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Brunet K, Martellosio JP, Tewes F, Marchand S, Rammaert B. Inhaled Antifungal Agents for Treatment and Prophylaxis of Bronchopulmonary Invasive Mold Infections. Pharmaceutics 2022; 14:pharmaceutics14030641. [PMID: 35336015 PMCID: PMC8949245 DOI: 10.3390/pharmaceutics14030641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Pulmonary mold infections are life-threatening diseases with high morbi-mortalities. Treatment is based on systemic antifungal agents belonging to the families of polyenes (amphotericin B) and triazoles. Despite this treatment, mortality remains high and the doses of systemic antifungals cannot be increased as they often lead to toxicity. The pulmonary aerosolization of antifungal agents can theoretically increase their concentration at the infectious site, which could improve their efficacy while limiting their systemic exposure and toxicity. However, clinical experience is poor and thus inhaled agent utilization remains unclear in term of indications, drugs, and devices. This comprehensive literature review aims to describe the pharmacokinetic behavior and the efficacy of inhaled antifungal drugs as prophylaxes and curative treatments both in animal models and humans.
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Affiliation(s)
- Kévin Brunet
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Laboratoire de Mycologie-Parasitologie, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
- Correspondence: (K.B.); (B.R.)
| | - Jean-Philippe Martellosio
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
| | - Frédéric Tewes
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
| | - Sandrine Marchand
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
| | - Blandine Rammaert
- Institut National de la Santé et de la Recherche Médicale, INSERM U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, 86022 Poitiers, France; (J.-P.M.); (F.T.); (S.M.)
- Faculté de Médecine et Pharmacie, Université de Poitiers, 6 rue de la Milétrie, 86073 Poitiers, France
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Milétrie, 86021 Poitiers, France
- Correspondence: (K.B.); (B.R.)
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Drew RH, Perfect JR. Conventional Antifungals for Invasive Infections Delivered by Unconventional Methods; Aerosols, Irrigants, Directed Injections and Impregnated Cement. J Fungi (Basel) 2022; 8:jof8020212. [PMID: 35205966 PMCID: PMC8879564 DOI: 10.3390/jof8020212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 12/10/2022] Open
Abstract
The administration of approved antifungals via unapproved formulations or administration routes (such as aerosol, direct injection, irrigation, topical formulation and antifungal-impregnated orthopedic beads or cement) may be resorted to in an attempt to optimize drug exposure while minimizing toxicities and/or drug interactions associated with conventional (systemic) administrations. Existing data regarding such administrations are mostly restricted to uncontrolled case reports of patients with diseases refractory to conventional therapies. Attribution of efficacy and tolerability is most often problematic. This review updates prior published summaries, reflecting the most recent data and its application by available prevention and treatment guidelines for invasive fungal infections. Of the various dosage forms and antifungals, perhaps none is more widely reported than the application of amphotericin B-containing aerosols for the prevention of invasive mold infections (notably Aspergillus spp.).
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Affiliation(s)
- Richard H. Drew
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC 27710, USA;
- College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA
- Correspondence: ; Tel.: +1-(919)681-6793; Fax: +1-(919)681-7494
| | - John R. Perfect
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC 27710, USA;
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Ram B, Aggarwal AN, Dhooria S, Sehgal IS, Garg M, Behera D, Chakrabarti A, Agarwal R. A pilot randomized trial of nebulized amphotericin in patients with allergic bronchopulmonary aspergillosis. J Asthma 2016; 53:517-24. [PMID: 26666774 DOI: 10.3109/02770903.2015.1127935] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND AIM Nebulized amphotericin B (NAB) has been used in the management of acute stage and exacerbations of allergic bronchopulmonary aspergillosis (ABPA). Whether NAB can prevent exacerbations of ABPA is not known. Herein, we evaluate the efficacy and safety of NAB in subjects with ABPA complicating asthma. METHODS Consecutive subjects of ABPA with recurrent exacerbations were randomized to receive either NAB plus nebulized budesonide (NEB) or NEB alone. The primary outcome was the time-to-first exacerbation of ABPA. The secondary outcomes were the number of subjects with ABPA exacerbations, ACQ7 scores, lung function, IgE levels, and adverse effects of treatment. RESULTS Twenty-one subjects (14 men; mean age, 32.3 years) were randomized to either the NAB (n = 12) or the NEB (n = 9) arm. The baseline characteristics were similar in the two groups. The time-to-first exacerbation was similar in the two groups. At one year, the numbers of patients experiencing exacerbation was significantly lower in the NAB arm (1/12 [8.3%] vs. 6/9 [66.7%]; p = 0.016). The other secondary end points were not different between the two groups. There were no major adverse events leading to discontinuation of any of the study drugs. Three patients experienced bronchospasm after first dose of NAB; however, the subsequent doses were well tolerated. CONCLUSIONS NAB seems to be beneficial in decreasing the frequency of exacerbations in patients with ABPA complicating asthma. Larger trials are required to confirm our study results.
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Affiliation(s)
- Babu Ram
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ashutosh N Aggarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Sahajal Dhooria
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Inderpaul Singh Sehgal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Mandeep Garg
- b Department of Radiodiagnosis and Imaging , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India , and
| | - Digambar Behera
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Arunaloke Chakrabarti
- c Department of Medical Microbiology , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ritesh Agarwal
- a Department of Pulmonary Medicine , Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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DiMondi VP, Drew RH. Aerosolized Antifungals for the Prevention and Treatment of Invasive Fungal Infections. CURRENT FUNGAL INFECTION REPORTS 2013. [DOI: 10.1007/s12281-013-0137-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tolman JA, Williams RO. Advances in the pulmonary delivery of poorly water-soluble drugs: influence of solubilization on pharmacokinetic properties. Drug Dev Ind Pharm 2010; 36:1-30. [DOI: 10.3109/03639040903092319] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kuiper L, Ruijgrok EJ. A review on the clinical use of inhaled amphotericin B. J Aerosol Med Pulm Drug Deliv 2009; 22:213-27. [PMID: 19466905 DOI: 10.1089/jamp.2008.0715] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Despite the systemic toxicity of amphotericin B (AMB), it still has a place in treatment or prophylactic regimes of fungal infections. METHODS A strategy for minimizing the potential of systemic side effects is to bring it in direct contact with the body site most likely to be infected, such as the administration of AMB as an aerosol. Nebulized amphotericin has been used in humans since 1959. However, due to a lack of sufficient data regarding efficacy, its use is still not established. Little is known about the optimal dose, frequency, duration of administration, and the pharmacokinetics of inhaled AMB in humans. RESULTS AND CONCLUSIONS In this review, published data regarding inhaled AMB are summarized, including available descriptions regarding preparation, dose, efficacy, and toxicity, and its place in therapy is discussed. The results from the studies that were reviewed in this article indicate that inhaled AMB may have a place in the prophylactic regimens of patients with prolonged neutropenia and in lung transplant recipients. Furthermore, nebulized (liposomal) AMB may have a place in the treatment of allergic bronchopulmonary aspergillosis (ABPA) in patients with corticosteroid-dependent ABPA.
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Affiliation(s)
- Laura Kuiper
- Department of Pharmacy, Ikazia Hospital Rotterdam, The Netherlands.
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Tolman JA, Nelson NA, Bosselmann S, Peters JI, Coalson JJ, Wiederhold NP, Williams RO. Dose tolerability of chronically inhaled voriconazole solution in rodents. Int J Pharm 2009; 379:25-31. [PMID: 19524030 DOI: 10.1016/j.ijpharm.2009.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 05/26/2009] [Accepted: 06/03/2009] [Indexed: 11/25/2022]
Abstract
Invasive pulmonary aspergillosis (IPA) is a fungal disease of the lung associated with high mortality rates in immunosuppressed patients despite treatment. Targeted drug delivery of aqueous voriconazole solutions has been shown in previous studies to produce high tissue and plasma drug concentrations as well as improved survival in a murine model of IPA. In the present study, rats were exposed to 20 min nebulizations of normal saline (control group) or aerosolized aqueous solutions of voriconazole at 15.625 mg (low dose group) or 31.25mg (high dose group). Peak voriconazole concentrations in rat lung tissue and plasma after 3 days of twice daily dosing in the high dose group were 0.85+/-0.63 microg/g wet lung weight and 0.58+/-0.30 microg/mL, with low dose group lung and plasma concentrations of 0.38+/-0.01 microg/g wet lung weight and 0.09+/-0.06 microg/mL, respectively. Trough plasma concentrations were low but demonstrated some drug accumulation over 21 days of inhaled voriconazole administered twice daily. Following multiple inhaled doses, statistically significant but clinically irrelevant abnormalities in laboratory values were observed. Histopathology also revealed an increase in the number of alveolar macrophages but without inflammation or ulceration of the airway, interstitial changes, or edema. Inhaled voriconazole was well tolerated in a rat model of drug inhalation.
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Affiliation(s)
- Justin A Tolman
- The University of Texas at Austin College of Pharmacy, Austin, TX, United States
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Tolman JA, Nelson NA, Son YJ, Bosselmann S, Wiederhold NP, Peters JI, McConville JT, Williams RO. Characterization and pharmacokinetic analysis of aerosolized aqueous voriconazole solution. Eur J Pharm Biopharm 2009; 72:199-205. [DOI: 10.1016/j.ejpb.2008.12.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Drew RH. Aerosol and other novel administrations for prevention and treatment of invasive aspergillosis. Med Mycol 2009; 47 Suppl 1:S355-61. [DOI: 10.1080/13693780802247710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Xie Y, Zeng P, Wiedmann TS. Disease guided optimization of the respiratory delivery of microparticulate formulations. Expert Opin Drug Deliv 2008; 5:269-89. [PMID: 18318650 DOI: 10.1517/17425247.5.3.269] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Inhalation of microparticulate dosage forms can be effectively used in the treatment of respiratory and systemic diseases. OBJECTIVE Disease states investigated for treatment by inhalation of microparticles were reviewed along with the drugs' pharmacological, pharmacokinetic and physical chemical properties to identify the advantages of microparticulate inhalation formulations and to identify areas for further improvement. METHODS Microbial infections of the lung, asthma, diabetes, lung transplantation and lung cancer were examined, with a focus on those systems intended to provide a sustained release. CONCLUSION In developing microparticulate formulations for inhalation in the lung, there is a need to understand the pharmacology of the drug as the key to revealing the optimal concentration time profile, the disease state, and the pharmacokinetic properties of the pure drug as determined by IV administration and inhalation. Finally, in vitro release studies will allow better identification of the best dosing strategy to be used in efficacy and safety studies.
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Affiliation(s)
- Yuanyuan Xie
- University of Minnesota, Department of Pharmaceutics, 308 Harvard St SE, Minneapolis, MN 55455, USA
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Abstract
Aerosolized delivery of a number of antimicrobial agents has been studied. Despite a theoretical soundness behind this strategy, full consideration of the potential toxicities associated with this mode of administration is imperative. Aerosolized amphotericin B, as both deoxycholate and lipid formulations, has been studied in a variety of high-risk patient populations for prophylaxis and treatment against fungal infections. Although available data remain inconclusive regarding the clinical efficacy of this therapy, variability among results may be due to lack of standardization of administration methods and doses. Akin to the lack of clinical consensus, data regarding the tolerability of this means of amphotericin B delivery are conflicting. This variability may again be accounted for by the lack of standardized means for aerosolized administration. Owing to uncertain clinical benefit and concern for pulmonary toxicities, the use of aerosolized amphotericin B should be limited to clinical investigations at this time.
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Affiliation(s)
- Stephanie A Knechtel
- Ferris State University, 1000 Oliver Street, Spindler Hall, Kalamazoo, Michigan, USA
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Lowry CM, Marty FM, Vargas SO, Lee JT, Fiumara K, Deykin A, Baden LR. Safety of aerosolized liposomal versus deoxycholate amphotericin B formulations for prevention of invasive fungal infections following lung transplantation: a retrospective study. Transpl Infect Dis 2007; 9:121-5. [PMID: 17461997 DOI: 10.1111/j.1399-3062.2007.00209.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nebulized amphotericin B deoxycholate (AmBd) has been used to prevent invasive pulmonary aspergillosis after lung transplantation. METHODS In this retrospective study we compared the safety and tolerability of nebulized AmBd and nebulized liposomal amphotericin B (L-AmB) in 38 consecutive lung transplant recipients. Progress notes, medication administration records, microbiology, and pulmonary function reports were reviewed. Histologic sections from lung tissue were examined. Plasma amphotericin B levels were measured. RESULTS A total of 1206 doses of AmBd and 1149 doses of L-AmB were administered. Eighteen patients received AmBd only, 11 received L-AmB only, and 9 received the medications sequentially. The total number of complaints vs. the number of doses administered was 1.0% for AmBd-treated patients and 1.2% for L-AmB-treated patients. No differences were observed between the treatment groups on lung biopsy specimens. Plasma amphotericin B levels were <0.2-0.9 microg/mL in AmBd-treated patients and <0.2 microg/mL in L-AmB-treated patients. CONCLUSIONS In lung transplant recipients, both inhaled AmBd and L-AmB were safe and well tolerated over a large number of medication exposures.
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Affiliation(s)
- C M Lowry
- Department of Pharmacy, Brigham & Women's Hospital, Boston, MA 02115, USA
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Husain S, Zaldonis D, Kusne S, Kwak EJ, Paterson DL, McCurry KR. Variation in antifungal prophylaxis strategies in lung transplantation. Transpl Infect Dis 2006; 8:213-8. [PMID: 17116134 DOI: 10.1111/j.1399-3062.2006.00156.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We conducted a survey of 50 lung transplant centers across the world to evaluate the variation in antifungal prophylaxis practices. These 50 centers performed 63% of the world's lung transplants reported in 2001. Eighty-six percent (43/50) of the centers responded to the survey. Sixty-nine percent (30/43) of centers used universal antifungal prophylaxis. Aerosolized amphotericin B deoxycholate (AmBd) alone or in combination with itraconazole was used at 56% (24/43) of centers. The median duration of prophylaxis with aerosolized AmBd and itraconazole was 30 and 90 days, respectively. Seventy-four percent of the centers surveyed agreed to participate in future research prophylaxis protocols, which they felt should include both diagnostic and therapeutic arms. Our survey is the first documentation of the international variation in antifungal prophylactic strategies in lung transplant recipients, and underscores the need for multicenter, randomized trials of antifungal prophylaxis in lung transplant recipients.
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Affiliation(s)
- S Husain
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Leather HL, Wingard JR. Prophylaxis, empirical therapy, or pre-emptive therapy of fungal infections in immunocompromised patients: which is better for whom? Curr Opin Infect Dis 2002; 15:369-75. [PMID: 12130932 DOI: 10.1097/00001432-200208000-00003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Immunocompromised patients are at risk of developing fungal infections. Over time, the incidence of fungal infections and the spectrum of causative organisms have changed. In addition, treatment strategies in this high-risk population have also changed. Traditional approaches (using polyene-based therapy and older azoles), including empirical treatment strategies, have evolved to include prophylaxis in populations at the greatest risk. These strategies, although effective against Candida species, have not really impacted infections caused by Aspergillus spp. With the recent approval of antifungal agents with demonstrated activity against Aspergillus and other mould infections, there is hope for better outcomes in the treatment of established infections. Several agents, with activity against Aspergillus, have been shown to be effective in the empirical setting. The role of these new antifungal agents in the prophylactic setting remains unknown at present, but the potential for reducing Aspergillus infections is promising and requires ongoing study. The other area of significant research in fungal infections has been the search for accurate, non-invasive, rapid diagnostic tests. Over the past year, several publications have indicated that early diagnosis is possible in immunocompromised patients. These new diagnostics have paved the way for a new strategy, called pre-emptive therapy, enabling infected patients to be identified at an earlier stage of infection. This strategy will permit targeted antifungal therapy in those at greatest risk, and will avoid unnecessary, potentially toxic therapy in those not infected. Validations of the various techniques show promise and are reviewed in this paper.
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Affiliation(s)
- Helen L Leather
- Department of Pharmacy, College of Medicine, University of Florida, Gainesville, Florida, USA.
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Abstract
Although the verdict may still be out on the clinical utility of prophylactic administration of amphotericin B, the findings presented by Marra et al. strengthen the argument for its theoretical use by demonstrating that a relatively reproducible range of concentrations can be achieved in the target patient group. Additionally, it was demonstrated that at an inhaled dose of 30 mg, amphotericin B concentrations at the interface of epithelial lining fluid and the lung tissue, the battleground for host invasion, approach therapeutically relevant concentrations. Even though the debate over the utility of aerosolized administration of antimicrobials is far from over, data continue to accumulate that demonstrate the tolerability and describe the characteristics of drug distribution of nebulized amphotericin B. Even with the absence of definitive clinical data, aerosolized administration of amphotericin B may become a viable option for prophylaxis against serious pulmonary fungal infections owing to the severity of disease, lack of serious toxicities associated with this route of administration, and pharmacokinetic and susceptibility data, suggesting a theoretical basis for activity.
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