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Munzen ME, Goncalves Garcia AD, Martinez LR. An update on the global treatment of invasive fungal infections. Future Microbiol 2023; 18:1095-1117. [PMID: 37750748 DOI: 10.2217/fmb-2022-0269] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023] Open
Abstract
Fungal infections are a serious problem affecting many people worldwide, creating critical economic and medical consequences. Fungi are ubiquitous and can cause invasive diseases in individuals mostly living in developing countries or with weakened immune systems, and antifungal drugs currently available have important limitations in tolerability and efficacy. In an effort to counteract the high morbidity and mortality rates associated with invasive fungal infections, various approaches are being utilized to discover and develop new antifungal agents. This review discusses the challenges posed by fungal infections, outlines different methods for developing antifungal drugs and reports on the status of drugs currently in clinical trials, which offer hope for combating this serious global problem.
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Affiliation(s)
- Melissa E Munzen
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL 32610, USA
| | | | - Luis R Martinez
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
- Center for Immunology and Transplantation, University of Florida, Gainesville, FL 32610, USA
- Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL 32610, USA
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2
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Ruhnke M, Cornely OA, Schmidt-Hieber M, Alakel N, Boell B, Buchheidt D, Christopeit M, Hasenkamp J, Heinz WJ, Hentrich M, Karthaus M, Koldehoff M, Maschmeyer G, Panse J, Penack O, Schleicher J, Teschner D, Ullmann AJ, Vehreschild M, von Lilienfeld-Toal M, Weissinger F, Schwartz S. Treatment of invasive fungal diseases in cancer patients-Revised 2019 Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Mycoses 2020; 63:653-682. [PMID: 32236989 DOI: 10.1111/myc.13082] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/05/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Invasive fungal diseases remain a major cause of morbidity and mortality in cancer patients undergoing intensive cytotoxic therapy. The choice of the most appropriate antifungal treatment (AFT) depends on the fungal species suspected or identified, the patient's risk factors (eg length and depth of granulocytopenia) and the expected side effects. OBJECTIVES Since the last edition of recommendations for 'Treatment of invasive fungal infections in cancer patients' of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) in 2013, treatment strategies were gradually moving away from solely empirical therapy of presumed or possible invasive fungal diseases (IFDs) towards pre-emptive therapy of probable IFD. METHODS The guideline was prepared by German clinical experts for infections in cancer patients in a stepwise consensus process. MEDLINE was systematically searched for English-language publications from January 1975 up to September 2019 using the key terms such as 'invasive fungal infection' and/or 'invasive fungal disease' and at least one of the following: antifungal agents, cancer, haematological malignancy, antifungal therapy, neutropenia, granulocytopenia, mycoses, aspergillosis, candidosis and mucormycosis. RESULTS AFT of IFDs in cancer patients may include not only antifungal agents but also non-pharmacologic treatment. In addition, the armamentarium of antifungals for treatment of IFDs has been broadened (eg licensing of isavuconazole). Additional antifungals are currently under investigation or in clinical trials. CONCLUSIONS Here, updated recommendations for the treatment of proven or probable IFDs are given. All recommendations including the levels of evidence are summarised in tables to give the reader rapid access to key information.
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Affiliation(s)
- Markus Ruhnke
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | | | - Nael Alakel
- Department I of Internal Medicine, Haematology and Oncology, University Hospital Dresden, Dresden, Germany
| | - Boris Boell
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Maximilian Christopeit
- Department of Stem Cell Transplantation & Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Justin Hasenkamp
- Clinic for Haematology and Medical Oncology with Department for Stem Cell Transplantation, University Medicine Göttingen, Göttingen, Germany
| | - Werner J Heinz
- Schwerpunkt Infektiologie, Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marcus Hentrich
- Hämatologie und Internistische Onkologie, Innere Medizin III, Rotkreuzklinikum München, München, Germany
| | - Meinolf Karthaus
- Department of Haematology & Oncology, Municipal Hospital Neuperlach, München, Germany
| | - Michael Koldehoff
- Klinik für Knochenmarktransplantation, Westdeutsches Tumorzentrum Essen, Universitätsklinikum Essen (AöR), Essen, Germany
| | - Georg Maschmeyer
- Department of Hematology, Onclogy and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Jens Panse
- Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Universitätsklinikum Aachen, Aachen, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Jan Schleicher
- Klinik für Hämatologie Onkologie und Palliativmedizin, Katharinenhospital, Stuttgart, Germany
| | - Daniel Teschner
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Andrew John Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Maria Vehreschild
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, Cologne, Germany.,ECMM Excellence Centre of Medical Mycology, Cologne, Germany.,Zentrum für Innere Medizin, Infektiologie, Goethe Universität Frankfurt, Frankfurt am Main, Deutschland.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Bonn-Köln, Deutschland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Weissinger
- Division of Haematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany
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3
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In vitro evaluation of antifungal combination against Cryptococcus neoformans. Diagn Microbiol Infect Dis 2019; 94:155-156. [DOI: 10.1016/j.diagmicrobio.2018.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/26/2018] [Accepted: 12/02/2018] [Indexed: 01/22/2023]
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4
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Al Jishi Y, Rotstein C, Kumar D, Humar A, Singer LG, Keshavjee S, Husain S. Echinocandin use in lung transplant recipients. Clin Transplant 2018; 32:e13437. [PMID: 30375050 DOI: 10.1111/ctr.13437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/12/2018] [Accepted: 10/22/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Invasive fungal infections (IFI) are associated with significant morbidity and mortality in lung transplant recipients (LTRs). However, data outlining use of echinocandins in prophylaxis and therapy of LTRs are limited. METHOD A single-center retrospective cohort study on all LTRs from January-2010 to December-2016. Participants were screened for antifungal use to assess rate, tolerability, and clinical outcome of echinocandin use in LTRs, during the first 6 weeks of posttransplant. RESULTS A total of 777 lung transplants were reviewed in 763 LTRs. Antifungals were administered to 268 (35%) of LTRs. Reasons included preemptive antifungal therapy (55% [149/268]), targeted antifungal prophylaxis (34% [92/268]), and definitive IFI therapy (10% [27/268]). Azoles were first-line agents in 80% (215/268) of LTRs, caspofungin in 11% (30/268), micafungin in 6.7% (18/268), amphotericin B in 1.5% (4/268), and anidulafungin in 0.4% (1/268]). LTRs were started on echinocandins due to abnormal liver enzymes in 91% (46/49). Overall, 23% (50/215) of LTR's were switched off azoles. Of these, 54% (27/50) were switched to echinocandins. Switch from azoles to echinocandin was undertaken due to abnormal liver enzymes in 63% (17/27). No patients receiving first-line echinocandins were switched to other therapies due to adverse events. CONCLUSIONS Our data suggest that echinocandins are utilized in approximately 18.3% of lung transplant recipients. They are the preferred second-line agents due to a lower adverse-effect profile compared to the azoles.
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Affiliation(s)
- Yamama Al Jishi
- Department of Medicine, Division of Infectious Diseases and Toronto Lung Transplant Program, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Coleman Rotstein
- Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Deepali Kumar
- Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Atul Humar
- Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada.,Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute and Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada.,Multi-Organ Transplant Program, University of Toronto, University Health Network, Toronto, Ontario, Canada
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5
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Rothenbühler C, Held U, Manz MG, Schanz U, Gerber B. Continuously infused amphotericin B deoxycholate for primary treatment of invasive fungal disease in acute myeloid leukaemia. Hematol Oncol 2018; 36:471-480. [PMID: 29431860 DOI: 10.1002/hon.2500] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 11/06/2022]
Abstract
Continuous administration of amphotericin B deoxycholate over 24 hours (24 h-D-AmB) is better tolerated than rapid infusions. However, toxicity and outcome have not been assessed in a homogenous patient population with acute myeloid leukaemia (AML). We retrospectively analysed renal function and outcome in all adult patients with AML undergoing intensive chemotherapy between 2007 and 2012 at our institution. We compared a patient group with exposure to 24 h-D-AmB to a patient group without exposure to 24 h-D-AmB. One hundred and eighty-one consecutive patients were analysed, 133 (73.5%) received at least 1 dose of 24 h-D-AmB, and 48 (26.5%) did not. Reasons for 24 h-D-AmB initiation were invasive fungal disease (IFD) in 63.5% and empirical treatment for febrile neutropenia in 36.5% of the cases. Most patients with IFD received an oral triazole drug at hospital discharge. Baseline characteristics were well matched. Amphotericin B deoxycholate over 24 hours was given for a median 7 days (interquartile range 3-13). Peak creatinine concentration was higher in the 24 h-D-AmB-group (104.5 vs. 76 μmol/L, P < .001) but normalized within 1 month after therapy (65.5 vs. 65 μmol/L, P = .979). In neither of the 2 groups, end-stage renal disease occurred. There was no difference in 60-day survival (90% vs. 90%) and 2-year survival (58% vs. 58%). Invasive fungal disease partial response or better was observed in 68% of the patients. We conclude that antifungal therapy with continuously infused amphotericin B deoxycholate is safe in patients with AML. An antiinfective strategy based on 24 h-D-AmB in first line followed by an oral triazole compound represents an economically attractive treatment option.
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Affiliation(s)
| | - Ulrike Held
- Department of Internal Medicine, Horten Center for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Markus G Manz
- Division of Hematology, University Hospital Zurich, Switzerland
| | - Urs Schanz
- Division of Hematology, University Hospital Zurich, Switzerland
| | - Bernhard Gerber
- Division of Hematology, University Hospital Zurich, Switzerland.,Division of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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6
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Caspofungin Treatment for Pulmonary Invasive Fungal Disease in Hematology Patients: A Retrospective Study in a Clinical Practice Setting in China. Clin Ther 2017; 39:1758-1768. [PMID: 28756883 DOI: 10.1016/j.clinthera.2017.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/30/2017] [Accepted: 07/10/2017] [Indexed: 11/20/2022]
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Nishimoto M, Koh H, Tokuwame A, Makuuchi Y, Kuno M, Takakuwa T, Okamura H, Koh S, Yoshimura T, Nanno S, Nakamae M, Hirose A, Nakashima Y, Nakane T, Hino M, Nakamae H. Drug interactions and safety profiles with concomitant use of caspofungin and calcineurin inhibitors in allogeneic haematopoietic cell transplantation. Br J Clin Pharmacol 2017; 83:2000-2007. [PMID: 28407449 DOI: 10.1111/bcp.13303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 03/09/2017] [Accepted: 04/04/2017] [Indexed: 12/01/2022] Open
Abstract
AIM Small-scale clinical studies have reported on drug interactions between caspofungin (CPFG) and calcineurin inhibitors in healthy subjects; however, little is known about these interactions in allogeneic haematopoietic cell transplantation (allo-HCT) patients. METHODS We retrospectively assessed the drug interactions and safety profiles in allo-HCT recipients treated concomitantly with CPFG and calcineurin inhibitors. RESULTS Ninety-one consecutive cases were evaluated. There were no statistically significant differences in the plasma concentration/dose (C/D) ratios of tacrolimus (TAC) in 34 patients before and after co-administration with CPFG (median: 575.6-672.4, P = 0.200). In contrast, the median C/D ratio of cyclosporin A (CsA) in 16 patients was significantly elevated after co-administration with CPFG (median: 62.8-74.9, P = 0.016). There were no serious adverse effects on liver or renal function associated with the therapy. CONCLUSIONS Our data show that CPFG did not affect the pharmacokinetics of TAC and that it could mildly increase CsA blood concentrations in allo-HCT patients.
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Affiliation(s)
- Mitsutaka Nishimoto
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Atsushi Tokuwame
- Department of Pharmacy, Osaka City University Hospital, Osaka, Japan
| | - Yosuke Makuuchi
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masatomo Kuno
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Teruhito Takakuwa
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hiroshi Okamura
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Shiro Koh
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Takuro Yoshimura
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Satoru Nanno
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Mika Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Asao Hirose
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yasuhiro Nakashima
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Takahiko Nakane
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
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8
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Neoh CF, Snell G, Levvey B, Morrissey CO, Stewart K, Kong DC. Antifungal prophylaxis in lung transplantation. Int J Antimicrob Agents 2014; 44:194-202. [DOI: 10.1016/j.ijantimicag.2014.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 05/12/2014] [Indexed: 10/25/2022]
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9
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Mousset S, Buchheidt D, Heinz W, Ruhnke M, Cornely OA, Egerer G, Krüger W, Link H, Neumann S, Ostermann H, Panse J, Penack O, Rieger C, Schmidt-Hieber M, Silling G, Südhoff T, Ullmann AJ, Wolf HH, Maschmeyer G, Böhme A. Treatment of invasive fungal infections in cancer patients-updated recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 2013; 93:13-32. [PMID: 24026426 PMCID: PMC3889633 DOI: 10.1007/s00277-013-1867-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 07/29/2013] [Indexed: 11/28/2022]
Abstract
The Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) here presents its updated recommendations for the treatment of documented fungal infections. Invasive fungal infections are a main cause of morbidity and mortality in cancer patients undergoing intensive chemotherapy regimens. In recent years, new antifungal agents have been licensed, and agents already approved have been studied in new indications. The choice of the most appropriate antifungal treatment depends on the fungal species suspected or identified, the patient's risk factors (e.g., length and depth of neutropenia), and the expected side effects. This guideline reviews the clinical studies that served as a basis for the following recommendations. All recommendations including the levels of evidence are summarized in tables to give the reader rapid access to the information.
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Affiliation(s)
- Sabine Mousset
- Interdisziplinäres Zentrum für Palliativmedizin, Agaplesion Markus Krankenhaus, Wilhelm Epstein-Straße 4, 60431, Frankfurt, Germany,
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10
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[Fungal infections in hematology patients and after blood stem cell transplantation: prophylaxis and treatment]. Med Klin Intensivmed Notfmed 2013; 109:526-30. [PMID: 23576010 DOI: 10.1007/s00063-013-0238-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 01/14/2013] [Accepted: 03/06/2013] [Indexed: 10/27/2022]
Abstract
Patients with prolonged neutropenia or immunosuppression after stem cell transplantation are at a high risk of developing invasive fungal infections. Antimycotic prophylaxis is used to reduce the associated morbidity and mortality. The following classes of antimycotic agents are currently available: azoles (e.g., fluconazole, itraconazole, posaconazole), echinocandins (caspofungin, micafungin), and amphotericin B.
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Jarque I, Tormo M, Bello JL, Rovira M, Batlle M, Julià A, Tabares S, Rivas C, Fernández-Sevilla A, García-Boyero R, Debén G, González-Campos J, Capote FJ, Sanz MA. Caspofungin for the treatment of invasive fungal disease in hematological patients (ProCAS Study). Med Mycol 2013; 51:150-4. [DOI: 10.3109/13693786.2012.693213] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Döring M, Hartmann U, Erbacher A, Lang P, Handgretinger R, Müller I. Caspofungin as antifungal prophylaxis in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation: a retrospective analysis. BMC Infect Dis 2012; 12:151. [PMID: 22747637 PMCID: PMC3449185 DOI: 10.1186/1471-2334-12-151] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 06/19/2012] [Indexed: 11/10/2022] Open
Abstract
Background Pediatric patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) often receive intravenous liposomal amphotericin B (L-AmB) as antifungal prophylaxis. There are no guidelines for antifungal prophylaxis in children in this situation. Caspofungin (CAS), a broad-spectrum echinocandin, could be an effective alternative with lower nephrotoxicity than L-AmB. Methods We retrospectively analyzed the safety, feasibility, and efficacy of CAS in our center, and compared the results with L-AmB as antifungal monoprophylaxis in pediatric patients undergoing HSCT. 60 pediatric patients received L-AmB (1 or 3 mg/kg bw/day) and another 60 patients received CAS (50 mg/m2/day) as antifungal monoprophylaxis starting on day one after HSCT. The median ages of patients receiving L-AmB and CAS were 7.5 years and 9.5 years, respectively. Results No proven breakthrough fungal infection occurred in either group during the median treatment period of 23 days in the L-AmB group and 24 days in the CAS group. One patient receiving CAS developed probable invasive aspergillosis. During L-AmB treatment, potassium levels significantly decreased below normal values. Patients treated with L-AmB had more drug-related side effects and an increased need for oral supplementation with potassium, sodium bicarbonate and calcium upon discharge as compared with the CAS group. CAS was well-tolerated and safe in this cohort of immunocompromised pediatric patients, who underwent high-dose chemotherapy and HSCT. Conclusion Prophylactic CAS and L-AmB showed similar efficacy in this biggest cohort of pediatric patients after allogeneic HSCT reported, so far. A prospective randomized trial in children is warranted to allow for standardized guidelines.
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Affiliation(s)
- Michaela Döring
- Department of Pediatric Hematology/Oncology, University Children's Hospital Tübingen, Tübingen, Germany.
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13
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Pharmacological and Host Considerations Surrounding Dose Selection and Duration of Therapy with Echinocandins. CURRENT FUNGAL INFECTION REPORTS 2012. [DOI: 10.1007/s12281-012-0085-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Abstract
The incidence of invasive fungal infections, especially those due to Aspergillus spp. and Candida spp., continues to increase. Despite advances in medical practice, the associated mortality from these infections continues to be substantial. The echinocandin antifungals provide clinicians with another treatment option for serious fungal infections. These agents possess a completely novel mechanism of action, are relatively well-tolerated, and have a low potential for serious drug-drug interactions. At the present time, the echinocandins are an option for the treatment of infections due Candida spp (such as esophageal candidiasis, invasive candidiasis, and candidemia). In addition, caspofungin is a viable option for the treatment of refractory aspergillosis. Although micafungin is not Food and Drug Administration-approved for this indication, recent data suggests that it may also be effective. Finally, caspofungin- or micafungin-containing combination therapy should be a consideration for the treatment of severe infections due to Aspergillus spp. Although the echinocandins share many common properties, data regarding their differences are emerging at a rapid pace. Anidulafungin exhibits a unique pharmacokinetic profile, and limited cases have shown a potential far activity in isolates with increased minimum inhibitory concentrations to caspofungin and micafungin. Caspofungin appears to have a slightly higher incidence of side effects and potential for drug-drug interactions. This, combined with some evidence of decreasing susceptibility among some strains of Candida, may lessen its future utility. However, one must take these findings in the context of substantially more data and use with caspofungin compared with the other agents. Micafungin appears to be very similar to caspofungin, with very few obvious differences between the two agents.
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Affiliation(s)
- Gregory Eschenauer
- Department of Pharmacy Services, University of Michigan Health System
- Department of Clinical Sciences, College of Pharmacy, University of Michigan
| | - Daryl D DePestel
- Department of Pharmacy Services, University of Michigan Health System
- Department of Clinical Sciences, College of Pharmacy, University of Michigan
| | - Peggy L Carver
- Department of Pharmacy Services, University of Michigan Health System
- Department of Clinical Sciences, College of Pharmacy, University of Michigan
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Yang CC, Hsu PC, Cheng CW, Lee MH. Coexistence of fatal disseminated invasive aspergillosis and pyoderma gangrenosum: a case report. Med Princ Pract 2011; 20:380-3. [PMID: 21577002 DOI: 10.1159/000324802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 10/18/2010] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report an unusual case of disseminated aspergillosis involving the lymph nodes, lungs, and skin in a patient with pyoderma gangrenosum (PG) and myelodysplastic syndrome (MDS). CASE PRESENTATION AND INTERVENTION A 46-year-old man presented with productive cough of 2 weeks' duration. Besides, several painless, fixed lymph nodes were palpated at his left neck. He had PG and MDS diagnosed in June 2004 with regular use of oral dapsone and prednisolone. His skin lesions healed with scar formation and no purulent discharge. A computed tomography scan of the head, neck and chest showed bilateral lung consolidation and abscesses at the left neck, right upper lung and right pleura. The neck abscess culture grew Aspergillus species. Dark reddish macules developed over the right arm, chest and abdominal wall, and the left lower limb 2 weeks after initiation of amphotericin B. The histology of the right arm skin biopsy showed invasive aspergillosis. Caspofungin was started then for suspicion of poor response to amphotericin B. He expired despite 35 days of antifungal therapy. CONCLUSION This report highlights the rarity of coexistence of disseminated aspergillosis and PG, and should alert physicians to the possibility of invasive fungal infection superimposed on a chronic skin lesion.
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Affiliation(s)
- Chien-Chang Yang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Doria C, Bodzin AS, Vaccino S, Daskalakis C, Krawitz S, Ramirez CB. A retrospective analysis of the use of caspofungin in recipients of liver transplant with a modified high index of suspicion for fungal infection. A critical review of mortality, acute cellular rejection, infections, and changes in the liver function test. Clin Transplant 2010; 25:569-75. [DOI: 10.1111/j.1399-0012.2010.01308.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Maertens J, Egerer G, Shin WS, Reichert D, Stek M, Chandwani S, Shivaprakash M, Viscoli C. Caspofungin use in daily clinical practice for treatment of invasive aspergillosis: results of a prospective observational registry. BMC Infect Dis 2010; 10:182. [PMID: 20569436 PMCID: PMC2914768 DOI: 10.1186/1471-2334-10-182] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 06/22/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A prospective observational registry assessed real world experience with caspofungin monotherapy or combination therapy for the initial or salvage treatment of proven or probable invasive aspergillosis (IA). METHODS Data were collected from April 2006 to September 2007 for patients treated with caspofungin for a single episode of IA. Clinical effectiveness was categorized as favorable (complete or partial) or unfavorable (stable disease or failure) at the end of caspofungin therapy (EOCT). RESULTS Consecutive patients (n = 103) with proven or probable IA (per EORTC/MSG criteria) were identified from 11 countries. Malignancy (76.7%), neutropenia (64.1%), allogeneic hematopoietic stem cell transplantation (HSCT, 22.3%), solid organ transplantation (8.7%), autologous HSCT (4.9%), and HIV/AIDS (2.9%) were the most common underlying conditions. Most patients (84.5%) had pulmonary IA. Aspergillus fumigatus was the most frequently isolated species. The majority of patients received caspofungin monotherapy (82.5%) primarily as salvage therapy (82.4%). The main reason for switching to salvage therapy was clinical failure of the first-line therapy (69%). A favorable response at EOCT was seen in 56.4% (57/101) of patients overall, including 56.5% (48/85) and 56.3% (9/16) of patients receiving caspofungin monotherapy and combination therapy, respectively. Favorable response rates in clinically relevant subgroups were: malignancy, 51.9% (41/79); allogeneic HSCT, 56.5% (13/23); and neutropenia at time of hospitalization, 53.0% (35/66). There was a 72.3% (73/101) survival at 7 days after EOCT. Serious adverse events related to caspofungin were reported in 4 cases (3.9%); 3 patients (2.9%) discontinued treatment due to an adverse event related to caspofungin. CONCLUSIONS Caspofungin was both effective and well tolerated among high-risk patient groups such as those with neutropenia and active malignancies.
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Affiliation(s)
| | | | - Wan Shik Shin
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | | | | | - Sheenu Chandwani
- UMDNJ- Robert Wood Johnson Medical School, Department of Family Medicine- Research Division, Somerset, NJ, USA
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Treatment of invasive fungal infections in cancer patients—Recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 2008; 88:97-110. [DOI: 10.1007/s00277-008-0622-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 09/23/2008] [Indexed: 10/21/2022]
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Constantin JM, Roszyk L, Guerin R, Bannier F, Chartier C, Perbet S, Futier E, Cayot-Constantin S, Sapin V, Bazin JE. [Tolerance of caspofungin in intensive care unit: a prospective study]. ACTA ACUST UNITED AC 2008; 27:819-24. [PMID: 18835682 DOI: 10.1016/j.annfar.2008.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 06/03/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Caspofungin has shown efficacy and very low toxicity in empirical antifungal therapy in refractory invasive Aspergillus infections and invasive candidiasis in neutropenic (or non) patients. To date, there is no data on tolerability of caspofungin in ICU patients. The aim of this study was to evaluate caspofungine tolerability in critical care patients. PATIENTS AND METHOD Over a 36-month period, 1430 patients were admitted in a general intensive care unit. All patients data were collected in a prospective database. All the clinical or biological side effects reported in the multicentric studies were required. The patients were laminated in two groups, according to the initial hepatic function. RESULTS Seventy-three patients were treated with caspofungin (5.1%) and 58% were immunocompromised. Immunosuppression was due to acute leukemia (30%), solid organ transplant (20%) or other causes of immunosuppression. In this group, SAPS2 was higher (51+/-20 versus 44+/-20; p<0.05) as mortality rate was (60% versus 23%). More than 90% of patients were ventilated and 55% needed extrarenal therapy. Caspofungin treatment was initiated for aspergillosis in 12 patients, candidiasis in 33 patients and others indications. Partial or complete response to treatment was 72%. Median duration of caspofungin administration was 11 days, no liver dysfunction or acute renal failure due to caspofungin was reported whatever initial liver function was. CONCLUSION This prospective open study demonstrate the very low toxicity of caspofungin even in critical care patients.
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Affiliation(s)
- J-M Constantin
- Pôle anesthésie-réanimation, service de réanimation adulte, hôpital Hôtel-Dieu, CHU de Clermont-Ferrand, boulevard Léon-Malfreyt, 63058 Clermont-Ferrand, France.
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Christopeit M, Eikam M, Behre G. Comedication of caspofungin acetate and cyclosporine A after allogeneic haematopoietic stem cell transplantation leads to negligible hepatotoxicity. Mycoses 2008; 51 Suppl 1:19-24. [DOI: 10.1111/j.1439-0507.2008.01524.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Lichtenstern C, Nguyen TH, Schemmer P, Hoppe-Tichy T, Weigand MA. Efficacy of caspofungin in invasive candidiasis and candidemia – de-escalation strategy. Mycoses 2008; 51 Suppl 1:35-46. [DOI: 10.1111/j.1439-0507.2008.01527.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Lehrnbecher T, Groll AH. Experiences with the use of caspofungin in paediatric patients. Mycoses 2008; 51 Suppl 1:58-64. [DOI: 10.1111/j.1439-0507.2008.01529.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Robenshtok E, Gafter-Gvili A, Goldberg E, Weinberger M, Yeshurun M, Leibovici L, Paul M. Antifungal Prophylaxis in Cancer Patients After Chemotherapy or Hematopoietic Stem-Cell Transplantation: Systematic Review and Meta-Analysis. J Clin Oncol 2007; 25:5471-89. [PMID: 17909198 DOI: 10.1200/jco.2007.12.3851] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To evaluate the effect of antifungal prophylaxis on all-cause mortality as primary outcome, invasive fungal infections (IFIs), and adverse events. Many studies have evaluated the role of antifungal prophylaxis in cancer patients, with inconsistent conclusions. Methods We performed a systematic review and meta-analysis of randomized, controlled trials comparing systemic antifungals with placebo, no intervention, or other antifungal agents for prophylaxis in cancer patients after chemotherapy. The Cochrane Library, MEDLINE, conference proceedings, and references were searched. Two reviewers independently appraised the quality of trials and extracted data. Results Sixty-four trials met inclusion criteria. Antifungal prophylaxis decreased all-cause mortality significantly at end of follow-up compared with placebo, no treatment, or nonsystemic antifungals (relative risk [RR], 0.84; 95% CI, 0.74 to 0.95). In allogeneic hematopoietic stem-cell transplantation (HSCT) recipients, prophylaxis reduced all-cause mortality (RR, 0.62; 95% CI, 0.45 to 0.85), fungal-related mortality, and documented IFI. In acute leukemia patients, there was a significant reduction in fungal-related mortality and documented IFI, whereas the difference in mortality was only borderline significant (RR, 0.88; 95% CI, 0.74 to 1.06). Prophylaxis with itraconazole suspension reduced documented IFI when compared with fluconazole, with no difference in survival, and at the cost of more adverse events. On the basis of two studies, posaconazole prophylaxis reduced all-cause mortality (RR, 0.74; 95% CI, 0.56 to 0.98), fungal-related mortality, and IFI when compared with fluconazole. Conclusion Antifungal prophylaxis decreases all-cause mortality significantly in patients after chemotherapy. Antifungal prophylaxis should be administered to patients undergoing allogeneic HSCT, and should probably be administered to high-risk acute leukemia patients.
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Affiliation(s)
- Eyal Robenshtok
- Department of Medicine E, Rabin Medical Center, Petah-Tiqva, Israel.
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25
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Metcalf SC, Dockrell DH. Improved outcomes associated with advances in therapy for invasive fungal infections in immunocompromised hosts. J Infect 2007; 55:287-99. [PMID: 17697716 DOI: 10.1016/j.jinf.2007.06.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2007] [Revised: 06/22/2007] [Accepted: 06/25/2007] [Indexed: 11/26/2022]
Abstract
Invasive fungal infections cause substantial morbidity and mortality in immunocompromised hosts. The response rate to therapy, in particular for invasive aspergillosis and invasive mould infections, has been poor. Recently a number of techniques to facilitate early diagnosis of these infections, in parallel with the development of a number of antifungals with increased potency and lower toxicity, have raised optimism that outcomes for invasive fungal infection can be improved upon. The availability of lipid formulations of amphotericin B, azoles with extended spectrum against filamentous fungi and the development of a new class of antifungal agents, the echinocandins, presents the clinician with a range of therapeutic choices. Recent clinical trials have provided important insights into how these agents should be used. In particular, voriconazole has demonstrated superior efficacy to amphotericin B in the management of invasive aspergillosis, posaconazole has been shown to have significant efficacy in the prophylaxis of invasive fungal infection in high-risk individuals and a role in salvage therapy of invasive aspergillosis, caspofungin has demonstrated efficacy in salvage therapy of invasive aspergillosis, and each of the echinocandins show activity without significant toxicity in invasive candidiasis. Nevertheless, many therapeutic areas of uncertainty remain, including the role of combination therapy, and will provide the focus for future studies.
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Affiliation(s)
- S C Metcalf
- Communicable Diseases Directorate, E Floor, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
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Kim R, Khachikian D, Reboli AC. A comparative evaluation of properties and clinical efficacy of the echinocandins. Expert Opin Pharmacother 2007; 8:1479-92. [PMID: 17661730 DOI: 10.1517/14656566.8.10.1479] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With the increase in prevalence of fungal infections, newer antifungal agents are needed to effectively treat invasive disease, and at the same time minimize adverse effects from therapy. The echinocandins comprise a novel class of antifungals; their mechanism of action involves inhibiting 1,3-beta-D-glucan synthase, which is essential in cell wall synthesis for certain fungi. All three echinocandins are US FDA-approved for the treatment of esophageal candidiasis. Caspofungin and anidulafungin are licensed for the treatment of candidemia, and other select forms of invasive candidiasis. Micafungin is at present the only echinocandin approved for prophylaxis of fungal infections in hematopoietic stem cell transplants; whereas caspofungin is approved for empiric therapy of febrile neutropenia. Although all three echinocandins are active against Aspergillus, only caspofungin is presently approved for salvage therapy in invasive aspergillosis. Combination therapy with echinocandins plus other licensed antifungal therapy shows promise in treating invasive aspergillosis. This article will explore the similarities and differences among the echinocandins.
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Affiliation(s)
- Rose Kim
- Cooper University Hospital/UMDNJ-Robert Wood Johnson Medical School Education and Research Building, Division of Infectious Diseases, Department of Medicine, Camden, NJ 08103, USA.
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Anttila VJ, Salonen J, Ylipalosaari P, Koivula I, Riikonen P, Nikoskelainen J. A retrospective nationwide case study on the use of a new antifungal agent: patients treated with caspofungin during 2001–2004 in Finland. Clin Microbiol Infect 2007; 13:606-12. [PMID: 17378926 DOI: 10.1111/j.1469-0691.2007.01709.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to evaluate the efficacy and safety of caspofungin in patients treated in Finland during the period 2001-2004. The medical records of 78 adult patients treated with caspofungin in five major hospitals were reviewed retrospectively. Fifty-nine (76%) patients had proven invasive fungal infection, of whom 22 (28%) had aspergillosis and 37 (47%) had candidiasis. Nineteen (24%) patients were treated empirically; only 13 (17%) patients received caspofungin as primary therapy. A favourable response was achieved in 52 (67%) patients. The response rate was 78% in patients with candidiasis, and 50% in patients with aspergillosis. At the end of the study period, 40 (51%) patients remained alive; of the 38 deaths, nine (24%) were caused by fungal infection. The response rates were lower, although not significantly, for patients with high (>20) vs. low (< or =20) Acute Physiology and Chronic Health Evaluation (APACHE II) scores (response rate 50% vs. 68%, p 0.48, respectively), and were also lower in patients with long-term (>20 days) vs. shorter duration (< or =20 days) neutropenia (55% vs. 73%, p 0.32, respectively), and in those with an underlying haematological malignancy vs. patients with other diseases (59% vs. 73%, p 0.2, respectively). In five (6%) patients, caspofungin therapy was discontinued prematurely because of adverse drug reactions (ADRs) (elevated liver enzyme values in three patients, neuropathic pain in one, and skin rash in one). Serious ADRs occurred in two (3%) patients (severe hepatic insufficiency with consequent death, and eosinophilia with elevated alkaline phosphatase levels), and laboratory abnormalities, mostly mild and reversible, in 24 (31%) patients. In this unselected patient population, caspofungin was safe, well-tolerated, and had an efficacy comparable to that in previous reports from prospective trials.
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Affiliation(s)
- V-J Anttila
- Helsinki University Central Hospital, Helsinki, Finland.
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Morrissey CO, Slavin MA, O'Reilly MA, Daffy JR, Seymour JF, Schwarer AP, Szer J. Caspofungin as salvage monotherapy for invasive aspergillosis in patients with haematological malignancies or following allogeneic stem cell transplantation: efficacy and concomitant cyclosporin A. Mycoses 2007; 50 Suppl 1:24-37. [PMID: 17394607 DOI: 10.1111/j.1439-0507.2007.01377.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Caspofungin (CAS) has shown efficacy as salvage monotherapy for invasive aspergillosis (IA) in two open label non-comparative trials. The association between hepatotoxicity and concomitant use of CAS and cyclosporin A (CsA) has not been fully elucidated. We report results on CAS efficacy in the first cohort from outside Europe and USA and the interaction between CAS and CsA. We retrospectively reviewed the charts of all patients with haematological malignancies or postallogeneic haematopoietic stem cell transplant (HSCT) who received >/=1 dose of CAS as salvage monotherapy for IA as part of the Australian Special Access Scheme (4/2001-8/2002). Outcomes were assessed at the end of CAS therapy. Favourable response (FR) was defined as >50% clinical and radiological improvement. Risk factors for elevation of liver transaminases (LTs) were examined using multivariate models. 54 patients were included in the analysis with 47 neutropenic at study entry. Proven or probable IA occurred in 11 and refractory IA in 28. An FR occurred in 26 (48.1%) and predictors for a poor response to CAS were allogeneic HSCT, graft vs. host disease and treatment with CAS for <14 days. Concomitant CAS and CsA for >7 days was an independent risk factor for laboratory hepatoxicity. The CAS efficacy results from the Australian cohort confirm those of previous studies. Close monitoring of LTs is necessary on concomitant CAS and CsA but clinically relevant hepatotoxicity is rare.
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Affiliation(s)
- C O Morrissey
- Infectious Diseases Unit, Alfred Hospital, Melbourne, Vic, Australia.
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Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis: a persistent public health problem. Clin Microbiol Rev 2007; 20:133-63. [PMID: 17223626 PMCID: PMC1797637 DOI: 10.1128/cmr.00029-06] [Citation(s) in RCA: 2754] [Impact Index Per Article: 162.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Invasive candidiasis (IC) is a leading cause of mycosis-associated mortality in the United States. We examined data from the National Center for Health Statistics and reviewed recent literature in order to update the epidemiology of IC. IC-associated mortality has remained stable, at approximately 0.4 deaths per 100,000 population, since 1997, while mortality associated with invasive aspergillosis has continued to decline. Candida albicans remains the predominant cause of IC, accounting for over half of all cases, but Candida glabrata has emerged as the second most common cause of IC in the United States, and several less common Candida species may be emerging, some of which can exhibit resistance to triazoles and/or amphotericin B. Crude and attributable rates of mortality due to IC remain unacceptably high and unchanged for the past 2 decades. Nonpharmacologic preventive strategies should be emphasized, including hand hygiene; appropriate use, placement, and care of central venous catheters; and prudent use of antimicrobial therapy. Given that delays in appropriate antifungal therapy are associated with increased mortality, improved use of early empirical, preemptive, and prophylactic therapies should also help reduce IC-associated mortality. Several studies have now identified important variables that can be used to predict risk of IC and to help guide preventive strategies such as antifungal prophylaxis and early empirical therapy. However, improved non-culture-based diagnostics are needed to expand the potential for preemptive (or early directed) therapy. Further research to improve diagnostic, preventive, and therapeutic strategies is necessary to reduce the considerable morbidity and mortality associated with IC.
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Affiliation(s)
- M A Pfaller
- Medical Microbiology Division, C606 GH, Department of Pathology, University of Iowa College of Medicine, Iowa City, IA 52242, USA.
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Turner MS, Drew RH, Perfect JR. Emerging echinocandins for treatment of invasive fungal infections. Expert Opin Emerg Drugs 2006; 11:231-50. [PMID: 16634699 DOI: 10.1517/14728214.11.2.231] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The echinocandins are a new class of antifungals, developed in response to the need for safe and effective antifungals for the treatment of invasive fungal infections. These agents work by inhibiting 1,3-beta-d-glucan synthase, an enzyme essential for production of cell walls in select fungi. Echinocandins appear to demonstrate favourable activity in vitro against a variety of yeasts (including both Candida albicans and non-albicans Candida) as well as select moulds (including Aspergillus spp.) In general, all echninocandins demonstrate a favourable safety profile and require once-daily parenteral administration. Caspofungin is the first of these agents to be available in the US, and is approved for empirical antifungal therapy in febrile neutropenic patients, candidaemia and select forms of invasive candidiasis, and for management of invasive aspergillosis in patients refractory to or intolerant of other therapies. Micafungin was recently approved by the FDA for treatment of oesophageal candidiasis, and for the prophylaxis of fungal infections in haematopoietic stem cell transplant recipients. Emerging data indicate micafungin may have an important role in the treatment of invasive forms of candidiasis. Anidulafungin is an echinocandin approved in the US for treatment of candidaemia and oesophageal candidiasis. Aminocandin (HMR-3702, IP-960) is an investigational agent, with published experience limited to in vitro studies and animal models of infection.
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