Successful treatment of Candida albicans septicemia in a preterm infant with severe congenital ichthyosis (Harlequin baby)

Antifungal Combinations against Candida Species: From Bench to Bedside

Candida spp. is the major causative agent of fungal infections in hospitalized patients and the fourth most common cause of nosocomial bloodstream infection (BSI). The availability of standardized methods for testing the in vitro activity of antifungals along with the expanding of antifungal armamentarium, the rising of drug-resistance and the persistence of a high mortality rate in systemic candidiasis have led to an increased interest in combination therapy. Therefore, we aimed to review the scientific literature concerning the antifungal combinations against Candida. A literature search performed in PubMed yielded 92 studies published from 2000 to 2021: 29 articles referring to in vitro studies, six articles referring to either in vitro and in vivo (i.e., animal models) studies and 57 clinical articles. Pre-clinical studies involved 735 isolates of Candida species and 12 unique types of antifungal combination approaches including azoles plus echinocandins (19%), polyenes plus echinocandins (16%), polyenes plus azoles (13%), polyenes plus 5-flucytosine ([5-FC], 13%), azoles plus 5-FC (11%) and other types of combinations (28%). Results varied greatly, often being species-, drug- and methodology-dependent. Some combinatorial regimens exerted a synergistic effect against difficult-to-treat Candida species (i.e., azoles plus echinocandins; polyenes plus 5-FC) or they were more effective than monotherapy in prevent or reducing biofilm formation and in speeding the clearance of infected tissues (i.e., polyenes plus echinocandins). In 283 patients with documented Candida infections (>90% systemic candidiasis/BSI), an antifungal combination approach could be evaluated. Combinations included: azoles plus echinocandins (36%), 5-FC-combination therapies (24%), polyenes plus azoles (18%), polyenes plus echinocandins (16%) and other types of combination therapy (6%). Case reports describing combination therapies yielded favorable response in most cases, including difficult-to-treat fungal infections (i.e., endocarditis, osteoarticular infections, CNS infections) or difficult-to-treat fungal pathogens. The only randomized trial comparing amphotericin-B deoxycholate (AMB) plus FLU vs. AMB alone for treatment of BSI in nonneutropenic patients showed that the combination trended toward improved success and more-rapid clearance from the bloodstream. In summary, antifungal combinations against Candida have produced great interest in the past two decades. To establish whether this approach can become a reliable treatment option, additional in vitro and clinical data are warranted.

Congenital systemic candidiasis: a comprehensive literature review and meta-analysis of 44 cases

Systemic candidiasis is a frequent complication in neonatal units, but congenital systemic candidiasis is an unusual diagnosis, observed in both full-term and preterm infants, with less than 50 cases reported to date. Congenital candidiasis presents with a wide spectrum of symptoms, ranging from diffuse skin eruptions to severe systemic disease, resulting in fetal demise or early neonatal death. Although management guidelines have been published almost two decades ago, due to the rarity of this type of infection, conclusive recommendations are difficult to establish, since they are based on anecdotal experience. In this paper, we present a comprehensive meta-analysis of the current scientific knowledge regarding congenital candidiasis, which spans 54 years and includes a total of 44 cases.

Inherited ichthyosis and fungal infection: an update on pathogenesis and treatment strategies

Inherited ichthyoses are a group of genodermatoses classified as either nonsyndromic or syndromic. Nonsyndromic ichthyoses and keratitis, ichthyosis and deafness (KID) syndrome predispose to fungal infection. The diagnosis and treatment of fungal infections underlying ichthyoses are challenging. In this review, we summarize reported cases of ichthyosis with fungal infection over the past 50 years. Atypical manifestations such as alopecia, papules and brittle nails occurred in patients with ichthyosis combined with fungal infection. Various pathogenic mechanisms have been implicated, including mutations of ichthyosis-related genes leading to disruption of the skin barrier via multiple pathways. Host immune disorders, including atopy and abnormal innate immunity also contribute to susceptibility. Specific fungi may escape the immune response. Extensive and recurrent fungal infections are not uncommon in patients with ichthyosis, making a cure more difficult and increasing the need for systemic antifungal therapy. Traditional and new ichthyosis treatments aiming to improve skin barrier function could help prevent fungal infection. In conclusion, the close relationship between ichthyosis and fungal infection is of vital importance in clinical practice and requires more attention from physicians. More studies are required to investigate the mechanisms and explore useful treatment strategies.

Echinocandin use in the neonatal intensive care unit

OBJECTIVE

To evaluate the literature regarding the use of echinocandins to treat invasive fungal infections caused by Candida spp. in patients in the neonatal intensive care unit.

DATA SOURCES

Literature retrieval was accessed through MEDLINE (Jan 2000-September 2011) using the search terms echinocandin, caspofungin, micafungin, anidulafungin, and neonate with limits for age group (ie, birth to 1 month). Reference citations from identified articles were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

Relevant information on the pharmacokinetics, efficacy, and safety of echinocandins in neonates was selected. Prospective studies, retrospective studies, and case series in English identified from MEDLINE were evaluated.

DATA SYNTHESIS

Neonates, especially preterm neonates, have many risk factors that predispose them for invasive fungal infections caused by Candida spp. To date, the only antifungals recommended for use in neonates for treatment of candidiasis are amphotericin B (deoxycholate or a lipid formulation) and fluconazole; however, the toxicities associated with amphotericin B and resistance of certain Candida spp. to fluconazole limit their use in neonates. There is a need for a broad-spectrum antifungal agent with limited toxicity for use in this patient population. The echinocandins may represent such a class of antifungals. To date, micafungin is the most studied echinocandin in the neonatal population, followed by caspofungin; however, studies evaluating their efficacy and pharmacokinetic parameters in neonates are few.

CONCLUSIONS

Although studies suggest that the echinocandins may have a favorable safety profile, the lack of pharmacokinetic data and standardized study designs limit current recommendations of use of echinocandins as first-line agents in neonates in the treatment of fungal infections. However, if an echinocandin is to be used in this population, the data presented in this review suggest the use of micafungin over the other echinocandins, and higher doses of micafungin (10-15 mg/kg/day) should be used when central nervous system involvement is suspected.

Caspofungin therapy in immunocompromised children and neonates

The prevalence of invasive fungal infections is increasing and the infections are becoming a major problem in immunocompromised children and neonates. Fortunately, there has been a recent surge in the development of new antifungal agents. Caspofungin, the first licensed echinocandin, is a novel class of antifungal and is approved for use in children 3 months of age or older for the treatment of invasive candidiasis, salvage therapy for invasive aspergillosis and as empirical therapy for febrile neutropenia. This article reviews the published data on the use of caspofungin in immunocompromised children and neonates with invasive fungal infections.