Use of amphotericin B during pregnancy: case report and review

Intra-amniotic Candida albicans Infection Treated With Liposomal Amphotericin B With a Successful Neonatal Outcome

Intra-amniotic infection with Candida species is an uncommon but severe condition with high fetal morbimortality and no established clinical guidelines for its management. We report a Candida albicans intra-amniotic infection diagnosed in a 25-week pregnant woman, successfully treated with high-dose liposomal amphotericin B. Pregnancy was prolonged until 30 weeks, and despite persistently positive Candida cultures in amniotic fluid, a healthy newborn was delivered without evidence of systemic infection. Amphotericin concentration was determined at birth, revealing levels over 30 times higher in mother's and cord blood than in the amniotic fluid, probably explaining the clinical protection despite failure in obtaining fungal clearance.

Candida glabrata chorioamnionitis in a twin pregnancy following in vitro fertilisation: a rare cause of septic miscarriage

Candida glabrata chorioamnionitis is uncommon and associated with poor fetal outcomes. We present a case of C. glabrata chorioamnionitis of a dichorionic diamniotic pregnancy conceived by fresh embryo transfer. Despite antifungal therapy with amphotericin B, spontaneous miscarriage of both twins occurred. The mother otherwise recovered uneventfully. Our case highlights the high fetal mortality associated with C. glabrata chorioamnionitis and the challenges of antifungal treatment in pregnancy. We recommend a low threshold of suspicion for Candida infection in pregnancy, notably those involving transvaginal uterine instrumentation such as in vitro fertilisation.

Cryptococcosis in pregnancy and the postpartum period: Case series and systematic review with recommendations for management

Cryptococcal meningitis causes 15% of AIDS-related deaths. Optimal management and clinical outcomes of pregnant women with cryptococcosis are limited to case reports, as pregnant women are often excluded from research. Amongst pregnant women with asymptomatic cryptococcosis, no treatment guidelines exist. We prospectively identified HIV-infected women who were pregnant or recently pregnant with cryptococcosis, screened during a series of meningitis research studies in Uganda from 2012 to 2018. Among 571 women screened for cryptococcosis, 13 were pregnant, one was breastfeeding, three were within 14 days postpartum, and two had recently miscarried. Of these 19 women (3.3%), 12 had cryptococcal meningitis, six had cryptococcal antigenemia, and one had a history of cryptococcal meningitis and was receiving secondary prophylaxis. All women with meningitis received amphotericin B deoxycholate (0.7-1.0 mg/kg). Five were exposed to 200-800 mg fluconazole during pregnancy. Of these five, three delivered healthy babies with no gross physical abnormalities at birth, one succumbed to meningitis, and one outcome was unknown. Maternal meningitis survival rate at hospital discharge was 75% (9/12), and neonatal/fetal survival rate was 44% (4/9) for those mothers who survived. Miscarriages and stillbirths were common (n = 4). Of six women with cryptococcal antigenemia, two received fluconazole, one received weekly amphotericin B, and three had unknown treatment courses. All women with antigenemia survived, and none developed clinical meningitis. We report good maternal outcomes but poor fetal outcomes for cryptococcal meningitis using amphotericin B, without fluconazole in the first trimester, and weekly amphotericin B in place of fluconazole for cryptococcal antigenemia.

A Review of Antiviral and Antifungal Use and Safety during Pregnancy

Antiviral and antifungal use in pregnancy presents challenges because of the paucity of clinical and safety data for many agents in these classes. If untreated, viral and fungal infections can have deleterious effects on both maternal and fetal health. Understanding the use and risks of these medications in pregnancy is vital to provide appropriate care. This article reviews the current literature for the use of antiviral and antifungals, the pharmacokinetics of these agents, and their safety in pregnancy.

Candida glabrata sepsis associated with chorioamnionitis in an IVF twin pregnancy: Should we deliver?

We report a case of in vitro fertilization (IVF)-acquired Candida glabrata chorioamnionitis successfully treated through systemic maternal antifungal treatment prior to delivery. To the best of our knowledge, this is the first case of its kind in the literature. C. glabrata chorioamnionitis in pregnancy is rare, but the current literature suggests a very high fetal fatality in such cases. It is known to have an association with cervical stitch, amniocentesis, chorionic villous sampling, and assisted reproductive techniques such as IVF. Given the increasing global use of artificial reproductive techniques, it is important to raise awareness of this condition and highlight its potential complications. Early recognition of possible fetal infection could enable early initiation of systemic antifungal treatment. It would be prudent to consider early delivery once fetal maturity is achieved despite normal fetal monitoring.

Unmasking cryptococcal meningitis immune reconstitution inflammatory syndrome in pregnancy induced by HIV antiretroviral therapy with postpartum paradoxical exacerbation

Cryptococcosis is the most common cause of meningitis in Africa due to the high burden of HIV. Immune reconstitution inflammatory syndrome (IRIS) is a frequent and deadly complication of cryptococcal meningitis. We report a fatal case of cryptococcal-IRIS in a pregnant woman that began after starting antiretroviral therapy (unmasking IRIS) and markedly worsened postpartum after delivery (paradoxical IRIS).

Severe systemic candidiasis following immunomodulation therapy in in vitro fertilisation-embryo transfer (IVF-ET)

A 41-year-old nulliparous woman, with a medical history of unexplained infertility and multiple in vitro fertilisation (IVF) cycles with immunosuppressive therapy, was admitted to our tertiary obstetrics unit with sepsis at 18 weeks of pregnancy with dichorionic diamniotic twins. Candida glabrata was grown from her blood cultures, then subsequently from the liquor and placentae. She was treated with intravenous ambisome (amphotericin), but unfortunately, the infection resulted in the rupture of her membranes, preterm labour and the demise of her twins. She delivered both twins at 23 weeks, 3 days apart. The antifungal agent was changed to high-dose fluconazole after delivery for 2 weeks and she is now well. Women undergoing IVF-embryo transfer with immunomodulation therapy have a potential risk of developing candidal chorioamnionitis and sepsis.

Candida glabrata sepsis associated with chorioamnionitis in an in vitro fertilization pregnancy: case report and review

We report a case of Candida glabrata sepsis associated with chorioamnionitis in an in vitro fertilization-assisted pregnancy. There is a strong association between C. glabrata chorioamnionitis and assisted fertility techniques. Candida glabrata chorioamnionitis presents unique management challenges.

Cryptococcal Meningitis in an HIV-Positive Pregnant Woman

Cryptococcal meningitis is uncommon in pregnant HIV-infected women. The clinical care of an HIV-1 positive pregnant woman with cryptococcal meningitis whose pathology has been previously reported is reviewed to highlight the treatment of the disease and some of the challenges associated with antifungal therapy during pregnancy, including the teratogenicity of antifungal agents, their variable pharmacokinetics in pregnancy, the lack of well-defined treatment duration for such infections, and host factors including compliance. This patient's disease relapsed due to nonadherence after an initial course of intravenous amphotericin. Subsequently, she was successfully treated, with a favorable fetal outcome, with another 2 weeks of amphotericin B, followed by consolidation and maintenance with fluconazole and antiretroviral treatment. This case highlights and reviews the complexities of the management of cryptococcal meningitis in HIV-infected pregnant women.

Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america

Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. These guidelines for its management have been built on the previous Infectious Diseases Society of America guidelines from 2000 and include new sections. There is a discussion of the management of cryptococcal meningoencephalitis in 3 risk groups: (1) human immunodeficiency virus (HIV)-infected individuals, (2) organ transplant recipients, and (3) non-HIV-infected and nontransplant hosts. There are specific recommendations for other unique risk populations, such as children, pregnant women, persons in resource-limited environments, and those with Cryptococcus gattii infection. Recommendations for management also include other sites of infection, including strategies for pulmonary cryptococcosis. Emphasis has been placed on potential complications in management of cryptococcal infection, including increased intracranial pressure, immune reconstitution inflammatory syndrome (IRIS), drug resistance, and cryptococcomas. Three key management principles have been articulated: (1) induction therapy for meningoencephalitis using fungicidal regimens, such as a polyene and flucytosine, followed by suppressive regimens using fluconazole; (2) importance of early recognition and treatment of increased intracranial pressure and/or IRIS; and (3) the use of lipid formulations of amphotericin B regimens in patients with renal impairment. Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies. However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients.

Treating common problems of the nose and throat in pregnancy: what is safe?

Although all kinds of medications should be avoided during pregnancy, the majority of pregnant women receive at least one drug and 6% of them during the high-risk period of the first trimester. The aim of the present paper is to discuss the appropriate management of rhinologic and laryngeal conditions that may be encountered during pregnancy. A literature review from Medline and database sources was carried out. Related books and written guidelines were also included. Controlled clinical trials, prospective and retrospective studies, case-control studies, laboratory studies, clinical and systematic reviews, metanalyses, and case reports were analysed. The following drugs are considered relatively safe: beta-lactam antibiotics (with dose adjustment), macrolides (although the use of erythromycin and clarithromycin carries a certain risk), clindamycin, metronidazole (better avoided in the first trimester), amphotericin-B (especially in immunocompromised situations during the second and third trimester) and acyclovir. First-line antituberculous agents isoniazid, ethambutol, pyrazinamide, and ciprofloxacine in drug-resistant tuberculosis can be also used. Non-selective NSAIDs (until the 32nd week), nasal decongestants (with caution and up to 7 days), intranasal corticosteroids, with budesonide as the treatment of choice, second generation antihistamines (cetirizine in the third trimester, or loratadine in the second and third trimester), H2 receptor antagonists (except nizatidine) and proton pump inhibitors (except omeprazole) can be used to relieve patients from the related symptoms. In cases of emergencies, epinephrine, prednisone, prednisolone, methylprednisolone, dimetindene and nebulised b(2) agonists can be used with extreme caution. By contrast, selective COX-2 inhibitors and BCG vaccination are contraindicated in pregnancy. When prescribing to a pregnant woman, the safety of the materno-foetal unit is considered paramount. Although medications are potentially hazardous, misconceptions and suboptimal treatment of the mother might be more harmful to the unborn child. Knowledge update is necessary to avoid unjustified hesitations and provide appropriate counselling and treatment for pregnant women.

Antifungal pharmacotherapy for neonatal candidiasis

Candida is a leading cause of late onset infection (> 3 days of age) in the premature infant. Therefore, decisions about the diagnosis and management of infections caused by Candida are commonplace in the neonatal intensive care unit. Despite this fact, there are few comparative trials about treatment of neonatal Candida infections to guide the practitioner. New antifungals have been developed in the past decade and some clinical experience has been reported that can be used to guide the treatment of infants with serious Candida infections. This article reviews recent pertinent data with regard to dosing guidelines, efficacy, and toxicities of available systemic antifungal agents in the newborn.

Antifungal drugs in pregnancy: a review

The use of any medication in pregnant women requires careful consideration of benefit to the mother versus risk posed to the fetus. Fungal infections are not uncommon in pregnant women; in fact, the incidence of certain infections such as Candida vaginitis is increased in this patient population. A variety of antimycotic agents are currently available to treat systemic or mucocutaneous fungal infections. Many of these agents are capable of penetrating the placental barrier and entering fetal cord blood, therefore adverse effects of these agents on the fetus are a valid concern. The use of topical azoles for the treatment of superficial fungal infections is safe and efficacious. However, there are some data suggesting a dose-related increase in the risk of teratogenicity associated with the use of systemic azoles. Amphotericin B remains the drug of choice for the treatment of systemic fungal infections in pregnancy. There are serious risks of fetal malformations associated with the use of griseofulvin, ketoconazole, voriconazole, flucytosine and potassium iodide. These drugs are contraindicated in pregnancy. There are insufficient data regarding the use of caspofungin in pregnancy. This article will review available data regarding the safety of antifungal drug use in pregnant women.

Use of antifungal drugs in pregnancy: a focus on safety

The use of antifungals in pregnancy requires special consideration for the safety of the developing fetus. Clinicians now have an increased repertoire of both topical and systemic antimycotics available to treat superficial or mucotaneous fungal infections including Candida vaginitis. The ability of many nontopical antifungals to penetrate the placenta and achieve measurable, often therapeutic, concentrations in cord blood, fetal tissue and amniotic fluid means that evidence exists of successful treatment of all varieties of systemic fungal disease in pregnant women, even with placental involvement. However, for the same reasons, safety considerations remain a concern. Although the use of azoles as topical agents for superficial infections is both efficacious and well tolerated, especially when used for short periods, systemic azole therapy is not recommended in pregnancy. Accordingly, amphotericin B remains the drug of choice for systemic, invasive mycotic infections, whether life-threatening or less severe. Unfortunately little if any information is available regarding the safety of the newer lipid formulations of amphotericin B. There is a general reluctance to perform randomised, comparative studies involving antifungal agents in pregnancy, hence cumulative anecdotal reports form much of the available data; animal studies, although useful, have several drawbacks. There is a need for additional safe and effective new antifungal agents for widespread use in pregnant women.

Intra amniotic candidiasis. Case report and meta-analysis of 54 cases

We present a case of mid pregnancy loss with retained intrauterine contraceptive device associated with fetal Candida infection. Review of English literature identified 53 additional cases of fetal candidal infection, with 17 associated with an IUCD in situ. The presence of an IUCD was associated with delivery at a statistically significant earlier gestational age when compared to cases not associated with an IUCD (23.3 +/- 4.9 vs 31.6 +/- 7.0, p < 0.001). Seventy-seven percent of fetal candidal infections associated with an IUCD were systemic (heart, brain, liver, gastrointestinal, lung) compared to 33% of cases not associated with an IUCD. In contrast to bacterial intraamniotic infections there was a low incidence of maternal febrile morbidity. An hypothesis as to the pathogenesis of Candidal infections in the presence and absence of an IUCD is offered as well as a paradigm for the management of the gravid patient with an IUCD in situ.

Antifungal agents. Part I. Amphotericin B preparations and flucytosine

Traditionally, amphotericin B has been the cornerstone of antifungal treatment. Toxicity, however, is a major dose-limiting factor of amphotericin B deoxycholate. Nevertheless, it continues to have a major role in the treatment of deep-seated mycotic infections. Recently, less nephrotic lipid formulations, including amphotericin B lipid complex, amphotericin B cholesteryl sulfate, and liposomal amphotericin B, have been introduced. The pharmacologic properties, main indications, recommended dosages, related costs, and adverse effects of these various preparations are summarized in this review. Orally administered flucytosine is useful in certain infections, particularly cryptococcal meningitis, but it should be used with caution in patients with renal insufficiency.

Cryptococcal pneumonia complicating pregnancy

In the present report we describe 4 previously healthy women who developed cryptococcal pneumonia during pregnancy, and 1 pregnant woman with cryptococcal meningitis. These cases illustrate a previously uncharacterized spectrum of cryptococcal disease. We also discuss 24 patients previously reported who had cryptococcal meningitis during pregnancy. Finally, we review the available data for each therapeutic option and present an algorithm for management based on appraisals of disease severity and risk to the unborn fetus. This report emphasizes the need for heightened awareness of cryptococcosis in the differential diagnosis of pneumonia, chest pain, and hypoxemia in the pregnant patient, but at present, there are insufficient epidemiologic data to determine whether incidences of pulmonary or disseminated cryptococcosis actually increase during pregnancy. The risk of congenital cryptococcosis to the unborn fetus is low, and the most likely mechanism whereby neonates acquire invasive fungal pulmonary infection is through aspiration. While it is unclear whether there is any real increased risk of spontaneous abortion or premature labor, the data indicate that overall fetal outcome depends on effective treatment of maternal infection. For patients with dense air-space consolidation, progressive pulmonary disease, or dissemination, antifungal therapy is necessary. Optimal treatment is determined by the acuity and severity of the clinical presentation. Amphotericin B (approximately 1 g) with or without flucytosine represents the choice for initial treatment of the more acutely ill patient with disseminated or progressive pulmonary cryptococcosis who requires hospitalization (whether during or after pregnancy). Oral fluconazole appears to be safe and effective alternative therapy after delivery for the less severely ill patient who can be managed on an outpatient basis. While the use of fluconazole during pregnancy generally appears safe in terms of fetal outcome (49, 58), the class C status and single report of fetal malformation (62) preclude confident recommendation for its use during pregnancy. The risks and benefits of this effective and generally less toxic drug should be discussed with the parents and weighed against the use of amphotericin B. For pregnant women with limited pulmonary cryptococcosis (segmental or nodular infiltrates) and no evidence of dissemination, we recommend close follow-up without antifungal therapy similar to the recommendation for normal hosts with minimal disease. However, it is important to note that there is no extensive experience upon which to base this recommendation for pregnant individuals (45, 55, 103, 108). It is prudent to use frequent physical examinations (for example, every 1-2 months), combined with chest roentgenograms and serum cryptococcal antigens to monitor progression and/or development of disease in both the mother and child for approximately 6 months postpartum. In conclusion, cryptococcosis during pregnancy presents a special challenge to the clinician. A balanced therapeutic approach holds great promise for successful maternal and fetal outcomes.

Fluconazole in Candida albicans sepsis during pregnancy: case report and review of the literature

Candida sepsis during pregnancy is a rare but life-threatening complication of infection with Candida albicans. In contrast to the situation with other antimicrobial agents, there exists only limited experience with systemic antifungal therapy during pregnancy. A recent report focuses on amphotericin B treatment in systemic fungal infection during pregnancy. The present report discusses a pregnant patient with Candida albicans sepsis and endophthalmitis as well as candida infection of the oral and genital mucous membranes, after hyperalimentation and broad spectrum antibiotic therapy via a central venous catheter. The patient was treated with 10 mg/kg fluconazole from week 16 of gestation for a total duration of 50 days. Adverse effects did not occur and the rest of the pregnancy proceeded favourably for both the mother and the baby.