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Jendoubi A, Pressiat C, De Roux Q, Hulin A, Ghaleh B, Tissier R, Kohlhauer M, Mongardon N. The impact of extracorporeal membrane oxygenation on antifungal pharmacokinetics: A systematic review. Int J Antimicrob Agents 2024; 63:107078. [PMID: 38161046 DOI: 10.1016/j.ijantimicag.2023.107078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/09/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND OBJECTIVE The use of extracorporeal membrane oxygenation (ECMO) as a cardiocirculatory or respiratory support has tremendously increased in critically ill patients. In the setting of ECMO support, invasive fungal infections are a severe cause of morbidity and mortality. This vulnerable population is at risk of suboptimal antifungal exposure due to an increased volume of distribution (Vd), drug sequestration and decreased clearance. Here, we aimed to summarize ex-vivo and clinical studies on the potential impact of ECMO on the pharmacokinetics (PK) of antifungal agents and dosing requirements. METHODS A systematic search of the literature within electronic databases PubMed and EMBASE was conducted from database inception to 30 April 2023. Inclusion criteria were as follows: critically ill patients receiving ECMO regardless of age and reporting at least one PK parameter. RESULTS Thirty-six studies met inclusion criteria, including seven ex-vivo experiments and 29 clinical studies evaluating three classes of antifungals: polyenes, triazoles and echinocandins. Based on the available ex-vivo PK data, we found a significant sequestration of highly lipophilic and protein-bound antifungals within the ECMO circuit such as voriconazole, posaconazole and micafungin but the PK of several antifungals remains to be addressed such as amphotericin B, isavuconazole and anidulafungin. Most clinical studies have shown increased Vd of some antifungals like fluconazole and micafungin, particularly in the pediatric population. Conflicting data exist about caspofungin exposure. CONCLUSIONS The available literature on the antifungal PK changes in ECMO setting is scarce. Whenever possible, therapeutic drug monitoring is highly advised to personalize antifungal therapy.
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Affiliation(s)
- Ali Jendoubi
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Claire Pressiat
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Quentin De Roux
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Anne Hulin
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Bijan Ghaleh
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France; Laboratoire de Pharmacologie, DMU Biologie-Pathologie, Assistance Publique des Hôpitaux de Paris (APHP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Renaud Tissier
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France
| | - Matthias Kohlhauer
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France
| | - Nicolas Mongardon
- Inserm U955-IMRB, Équipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", École Nationale Vétérinaire d'Alfort (EnVA), Université Paris Est Créteil (UPEC), Maisons-Alfort, France; Service d'Anesthésie-Réanimation Chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France; Faculté de Santé, Université Paris Est Créteil, Créteil, France.
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Stover KR, Jordan TE, Wagner JL, Barber KE. High-dose amphotericin: yay or nay? A case series and literature review. Drugs Context 2024; 13:2023-9-1. [PMID: 38264401 PMCID: PMC10803125 DOI: 10.7573/dic.2023-9-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/29/2023] [Indexed: 01/25/2024] Open
Abstract
Invasive fungal infections pose significant morbidity and mortality risks, particularly those caused by moulds. Available antifungal classes are limited by toxicities and are increasingly susceptible to resistance, particularly amongst challenging fungal pathogens. The purpose of this case series and literature review was to characterize the use of a high-dose lipid formulation of amphotericin B. A case series is presented including patients who received high-dose lipid formulation amphotericin B (≥7.5 mg/kg/day) between June 2012 and August 2021. Additionally, a systematic literature review was conducted by searching the PubMed database for English-language studies involving individuals who received high-dose amphotericin B therapy (≥7.5 mg/kg) using lipid formulations. Nine patients were included in the case series, receiving an average of 8.9 ± 1.3 mg/kg liposomal amphotericin B over a mean of 11.0 ± 10.8 days predominantly for mould infections including Mucorales, aspergillosis and Fusarium. The patients were primarily cared for in intensive care units, with varying treatment histories and outcomes. A total of 11 studies (n=260 patients) met inclusion criteria for the literature review. Responses to high-dose liposomal amphotericin B ranged from 8% to 100%, often showing favourable outcomes. High doses of liposomal amphotericin B were well tolerated both in the case series and in published literature, with serum creatinine changes being the most commonly reported adverse event. However, multi-patient studies continue to report less than favourable (range 8-62%) response rates. High-dose liposomal amphotericin B, either alone or in combination with other antifungal agents, might be a viable strategy for managing invasive fungal infections when few treatment choices exist. This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.
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Affiliation(s)
- Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Taylor E Jordan
- Department of Pharmacy, Mississippi Baptist Medical Center, Jackson, MS, USA
| | - Jamie L Wagner
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Katie E Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
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Dillon B, Wothe J, Evans D, Damroth K, Bohman J, Saavedra-Romero R, Prekker M, Brunsvold M. Use of Venovenous Extracorporeal Membrane Oxygenation in Patients With Acute Respiratory Distress Syndrome Caused by Fungal Pneumonia. Surg Infect (Larchmt) 2023; 24:632-636. [PMID: 37594771 DOI: 10.1089/sur.2023.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Background: Patients with fungal pneumonias sometimes progress to acute respiratory distress syndrome (ARDS). Mortality has been reported as high as 60% to 90% in this group. Venovenous extracorporeal membrane oxygenation (VV-ECMO) can be used to support such patients, however, outcomes are not well understood. Patients and Methods: This was a retrospective study across the four adult ECMO centers in Minnesota for one decade (2012-2022). The outcomes of interest were duration of ECMO, survival rate, and complications. Data were extracted from the electronic medical record and analyzed using descriptive statistics. Results: Fungal pneumonia was the etiology of ARDS in 22 of 422 (5%) adults supported with VV-ECMO during the 10-year study period. Median patient age was 43 years (interquartile range [IQR], 35-56) and 68% were male. By type of fungal infection, 16 (72%) had blastomycosis, five (22%) had pneumocystis, and one (5%) had cryptococcus. Of the 16 patients with blastomycosis two were immunosuppressed whereas all five of the pneumocystis patients were immunosuppressed. The overall survival rate was 73%; most patients with blastomycosis (67%) and pneumocystis (80%) survived to hospital discharge. The duration of ECMO support was greater for the pneumocystis group (median, 30 days; IQR, 21-43) compared with blastomycosis (median, 10 days; IQR, 8-18). Conclusions: Our findings support the use of VV-ECMO for ARDS caused by fungal pneumonias in select immunocompetent and immunocompromised patients. Although survival was high, patients with pneumocystis required longer ECMO runs.
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Affiliation(s)
- Bridget Dillon
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jillian Wothe
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Critical Care, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Danika Evans
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Karl Damroth
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John Bohman
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthew Prekker
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Melissa Brunsvold
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Prasanna P, Rathee S, Upadhyay A, Sulakshana S. Nanotherapeutics in the treatment of acute respiratory distress syndrome. Life Sci 2021; 276:119428. [PMID: 33785346 PMCID: PMC7999693 DOI: 10.1016/j.lfs.2021.119428] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/12/2021] [Accepted: 03/20/2021] [Indexed: 01/08/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a form of oxygenation failure primarily characterized by rapid inflammation resulting from a direct pulmonary or indirect systemic insult. ARDS has been a major cause of death in the recent COVID-19 outbreak wherein asymptomatic respiratory tract infection progresses to ARDS from pneumonia have emphasized the need for a reliable therapy for the disease. The disease has a high mortality rate of approximately 30-50%. Despite the high mortality rate, a dearth of effective pharmacotherapy exists that demands extensive research in this area. The complex ARDS pathophysiology which remains to be understood completely and the multifactorial etiology of the disease has led to the poor diagnosis, impeded drug-delivery to the deeper pulmonary tissues, and delayed treatment of the ARDS patients. Besides, critically ill patients are unable to tolerate the off-target side effects. The vast domain of nanobiotechnology presents several drug delivery systems offering numerous benefits such as targeted delivery, prolonged drug release, and uniform drug-distribution. The present review presents a brief insight into the ARDS pathophysiology and summarizes conventional pharmacotherapies available to date. Furthermore, the review provides an updated report of major developments in the nanomedicinal approaches for the treatment of ARDS. We also discuss different nano-formulations studied extensively in the ARDS preclinical models along with underlining the advantages as well as challenges that need to be addressed in the future.
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Affiliation(s)
- Pragya Prasanna
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar 844102, India
| | - Shweta Rathee
- Department of Food Science and Technology, National Institute of Food Technology Entrepreneurship and Management, Sonipat, Haryana 131028, India
| | - Arun Upadhyay
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Sulakshana Sulakshana
- Department of Anesthesiology and Critical Care, Sri Ram Murti Smarak Institute of Medical Sciences (SRMS-IMS), Bareilly, Uttar Pradesh 243202, India.
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Abstract
Blastomycosis is the fungal disease caused by thermally dimorphic fungi in the genus Blastomyces, with B dermatitidis complex causing most cases. It is considered hyperendemic in areas adjacent to the Great Lakes and along the St. Lawrence, Mississippi, and Ohio rivers, but definitive geographic distribution of blastomycoses remains obscure. Clinical presentation is variable. Disseminated blastomycosis with extrapulmonary manifestations is more common in immunosuppressed individuals. Culture positivity is required for definitive diagnosis, but compatible histology is often sufficient for presumptive diagnosis and initiation of treatment. Treatment should be provided to all symptomatic cases to prevent progression or recurrence.
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