recent healthcare-associated outbreaks. This review summarizes recently published information on treatment and diagnosis of this infection. RECENT FINDINGS Incidence of Fusarium species meningitis and invasive fusariosis are increasing. Molecular techniques are improving the speed of diagnosis. New antifungal agents in development show good in vitro activity against some Fusarium species. New technologies, including cerebrospinal fluid (CSF) filtration, may play a role in treatment of central nervous system (CNS) disease. Due to the continued prime importance of the host immune system in recovery, immunomodulatory treatments may play a role in treatment. SUMMARY The overall incidence of CNS fusariosis is increasing with a continued poor prognosis, but new diagnostic and treatment modalities are in development which may offer improvements.
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Affiliation(s)
- Nora Strong
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Hodges MR, Hazel S, Kramer WG, van Hoogdalem EJ, van Marle S, Tawadrous M, Jakate A. Pharmacokinetics, safety, and tolerability of fosmanogepix IV to oral switch and multiple IV doses in healthy participants. Antimicrob Agents Chemother 2024; 68:e0145523. [PMID: 38551346 PMCID: PMC11064621 DOI: 10.1128/aac.01455-23] [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: 11/07/2023] [Accepted: 02/28/2024] [Indexed: 04/10/2024] Open
Abstract
Fosmanogepix [FMGX, APX001; active form: manogepix (MGX), APX001A] is a first-in-class, intravenous (IV)/oral antifungal currently being evaluated for invasive fungal disease treatment. Data from two phase 1, placebo-controlled studies [IV-oral switch (study 1) and multiple IV doses (study 2)] evaluating FMGX tolerability, and pharmacokinetics (PK) are presented. Healthy adults (study 1: 18-65 years; study 2: 18-55 years) were eligible (randomized 3:1 to FMGX: placebo). Eleven participants completed study 1. In study 2, 51 participants (48 planned + 3 replacement) were enrolled in six cohorts (8 participants each; 34 completed the study). In study 1, overall MGX systemic exposures were comparable from day 1 to day 42 of dosing; steady-state plasma concentrations were achieved in ≤24 h following two IV loading doses (1,000 mg) and exposures maintained after switching [IV (600 mg) to daily oral doses (800 mg)]. FMGX was safe and well-tolerated. In study 2, FMGX IV doses (loading doses twice daily/maintenance doses once daily; 3-h infusion) of 1,500/900 mg (cohort A), 900/900 mg (cohort B), and 1,000/900 mg (cohort C: with ondansetron) were not well-tolerated; most participants reported nausea and infrequent vomiting. FMGX IV doses of 1,000/750 mg (cohort D), 1,000/850 mg (cohort E), and 1,000/900 mg (cohort F: ondansetron prn) were relatively better tolerated. Steady-state systemic exposures were achieved between days 2 and 4. All cohorts had similar geometric mean (GM) concentrations during maintenance dosing and similar GM PK parameters. Dosing regimen evaluated in study 1 was safe, well-tolerated, and may be used for future clinical evaluations.
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Affiliation(s)
| | - Susan Hazel
- Amplyx Pharmaceuticals, Inc., San Diego, California, USA
- Pfizer Inc., New York, New York, USA
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Shaban S, Patel M, Ahmad A. Antifungal activity of human antimicrobial peptides targeting apoptosis in Candida auris. J Med Microbiol 2024; 73. [PMID: 38743468 DOI: 10.1099/jmm.0.001835] [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: 05/16/2024] Open
Abstract
Introduction. Innovative antifungal therapies are of crucial importance to combat the potentially life-threatening infections linked to the multidrug-resistant fungal pathogen Candida auris. Induction of regulated cell death, apoptosis, could provide an outline for future therapeutics. Human antimicrobial peptides (AMPs), well-known antifungal compounds, have shown the ability to induce apoptosis in pathogenic fungi.Hypothesis/Gap Statement . Although it is known that AMPs possess antifungal activity against C. auris, their ability to induce apoptosis requires further investigations.Aim. This study evaluated the effects of AMPs on the induction of apoptosis in C. auris.Methods. Human neutrophil peptide-1 (HNP-1), human β-Defensins-3 (hBD-3) and human salivary histatin 5 (His 5) were assessed against two clinical C. auris isolates. Apoptosis hallmarks were examined using FITC-Annexin V/PI double labelling assay and terminal deoxynucleotidyl transferase deoxynucleotidyl transferase nick-end labelling (TUNEL) to detect phosphatidylserine externalization and DNA fragmentation, respectively. Then, several intracellular triggers were studied using JC-10 staining, spectrophotometric assay and 2',7'-dichlorofluorescin diacetate staining to measure the mitochondrial membrane potential, cytochrome-c release and reactive oxygen species (ROS) production, respectively.Results and conclusion. FITC-Annexin V/PI staining and TUNEL analysis revealed that exposure of C. auris cells to HNP-1 and hBD-3 triggered both early and late apoptosis, while His 5 caused significant necrosis. Furthermore, HNP-1 and hBD-3 induced significant mitochondrial membrane depolarization, which resulted in substantial cytochrome c release. In contrast to His 5, which showed minimal mitochondrial depolarization and no cytochrome c release. At last, all peptides significantly increased ROS production, which is related to both types of cell death. Therefore, these peptides represent promising and effective antifungal agents for treating invasive infections caused by multidrug-resistant C. auris.
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Affiliation(s)
- Siham Shaban
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Mrudula Patel
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
- Division of Infection Control, Charlotte Maxeke Johannesburg Academic Hospital, National Health Laboratory Service, Johannesburg, South Africa
| | - Aijaz Ahmad
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
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He R, Lin F, Yu B, Huang L. Efficacy and safety of ibrexafungerp in the treatment of vulvovaginal candidiasis: A meta-analysis of randomized controlled trials. Heliyon 2024; 10:e28776. [PMID: 38628772 PMCID: PMC11019174 DOI: 10.1016/j.heliyon.2024.e28776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024] Open
Abstract
Background This study aims to evaluate the efficacy and safety associated with ibrexafungerp in the treatment of vulvovaginal candidiasis infection patients. Methods We conducted a comprehensive search of the PubMed, Embase, Cochrane Library, and Clinical Trials databases up to December 25, 2022. The primary outcomes were clinical cure rate and mycological eradication rate, whereas the secondary outcomes were the risk of an adverse events. Results In total of four studies encompassing 880 patients diagnosed with vulvovaginal candidiasis (VVC) were included in the analysis. The findings demonstrated that ibrexafungerp exhibited superior clinical cure ratio (RR = 1.33 [1.07, 1.66]), mycological eradication rate (RR = 1.72 [1.00, 2.95]), and overall success ratio (RR = 1.64 [0.92, 2.92]) when compared to the fluconazole/placebo in the treatment of VVC. Furthermore, patients treated with ibrexafungerp demonstrated significantly higher clinical cure rates, mycological eradication, and overall success ratio compared to those receiving other treatments for vulvovaginal candidiasis caused by C. albicans. When ibrexafungerp was compared to fluconazole/placebo, the duration of any treatment-related treatment-emergent adverse events (TEAE), nausea, and diarrhea during therapy was significantly longer. Conclusion In summary, the use of ibrexafungerp was linked to superior clinical cure ratio, and mycological eradication when compared to fluconazole/placebo.
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Affiliation(s)
- Rong He
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- Clinical Medical College, Chengdu Medical College, Chengdu, China
| | - Fei Lin
- Clinical Medical College, Chengdu Medical College, Chengdu, China
- Department of Pharmacy, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Bin Yu
- Department of Pharmacy, Mianyang Central Hospital, Mianyang, China
| | - Ling Huang
- Clinical Medical College, Chengdu Medical College, Chengdu, China
- Department of Pharmacy, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
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Kumar V, Huang J, Dong Y, Hao GF. Targeting Fks1 proteins for novel antifungal drug discovery. Trends Pharmacol Sci 2024; 45:366-384. [PMID: 38493014 DOI: 10.1016/j.tips.2024.02.007] [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] [Received: 01/09/2024] [Revised: 01/26/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024]
Abstract
Fungal infections are a major threat to human health. The limited availability of antifungal drugs, the emergence of drug resistance, and a growing susceptible population highlight the critical need for novel antifungal agents. The enzymes involved in fungal cell wall synthesis offer potential targets for antifungal drug development. Recent studies have enhanced our focus on the enzyme Fks1, which synthesizes β-1,3-glucan, a critical component of the cell wall. These studies provide a deeper understanding of Fks1's function in cell wall biosynthesis, pathogenicity, structural biology, evolutionary conservation across fungi, and interaction with current antifungal drugs. Here, we discuss the role of Fks1 in the survival and adaptation of fungi, guided by insights from evolutionary and structural analyses. Furthermore, we delve into the dynamics of Fks1 modulation with novel antifungal strategies and assess its potential as an antifungal drug target.
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Affiliation(s)
- Vinit Kumar
- National Key Laboratory of Green Pesticide, Key Laboratory of Green Pesticide and Agricultural Bioengineering, Ministry of Education, Center for Research and Development of Fine Chemicals, Guizhou University, Guiyang 550025, PR China; BMLT, Markham College of Commerce, Vinoba Bhave University, Hazaribagh, Jharkhand 825301, India
| | - Juan Huang
- School of Pharmaceutical Sciences, Guizhou University, Guiyang 550025, PR China
| | - Yawen Dong
- School of Pharmaceutical Sciences, Guizhou University, Guiyang 550025, PR China.
| | - Ge-Fei Hao
- National Key Laboratory of Green Pesticide, Key Laboratory of Green Pesticide and Agricultural Bioengineering, Ministry of Education, Center for Research and Development of Fine Chemicals, Guizhou University, Guiyang 550025, PR China; National Key Laboratory of Green Pesticide, Central China Normal University, Wuhan 430079, PR China.
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Lax C, Nicolás FE, Navarro E, Garre V. Molecular mechanisms that govern infection and antifungal resistance in Mucorales. Microbiol Mol Biol Rev 2024; 88:e0018822. [PMID: 38445820 PMCID: PMC10966947 DOI: 10.1128/mmbr.00188-22] [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] [Indexed: 03/07/2024] Open
Abstract
SUMMARYThe World Health Organization has established a fungal priority pathogens list that includes species critical or highly important to human health. Among them is the order Mucorales, a fungal group comprising at least 39 species responsible for the life-threatening infection known as mucormycosis. Despite the continuous rise in cases and the poor prognosis due to innate resistance to most antifungal drugs used in the clinic, Mucorales has received limited attention, partly because of the difficulties in performing genetic manipulations. The COVID-19 pandemic has further escalated cases, with some patients experiencing the COVID-19-associated mucormycosis, highlighting the urgent need to increase knowledge about these fungi. This review addresses significant challenges in treating the disease, including delayed and poor diagnosis, the lack of accurate global incidence estimation, and the limited treatment options. Furthermore, it focuses on the most recent discoveries regarding the mechanisms and genes involved in the development of the disease, antifungal resistance, and the host defense response. Substantial advancements have been made in identifying key fungal genes responsible for invasion and tissue damage, host receptors exploited by the fungus to invade tissues, and mechanisms of antifungal resistance. This knowledge is expected to pave the way for the development of new antifungals to combat mucormycosis. In addition, we anticipate significant progress in characterizing Mucorales biology, particularly the mechanisms involved in pathogenesis and antifungal resistance, with the possibilities offered by CRISPR-Cas9 technology for genetic manipulation of the previously intractable Mucorales species.
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Affiliation(s)
- Carlos Lax
- Departamento de Genética y Microbiología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
| | - Francisco E. Nicolás
- Departamento de Genética y Microbiología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
| | - Eusebio Navarro
- Departamento de Genética y Microbiología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
| | - Victoriano Garre
- Departamento de Genética y Microbiología, Facultad de Biología, Universidad de Murcia, Murcia, Spain
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Zhang F, Muhire J, Sun X, Pei D, Huang X. Comparison of two different multiple dual-mode counter-current chromatograph for separation of ketoconazole enantiomers. J Chromatogr A 2024; 1718:464724. [PMID: 38350351 DOI: 10.1016/j.chroma.2024.464724] [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] [Received: 10/18/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/15/2024]
Abstract
In this work, two different multiple dual-mode (MDM) counter-current chromatography methods, conventional MDM and modified MDM elution modes, were compared for the chiral separation of the ketoconazole enantiomers. The biphasic solvent system which consisted of n-hexane: isobutyl acetate: 0.1 mol/L phosphate buffer (2:4:6, v/v) (pH = 8.5) was employed as stationary phase and mobile phase. And the hydroxypropyl-β-cyclodextrin (HP-β-CD) with a concentration of 100 mmol/L was dissolved in the phosphate buffer, as the chiral selector. Under two different methods, dual-mode (DM) elution was performed to determine the time of the transformed phase roles and multiple cycles were performed to isolate ketoconazole, respectively. The result indicated that the modified MDM elution had a significant improvement on the separation, increasing the resolution from 0.51 to 1.19, while the resolution was increased from 0.40 to 0.79 by the conventional MDM elution. Ultimately, baseline separation of ketoconazole enantiomers was essentially achieved by high-speed counter-current chromatography under optimized modified MDM separation conditions. The final recoveries of the two enantiomers, R-(K) and S-(K), were 92.5 % and 83.3 %, respectively, corresponding to enantiomeric excess values of 99.0 % and 97.0 %, as determined by HPLC.
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Affiliation(s)
- Fuxin Zhang
- CAS Key Laboratory of Chemistry of Northwestern Plant Resources and Key Laboratory of Natural Medicine of Gansu Province, Lanzhou Institute of Chemical Physics, Chinese Academy of Sciences (CAS), Lanzhou 730000, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Jules Muhire
- CAS Key Laboratory of Chemistry of Northwestern Plant Resources and Key Laboratory of Natural Medicine of Gansu Province, Lanzhou Institute of Chemical Physics, Chinese Academy of Sciences (CAS), Lanzhou 730000, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Xiao Sun
- CAS Key Laboratory of Chemistry of Northwestern Plant Resources and Key Laboratory of Natural Medicine of Gansu Province, Lanzhou Institute of Chemical Physics, Chinese Academy of Sciences (CAS), Lanzhou 730000, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Dong Pei
- CAS Key Laboratory of Chemistry of Northwestern Plant Resources and Key Laboratory of Natural Medicine of Gansu Province, Lanzhou Institute of Chemical Physics, Chinese Academy of Sciences (CAS), Lanzhou 730000, China; University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Xinyi Huang
- CAS Key Laboratory of Chemistry of Northwestern Plant Resources and Key Laboratory of Natural Medicine of Gansu Province, Lanzhou Institute of Chemical Physics, Chinese Academy of Sciences (CAS), Lanzhou 730000, China; University of Chinese Academy of Sciences, Beijing 100049, China.
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Fernández-Ruiz M. Pharmacological management of invasive mold infections in solid organ transplant recipients. Expert Opin Pharmacother 2024; 25:239-254. [PMID: 38436619 DOI: 10.1080/14656566.2024.2326507] [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] [Received: 11/09/2023] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Solid organ transplant (SOT) recipients face an increased susceptibility to invasive fungal infection (IFI) due to filamentous fungi. Post-transplant invasive aspergillosis (IA) and mucormycosis are related to exceedingly high mortality rates and graft loss risk, and its management involve a unique range of clinical challenges. AREAS COVERED First, the current treatment recommendations for IA and mucormycosis among SOT recipients are critically reviewed, including the supporting evidence. Next, we discussed particular concerns in this patient population, such as drug-drug interactions (DDIs) between triazoles and post-transplant immunosuppression or treatment-related toxicity. The role for immunomodulatory and host-targeted therapies is also considered, as well as the theoretical impact of the intrinsic antifungal activity of calcineurin inhibitors. Finally, a personal opinion is made on future directions in the pharmacological approach to post-transplant IFI. EXPERT OPINION Despite relevant advances in the treatment of mold IFIs in the SOT setting, such as the incorporation of isavuconazole (with lower incidence of DDIs and better tolerability than voriconazole), there remains a large room for improvement in areas such as the position of combination therapy or the optimal strategy for the reduction of baseline immunosuppression. Importantly, future studies should define the specific contribution of newer antifungal agents and classes.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Matsuo T, Wurster S, Jiang Y, Sasaki K, Tarrand J, Lewis RE, Kontoyiannis DP. Invasive fusariosis in patients with leukaemia in the era of mould-active azoles: increasing incidence, frequent breakthrough infections and lack of improved outcomes. J Antimicrob Chemother 2024; 79:297-306. [PMID: 38073151 DOI: 10.1093/jac/dkad377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/17/2023] [Indexed: 02/02/2024] Open
Abstract
OBJECTIVES Historically, patients with leukaemia and invasive fusariosis (IF) have experienced poor outcomes in the setting of persistent immunosuppression. Herein, we retrospectively reviewed the incidence, presentation and outcomes of IF that are scarcely studied in contemporary cohorts of leukaemia patients. METHODS We identified adult leukaemia patients with proven or probable IF at MD Anderson Cancer Center during 2009-21. Independent risk factors for 42 day mortality after IF diagnosis were determined using a multivariable logistic regression model. Combined with historical data, the annual IF incidence density over the past 23 years was estimated using Poisson regression analysis. RESULTS Among 140 leukaemia patients with IF (114 proven), 118 patients (84%) had relapsed/refractory leukaemia and 124 (89%) had neutropenia at IF diagnosis. One hundred patients (71%) had pulmonary IF, 88 (63%) had disseminated IF and 48 (34%) had fungaemia. Coinfections were common (55%). Eighty-nine patients (64%) had breakthrough IF to mould-active triazoles. Most patients (84%) received combination antifungal therapy. Neutrophil recovery [adjusted OR (aOR), 0.04; 95% CI, 0.01-0.14; P < 0.0001], pulmonary IF (aOR, 3.28; 95% CI, 1.11-9.70; P = 0.032) and high SOFA score (aOR, 1.91 per 1-point increase; 95% CI, 1.47-2.50; P < 0.0001) were independent predictors of 42 day mortality outcomes. From 1998 to 2021, IF incidence density increased significantly at an annual ratio of 1.03 (95% CI, 1.01-1.06; P = 0.04). CONCLUSIONS IF is predominantly seen in patients with relapsed/refractory leukaemia and increasingly seen as a breakthrough infection to mould-active triazoles. Despite frequent combination antifungal therapy, high mortality rates have persisted in patients with lasting neutropenia.
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Affiliation(s)
- Takahiro Matsuo
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Tarrand
- Section of Clinical Microbiology and Virology, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell E Lewis
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Eschenauer GA. Antifungal Therapies for Aspergillus spp.: Present and Future. Semin Respir Crit Care Med 2024; 45:61-68. [PMID: 38151025 DOI: 10.1055/s-0043-1776776] [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: 12/29/2023]
Abstract
Currently available and recommended options for the treatment of pulmonary aspergillosis include the triazoles, echinocandins, and amphotericin B products. These therapies have significant limitations. Only the azoles are available orally, but their use is often limited by toxicities, drug-drug interactions, pharmacokinetic variability, and emerging resistance. While the echinocandins are safe agents and may have a role in combination therapy, they are unproven as monotherapy. Amphotericin B preparations are toxic and require intensive monitoring. Finally, aspergillosis continues to be a disease conferring substantial morbidity and mortality, and clinical trials have not identified a therapeutic approach clearly associated with improved outcomes. As a result, there is a great need for new options in the treatment of invasive aspergillosis. Ideally, such options would be safe, have high oral bioavailability, have favorable pharmacokinetics to sequestered sites and retain activity against azole-resistant isolates. Reassuringly, there is a robust pipeline of novel therapies in development. Rezafungin (a once-weekly dosed echinocandin) and ibrexafungerp (oral agent with same mechanism of action as echinocandins) will likely be reserved for combination therapy or refractory/intolerance scenarios with no other options. Inhaled opelconazole is an attractive option for combination therapy and prophylaxis of pulmonary aspergillosis. Development of an oral form of amphotericin B that avoids nephrotoxicity and electrolyte disturbances is an exciting development. Finally, olorofim and fosmanogepix, two agents with novel mechanisms of action and oral formulations, hold significant potential to challenge the triazole antifungals place as preferred therapies. However, many questions remain regarding these novel agents, and at the time of this writing, none of these agents have been robustly studied in Phase III studies of aspergillosis, and so their promise remains investigational.
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Affiliation(s)
- Gregory A Eschenauer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan
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Mori G, Diotallevi S, Farina F, Lolatto R, Galli L, Chiurlo M, Acerbis A, Xue E, Clerici D, Mastaglio S, Lupo Stanghellini MT, Ripa M, Corti C, Peccatori J, Puoti M, Bernardi M, Castagna A, Ciceri F, Greco R, Oltolini C. High-Risk Neutropenic Fever and Invasive Fungal Diseases in Patients with Hematological Malignancies. Microorganisms 2024; 12:117. [PMID: 38257945 PMCID: PMC10818361 DOI: 10.3390/microorganisms12010117] [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: 12/11/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Invasive fungal diseases (IFDs) still represent a relevant cause of mortality in patients affected by hematological malignancies, especially acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) undergoing remission induction chemotherapy, and in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. Mold-active antifungal prophylaxis (MAP) has been established as a standard of care. However, breakthrough IFDs (b-IFDs) have emerged as a significant issue, particularly invasive aspergillosis and non-Aspergillus invasive mold diseases. Here, we perform a narrative review, discussing the major advances of the last decade on prophylaxis, the diagnosis of and the treatment of IFDs in patients with high-risk neutropenic fever undergoing remission induction chemotherapy for AML/MDS and allo-HSCT. Then, we present our single-center retrospective experience on b-IFDs in 184 AML/MDS patients undergoing high-dose chemotherapy while receiving posaconazole (n = 153 induction treatments, n = 126 consolidation treatments, n = 60 salvage treatments). Six cases of probable/proven b-IFDs were recorded in six patients, with an overall incidence rate of 1.7% (6/339), which is in line with the literature focused on MAP with azoles. The incidence rates (IRs) of b-IFDs (95% confidence interval (95% CI), per 100 person years follow-up (PYFU)) were 5.04 (0.47, 14.45) in induction (n = 2), 3.25 (0.0013, 12.76) in consolidation (n = 1) and 18.38 (3.46, 45.06) in salvage chemotherapy (n = 3). Finally, we highlight the current challenges in the field of b-IFDs; these include the improvement of diagnoses, the expanding treatment landscape of AML with molecular targeted drugs (and related drug-drug interactions with azoles), evolving transplantation techniques (and their related impacts on IFDs' risk stratification), and new antifungals and their features (rezafungin and olorofim).
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Affiliation(s)
- Giovanni Mori
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, Ospedale Santa Chiara, 38122 Trento, Italy
| | - Sara Diotallevi
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Francesca Farina
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Riccardo Lolatto
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Laura Galli
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Matteo Chiurlo
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Andrea Acerbis
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Elisabetta Xue
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Centre for Immuno-Oncology, National Cancer Institute, Eliminate NIH, Bethesda, MD 20850, USA
| | - Daniela Clerici
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sara Mastaglio
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | | | - Marco Ripa
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Consuelo Corti
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Jacopo Peccatori
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Massimo Puoti
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20161 Milan, Italy
- Faculty of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Massimo Bernardi
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Antonella Castagna
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
| | - Fabio Ciceri
- Infectious Diseases Unit, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.M.)
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Raffaella Greco
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Chiara Oltolini
- Infectious Diseases Unit, IRCCS San Raffaele Scientific Institute, 20127 Milan, Italy
- Infectious Diseases Unit, ASST Grande Ospedale Metropolitano Niguarda, 20161 Milan, Italy
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12
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Groll AH, Körholz K, Holterhus M, Lehrnbecher T. New and emerging options for management of invasive fungal diseases in paediatric patients. Mycoses 2024; 67:e13654. [PMID: 37789721 DOI: 10.1111/myc.13654] [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] [Received: 07/10/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 10/05/2023]
Abstract
Invasive fungal diseases (IFDs) play an important role in the supportive care of paediatric patients with acute leukaemia and those undergoing allogeneic haematopoietic cell transplantation, and they are associated with significantly decreased overall survival rates in affected individuals. Relative to adults, children and adolescents are distinct in terms of host biology, predisposing conditions, presentation and epidemiology of fungal diseases, and in the pharmacology of antifungal agents. The paediatric development of antifungal agents has moved forward in a coordinated manner, and major advances have been made regarding concepts and recommendations for the prevention and treatment of IFDs. However, antifungal therapy is increasingly complex, and a solid knowledge of the available options is needed more than ever for successful management. This narrative review provides a summary of the paediatric development of agents that have been recently approved (anidulafungin, posaconazole) or are in advanced stages of development (isavuconazole). It also reviews the emerging evidence for the efficacy of echinocandins for prophylaxis of invasive aspergillosis, presents new data on alternative dosing regimens of echinocandins and voriconazole, and provides a brief overview of new antifungal agents in clinical development that are expected to be developed for paediatric patients.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Katharina Körholz
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Malcolm Holterhus
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology, Children's University Hospital Münster, Münster, Germany
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt, Germany
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13
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Boutin CA, Luong ML. Update on therapeutic approaches for invasive fungal infections in adults. Ther Adv Infect Dis 2024; 11:20499361231224980. [PMID: 38249542 PMCID: PMC10799587 DOI: 10.1177/20499361231224980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Invasive fungal infections are increasingly encountered with the expansion of iatrogenic immunosuppression, including not only solid organ and hematopoietic stem cell transplant recipients but also patients with malignancies or autoimmune diseases receiving immunomodulatory therapies, such as Bruton Tyrosine Kinase (BTK) inhibitor. Their attributable mortality remains elevated, part of which is a contribution from globally emerging resistance in both molds and yeasts. Because antifungal susceptibility test results are often unavailable or delayed, empiric and tailored antifungal approaches including choice of agent(s) and use of combination therapy are heterogeneous and often based on clinician experience with knowledge of host's net state of immunosuppression, prior antifungal exposure, antifungal side effects and interaction profile, clinical severity of disease including site(s) of infection and local resistance data. In this review, we aim to summarize previous recommendations and most recent literature on treatment of invasive mold and yeast infections in adults to guide optimal evidence-based therapeutic approaches. We review the recent data that support use of available antifungal agents, including the different triazoles that have now been studied in comparison to previously preferred agents. We discuss management of complex infections with specific emerging fungi such as Scedosporium spp., Fusarium spp., Trichosporon asahii, and Candida auris. We briefly explore newer antifungal agents or formulations that are now being investigated to overcome therapeutic pitfalls, including but not limited to olorofim, rezafungin, fosmanogepix, and encochleated Amphotericin B. We discuss the role of surgical resection or debridement, duration of treatment, follow-up modalities, and need for secondary prophylaxis, all of which remain challenging, especially in patients chronically immunocompromised or awaiting more immunosuppressive therapies.
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Affiliation(s)
- Catherine-Audrey Boutin
- Division of Infectious Diseases, Department of Medicine, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
| | - Me-Linh Luong
- Department of Medicine, Division of Infectious Diseases, Université de Montréal, Centre Hospitalier de l’Université de Montréal (CHUM), F Building, 6th Floor, Room F06.1102F, 1051 Sanguinet, Montreal, QC, H2X 0C1, Canada
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14
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Girase R, Ahmad I, Oh JM, Kim H, Mathew B, Vagolu SK, Tønjum T, Desai NC, Sriram D, Kumari J, Patel HM. Repurposing Azoles to Resolve Serotogenic Toxicity Associated with Linezolid to Combat Multidrug-Resistant Tuberculosis. ACS Med Chem Lett 2023; 14:1754-1759. [PMID: 38116435 PMCID: PMC10726462 DOI: 10.1021/acsmedchemlett.3c00406] [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: 09/12/2023] [Revised: 10/15/2023] [Accepted: 10/25/2023] [Indexed: 12/21/2023] Open
Abstract
Serotogenic toxicity is a major hurdle associated with Linezolid in the treatment of drug-resistant tuberculosis (TB) due to the inhibition of monoamine oxidase (MAO) enzymes. Azole compounds demonstrate structural similarities to the recognized anti-TB drug Linezolid, making them intriguing candidates for repurposing. Therefore, we have repurposed azoles (Posaconazole, Itraconazole, Miconazole, and Clotrimazole) for the treatment of drug-resistant TB with the anticipation of their selectivity in sparing the MAO enzyme. The results of repurposing revealed that Clotrimazole showed equipotent activity against the Mycobacterium tuberculosis (Mtb) H37Rv strain compared to Linezolid, with a minimal inhibitory concentration (MIC) of 2.26 μM. Additionally, Clotrimazole exhibited reasonable MIC50 values of 0.17 μM, 1.72 μM, 1.53 μM, and 5.07 μM against the inhA promoter+, katG+, rpoB+, and MDR clinical Mtb isolates, respectively, compared to Linezolid. Clotrimazole also exhibited 3.90-fold less inhibition of MAO-A and 50.35-fold less inhibition of MAO-B compared to Linezolid, suggesting a reduced serotonergic toxicity burden.
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Affiliation(s)
- Rukaiyya
T. Girase
- Department
of Pharmaceutical Chemistry, R. C. Patel
Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra India, 4254
| | - Iqrar Ahmad
- Department
of Pharmaceutical Chemistry, R. C. Patel
Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra India, 4254
| | - Jong Min Oh
- Department
of Pharmacy, and Research Institute of Life Pharmaceutical Sciences, Sunchon National University, Suncheon 57922, Republic of Korea
| | - Hoon Kim
- Department
of Pharmacy, and Research Institute of Life Pharmaceutical Sciences, Sunchon National University, Suncheon 57922, Republic of Korea
| | - Bijo Mathew
- Department
of Pharmaceutical Chemistry, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi 690525, India
| | - Siva K. Vagolu
- Department
of Microbiology, University of Oslo, N-0316 Oslo, Norway
| | - Tone Tønjum
- Department
of Microbiology, University of Oslo, N-0316 Oslo, Norway
- Department
of Microbiology, Oslo University Hospital, N-0424 Oslo, Norway
| | - Nisheeth C. Desai
- Division
of Medicinal Chemistry, Department of Chemistry (DST-FIST Sponsored), Maharaja Krishnakumarsinhji Bhavnagar University, Mahatma Gandhi Campus, Bhavnagar 364 002, India
| | - Dharmarajan Sriram
- Department
of Pharmacy, Birla Institute of Technology
and Science-Pilani, Hyderabad Campus, Jawahar Nagar, Shameerpet Mandal, R. R. District, Hyderabad 500078, India
| | - Jyothi Kumari
- Department
of Pharmacy, Birla Institute of Technology
and Science-Pilani, Hyderabad Campus, Jawahar Nagar, Shameerpet Mandal, R. R. District, Hyderabad 500078, India
| | - Harun M. Patel
- Department
of Pharmaceutical Chemistry, R. C. Patel
Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra India, 4254
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15
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Wang Q, Cheng S, Wang Y, Li F, Chen J, Du W, Kang H, Wang Z. Global characteristics and trends in research on Candida auris. Front Microbiol 2023; 14:1287003. [PMID: 38125576 PMCID: PMC10731253 DOI: 10.3389/fmicb.2023.1287003] [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: 09/01/2023] [Accepted: 11/13/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Candida auris, a fungal pathogen first reported in 2009, has shown strong resistance to azole antifungal drugs and has caused severe nosocomial outbreaks. It can also form biofilms, which can colonize patients' skin and transmit to others. Despite numerous reports of C. auris isolation in various countries, many studies have reported contradictory results. Method A bibliometric analysis was conducted using VOSviewer to summarize research trends and provide guidance for future research on controlling C. auris infection. The analysis revealed that the United States and the US CDC were the most influential countries and research institutions, respectively. For the researchers, Jacques F. Meis published the highest amount of related articles, and Anastasia P. Litvintseva's articles with the highest average citation rate. The most cited publications focused on clade classification, accurate identification technologies, nosocomial outbreaks, drug resistance, and biofilm formation. Keyword co-occurrence analysis revealed that the top five highest frequencies were for 'drug resistance,' 'antifungal susceptibility test,' 'infection,' 'Candida auris,' and 'identification.' The high-frequency keywords clustered into four groups: rapid and precise identification, drug resistance research, pathogenicity, and nosocomial transmission epidemiology studies. These clusters represent different study fields and current research hotspots of C. auris. Conclusion The bibliometric analysis identified the most influential country, research institution, and researcher, indicating current research trends and hotspots for controlling C. auris.
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Affiliation(s)
- Qihui Wang
- Laboratory of Microbiology, Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Shitong Cheng
- Laboratory of Microbiology, Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yinling Wang
- Laboratory of Microbiology, Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Fushun Li
- Laboratory of Microbiology, Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jingjing Chen
- Laboratory of Microbiology, Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wei Du
- National Clinical Research Center for Laboratory Medicine, Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Hui Kang
- Laboratory of Microbiology, Department of Clinical Laboratory, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhongqing Wang
- Department of Information Centre, The First Hospital of China Medical University, Shenyang, Liaoning, China
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16
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Nucci M, Nouér SA. Practical issues related to non-Aspergillus invasive mold infections. Mol Aspects Med 2023; 94:101230. [PMID: 38011770 DOI: 10.1016/j.mam.2023.101230] [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] [Received: 01/04/2023] [Revised: 11/04/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
Infection by non-Aspergillus molds has been increasingly reported. The management of such infections is challenging both for diagnosis and treatment, including the need of well-trained mycologists to properly identify rare fungi, difficulties in distinguishing between contamination, colonization and infection, the lack of randomized studies comparing different drugs or regimens, poor activity of available antifungal agents, lack of correlation between in vitro antifungal susceptibility tests and clinical outcome, and poor prognosis. Mucormycosis and fusariosis are the most frequent non-Aspergillus mold infections. Mucormycosis occurs more frequently in four major groups of patients: solid organ transplant recipients, patients with hematologic malignancies receiving chemotherapy or hematopoietic cell transplantation, diabetic patients, and immunocompetent individuals who suffer various types of skin and soft tissue trauma. Invasive fusariosis occurs almost exclusively in patients with hematologic malignancies. In this review we discuss practical issues related to the management of these and other non-Aspergillus mold infections.
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Affiliation(s)
- Marcio Nucci
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Grupo Oncoclínicas, Rio de Janeiro, Brazil.
| | - Simone A Nouér
- Department of Infectious Diseases, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
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17
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Dailey Garnes NJM, Kontoyiannis DP. Mucormycosis: update on clinical presentation, diagnosis, and treatment. Curr Opin Infect Dis 2023; 36:427-435. [PMID: 37732771 DOI: 10.1097/qco.0000000000000976] [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: 09/22/2023]
Abstract
PURPOSE OF REVIEW Mucormycosis (MCR) is a common opportunistic mold infection, and Mucorales were recently designated by WHO as priority pathogens. The interest in this infection has risen significantly since the major outbreak of MCR in the context of the COVID-19 pandemic, particularly in India. Herein, we summarize recently (last 24 months) published information regarding clinical aspects of MCR. RECENT FINDINGS The disease remains protean in its clinical presentation, difficult to diagnose, and challenging to treat. In 2021, cases of COVID-19-associated mucormycosis (CAM) exploded in India during COVID-19 and manifested primarily as sino-orbital or sino-cerebral disease. Its classic risk factors included the triad of COVID-19, uncontrolled diabetes mellitus and use of corticosteroids. Despite difficulties in the timely diagnosis of MCR, significant progress has been made with the use of molecular techniques in blood to assist with earlier diagnosis, which can facilitate earlier appropriate therapy and improve outcomes. In addition, advances have been made in the use of imaging to stage the disease, determining what types of multimodal therapy are required depending on staging, and tissue-based identification of Mucorales. SUMMARY Although the outlook for MCR has improved, effective new antifungals, risk stratification, and the optimal multimodality approaches remain an unmet need.
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Affiliation(s)
- Natalie J M Dailey Garnes
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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18
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Klugherz I, Basch M, Ng N, Zhu Z, Wagener N, Wagener J. Only One of Three Bcs1 Homologs in Aspergillus fumigatus Confers Respiratory Growth. J Fungi (Basel) 2023; 9:1074. [PMID: 37998879 PMCID: PMC10672213 DOI: 10.3390/jof9111074] [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: 10/04/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/25/2023] Open
Abstract
The mitochondrial translocase Bcs1 is required for the correct assembly of complex III of the mitochondrial respiratory chain. Because of its importance, Bcs1 was recently proposed as a target for antifungal agents. The function of this AAA (ATPase Associated with diverse cellular Activities) protein has been extensively characterized in Saccharomyces cerevisiae. This yeast as well as previously studied mammals each encode only one homolog. In contrast, the pathogenic mold Aspergillus fumigatus encodes three putative Bcs1 homologs, none of which have been characterized to date. To study the role of these three homologs in A. fumigatus, conditional and deletion mutants of the respective genes AFUA_3G13000 (bcs1A), AFUA_4G01260 (bcs1B), and AFUA_2G14760 (bcs1C) were generated. A deletion or downregulation of bcs1A resulted in drastically reduced growth and sporulation rates and in a significantly altered susceptibility to azole antifungals. In contrast, mutants lacking Bcs1B or Bcs1C did not show any phenotypes differing from the wild type. Salicylhydroxamic acid-an inhibitor of the alternative oxidase that allows the respiratory chain to bypass complex III in some species-caused a complete growth arrest of the bcs1A deletion mutant. In a Galleria mellonella infection model, the deletion of bcs1A resulted in significantly decreased virulence. Only Bcs1A was able to partially complement a deletion of BCS1 in S. cerevisiae. The subcellular localization of Bcs1B and Bcs1C outside of mitochondria suggests that these Bcs1 homologs exert cellular functions different from that of Bcs1. Our data demonstrate that Bcs1A is the sole Bcs1 ortholog in A. fumigatus.
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Affiliation(s)
- Isabel Klugherz
- Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Medizinische Fakultät, Ludwig-Maximilians-Universität München, 80336 Munich, Germany; (I.K.)
- Diagnostic and Research Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, 8010 Graz, Austria
| | - Marion Basch
- Zell- und Entwicklungsbiologie, Department Biologie II, Ludwig-Maximilians-Universität München, Planegg-Martinsried, 82152 Munich, Germany
| | - Natanya Ng
- Department of Clinical Microbiology, School of Medicine, Trinity College Dublin, The University of Dublin, St James’s Hospital Campus, D08 RX0X Dublin, Ireland
| | - Zhaojun Zhu
- Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Medizinische Fakultät, Ludwig-Maximilians-Universität München, 80336 Munich, Germany; (I.K.)
| | - Nikola Wagener
- Zell- und Entwicklungsbiologie, Department Biologie II, Ludwig-Maximilians-Universität München, Planegg-Martinsried, 82152 Munich, Germany
| | - Johannes Wagener
- Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Medizinische Fakultät, Ludwig-Maximilians-Universität München, 80336 Munich, Germany; (I.K.)
- Department of Clinical Microbiology, School of Medicine, Trinity College Dublin, The University of Dublin, St James’s Hospital Campus, D08 RX0X Dublin, Ireland
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19
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Li W, Li Y, Cai J, Wang Y, Liu Y, Hu H, Liu L. Simultaneous Quantification of Seven Antifungal Agents in Human Serum Using Liquid Chromatography-Tandem Mass Spectrometry. Pharmaceuticals (Basel) 2023; 16:1537. [PMID: 38004403 PMCID: PMC10675106 DOI: 10.3390/ph16111537] [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: 08/22/2023] [Revised: 09/24/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
Systemic antifungal agents are essential for high-risk patients undergoing immunosuppressive therapy or cancer chemotherapy because of the rapid increase in opportunistic fungal infections. Therapeutic drug monitoring is crucial to ensuring the efficacy and safety of antifungal agents owing to their pharmacokinetic variability. In the present study, we developed and validated a quantitative method for the simultaneous detection of seven commonly used antifungal drugs (amphotericin B, isavuconazole, voriconazole, fluconazole, posaconazole, caspofungin, and micafungin) using liquid chromatography-tandem mass spectrometry. Methanol (containing 0.1% formic acid) was used for protein precipitation and only 50 μL of serum was required for the analysis. Chromatographic separation was conducted using a Waters Acquity UPLC C8 column, and one stable isotope-labeled agent and two analogs were used as internal standards. The calibration curves ranged from 0.1 to 50 μg/mL for all agents, and the correlation coefficient (R2) for all calibration curves was above 0.9835. The intra-day precision (1.2-11.2%), inter-day precision (2.4-13.2%), and mean bias values (-10.9 to 13.6%) were within an acceptable range of ±15%. Successful implementation of the developed method in clinical practice would facilitate the effective monitoring of these antifungal agents.
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Affiliation(s)
- Wenjing Li
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China; (W.L.); (Y.W.); (Y.L.); (H.H.)
| | - Yang Li
- Department of Blood Transfusion, Zhongnan Hospital of Wuhan University, Wuhan 430071, China;
| | - Junlong Cai
- Department of Clinical Trial Center, Zhongnan Hospital of Wuhan University, Wuhan 430071, China;
| | - Yue Wang
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China; (W.L.); (Y.W.); (Y.L.); (H.H.)
| | - Yanan Liu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China; (W.L.); (Y.W.); (Y.L.); (H.H.)
| | - Hankun Hu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China; (W.L.); (Y.W.); (Y.L.); (H.H.)
| | - Liang Liu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan 430071, China; (W.L.); (Y.W.); (Y.L.); (H.H.)
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20
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Ramadán S, Dalmaso H, Luque A, Sortino M, Cuestas ML, Alava KH, Bertola D, Bulacio L. Scedosporium boydii finding in an immunocompromised patient and review of the literature. Rev Iberoam Micol 2023; 40:39-44. [PMID: 38326154 DOI: 10.1016/j.riam.2023.10.001] [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] [Received: 06/22/2023] [Revised: 08/14/2023] [Accepted: 10/26/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Scedosporiasis is an emerging mycosis that has gained importance in recent years due to its worldwide prevalence. It is caused by species of the Scedosporium apiospermum complex. These species can cause opportunistic infections in immunocompromised patients and, occasionally, in immunocompetent patients as well. The high intrinsic antifungal resistance make these infections difficult to manage. AIMS The objective of this study was to interpret the mycological findings in a transplant patient, together with the images obtained in the radiological studies, in order to provide an early and effective antifungal therapy. METHODS The mycological analysis of samples taken from a heart transplant patient with radiological images suggesting a fungal infection was performed. Computed tomography scan of the head and thorax showed space-occupying lesions in both the frontal lobe and cerebellum, and multiple pulmonary nodules. The nodules were punctured and the samples obtained were analyzed according to the procedures for mycological analysis. The identity of the isolates was confirmed by nucleotide sequencing. Eventually, the antifungal susceptibility was studied. RESULTS The fungal isolates obtained, whose identity was confirmed by sequencing, belonged to the species Scedosporium boydii. Injured tissues were surgically removed and a treatment with amphotericin B and voriconazole-minimum inhibitory concentration (MIC) 0.5μg/mL and ≥0.5μg/mL respectively - was administered. CONCLUSIONS Although the patient died due to complications of a Klebsiella pneumoniae sepsis refractory to treatment, the progression of the fungal disease, although slow, was favourable in the early phases of the treatment due to a correct diagnosis and the antifungal susceptibility test carried out. Clinical cases of this nature highlight the need to increase the epidemiological study of these microorganisms, as well as the proper treatment of the diseases caused, in order to achieve early diagnoses that reduce the morbidity and mortality of patients.
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Affiliation(s)
- Silvana Ramadán
- CEREMIC (Centro de Referencia de Micología), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina.
| | - Hernán Dalmaso
- CEREMIC (Centro de Referencia de Micología), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Alicia Luque
- CEREMIC (Centro de Referencia de Micología), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Maximiliano Sortino
- CEREMIC (Centro de Referencia de Micología), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina; Área Farmacognosia, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - María Luján Cuestas
- Centro de Micología, Instituto de Investigaciones en Microbiología y Parasitología Médica, Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y Técnicas (IMPaM, UBA-CONICET), Buenos Aires, Argentina
| | - Katherine Hermida Alava
- Centro de Micología, Instituto de Investigaciones en Microbiología y Parasitología Médica, Universidad de Buenos Aires, Consejo Nacional de Investigaciones Científicas y Técnicas (IMPaM, UBA-CONICET), Buenos Aires, Argentina
| | - Diego Bertola
- Servicio de Clínica, Hospital Provincial del Centenario, Rosario, Argentina
| | - Lucía Bulacio
- CEREMIC (Centro de Referencia de Micología), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
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21
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Alqarihi A, Kontoyiannis DP, Ibrahim AS. Mucormycosis in 2023: an update on pathogenesis and management. Front Cell Infect Microbiol 2023; 13:1254919. [PMID: 37808914 PMCID: PMC10552646 DOI: 10.3389/fcimb.2023.1254919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Mucormycosis (MCR) is an emerging and frequently lethal fungal infection caused by the Mucorales family, with Rhizopus, Mucor, and Lichtheimia, accounting for > 90% of all cases. MCR is seen in patients with severe immunosuppression such as those with hematologic malignancy or transplantation, Diabetes Mellitus (DM) and diabetic ketoacidosis (DKA) and immunocompetent patients with severe wounds. The recent SARS COV2 epidemy in India has resulted in a tremendous increase in MCR cases, typically seen in the setting of uncontrolled DM and corticosteroid use. In addition to the diversity of affected hosts, MCR has pleiotropic clinical presentations, with rhino-orbital/rhino-cerebral, sino-pulmonary and necrotizing cutaneous forms being the predominant manifestations. Major insights in MCR pathogenesis have brought into focus the host receptors (GRP78) and signaling pathways (EGFR activation cascade) as well as the adhesins used by Mucorales for invasion. Furthermore, studies have expanded on the importance of iron availability and the complex regulation of iron homeostasis, as well as the pivotal role of mycotoxins as key factors for tissue invasion. The molecular toolbox to study Mucorales pathogenesis remains underdeveloped, but promise is brought by RNAi and CRISPR/Cas9 approaches. Important recent advancements have been made in early, culture-independent molecular diagnosis of MCR. However, development of new potent antifungals against Mucorales remains an unmet need. Therapy of MCR is multidisciplinary and requires a high index of suspicion for initiation of early Mucorales-active antifungals. Reversal of underlying immunosuppression, if feasible, rapid DKA correction and in selected patients, surgical debulking are crucial for improved outcomes.
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Affiliation(s)
- Abdullah Alqarihi
- Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, CA, United States
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, United States
| | - Ashraf S Ibrahim
- Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, CA, United States
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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22
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Lohse MB, Laurie MT, Levan S, Ziv N, Ennis CL, Nobile CJ, DeRisi J, Johnson AD. Broad susceptibility of Candida auris strains to 8-hydroxyquinolines and mechanisms of resistance. mBio 2023; 14:e0137623. [PMID: 37493629 PMCID: PMC10470496 DOI: 10.1128/mbio.01376-23] [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: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 07/27/2023] Open
Abstract
The fungal pathogen Candida auris represents a severe threat to hospitalized patients. Its resistance to multiple classes of antifungal drugs and ability to spread and resist decontamination in healthcare settings make it especially dangerous. We screened 1,990 clinically approved and late-stage investigational compounds for the potential to be repurposed as antifungal drugs targeting C. auris and narrowed our focus to five Food and Drug Administration (FDA)-approved compounds with inhibitory concentrations under 10 µM for C. auris and significantly lower toxicity to three human cell lines. These compounds, some of which had been previously identified in independent screens, include three dihalogenated 8-hydroxyquinolines: broxyquinoline, chloroxine, and clioquinol. A subsequent structure-activity study of 32 quinoline derivatives found that 8-hydroxyquinolines, especially those dihalogenated at the C5 and C7 positions, were the most effective inhibitors of C. auris. To pursue these compounds further, we exposed C. auris to clioquinol in an extended experimental evolution study and found that C. auris developed only twofold to fivefold resistance to the compound. DNA sequencing of resistant strains and subsequent verification by directed mutation in naive strains revealed that resistance was due to mutations in the transcriptional regulator CAP1 (causing upregulation of the drug transporter MDR1) and in the drug transporter CDR1. These mutations had only modest effects on resistance to traditional antifungal agents, and the CDR1 mutation rendered C. auris more susceptible to posaconazole. This observation raises the possibility that a combination treatment involving an 8-hydroxyquinoline and posaconazole might prevent C. auris from developing resistance to this established antifungal agent. IMPORTANCE The rapidly emerging fungal pathogen Candida auris represents a growing threat to hospitalized patients, in part due to frequent resistance to multiple classes of antifungal drugs. We identify a class of compounds, the dihalogenated 8-hydroxyquinolines, with broad fungistatic ability against a diverse collection of 13 strains of C. auris. Although this compound has been identified in previous screens, we extended the analysis by showing that C. auris developed only modest twofold to fivefold increases in resistance to this class of compounds despite long-term exposure; a noticeable difference from the 30- to 500-fold increases in resistance reported for similar studies with commonly used antifungal drugs. We also identify the mutations underlying the resistance. These results suggest that the dihalogenated 8-hydroxyquinolines are working inside the fungal cell and should be developed further to combat C. auris and other fungal pathogens. Lohse and colleagues characterize a class of compounds that inhibit the fungal pathogen C. auris. Unlike many other antifungal drugs, C. auris does not readily develop resistance to this class of compounds.
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Affiliation(s)
- Matthew B. Lohse
- Department of Microbiology and Immunology, University of California, San Francisco, California, USA
| | - Matthew T. Laurie
- Department of Biochemistry and Biophysics, University of California, San Francisco, California, USA
| | - Sophia Levan
- Department of Medicine, University of California, San Francisco, California, USA
| | - Naomi Ziv
- Department of Microbiology and Immunology, University of California, San Francisco, California, USA
| | - Craig L. Ennis
- Department of Molecular and Cell Biology, School of Natural Sciences, University of California, Merced, California, USA
- Quantitative and Systems Biology Graduate Program, University of California, Merced, California, USA
| | - Clarissa J. Nobile
- Department of Molecular and Cell Biology, School of Natural Sciences, University of California, Merced, California, USA
- Health Sciences Research Institute, University of California, Merced, California, USA
| | - Joseph DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, California, USA
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Alexander D. Johnson
- Department of Microbiology and Immunology, University of California, San Francisco, California, USA
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23
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Qiu H, Xiang H, Wen M, Chen S, Zhu J, Tong S. Enantioseparation of two antifungal azole drugs by analytical countercurrent chromatography using sulfobutyl ether-β-cyclodextrin as chiral selector. J Chromatogr A 2023; 1705:464185. [PMID: 37429079 DOI: 10.1016/j.chroma.2023.464185] [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] [Received: 05/10/2023] [Revised: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023]
Abstract
This study reports a successful enantioseparation of two antifungal drugs, Ketoconazole and Voriconazole, using countercurrent chromatography (CCC) with synthesized sulfobutyl ether-β-cyclodextrin (SBE-β-CD) as chiral selector. Two biphasic solvent systems composed of dichloromethane: 0.1 mol L-1 of phosphate buffer solution (pH 3.0) (1:1, v/v) and n-hexane: ethyl acetate: 0.1 mol L-1 phosphate buffer solution (pH 3.0) (1.5:0.5:2, v/v/v) were selected. Influence factors were investigated, including degree of substitution of SBE-β-CD, concentration of SBE-β-CD, equilibrium temperature, and pH of aqueous phase. Under optimized separation conditions, a large enantioseparation factor of α ≥ 3.26 and a high peak resolution Rs= 1.82, was achieved for enantioseparation of Voriconazole by countercurrent chromatography, and purity of two azole stereoisomers collected from CCC separation reached 98.5%, as determined by HPLC. Molecular docking was employed to investigate the formation of inclusion complex.
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Affiliation(s)
- Huiyun Qiu
- College of Pharmaceutical Science, Zhejiang University of Technology, Huzhou, 313200, China
| | - Haiping Xiang
- College of Pharmaceutical Science, Zhejiang University of Technology, Huzhou, 313200, China
| | - Mengyi Wen
- College of Pharmaceutical Science, Zhejiang University of Technology, Huzhou, 313200, China
| | - Songlin Chen
- College of Pharmaceutical Science, Zhejiang University of Technology, Huzhou, 313200, China
| | - Junchao Zhu
- College of Pharmaceutical Science, Zhejiang University of Technology, Huzhou, 313200, China
| | - Shengqiang Tong
- College of Pharmaceutical Science, Zhejiang University of Technology, Huzhou, 313200, China.
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24
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Lai Y, Jiang B, Hou F, Huang X, Ling B, Lu H, Zhong T, Huang J. The emerging role of extracellular vesicles in fungi: a double-edged sword. Front Microbiol 2023; 14:1216895. [PMID: 37533824 PMCID: PMC10390730 DOI: 10.3389/fmicb.2023.1216895] [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: 05/04/2023] [Accepted: 07/05/2023] [Indexed: 08/04/2023] Open
Abstract
Fungi are eukaryotic microorganisms found in nature, which can invade the human body and cause tissue damage, inflammatory reactions, organ dysfunctions, and diseases. These diseases can severely damage the patient's body systems and functions, leading to a range of clinical symptoms that can be life-threatening. As the incidence of invasive fungal infections has progressively increased in the recent years, a wealth of evidence has confirmed the "double-edged sword" role of fungal extracellular vesicles (EVs) in intercellular communication and pathogen-host interactions. Fungal EVs act as mediators of cellular communication, affecting fungal-host cell interactions, delivering virulence factors, and promoting infection. Fungal EVs can also have an induced protective effect, affecting fungal growth and stimulating adaptive immune responses. By integrating recent studies, we discuss the role of EVs in fungi, providing strong theoretical support for the early prevention and treatment of invasive fungal infections. Finally, we highlight the feasibility of using fungal EVs as drug carriers and in vaccine development.
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Affiliation(s)
- Yi Lai
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Bowei Jiang
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Fangpeng Hou
- The First School of Clinical Medicine, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Xinhong Huang
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Baodian Ling
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Hongfei Lu
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Tianyu Zhong
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Junyun Huang
- Laboratory Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
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25
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Oliva A, De Rosa FG, Mikulska M, Pea F, Sanguinetti M, Tascini C, Venditti M. Invasive Candida infection: epidemiology, clinical and therapeutic aspects of an evolving disease and the role of rezafungin. Expert Rev Anti Infect Ther 2023; 21:957-975. [PMID: 37494128 DOI: 10.1080/14787210.2023.2240956] [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] [Received: 07/03/2023] [Revised: 07/21/2023] [Accepted: 07/21/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Invasive Candida Infections (ICIs) have undergone a series of significant epidemiological, pathophysiological, and clinical changes during the last decades, with a shift toward non-albicans species, an increase in the rate of exogenous infections and clinical manifestations ranging from candidemia to an array of highly invasive and life-threatening clinical syndromes. The long-acting echinocandin rezafungin exhibits potent in-vitro activity against most wild-type and azole-resistant Candida spp. including C.auris. AREAS COVERED The following topics regarding candidemia only and ICIs were reviewed and addressed: i) pathogenesis; ii) epidemiology and temporal evolution of Candida species; iii) clinical approach; iv) potential role of the novel long-acting rezafungin in the treatment of ICIs. EXPERT OPINION Authors' expert opinion focused on considering the potential role of rezafungin in the evolving context of ICIs. Rezafungin, which combines a potent in-vitro activity against Candida species, including azole-resistant strains and C.auris, with a low likelihood of drug-drug interactions and a good safety profile, may revolutionize the treatment of candidemia/ICI. Indeed, it may shorten the length of hospital stays when clinical conditions allow and extend outpatient access to treatment of invasive candidiasis, especially when prolonged treatment duration is expected.
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Affiliation(s)
- Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, University of Turin, Infectious Diseases, City of Health and Sciences, Turin, Italy
| | - Malgorzata Mikulska
- Division of Infectious Diseases Department of Health Sciences (DISSAL), University of Genoa IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Maurizio Sanguinetti
- Department of Laboratory Sciences and Infectious Diseases, Fondazione Policlinico Universitario "A. Gemelli"; IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Carlo Tascini
- Infectious Diseases Clinic: Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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26
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Fallas-Mora A, Díaz-Madriz JP, Chaverri-Fernández JM, Zavaleta-Monestel E. Evaluation of Systemic Antifungal Use in a Latin American General Care Hospital: A Retrospective Study. PHARMACY 2023; 11:108. [PMID: 37489339 PMCID: PMC10366784 DOI: 10.3390/pharmacy11040108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/19/2023] [Accepted: 06/23/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Invasive fungal infections significantly contribute to mortality and morbidity rates. Despite the presence of all four major classes of antifungal medications, it is estimated that these infections result in the death of 1.5 million people each year, and death rates are increasing at an alarming rate. With increasing concerns about the emergence of antifungal resistance, there is a growing consideration in many countries to incorporate antifungal stewardship into existing antimicrobial stewardship programs. This approach aims to address issues hindering the appropriate use of antifungal drugs and to optimize their utilization. METHODS An analytical retrospective study of 48 hospitalized patients was conducted to assess factors related to the use of systemic antifungals and develop and implement an internal protocol to improve its use. RESULTS All patients with severe comorbidity had SOFA scores linked with a mortality risk of more than 10%. Based on 48 evaluations of antifungal orders, 62.5% were considered appropriate, 14.6% were considered debatable, and 22.9% were considered inappropriate. Infectious disease physicians made most of the prescriptions considered appropriate in this study. CONCLUSIONS Comorbidities and risk factors in patients receiving systemic antifungals can be associated with the development of more serious fungal infections; hence, the implementation of antifungal stewardship as a complement to antimicrobial stewardship programs can help facilitate decision-making when dealing with a suspected case of fungal infection.
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Affiliation(s)
- Abigail Fallas-Mora
- Pharmacy Department, Hospital Clinica Biblica, San Jose 1307-1000, Costa Rica
- Department of Pharmacology, Toxicology and Pharmacodependence, University of Costa Rica, San Jose 1260-1000, Costa Rica
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27
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Goggin KP, Londeree J, Freeman AF, Garro R, George RP. Successful Use of Fosmanogepix for Treatment of Rare Highly Resistant Cutaneous Fusariosis in a Pediatric Patient With STAT3 Hyper-Immunoglobulin E Syndrome and End-Stage Kidney Disease. Open Forum Infect Dis 2023; 10:ofad285. [PMID: 37305844 PMCID: PMC10249262 DOI: 10.1093/ofid/ofad285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/19/2023] [Indexed: 06/13/2023] Open
Abstract
We describe the successful use of the novel antifungal drug fosmanogepix to treat a chronic case of multidrug-resistant cutaneous Fusarium suttonianum infection in a pediatric patient with STAT3 hyper-IgE syndrome and end-stage kidney disease on peritoneal dialysis.
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Affiliation(s)
- Kathryn P Goggin
- Correspondence: Kathryn P. Goggin, MD, MSc, Infectious Diseases Division Emory Department of Pediatrics 2015 Uppergate Drive, Suite 534 Atlanta, GA 30322 ()
| | - Jackson Londeree
- Division of Nephrology, Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Rouba Garro
- Division of Nephrology, Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
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28
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Arrieta AC, Lee A, Tran MT. Invasive Mold Infections in Children: Navigating Troubled Waters with a Broken Compass. Infect Dis Ther 2023:10.1007/s40121-023-00819-9. [PMID: 37209297 DOI: 10.1007/s40121-023-00819-9] [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: 02/22/2023] [Accepted: 05/03/2023] [Indexed: 05/22/2023] Open
Abstract
Incidence of invasive mold infections in children, while rare, is increasing as the population of high-risk patients expands, including premature infants, pediatric patients undergoing treatment for hematological malignancies, or recipients of allogeneic hematologic stem cell transplants. The infectious agents, including Aspergillus spp., Mucorales, and other molds, are especially difficult to treat and have serious morbidity and high mortality. Clinicians must maintain a high index of suspicion for invasive mold infections in at-risk patients. Diagnosis of invasive mold infections is complicated by difficulties isolating pathogens on culture, but progress is being made in immunological and molecular diagnostic technologies. Treatment in children is challenging; no randomized controlled trials exist. There is a growing body of data on treatment, specifically on safer antifungal agents, including indications for treatment, spectrum of coverage, pharmacokinetics for different ages, and pharmacodynamic targets associated with therapeutic success. However, pediatricians must often extrapolate from adult data. In this review, we aim to harmonize the existing body of literature on invasive mold infections in children, covering epidemiology, clinical presentations, diagnostic methods, and principles of management.
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Affiliation(s)
- Antonio C Arrieta
- Department of Infectious Diseases, Children's Hospital of Orange County, Orange, CA, USA
- Department of Pediatrics, University of California, Irvine, School of Medicine, Irvine, CA, USA
| | - Adam Lee
- Department of Infectious Diseases, Children's Hospital of Orange County, Orange, CA, USA.
| | - M Tuan Tran
- Department of Pharmacy, Children's Hospital of Orange County, Orange, CA, USA
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29
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Lionakis MS. Exploiting antifungal immunity in the clinical context. Semin Immunol 2023; 67:101752. [PMID: 37001464 PMCID: PMC10192293 DOI: 10.1016/j.smim.2023.101752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Indexed: 03/31/2023]
Abstract
The continuous expansion of immunocompromised patient populations at-risk for developing life-threatening opportunistic fungal infections in recent decades has helped develop a deeper understanding of antifungal host defenses, which has provided the foundation for eventually devising immune-based targeted interventions in the clinic. This review outlines how genetic variation in certain immune pathway-related genes may contribute to the observed clinical variability in the risk of acquisition and/or severity of fungal infections and how immunogenetic-based patient stratification may enable the eventual development of personalized strategies for antifungal prophylaxis and/or vaccination. Moreover, this review synthesizes the emerging cytokine-based, cell-based, and other immunotherapeutic strategies that have shown promise as adjunctive therapies for boosting or modulating tissue-specific antifungal immune responses in the context of opportunistic fungal infections.
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Affiliation(s)
- Michail S Lionakis
- From the Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
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30
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Wurster S, Pantaleón García J, Albert ND, Jiang Y, Bhoda K, Kulkarni VV, Wang Y, Walsh TJ, Evans S, Kontoyiannis DP. Development of a Corticosteroid-Immunosuppressed Mouse Model to Study the Pathogenesis and Therapy of Influenza-Associated Pulmonary Aspergillosis. J Infect Dis 2023; 227:901-906. [PMID: 36611269 PMCID: PMC10319956 DOI: 10.1093/infdis/jiad001] [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: 09/09/2022] [Revised: 12/15/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
Influenza-associated pulmonary aspergillosis (IAPA) is a feared complication in patients with influenza tracheobronchitis, especially those receiving corticosteroids. Herein, we established a novel IAPA mouse model with low-inoculum Aspergillus infection and compared outcomes in mice with and without cortisone acetate (CA) immunosuppression. CA was an independent predictor of increased morbidity/mortality in mice with IAPA. Early antifungal treatment with liposomal amphotericin B was pivotal to improve IAPA outcomes in CA-immunosuppressed mice, even after prior antiviral therapy with oseltamivir. In summary, our model recapitulates key clinical features of IAPA and provides a robust preclinical platform to study the pathogenesis and treatment of IAPA.
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Affiliation(s)
- Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jezreel Pantaleón García
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Nathaniel D Albert
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Keerthi Bhoda
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Vikram V Kulkarni
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Yongxing Wang
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Thomas J Walsh
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
| | - Scott Evans
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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31
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Vuong NN, Hammond D, Kontoyiannis DP. Clinical Uses of Inhaled Antifungals for Invasive Pulmonary Fungal Disease: Promises and Challenges. J Fungi (Basel) 2023; 9:jof9040464. [PMID: 37108918 PMCID: PMC10146217 DOI: 10.3390/jof9040464] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/08/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023] Open
Abstract
The role of inhaled antifungals for prophylaxis and treatment of invasive fungal pneumonias remains undefined. Herein we summarize recent clinically relevant literature in high-risk groups such as neutropenic hematology patients, including those undergoing stem cell transplant, lung and other solid transplant recipients, and those with sequential mold lung infections secondary to viral pneumonias. Although there are several limitations of the available data, inhaled liposomal amphotericin B administered 12.5 mg twice weekly could be an alternative method of prophylaxis in neutropenic populations at high risk for invasive fungal pneumonia where systemic triazoles are not tolerated. In addition, inhaled amphotericin B has been commonly used as prophylaxis, pre-emptive, or targeted therapy for lung transplant recipients but is considered as a secondary alternative for other solid organ transplant recipients. Inhaled amphotericin B seems promising as prophylaxis in fungal pneumonias secondary to viral pneumonias, influenza, and SARS CoV-2. Data remain limited for inhaled amphotericin for adjunct treatment, but the utility is feasible.
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Affiliation(s)
- Nancy N Vuong
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Danielle Hammond
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Disease, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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32
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Liu N, Tu J, Huang Y, Yang W, Wang Q, Li Z, Sheng C. Target- and prodrug-based design for fungal diseases and cancer-associated fungal infections. Adv Drug Deliv Rev 2023; 197:114819. [PMID: 37024014 DOI: 10.1016/j.addr.2023.114819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Abstract
Invasive fungal infections (IFIs) are emerging as a serious threat to public health and are associated with high incidence and mortality. IFIs also represent a frequent complication in patients with cancer who are undergoing chemotherapy. However, effective and safe antifungal agents remain limited, and the development of severe drug resistance further undermines the efficacy of antifungal therapy. Therefore, there is an urgent need for novel antifungal agents to treat life-threatening fungal diseases, especially those with new mode of action, favorable pharmacokinetic profiles, and anti-resistance activity. In this review, we summarize new antifungal targets and target-based inhibitor design, with a focus on their antifungal activity, selectivity, and mechanism. We also illustrate the prodrug design strategy used to improve the physicochemical and pharmacokinetic profiles of antifungal agents. Dual-targeting antifungal agents offer a new strategy for the treatment of resistant infections and cancer-associated fungal infections.
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33
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Abstract
Infections are the leading cause of mortality in burn patients who survive their initial resuscitation. Burn injury leads to immunosuppression and a dysregulated inflammatory response which can have a prolonged impact. Early surgical excision along with support of the multidisciplinary burn team has improved mortality in burn patients. The authors review diagnostic and therapeutic challenges as well as strategies for management of burn related infections.
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34
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What Is New in Pulmonary Mucormycosis? J Fungi (Basel) 2023; 9:jof9030307. [PMID: 36983475 PMCID: PMC10057210 DOI: 10.3390/jof9030307] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 03/06/2023] Open
Abstract
Mucormycosis is a rare but life-threatening fungal infection due to molds of the order Mucorales. The incidence has been increasing over recent decades. Worldwide, pulmonary mucormycosis (PM) presents in the lungs, which are the third main location for the infection after the rhino-orbito-cerebral (ROC) areas and the skin. The main risk factors for PM include hematological malignancies and solid organ transplantation, whereas ROC infections are classically favored by diabetes mellitus. The differences between the ROC and pulmonary locations are possibly explained by the activation of different mammalian receptors—GRP78 in nasal epithelial cells and integrin β1 in alveolar epithelial cells—in response to Mucorales. Alveolar macrophages and neutrophils play a key role in the host defense against Mucorales. The diagnosis of PM relies on CT scans, cultures, PCR tests, and histology. The reversed halo sign is an early, but very suggestive, sign of PM in neutropenic patients. Recently, the serum PCR test showed a very encouraging performance for the diagnosis and follow-up of mucormycosis. Liposomal amphotericin B is the drug of choice for first-line therapy, together with correction of underlying disease and surgery when feasible. After a stable or partial response, the step-down treatment includes oral isavuconazole or posaconazole delayed release tablets until a complete response is achieved. Secondary prophylaxis should be discussed when there is any risk of relapse, such as the persistence of neutropenia or the prolonged use of high-dose immunosuppressive therapy. Despite these novelties, the mortality rate from PM remains higher than 50%. Therefore, future research must define the place for combination therapy and adjunctive treatments, while the development of new treatments is necessary.
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35
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Lamoth F. Novel Therapeutic Approaches to Invasive Candidiasis: Considerations for the Clinician. Infect Drug Resist 2023; 16:1087-1097. [PMID: 36855391 PMCID: PMC9968438 DOI: 10.2147/idr.s375625] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/01/2023] [Indexed: 02/24/2023] Open
Abstract
Invasive candidiasis (IC), due to the yeast pathogen Candida, is still a major cause of in-hospital morbidity and mortality. The limited number of antifungal drug classes and the emergence of multi-resistant Candida species, such as Candida auris and some Candida glabrata isolates, is concerning. However, recent advances in antifungal drug development provide promising perspectives for the therapeutic approach of IC. Notably, three novel antifungal agents, currently in Phase II/III clinical trials, are expected to have an important place for the treatment of IC in the future. Rezafungin is a novel echinocandin with prolonged half-life. Ibrexafungerp and fosmanogepix are two first-in-class antifungal drugs with broad spectrum activity against Candida spp., including C. auris and echinocandin-resistant species. These novel antifungal agents also represent interesting alternative options because of their acceptable oral bioavailability (ibrexafungerp and fosmanogepix) or their large interdose interval (once weekly intravenous administration for rezafungin) for prolonged and/or outpatient treatment of complicated IC. This review discusses the potential place of these novel antifungal drugs for the treatment of IC considering their pharmacologic properties and their preclinical and clinical data.
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Affiliation(s)
- Frederic Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Microbiology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Correspondence: Frederic Lamoth, Service of Infectious Diseases and Institute of Microbiology, CHUV | Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 48, Lausanne, 1011, Switzerland, Tel +41 21 314 10 10, Email
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Lohse MB, Laurie MT, Levan S, Ziv N, Ennis CL, Nobile CJ, DeRisi J, Johnson AD. Broad sensitivity of Candida auris strains to quinolones and mechanisms of resistance. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.16.528905. [PMID: 36824717 PMCID: PMC9949084 DOI: 10.1101/2023.02.16.528905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The fungal pathogen Candida auris represents a severe threat to hospitalized patients. Its resistance to multiple classes of antifungal drugs and ability to spread and resist decontamination in health-care settings make it especially dangerous. We screened 1,990 clinically approved and late-stage investigational compounds for the potential to be repurposed as antifungal drugs targeting C. auris and narrowed our focus to five FDA-approved compounds with inhibitory concentrations under 10 µM for C. auris and significantly lower toxicity to three human cell lines. These compounds, some of which had been previously identified in independent screens, include three dihalogenated 8-hydroxyquinolines: broxyquinoline, chloroxine, and clioquinol. A subsequent structure-activity study of 32 quinoline derivatives found that 8-hydroxyquinolines, especially those dihalogenated at the C5 and C7 positions, were the most effective inhibitors of C. auris . To pursue these compounds further, we exposed C. auris to clioquinol in an extended experimental evolution study and found that C. auris developed only 2- to 5-fold resistance to the compound. DNA sequencing of resistant strains and subsequent verification by directed mutation in naive strains revealed that resistance was due to mutations in the transcriptional regulator CAP1 (causing upregulation of the drug transporter MDR1 ) and in the drug transporter CDR1 . These mutations had only modest effects on resistance to traditional antifungal agents, and the CDR1 mutation rendered C. auris more sensitive to posaconazole. This observation raises the possibility that a combination treatment involving an 8-hydroxyquinoline and posaconazole might prevent C. auris from developing resistance to this established antifungal agent. Abstract Importance The rapidly emerging fungal pathogen Candida auris represents a growing threat to hospitalized patients, in part due to frequent resistance to multiple classes of antifungal drugs. We identify a class of compounds, the dihalogenated hydroxyquinolines, with broad fungistatic ability against a diverse collection of 13 strains of C. auris . Although this compound has been identified in previous screens, we extended the analysis by showing that C. auris developed only modest 2- to 5-fold increases in resistance to this class of compounds despite long-term exposure; a noticeable difference from the 30- to 500- fold increases in resistance reported for similar studies with commonly used antifungal drugs. We also identify the mutations underlying the resistance. These results suggest that the dihalogenated hydroxyquinolines are working inside the fungal cell and should be developed further to combat C. auris and other fungal pathogens. Tweet Lohse and colleagues characterize a class of compounds that inhibit the fungal pathogen C. auris . Unlike many other antifungal drugs, C. auris does not readily develop resistance to this class of compounds.
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Non- Aspergillus Hyaline Molds: A Host-Based Perspective of Emerging Pathogenic Fungi Causing Sinopulmonary Diseases. J Fungi (Basel) 2023; 9:jof9020212. [PMID: 36836326 PMCID: PMC9964096 DOI: 10.3390/jof9020212] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
The incidence of invasive sino-pulmonary diseases due to non-Aspergillus hyaline molds is increasing due to an enlarging and evolving population of immunosuppressed hosts as well as improvements in the capabilities of molecular-based diagnostics. Herein, we review the following opportunistic pathogens known to cause sinopulmonary disease, the most common manifestation of hyalohyphomycosis: Fusarium spp., Scedosporium spp., Lomentospora prolificans, Scopulariopsis spp., Trichoderma spp., Acremonium spp., Paecilomyces variotii, Purpureocillium lilacinum, Rasamsonia argillacea species complex, Arthrographis kalrae, and Penicillium species. To facilitate an understanding of the epidemiology and clinical features of sino-pulmonary hyalohyphomycoses in the context of host immune impairment, we utilized a host-based approach encompassing the following underlying conditions: neutropenia, hematologic malignancy, hematopoietic and solid organ transplantation, chronic granulomatous disease, acquired immunodeficiency syndrome, cystic fibrosis, and healthy individuals who sustain burns, trauma, or iatrogenic exposures. We further summarize the pre-clinical and clinical data informing antifungal management for each pathogen and consider the role of adjunctive surgery and/or immunomodulatory treatments to optimize patient outcome.
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Systemic Antifungal Therapy for Invasive Pulmonary Infections. J Fungi (Basel) 2023; 9:jof9020144. [PMID: 36836260 PMCID: PMC9966409 DOI: 10.3390/jof9020144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Antifungal therapy for pulmonary fungal diseases is in a state of flux. Amphotericin B, the time-honored standard of care for many years, has been replaced by agents demonstrating superior efficacy and safety, including extended-spectrum triazoles and liposomal amphotericin B. Voriconazole, which became the treatment of choice for most pulmonary mold diseases, has been compared with posaconazole and itraconazole, both of which have shown clinical efficacy similar to that of voriconazole, with fewer adverse events. With the worldwide expansion of azole-resistant Aspergillus fumigatus and infections with intrinsically resistant non-Aspergillus molds, the need for newer antifungals with novel mechanisms of action becomes ever more pressing.
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Maione A, Mileo A, Pugliese S, Siciliano A, Cirillo L, Carraturo F, de Alteriis E, De Falco M, Guida M, Galdiero E. VT-1161-A Tetrazole for Management of Mono- and Dual-Species Biofilms. Microorganisms 2023; 11:microorganisms11020237. [PMID: 36838202 PMCID: PMC9963680 DOI: 10.3390/microorganisms11020237] [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: 12/12/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
VT-1161 is a novel tetrazole antifungal agent with high specificity for fungal CYP51 (compared to human CYP enzymes) which has been proven to have fewer adverse effects and drug-drug interaction profiles due to fewer off-target inhibitors. In this study, we evaluated the anti-biofilm potential of VT-1161 against mono- and dual-species biofilms of Candida albicans, Klebsiella pneumoniae and Staphylococcus aureus. VT-1161 inhibited planktonic growth of all three strains, with an MIC value of 2 µg mL-1 for C. albicans and 0.5 µg mL-1 for K. pneumoniae and S. aureus, and killed 99.9% of the microbial populations, indicating a cytocidal action. Additionally, VT-1161 showed an excellent anti-biofilm action, since it inhibited mono-microbial biofilms by 80% at 0.5 µg mL-1, and dual-species biofilms of C. albicans/K. pneumoniae and C. albicans/S. aureus by 90% at the same concentration. Additionally, the eradication of mature biofilms after 24 h of VT-1161 exposure was excellent, reaching 90% at 2 μg mL-1 for both mono- and dual-species biofilms. In such mixed biofilms, the use of VT-1161 was revealed to be an alternative treatment because it was able to reduce the number of cells of each species during both inhibition and eradication. Since long-term therapy is necessary for most fungal biofilm infections due to their recurrence and obstinacy, VT-1161 showed low cytotoxicity against normal human cell lines and also against the invertebrate model Caenorhabditis elegans. Considering the excellent anti-biofilm potential and its GRAS (generally recognized as safe) status, VT-1161 may find use in the prevention or therapeutic treatment of mono- or poly-microbial biofilms.
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Affiliation(s)
- Angela Maione
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
| | - Aldo Mileo
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
| | - Stefano Pugliese
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
| | - Antonietta Siciliano
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
| | - Luigi Cirillo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, 80126 Naples, Italy
| | - Federica Carraturo
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
| | - Elisabetta de Alteriis
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
| | - Maria De Falco
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
- National Institute of Biostructures and Biosystems (INBB), 00136 Rome, Italy
- Center for Studies on Bioinspired Agro-Environmental Technology (BAT Center), 80055 Portici, Italy
| | - Marco Guida
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
- Center for Studies on Bioinspired Agro-Environmental Technology (BAT Center), 80055 Portici, Italy
| | - Emilia Galdiero
- Department of Biology, University of Naples “Federico II”, Via Cinthia, 80126 Naples, Italy
- Center for Studies on Bioinspired Agro-Environmental Technology (BAT Center), 80055 Portici, Italy
- Correspondence:
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Liu H, Zhang K, Jang YO, Qiao Z, Jin J, Thi Dao TN, Koo B, Park CO, Shin Y. Homobifunctional imidoester-modified zinc nano-spindle attenuated hyphae growth of Aspergillus against hypersensitivity responses. iScience 2023; 26:105922. [PMID: 36866037 PMCID: PMC9971823 DOI: 10.1016/j.isci.2022.105922] [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: 10/11/2022] [Revised: 12/05/2022] [Accepted: 12/30/2022] [Indexed: 01/13/2023] Open
Abstract
Fungi cause various forms of invasive fungal disease (IFD), and fungal sensitization can contribute to the development of asthma, asthma severity, and other hypersensitivity diseases, such as atopic dermatitis (AD). In this study, we introduce a facile and controllable approach, using homobifunctional imidoester-modified zinc nano-spindle (HINS), for attenuating hyphae growth of fungi and reducing the hypersensitivity response complications in fungi-infected mice. To extend the study of the specificity and immune mechanisms, we used HINS-cultured Aspergillus extract (HI-AsE) and common agar-cultured Aspergillus extract (Con-AsE) as the refined mouse models. HINS composites within the safe concentration range inhibited the hyphae growth of fungi but also reduce the number of fungal pathogens. Through the evaluation of lung and skin tissues from the mice, asthma pathogenesis (lung) and the hypersensitivity response (skin) to invasive aspergillosis were least severe in HI-AsE-infected mice. Therefore, HINS composites attenuate asthma and the hypersensitivity response to invasive aspergillosis.
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Affiliation(s)
- Huifang Liu
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul 03722, Republic of Korea
| | - KeLun Zhang
- Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ok Jang
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul 03722, Republic of Korea
| | - Zhen Qiao
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul 03722, Republic of Korea
| | - Jie Jin
- Department of Chemical and Biomolecular Engineering, Yonsei University, Seoul 03722, Republic of Korea
| | - Thuy Nguyen Thi Dao
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul 03722, Republic of Korea
| | - Bonhan Koo
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul 03722, Republic of Korea
| | - Chang Ook Park
- Department of Dermatology, Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea,Corresponding author
| | - Yong Shin
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul 03722, Republic of Korea,Corresponding author
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Lamoth F, Calandra T. Pulmonary aspergillosis: diagnosis and treatment. Eur Respir Rev 2022; 31:31/166/220114. [DOI: 10.1183/16000617.0114-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/18/2022] [Indexed: 12/05/2022] Open
Abstract
Aspergillusspecies are the most frequent cause of fungal infections of the lungs with a broad spectrum of clinical presentations including invasive pulmonary aspergillosis (IPA) and chronic pulmonary aspergillosis (CPA). IPA affects immunocompromised populations, which are increasing in number and diversity with the advent of novel anti-cancer therapies. Moreover, IPA has emerged as a complication of severe influenza and coronavirus disease 2019 in apparently immunocompetent hosts. CPA mainly affects patients with pre-existing lung lesions and is recognised increasingly frequently among patients with long-term survival following cure of tuberculosis or lung cancer. The diagnosis of pulmonary aspergillosis is complex as it relies on the presence of clinical, radiological and microbiological criteria, which differ according to the type of pulmonary aspergillosis (IPA or CPA) and the type of patient population. The management of pulmonary aspergillosis is complicated by the limited number of treatment options, drug interactions, adverse events and the emergence of antifungal resistance.
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Rybak JM, Cuomo CA, Rogers PD. The molecular and genetic basis of antifungal resistance in the emerging fungal pathogen Candida auris. Curr Opin Microbiol 2022; 70:102208. [PMID: 36242897 PMCID: PMC10364995 DOI: 10.1016/j.mib.2022.102208] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 01/25/2023]
Abstract
Fungal infections are responsible for significant morbidity and mortality. Resistance to the limited number of agents in the antifungal armamentarium among pathogenic fungi represents a growing public health threat. Particularly concerning is the emerging fungal pathogen Candida auris that frequently exhibits resistance to the triazole class of antifungals and amphotericin B, and for which isolates resistant to all of the major antifungal classes have been reported. In this brief review, we provide an overview of what is currently known about the molecular and genetic basis for antifungal resistance in this fungal pathogen.
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Affiliation(s)
- Jeffrey M Rybak
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Christina A Cuomo
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - P David Rogers
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Bourlond B, Cipriano A, Regamey J, Papadimitriou-Olivgeris M, Kamani C, Seidel D, Lamoth F, Muller O, Yerly P. Case report: Disseminated Scedosporium apiospermum infection with invasive right atrial mass in a heart transplant patient. Front Cardiovasc Med 2022; 9:1045353. [DOI: 10.3389/fcvm.2022.1045353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
Scedosporium apiospermum associated endocarditis is extremely rare. We report a case of a disseminated S. apiospermum infection with an invasive right atrial mass in a 52-year-old male, 11 months after heart transplantation, referred to our institution for an endogenous endophthalmitis with a one-month history of diffuse myalgias and fatigue. The patient had been supported two times with extracorporeal membrane oxygenation (ECMO) during the first three postoperative months. The echocardiography on admission revealed a mass in the right atrium attached to a thickened lateral wall. The whole-body [18F]FDG PET/CT revealed systemic dissemination in the lungs, muscles, and subcutaneous tissue. Blood cultures were positive on day three for filamentous fungi later identified as S. apiospermum. The disease was refractory to a 3-week dual antifungal therapy with voriconazole and anidulafungin in addition to reduced immunosuppression, and palliative care was implemented.
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Wurster S, Watowich SS, Kontoyiannis DP. Checkpoint inhibitors as immunotherapy for fungal infections: Promises, challenges, and unanswered questions. Front Immunol 2022; 13:1018202. [PMID: 36389687 PMCID: PMC9640966 DOI: 10.3389/fimmu.2022.1018202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/11/2022] [Indexed: 09/22/2023] Open
Abstract
Opportunistic fungal infections have high mortality in patients with severe immune dysfunction. Growing evidence suggests that the immune environment of invasive fungal infections and cancers share common features of immune cell exhaustion through activation of immune checkpoint pathways. This observation gave rise to several preclinical studies and clinical case reports describing blockade of the Programmed Cell Death Protein 1 and Cytotoxic T-Lymphocyte Antigen 4 immune checkpoint pathways as an adjunct immune enhancement strategy to treat opportunistic fungal infections. The first part of this review summarizes the emerging evidence for contributions of checkpoint pathways to the immunopathology of fungal sepsis, opportunistic mold infections, and dimorphic fungal infections. We then review the potential merits of immune checkpoint inhibitors (ICIs) as an antifungal immunotherapy, including the incomplete knowledge of the mechanisms involved in both immuno-protective effects and toxicities. In the second part of this review, we discuss the limitations of the current evidence and the many unknowns about ICIs as an antifungal immune enhancement strategy. Based on these gaps of knowledge and lessons learned from cancer immunology studies, we outline a research agenda to determine a "sweet spot" for ICIs in medical mycology. We specifically discuss the importance of more nuanced animal models, the need to study ICI-based combination therapy, potential ICI resistance, the role of the immune microenvironment, and the impact of ICIs given as part of oncological therapies on the natural immunity to various pathogenic fungi.
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Affiliation(s)
- Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Stephanie S. Watowich
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Colombo AL, De Almeida JN, Lewis RE, Kontoyiannis DP. Quandaries of deciding when to change first-line therapy in invasive pulmonary aspergillosis. J Antimicrob Chemother 2022; 77:2897-2900. [PMID: 36059133 DOI: 10.1093/jac/dkac301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We read the excellent viewpoint by Slavin et al. (J Antimicrob Chemother 2022; 77: 16-23) that draws upon the experience of an advisory board of notable experts to comprehensively address many of the clinical factors that drive the need for changes in antifungal therapy for invasive aspergillosis (IA). As noted by the authors, there remains a paucity of quality data to support many of the decisions faced by clinicians managing patients with IA. However, we would like to highlight several other important issues, not fully addressed in that viewpoint, that play an important role in deciding when to change antifungal therapy for IA.
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Affiliation(s)
- Arnaldo L Colombo
- Department of Medicine, Division of Infectious Diseases, Special Mycology Laboratory-LEMI, Federal University of São Paulo, São Paulo, Brazil
| | - João N De Almeida
- Department of Medicine, Division of Infectious Diseases, Special Mycology Laboratory-LEMI, Federal University of São Paulo, São Paulo, Brazil
| | - Russell E Lewis
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases Infection Control and Employee Health, MD Anderson Cancer Center, Houston, TX, USA
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Challenges in the Treatment of Invasive Aspergillosis in Immunocompromised Children. Antimicrob Agents Chemother 2022; 66:e0215621. [PMID: 35766509 PMCID: PMC9295552 DOI: 10.1128/aac.02156-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Invasive aspergillosis (IA) is associated with significant morbidity and mortality. Voriconazole remains the drug of choice for the treatment of IA in children; however, the complex kinetics of voriconazole in children make dosing challenging and therapeutic drug monitoring (TDM) essential for treatment success. The overarching goal of this review is to discuss the role of voriconazole, posaconazole, isavuconazole, liposomal amphotericin B, echinocandins, and combination antifungal therapy for the treatment of IA in children. We also provide a detailed discussion of antifungal TDM in children.
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Lamoth F. The unresolved issues in the management of mucormycosis. Eur J Intern Med 2022; 100:29-30. [PMID: 35351351 DOI: 10.1016/j.ejim.2022.03.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Frederic Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Institute of Microbiology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Garre V. Recent Advances and Future Directions in the Understanding of Mucormycosis. Front Cell Infect Microbiol 2022; 12:850581. [PMID: 35281441 PMCID: PMC8907824 DOI: 10.3389/fcimb.2022.850581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
Mucormycosis is an emerging infection caused by fungi of the order Mucorales that has recently gained public relevance due to the high incidence among COVID-19 patients in some countries. The reduced knowledge about Mucorales pathogenesis is due, in large part, to the historically low interest for these fungi fostered by their reluctance to be genetically manipulated. The recent introduction of more tractable genetic models together with an increasing number of available whole genome sequences and genomic analyses have improved our understanding of Mucorales biology and mucormycosis in the last ten years. This review summarizes the most significant advances in diagnosis, understanding of the innate and acquired resistance to antifungals, identification of new virulence factors and molecular mechanisms involved in the infection. The increased awareness about the disease and the recent successful genetic manipulation of previous intractable fungal models using CRISPR-Cas9 technology are expected to fuel the characterization of Mucorales pathogenesis, facilitating the development of effective treatments to fight this deadly infection.
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