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Khalifa HO, Majima H, Watanabe A, Kamei K. In Vitro Characterization of Twenty-One Antifungal Combinations against Echinocandin-Resistant and -Susceptible Candida glabrata. J Fungi (Basel) 2021; 7:jof7020108. [PMID: 33540778 PMCID: PMC7912999 DOI: 10.3390/jof7020108] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/27/2021] [Accepted: 01/30/2021] [Indexed: 12/21/2022] Open
Abstract
This study was designed to analyze the interaction of 21 antifungal combinations consisting of seven major antifungal agents against 11 echinocandin- susceptible and six-resistant C. glabrata isolates. The combinations were divided into five major groups and were evaluated by checkerboard, disc diffusion, and time-killing assays. Synergy based on the fractional inhibitory concentration index of ≤0.50 was observed in 17.65-29.41% of the cases for caspofungin combinations with azoles or amphotericin B. Amphotericin B combination with azoles induced synergistic interaction in a range of 11.76-29.41%. Azole combinations and 5-flucytosine combinations with azoles or amphotericin B did not show synergistic interactions. None of the 21 combinations showed antagonistic interactions. Interestingly, 90% of the detected synergism was among the echinocandin-resistant isolates. Disk diffusion assays showed that the inhibition zones produced by antifungal combinations were equal to or greater than those produced by single drugs. The time-killing assay showed the synergistic action of caspofungin combination with fluconazole, voriconazole, and posaconazole, and the amphotericin B-5-flucytosine combination. Furthermore, for the first time, this assay confirmed the fungicidal activity of caspofungin-voriconazole and amphotericin B-5-flucytosine combinations. The combination interactions ranged from synergism to indifference and, most importantly, no antagonism was reported and most of the synergistic action was among echinocandin-resistant isolates.
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Affiliation(s)
- Hazim O. Khalifa
- Division of Clinical Research, Medical Mycology Research Centre, Chiba University, Chiba 260-8673, Japan; (H.O.K.); (H.M.); (K.K.)
- Department of Pharmacology, Faculty of Veterinary Medicine, Kafrelsheikh University, Kafr El-Sheikh 33516, Egypt
| | - Hidetaka Majima
- Division of Clinical Research, Medical Mycology Research Centre, Chiba University, Chiba 260-8673, Japan; (H.O.K.); (H.M.); (K.K.)
| | - Akira Watanabe
- Division of Clinical Research, Medical Mycology Research Centre, Chiba University, Chiba 260-8673, Japan; (H.O.K.); (H.M.); (K.K.)
- Correspondence: ; Tel.: +043-222-7171
| | - Katsuhiko Kamei
- Division of Clinical Research, Medical Mycology Research Centre, Chiba University, Chiba 260-8673, Japan; (H.O.K.); (H.M.); (K.K.)
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Wang Z, Yang K, Chen L, Yan R, Qu S, Li YX, Liu M, Zeng H, Tian J. Activities of Nerol, a natural plant active ingredient, against Candida albicans in vitro and in vivo. Appl Microbiol Biotechnol 2020; 104:5039-5052. [DOI: 10.1007/s00253-020-10559-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/09/2020] [Accepted: 03/18/2020] [Indexed: 12/12/2022]
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Resistance to antifungal therapies. Essays Biochem 2017; 61:157-166. [DOI: 10.1042/ebc20160067] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/02/2017] [Accepted: 01/05/2017] [Indexed: 11/17/2022]
Abstract
The evolution of antifungal resistance among fungal pathogens has rendered the limited arsenal of antifungal drugs futile. Considering the recent rise in the number of nosocomial fungal infections in immunocompromised patients, the emerging clinical multidrug resistance (MDR) has become a matter of grave concern for medical professionals. Despite advances in therapeutic interventions, it has not yet been possible to devise convincing strategies to combat antifungal resistance. Comprehensive understanding of the molecular mechanisms of antifungal resistance is essential for identification of novel targets that do not promote or delay emergence of drug resistance. The present study discusses features and limitations of the currently available antifungals, mechanisms of antifungal resistance and highlights the emerging therapeutic strategies that could be deployed to combat MDR.
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Analysis of the Protein Kinase A-Regulated Proteome of Cryptococcus neoformans Identifies a Role for the Ubiquitin-Proteasome Pathway in Capsule Formation. mBio 2016; 7:e01862-15. [PMID: 26758180 PMCID: PMC4725006 DOI: 10.1128/mbio.01862-15] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The opportunistic fungal pathogen Cryptococcus neoformans causes life-threatening meningitis in immunocompromised individuals. The expression of virulence factors, including capsule and melanin, is in part regulated by the cyclic-AMP/protein kinase A (cAMP/PKA) signal transduction pathway. In this study, we investigated the influence of PKA on the composition of the intracellular proteome to obtain a comprehensive understanding of the regulation that underpins virulence. Through quantitative proteomics, enrichment and bioinformatic analyses, and an interactome study, we uncovered a pattern of PKA regulation for proteins associated with translation, the proteasome, metabolism, amino acid biosynthesis, and virulence-related functions. PKA regulation of the ubiquitin-proteasome pathway in C. neoformans showed a striking parallel with connections between PKA and protein degradation in chronic neurodegenerative disorders and other human diseases. Further investigation of proteasome function with the inhibitor bortezomib revealed an impact on capsule production as well as hypersusceptibility for strains with altered expression or activity of PKA. Parallel studies with tunicamycin also linked endoplasmic reticulum stress with capsule production and PKA. Taken together, the data suggest a model whereby expression of PKA regulatory and catalytic subunits and the activation of PKA influence proteostasis and the function of the endoplasmic reticulum to control the elaboration of the polysaccharide capsule. Overall, this study revealed both broad and conserved influences of the cAMP/PKA pathway on the proteome and identified proteostasis as a potential therapeutic target for the treatment of cryptococcosis. Fungi cause life-threatening diseases, but very few drugs are available to effectively treat fungal infections. The pathogenic fungus Cryptococcus neoformans causes a substantial global burden of life-threatening meningitis in patients suffering from HIV/AIDS. An understanding of the mechanisms by which fungi deploy virulence factors to cause disease is critical for developing new therapeutic approaches. We employed a quantitative proteomic approach to define the changes in the protein complement that occur upon modulating the cAMP signaling pathway that regulates virulence in C. neoformans. This approach identified a conserved role for cAMP signaling in the regulation of the ubiquitin-proteasome pathway and revealed a link between this pathway and elaboration of a major virulence determinant, the polysaccharide capsule. Targeting the ubiquitin-proteasome pathway opens new therapeutic options for the treatment of cryptococcosis.
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Leung S, Poulakos MN, Machin J. Posaconazole: An Update of Its Clinical Use. PHARMACY 2015; 3:210-268. [PMID: 28975914 PMCID: PMC5597105 DOI: 10.3390/pharmacy3040210] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 08/11/2015] [Accepted: 08/26/2015] [Indexed: 12/03/2022] Open
Abstract
Posaconazole (PCZ) is a relatively new addition to the azole antifungals. It has fungicidal activities against Aspergillus fumigatus, Blastomyces dermatitidis, selected Candida species, Crytopcoccus neoformans, and Trichosporon. PCZ also has fungistatic activities against Candida, Coccidioides, selected Fusarium spp., Histoplasma, Scedosporium and Zygomycetes. In addition, combining the drug with caspofungin or amphotericin B results in a synergistic interaction against A. fumigatus, C. glabrata and C. neoformans. The absorption of PCZ suspension is enhanced when given with food, nutritional supplements, and carbonated beverages. Oral administration of PCZ in divided doses also increases its bioavailability. PCZ has a large volume of distribution and is highly protein bound (>95%). The main elimination route of PCZ is fecal. PCZ is an inhibitor of the CYP3A4 enzyme; therefore, monitoring for drug-drug interactions is warranted with other CYP3A4 substrates/inhibitors/inducers. The most common adverse effects include headache, fatigue, nausea, vomiting and elevated hepatic enzymes. PCZ, with its unique antifungal activities, expands the azole class of antifungal agents. Because of its limit in formulation, PCZ oral suspension is recommended in immunocompromised patients with functional gastrointestinaltracts who fail conventional antifungal therapies or who are suspected to have a breakthrough fungal infection. However, a delayed-release tablet formulation and intravenous (IV) injection became available in 2014, expanding the use of PCZ in other patient populations, including individuals who are unable to take oral formulations.
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Affiliation(s)
- Simon Leung
- Memorial Regional Hospital, Hollywood, FL 33021, USA.
| | - Mara N Poulakos
- Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL 33416.
| | - Jade Machin
- Boca Raton Regional Hospital, Boca Raton, FL 33486, USA.
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Mehta AK, Langston AA. Use of posaconazole in the treatment of invasive fungal infections. Expert Rev Hematol 2014; 2:619-30. [DOI: 10.1586/ehm.09.46] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pettit RK, Weber CA, Lawrence SB, Pettit GR, Kean MJ, Cage GD. In vivo activity of anprocide alone, and in vitro activity in combination with conventional antibiotics against Staphylococcus aureus and Staphylococcus epidermidis biofilms. J Med Microbiol 2009; 58:1203-1206. [PMID: 19528175 DOI: 10.1099/jmm.0.008268-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The alarming spread of multiple drug resistance in Staphylococcus aureus, combined with the frequent occurrence of S. aureus and Staphylococcus epidermidis in biofilm-type infections, indicates a growing need for new therapies. The experimental steroidal amide anprocide [3beta-acetoxy-17beta-(l-prolyl)amino-5alpha-androstane] significantly reduced c.f.u. ml(-1) per suture (P <0.0001) in a murine model of topical S. aureus infection. In chequerboard assays with planktonic-grown S. aureus and S. epidermidis, anprocide was synergistic with bacitracin, oxacillin, clindamycin or ceftriaxone. Anprocide was also synergistic in combination with bacitracin or oxacillin against some isolates of biofilm-grown S. aureus and S. epidermidis.
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Affiliation(s)
- Robin K Pettit
- Cancer Research Institute and Department of Chemistry and Biochemistry, Arizona State University, Tempe, AZ 85287, USA
| | - Christine A Weber
- Cancer Research Institute and Department of Chemistry and Biochemistry, Arizona State University, Tempe, AZ 85287, USA
| | - Stacey B Lawrence
- Cancer Research Institute and Department of Chemistry and Biochemistry, Arizona State University, Tempe, AZ 85287, USA
| | - George R Pettit
- Cancer Research Institute and Department of Chemistry and Biochemistry, Arizona State University, Tempe, AZ 85287, USA
| | - Melissa J Kean
- Cancer Research Institute and Department of Chemistry and Biochemistry, Arizona State University, Tempe, AZ 85287, USA
| | - Gary D Cage
- Phoenix Children's Hospital, Phoenix, AZ 85016, USA
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Benabbou R, Zihler A, Desbiens M, Kheadr E, Subirade M, Fliss I. Inhibition ofListeria monocytogenesby a combination of chitosan and divergicin M35. Can J Microbiol 2009; 55:347-55. [DOI: 10.1139/w08-154] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The antimicrobial activities of the class IIa bacteriocin divergicin M35 and several types of chitosan against Listeria monocytogenes were quantified by agar diffusion, critical micro-dilution, and viable count and observed by electron microscopy. Antimicrobial activity of chitosan depended on its molecular mass (MM) and the pH. Three chitosans with MM values of 2, 20, and 100 kDa and 87.4% degree of deacetylation (DDA) were chosen for further study, based on high anti-listerial activity at pH 4.5. Electron microscopy suggested that the mechanism of anti-listerial activity also varied with the MM. Low-MM chitosan appeared to inhibit L. monocytogenes by affecting cell permeability and growth, whereas medium- and high-MM chitosan may form a barrier on the cell surface that prevents entry of nutrients. The minimum inhibitory concentrations (MICs) of 2, 20, and 100 kDa chitosan and divergicin M35 against a divergicin-resistant strain of L. monocytogenes (LSD 535) were 2.5, 2.5, 0.625, and 0.25 mg/mL, respectively. The combination of any of these 3 chitosans and divergicin M35 appeared to have an additive effect against L. monocytogenes, as determined by fractional inhibitory concentration (FIC) index. This study provides useful data for the development of chitosan films incorporating divergicin M35 for inhibiting L. monocytogenes in foods.
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Affiliation(s)
- R. Benabbou
- Institut des Nutraceutiques et des aliments fonctionnels, Université Laval, QC G1K 7P4, Canada
- Institute of Food Science and Nutrition, Swiss Federal Institute of Technology, ETH Zentrum, LFO F18 CH-8092 Zurich, Switzerland
- Centre Technologique des Produits aquatiques, Ministère de l’Agriculture des Pêcheries et de l’Alimentation, Gaspé, QC G4X 2V6, Canada
- Department of Dairy Science and Technology, Faculty of Agriculture, University of Alexandria, Alexandria, Egypt
| | - A. Zihler
- Institut des Nutraceutiques et des aliments fonctionnels, Université Laval, QC G1K 7P4, Canada
- Institute of Food Science and Nutrition, Swiss Federal Institute of Technology, ETH Zentrum, LFO F18 CH-8092 Zurich, Switzerland
- Centre Technologique des Produits aquatiques, Ministère de l’Agriculture des Pêcheries et de l’Alimentation, Gaspé, QC G4X 2V6, Canada
- Department of Dairy Science and Technology, Faculty of Agriculture, University of Alexandria, Alexandria, Egypt
| | - M. Desbiens
- Institut des Nutraceutiques et des aliments fonctionnels, Université Laval, QC G1K 7P4, Canada
- Institute of Food Science and Nutrition, Swiss Federal Institute of Technology, ETH Zentrum, LFO F18 CH-8092 Zurich, Switzerland
- Centre Technologique des Produits aquatiques, Ministère de l’Agriculture des Pêcheries et de l’Alimentation, Gaspé, QC G4X 2V6, Canada
- Department of Dairy Science and Technology, Faculty of Agriculture, University of Alexandria, Alexandria, Egypt
| | - E. Kheadr
- Institut des Nutraceutiques et des aliments fonctionnels, Université Laval, QC G1K 7P4, Canada
- Institute of Food Science and Nutrition, Swiss Federal Institute of Technology, ETH Zentrum, LFO F18 CH-8092 Zurich, Switzerland
- Centre Technologique des Produits aquatiques, Ministère de l’Agriculture des Pêcheries et de l’Alimentation, Gaspé, QC G4X 2V6, Canada
- Department of Dairy Science and Technology, Faculty of Agriculture, University of Alexandria, Alexandria, Egypt
| | - M. Subirade
- Institut des Nutraceutiques et des aliments fonctionnels, Université Laval, QC G1K 7P4, Canada
- Institute of Food Science and Nutrition, Swiss Federal Institute of Technology, ETH Zentrum, LFO F18 CH-8092 Zurich, Switzerland
- Centre Technologique des Produits aquatiques, Ministère de l’Agriculture des Pêcheries et de l’Alimentation, Gaspé, QC G4X 2V6, Canada
- Department of Dairy Science and Technology, Faculty of Agriculture, University of Alexandria, Alexandria, Egypt
| | - I. Fliss
- Institut des Nutraceutiques et des aliments fonctionnels, Université Laval, QC G1K 7P4, Canada
- Institute of Food Science and Nutrition, Swiss Federal Institute of Technology, ETH Zentrum, LFO F18 CH-8092 Zurich, Switzerland
- Centre Technologique des Produits aquatiques, Ministère de l’Agriculture des Pêcheries et de l’Alimentation, Gaspé, QC G4X 2V6, Canada
- Department of Dairy Science and Technology, Faculty of Agriculture, University of Alexandria, Alexandria, Egypt
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ZOUHIR ABDELMAJEED, KHEADR EHAB, TAHIRI IMANE, BEN HAMIDA JEANNETTE, FLISS ISMAIL. COMBINATION WITH PLANT EXTRACTS IMPROVES THE INHIBITORY ACTION OF DIVERGICIN M35 AGAINST LISTERIA MONOCYTOGENES. J FOOD QUALITY 2008. [DOI: 10.1111/j.1745-4557.2007.00181.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
Invasive fungal infections are an important cause of morbidity and mortality in specific patient populations. There has been an impressive increase in the antifungal armamentarium, yet optimal therapies for many invasive fungal infections remain unknown. Genomic sequencing of a number of pathogenic fungi will pave the way to discovering additional newer targets for antifungal drug design. These new discoveries, plus the existing repertoire of antifungal agents, create the need to effectively model single and combination antifungal agents. Future therapies may also include the use of cell-stress pathway inhibitors in combination with existing antifungal agents. This review focuses on combination antifungal therapy against Cryptococcus neoformans, Candida and Aspergillus species. Combination therapy is only supported by randomized clinical trials for cryptococcal meningitis. We review data from in vitro and animal model studies as well as insights from clinical trials to discuss current thoughts and highlight the gaps in our knowledge surrounding combination antifungal therapy.
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Affiliation(s)
- Brahm H Segal
- Roswell Park Cancer Institute, Division of Infectious Diseases, Elm & Carlton Streets, Buffalo, NY 14263, USA.
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Groll AH, Walsh TJ. Antifungal efficacy and pharmacodynamics of posaconazole in experimental models of invasive fungal infections. Mycoses 2007; 49 Suppl 1:7-16. [PMID: 16961576 DOI: 10.1111/j.1439-0507.2006.01296.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Posaconazole is a novel lipophilic antifungal triazole with potent and broad-spectrum activity against opportunistic, endemic and dermatophytic fungi. This activity extends to organisms that are often refractory to existing triazoles, amphotericin B or echinocandins such as Candida glabrata, Candida krusei, Aspergillus terreus, Fusarium spp. and the Zygomycetes. A large number of experimental animal models of invasive fungal infections has demonstrated the potent and broad-spectrum efficacy of posaconazole in vivo, both in normal and in immunocompromised animals. Consistent with these preclinical data, posaconazole showed strong a antifungal efficacy in phase II and phase III clinical trials in immunocompromised patients with oropharyngeal and oesophageal candidiasis and as salvage therapy in patients with invasive fungal infections, and was effective as antifungal prophylaxis in high-risk patients. This paper reviews the preclinical disposition, antifungal efficacy and pharmacodynamics of posaconazole in and its implications for treatment and prevention of invasive fungal infections.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology/Oncology, Children's University Hospital, Münster, Germany.
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Groll AH, Walsh TJ. Posaconazole: clinical pharmacology and potential for management of fungal infections. Expert Rev Anti Infect Ther 2007; 3:467-87. [PMID: 16107193 DOI: 10.1586/14787210.3.4.467] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Posaconazole is a novel lipophilic antifungal triazole that inhibits cytochrome P450-dependent 14-alpha demethylase in the biosynthetic pathway of ergosterol. Inhibition of this enzyme leads to an accumulation of toxic 14-alpha methylsterols and a depletion of ergosterol, resulting in a perturbation of the function of the fungal cell membrane and blockage of cell growth and division. In vitro, posaconazole has potent and broad-spectrum activity against opportunistic, endemic and dermatophytic fungi. This activity extends to organisms that are often refractory to existing triazoles, amphotericin B or echinocandins, such as Candida glabrata, Candida krusei, Aspergillus terreus, Fusarium spp. and the Zygomycetes. A large variety of animal models of invasive fungal infections have provided consistent evidence of efficacy against these organisms in vivo, both in normal and immunocompromised animals. Posaconazole is available as an oral suspension and optimal exposure is achieved when the drug is administered in two to four divided doses along with food or a nutritional supplement. The compound has a large volume of distribution, in the order of 5 l/kg, and a half-life of approximately 20 h. Posaconazole is not metabolized to a significant extent through the cytochrome P450 enzyme system and is primarily excreted in an unchanged form in the feces. Although it is inhibitory, cytochrome P3A4 has no effect on 1A2, 2C8, 2C9, 2D6 and 2E1 isoenzymes, and therefore, a limited spectrum of drug-drug interactions can be expected. Pharmacokinetic studies in special populations revealed no necessity for dosage adjustment based on differences in age, gender, race, renal or hepatic function. Posaconazole has demonstrated strong antifungal efficacy in Phase II and III clinical trials in immunocompromised patients with oropharyngeal and esophageal candidiasis. Posaconazole also showed promising efficacy as salvage therapy in a large Phase II study including 330 patients with invasive fungal infections intolerant to or refractory to standard therapies. Posaconazole appears to be well tolerated in a manner comparable with that of fluconazole and it is currently under regulatory review in the USA and Europe for the treatment of refractory invasive fungal infections. This drug profile reviews the preclinical and clinical pharmacology of posaconazole and its potential role for prevention and treatment of invasive fungal infections.
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Affiliation(s)
- Andreas H Groll
- Children's University Hospital, Dept. of Hematology/Oncology, Center for Bone Marrow Transplantation, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany.
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Cada DJ, Levien T, Baker DE. Posaconazole Oral Suspension. Hosp Pharm 2007. [DOI: 10.1310/hpj4201-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Each month, subscribers to The Formulary Monograph Service receive five to six well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to your Pharmacy and Therapeutics Committee. Subscribers also receive monthly one-page summary monographs on the agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation (DUE) is also provided each month. With a subscription, the monographs are sent to you in print and CD-ROM forms and are available online. Monographs can be customized to meet the needs of your facility. Subscribers to the The Formulary Monograph Service also receive access to a pharmacy bulletin board, The Formulary Information Exchange (The F.I.X.). All topics pertinent to clinical and hospital pharmacy are discussed on The F.I.X. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. If you would like information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The January 2007 monograph topics are telbivudine, budesonide/formoterol inhalation aerosol, ciclesonide nasal spray, eculizumab, ceftobiprole medocaril. The DUE is telbivudine.
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Affiliation(s)
| | - Terri Levien
- Drug Information Pharmacist, Drug Information Center, Washington State University Spokane
| | - Danial E. Baker
- Drug Information Center and College of Pharmacy, Washington State University Spokane, PO Box 1495, Spokane, WA 99210-1495
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Torres HA, Hachem RY, Chemaly RF, Kontoyiannis DP, Raad II. Posaconazole: a broad-spectrum triazole antifungal. THE LANCET. INFECTIOUS DISEASES 2005; 5:775-85. [PMID: 16310149 DOI: 10.1016/s1473-3099(05)70297-8] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Posaconazale is a new triazole drug being investigated in phase III clinical trials for the treatment and prevention of invasive fungal infections. In-vitro and in-vivo studies showed that posaconazole has broad-spectrum activity against most Candida species, Cryptococcus neoformans, Aspergillus species, Fusarium species, zygomycetes, and endemic fungi. Posaconazole is given orally two to four times daily. This triazole is widely distributed in the body, metabolised mainly by the liver, and is well tolerated, even in long-term courses. Adverse events are generally mild and include headache and gastrointestinal complaints. Posaconazole has shown promising clinical efficacy against life-threatening fungal infections that are often refractory to the currently available antifungal therapies-eg, invasive aspergillosis, fusariosis, and the emerging zygomycosis.
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Affiliation(s)
- Harrys A Torres
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas M D Anderson Cancer Center, Houston, Texas 77030-4009, USA
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Serena C, Fernández-Torres B, Pastor FJ, Trilles L, Lazéra MDS, Nolard N, Guarro J. In vitro interactions of micafungin with other antifungal drugs against clinical isolates of four species of Cryptococcus. Antimicrob Agents Chemother 2005; 49:2994-6. [PMID: 15980382 PMCID: PMC1168639 DOI: 10.1128/aac.49.7.2994-2996.2005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The combination of micafungin (MFG) with amphotericin B (AMB), fluconazole, itraconazole, voriconazole, or ravuconazole was evaluated against 37 strains of four species of Cryptococcus by the checkerboard method. Antagonism was never seen. Synergy was observed for some isolates for each combination and was most frequent with MFG-AMB.
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Affiliation(s)
- Carolina Serena
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, Universitat Rovira i Virgili, Reus, Spain
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Mukherjee PK, Sheehan DJ, Hitchcock CA, Ghannoum MA. Combination treatment of invasive fungal infections. Clin Microbiol Rev 2005; 18:163-94. [PMID: 15653825 PMCID: PMC544182 DOI: 10.1128/cmr.18.1.163-194.2005] [Citation(s) in RCA: 209] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The persistence of high morbidity and mortality from systemic fungal infections despite the availability of novel antifungals points to the need for effective treatment strategies. Treatment of invasive fungal infections is often hampered by drug toxicity, tolerability, and specificity issues, and added complications often arise due to the lack of diagnostic tests and to treatment complexities. Combination therapy has been suggested as a possible approach to improve treatment outcome. In this article, we undertake a historical review of studies of combination therapy and also focus on recent studies involving newly approved antifungal agents. The limitations surrounding antifungal combinations include nonuniform interpretation criteria, inability to predict the likelihood of clinical success, strain variability, and variations in pharmacodynamic/pharmacokinetic properties of antifungals used in combination. The issue of antagonism between polyenes and azoles is beginning to be addressed, but data regarding other drug combinations are not adequate for us to draw definite conclusions. However, recent data have identified potentially useful combinations. Standardization of assay methods and adoption of common interpretive criteria are essential to avoid discrepancies between different in vitro studies. Larger clinical trials are needed to assess whether combination therapy improves survival and treatment outcome in the most seriously debilitated patients afflicted with life-threatening fungal infections.
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Affiliation(s)
- Pranab K Mukherjee
- Center for Medical Mycology, Department of Dermatology, Case Western Reserve University and University Hospitals of Cleveland, 11100 Euclid Ave., LKS-5028, Cleveland, OH 44106-5028, USA
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Arikan S, Rex JH. New agents for the treatment of systemic fungal infections – current status. Expert Opin Emerg Drugs 2005; 7:3-32. [PMID: 15989533 DOI: 10.1517/14728214.7.1.3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Systemic antifungal chemotherapy is enjoying its most dynamic era. More antifungal agents are under development than ever before, including agents in entirely new classes. Major goals of current investigations are to identify compounds with a wide spectrum of activity, minimal toxicity and a high degree of target specificity. The antifungal drugs in development include new azoles {voriconazole, posaconazole (formerly SCH-56592), ravuconazole (formerly BMS-207147)}, lipid formulations of amphotericin B, a lipid formulation of nystatin, echinocandins {anidulafungin (formerly, LY-303366, VER-002), caspofungin (formerly MK-991), micafungin (formerly FK-463)}, antifungal peptides other than echinocandins, and sordarin derivatives. This discussion reviews the currently available antifungal agents and summarises the developmental issues that surround these new systemic antifungal drugs.
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Affiliation(s)
- Sevtap Arikan
- Department of Microbiology and Clinical Microbiology, Hacettepe University Medical School, 06100 Ankara, Turkey.
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Barchiesi F, Spreghini E, Maracci M, Fothergill AW, Baldassarri I, Rinaldi MG, Scalise G. In vitro activities of voriconazole in combination with three other antifungal agents against Candida glabrata. Antimicrob Agents Chemother 2004; 48:3317-22. [PMID: 15328091 PMCID: PMC514763 DOI: 10.1128/aac.48.9.3317-3322.2004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Candida glabrata has recently emerged as a significant pathogen involved in both superficial and deep-seated infections. In the present study, a checkerboard broth microdilution method was performed to investigate the in vitro activities of voriconazole (VOR) in combination with terbinafine (TRB), amphotericin B (AMB), and flucytosine (5FC) against 20 clinical isolates of C. glabrata. Synergy, defined as a fractional inhibitory concentration (FIC) index of < or = 0.50, was observed in 75% of VOR-TRB, 10% of VOR-AMB, and 5% of VOR-5FC interactions. None of these combinations yielded antagonistic interactions (FIC index > 4). When synergy was not achieved, there was still a decrease in the MIC of one or both drugs used in the combination. In particular, the MICs were reduced to < or = 1.0 microg/ml as a result of the combination for all isolates for which the AMB MIC at the baseline was > or = 2.0 microg/ml. By a disk diffusion assay, the halo diameters produced by antifungal agents in combination were greater that those produced by each drug alone. Finally, killing curves showed that VOR-AMB exhibited synergistic interactions, while VOR-5FC sustained fungicidal activities against C. glabrata. These studies demonstrate that the in vitro activity of VOR against this important yeast pathogen can be enhanced upon combination with other drugs that have different modes of action or that target a different step in the ergosterol pathway. Further studies are warranted to elucidate the potential beneficial effects of such combination regimens in vivo.
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Affiliation(s)
- Francesco Barchiesi
- Istituo di Malattie Infettive e Medicina Pubblica, Università Politecnica delle Marche, Azienda Ospedaliera Umberto I degrees, Via Conca, 60020 Torrette di Ancona, Ancona, Italy
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Barchiesi F, Spreghini E, Schimizzi AM, Maracci M, Giannini D, Carle F, Scalise G. Posaconazole and amphotericin B combination therapy against Cryptococcus neoformans infection. Antimicrob Agents Chemother 2004; 48:3312-6. [PMID: 15328090 PMCID: PMC514762 DOI: 10.1128/aac.48.9.3312-3316.2004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To investigate the effects of posaconazole (POS) and amphotericin B (AMB) combination therapy in cryptococcal infection, we established an experimental model of systemic cryptococcosis in CD1 mice by intravenous injection of three distinct clinical isolates of Cryptococcus neoformans. Therapy was started 24 h after the infection and continued for 10 consecutive days. POS was given at 3 and 10 mg/kg of body weight/day, while AMB was given at 0.3 mg/kg/day. Combination therapy consisted of POS given at a low (combo 3) or at a high (combo 10) dose plus AMB. Survival studies showed that combo 3 was significantly more effective than POS at 3 mg/kg for two isolates tested (P value, < or = 0.001), while combo 10 was significantly more effective than POS at 10 mg/kg for all three isolates (P values ranging from <0.001 to 0.005). However, neither combination regimen was more effective than AMB alone. For two isolates, combination therapy was significantly more effective than each single drug at reducing the fungal burden in the brain (P values ranging from 0.001 to 0.015) but not in the lungs. This study demonstrates that the major impact of POS and AMB combination therapy is on brain fungal burden rather than on survival.
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Affiliation(s)
- Francesco Barchiesi
- Istituo di Malattie Infettive e Medicina Pubblica, Università Politecnica delle Marche, Azienda Ospedaliera Umberto I, Via Conca, 60020 Torrette di Ancona, Ancona, Italy
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22
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Cuenca-Estrella M. Combinations of antifungal agents in therapy--what value are they? J Antimicrob Chemother 2004; 54:854-69. [PMID: 15375111 DOI: 10.1093/jac/dkh434] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Concurrent or sequential antifungal treatment for invasive mycoses has been typically considered as an option to improve results of monotherapy. However, data on the efficacy of combination therapy are sparse and consist largely of results from studies in vitro and experimental animal models. These studies have yielded controversial results depending on the criteria used to evaluate the antifungal interaction. Several combinations that showed synergy in vitro failed to do so in animal models. Overall, apart from cryptococcal infections, combined antifungal therapy is not significantly better than monotherapy in terms of clinical efficacy. It is questionable whether combination therapy should be used in most cases as there is a lack of evidence from well-designed clinical trials. However, combination therapy could be an alternative to monotherapy for patients with invasive infections that are difficult to treat, such as those due to multi-resistant species and for those who fail to respond to standard treatment.
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Affiliation(s)
- Manuel Cuenca-Estrella
- Servicio de Micología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Ctra Majadahonda-Pozuelo Km 2, 28220 Majadahonda, Madrid, Spain.
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Johnson MD, MacDougall C, Ostrosky-Zeichner L, Perfect JR, Rex JH. Combination antifungal therapy. Antimicrob Agents Chemother 2004; 48:693-715. [PMID: 14982754 PMCID: PMC353116 DOI: 10.1128/aac.48.3.693-715.2004] [Citation(s) in RCA: 395] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Melissa D Johnson
- Departments of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Lupetti A, Nibbering PH, Campa M, Del Tacca M, Danesi R. Molecular targeted treatments for fungal infections: the role of drug combinations. Trends Mol Med 2003; 9:269-76. [PMID: 12829016 DOI: 10.1016/s1471-4914(03)00091-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Invasive mycoses are associated with a high mortality rate, and their incidence is increased in immunologically deficient patients. From a diagnostic and therapeutic perspective, these infections represent a significant challenge to medicine. In addition to new antifungal agents, drug combinations are an important therapeutic resource, which might be exploited clinically, owing to the multiplicity of fungal targets against which currently available agents are active. In this review, we examine the experimental data regarding the combination of conventional antifungal agents with cytokines, antibacterial agents, calcineurin inhibitors and drugs under development characterized by novel mechanisms of action.
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Affiliation(s)
- Antonella Lupetti
- Section of Microbiology, Department of Experimental Pathology, Medical Biotechnologies, Infectious Diseases and Epidemiology, University of Pisa, 56126 Pisa, Italy
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Polak A. Antifungal therapy--state of the art at the beginning of the 21st century. PROGRESS IN DRUG RESEARCH. FORTSCHRITTE DER ARZNEIMITTELFORSCHUNG. PROGRES DES RECHERCHES PHARMACEUTIQUES 2003; Spec No:59-190. [PMID: 12675476 DOI: 10.1007/978-3-0348-7974-3_4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The most relevant information on the present state of the art of antifungal chemotherapy is reviewed in this chapter. For dermatomycoses a variety of topical antifungals are available, and safe and efficacious systemic treatment, especially with the fungicidal drug terbinafine, is possible. The duration of treatment can be drastically reduced. Substantial progress in the armamentarium of drugs for invasive fungal infections has been made, and a new class of antifungals, echinocandins, is now in clinical use. The following drugs in oral and/or intravenous formulations are available: the broad spectrum polyene amphotericin B with its new "clothes"; the sterol biosynthesis inhibitors fluconazole, itraconazole, and voriconazole; the glucan synthase inhibitor caspofungin; and the combination partner flucytosine. New therapy schedules have been studied; combination therapy has found a significant place in the treatment of severely compromised patients, and the field of prevention and empiric therapy is fast moving. Guidelines exist nowadays for the treatment of various fungal diseases and maintenance therapy. New approaches interfering with host defenses or pathogenicity of fungal cells are being investigated, and molecular biologists are looking for new targets studying the genomics of pathogenic fungi.
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Kontoyiannis DP, Mantadakis E, Samonis G. Systemic mycoses in the immunocompromised host: an update in antifungal therapy. J Hosp Infect 2003; 53:243-58. [PMID: 12660121 DOI: 10.1053/jhin.2002.1278] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite significant advances in the management of immunosuppressed patients, invasive fungal infections remain an important life-threatening complication. In the last decade several new antifungal agents, including compounds in pre-existing classes (new generation of triazoles, polyenes in lipid formulations) and novel classes of antifungals with a unique mechanism of action (echinocandins), have been introduced in clinical practice. Ongoing and future studies will determine their exact role in the management of different mycoses. The acceleration of antifungal drug discovery offers promise for the management of these difficult to treat opportunistic infections.
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Affiliation(s)
- D P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas, M. D. Anderson Cancer Center, Houston 77030, USA.
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Abstract
PURPOSE OF REVIEW An increase in refractory invasive fungal infections in the setting of marrow/solid organ transplantation and other immune-compromising clinical entities has provided the impetus for the development of new, more efficacious/less toxic antifungal agents. This review (1) examines currently available laboratory methods for the in-vitro evaluation of these new agents against both yeasts and filamentous fungi; (2) provides a summary of the most attractive investigational agents currently undergoing clinical trials/development; and (3) outlines the major refractory mycoses in contemporary medicine. RECENT FINDINGS Fluconazole-resistant Candida spp., Trichosporon spp., zygomycetous genera, the endemic mycoses, Scedosporium, Aspergillus, and Fusarium spp., and an ever-expanding list of lesser-known hyaline and phaeoid genera inciting invasive fungal infections comprise the bulk of refractory mycoses in the immune-compromised host. In-vitro data generated from reference-based antifungal susceptibility testing methods indicate an increased armamentarium of potentially efficacious agents against most of these mycoses. SUMMARY The newly approved antifungal agents caspofungin and voriconazole, used either as monotherapy or in combination regimens, have a significantly improved spectrum of activity over previously available therapeutic options. Correlation of clinical outcomes with investigational agents demonstrating in-vivo/in-vitro activity will provide critical information needed for the development of clinically significant minimum inhibitory concentration interpretative breakpoints.
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Affiliation(s)
- Deanna A Sutton
- Fungus Testing Laboratory, Department of Pathology, Unversity of Texas Halth Science Center at San Antonio, Texas 78229-3900, USA.
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Abstract
In 1992, the Food and Drug Administration (FDA) issued new guidelines governing stereoisomerism in new-drug development. The guidelines strongly encourage the development of single isomers and discourage stereoisomeric (eg, racemic) mixtures. As a result, most new chiral drugs are being developed as single enantiomers (ie, single isomers). There are three mechanisms for the identification and development of new single-isomer drugs: chiral switches (CS), chiral metashifts (CM), and new single-isomer chemical entities (NSICEs). In a CS, one of the two enantiomers of an established racemate is developed as a new drug, with the expectation that the single-isomer form has advantages over the racemic parent in terms of efficacy and/or adverse effects. Many new CS drugs are in development, eg, (S)-oxybutynin for urinary incontinence and escitalopram for depression. In a CM, a chiral metabolite of a drug is developed, in single-isomer form, as an agent with advantages over the parent. Among the current CM drugs in development are (+)-norcisapride (safer GI prokinetic agent than the racemic parent cisapride) and (S)-desmethylzopiclone (antianxiety agent, metabolite of the sedative-hypnotic zopiclone). Many NSICEs are in development, eg, rosuvastatin as an antihypercholesterolemic, posaconazole as an antifungal, sitafloxacin as a fluoroquinolone antibacterial, pregabalin as an anticonvulsant, abarelix as an antineoplastic, etc. As in the development of any new drug, not every single-isomer candidate will reach the clinic, but there is no doubt that the move to single-isomer agents is an important step forward in the search for better and safer drugs.
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Affiliation(s)
- Joseph Gal
- Division of Clinical Pharmacology, University of Colorado School of Medicine, Denver, Colorado, USA
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Pound MW, Drew RH, Perfect JR. Recent advances in the epidemiology, prevention, diagnosis, and treatment of fungal pneumonia. Curr Opin Infect Dis 2002; 15:183-94. [PMID: 11964921 DOI: 10.1097/00001432-200204000-00014] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Although pneumonia caused by fungi is not a common occurrence in the general population, disease in an enlarging immunocompromised population is encountered with increasing frequency. Fungal pneumonias are most frequently caused by Aspergillus spp., dimorphic fungi and Cryptococcus neoformans. Recent studies have identified risk factors of thrombocytopenia, environmental events (such as construction or renovation) and immunosuppressive drug therapies as being specific risk factors for invasive fungal disease in select patient populations. Diagnostic strategies to detect circulating antigens and polymerase chain reaction based detection systems have been explored to improve identification prior to the progressive advanced disease. Advances in prophylactic strategies include increased use of aerosolized formulations of amphotericin B, usually in conjunction with new and old systemic antifungal agents. Despite recent published guidelines for treatment of fungal pneumonia based on etiology, mortality remains high in some infections with advanced disease. Caspofungin, a new echinocandin antifungal, has recently been approved by the US Food and Drug Administration for the treatment of invasive Aspergillus infections in patients unresponsive to or unable to receive amphotericin B. A triazole antifungal, voriconazole, has shown promise in phase III clinical trials in patients with refractory fungal infections and is expected to be available in early 2002. Other echinocandin and triazole antifungals are under development in attempts to provide improved effective therapy for fungal pneumonia.
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Affiliation(s)
- Melanie W Pound
- Internal Medicine/Infectious Diseases/Academia, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina 27710, USA.
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