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Schwarzer P, Blaser F, Sellner M, Rauthe SC, Tandogan T, Tappeiner C, Goldblum D. [Successful Treatment of Therapy-refractory Acanthamoeba Keratitis with Systemic Miltefosine and Topical Voriconazole]. Klin Monbl Augenheilkd 2024; 241:406-408. [PMID: 38653269 DOI: 10.1055/a-2196-6011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Affiliation(s)
| | - Frank Blaser
- Augenklinik und Poliklinik, Universitätsspital, Zürich, Schweiz
| | | | | | - Tamer Tandogan
- Pallas Kliniken AG, Bern und Olten, Schweiz
- Augenklinik, Universitätsklinikum, Heidelberg, Deutschland
| | - Christoph Tappeiner
- Pallas Kliniken AG, Bern und Olten, Schweiz
- Klinik für Augenheilkunde, Universitätsklinikum Duisburg-Essen, Essen, Deutschland
- Unità di Oculistica, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele, Università Vita-Salute, Milano, Italia
- Medizinische Fakultät, Bern, Schweiz
| | - David Goldblum
- Pallas Kliniken AG, Bern und Olten, Schweiz
- Universität Basel, Schweiz
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Affiliation(s)
- Ilya M Sluch
- Central Florida Eye Specialists, DeLand, FL; and
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Yu AC, Myerscough J, Socea S, Furiosi L, Spena R, Bovone C, Busin M. Interface Drainage and Antimicrobial Irrigation Avoid Repeat Keratoplasty for Post-DSAEK Cold Interface Abscess. Cornea 2021; 40:1207-1210. [PMID: 33782265 DOI: 10.1097/ico.0000000000002710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/23/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe a surgical technique for the diagnosis and treatment of post-Descemet stripping automated endothelial keratoplasty (DSAEK) infectious interface keratitis presenting as a cold abscess. METHODS This study included 2 eyes of 2 patients that developed delayed-onset interface infections after DSAEK. Through an anterior keratotomy, diagnostic samples for microbial culture and histopathology examination were collected, and empiric antibiotic therapy was delivered directly to the site of the infection at the graft-host interface. RESULTS In both cases, microbiological examinations confirmed a fungal etiology consistent with Candida. Resolution of infection was achieved, and no signs of posterior segment involvement or recurrence of infection were observed. Both corneas remained clear with final visual acuity of 20/25 and 20/32. No case required additional surgical intervention or repeat keratoplasty after more than 15 months of follow-up. CONCLUSIONS Interface drainage with antimicrobial irrigation may be considered for the management of post-DSAEK interface infections presenting as a peripheral cold abscess. By avoiding intraocular seeding of infectious pathogens, the anterior approach can achieve clinical resolution of infection, maintain visual function, and preserve the DSAEK graft, thereby obviating the need for a therapeutic keratoplasty.
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Affiliation(s)
- Angeli Christy Yu
- University of Ferrara, Department of Morphology, Surgery and Experimental Medicine, Ferrara, Italy
- Ospedali Privati Forlì "Villa Igea", Department of Ophthalmology, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - James Myerscough
- Ospedali Privati Forlì "Villa Igea", Department of Ophthalmology, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
- Southend University Hospital, Southend, United Kingdom; and
| | - Sergiu Socea
- Ospedali Privati Forlì "Villa Igea", Department of Ophthalmology, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
- Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel
| | - Luca Furiosi
- University of Ferrara, Department of Morphology, Surgery and Experimental Medicine, Ferrara, Italy
- Ospedali Privati Forlì "Villa Igea", Department of Ophthalmology, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - Rossella Spena
- University of Ferrara, Department of Morphology, Surgery and Experimental Medicine, Ferrara, Italy
- Ospedali Privati Forlì "Villa Igea", Department of Ophthalmology, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - Cristina Bovone
- University of Ferrara, Department of Morphology, Surgery and Experimental Medicine, Ferrara, Italy
- Ospedali Privati Forlì "Villa Igea", Department of Ophthalmology, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
| | - Massimo Busin
- University of Ferrara, Department of Morphology, Surgery and Experimental Medicine, Ferrara, Italy
- Ospedali Privati Forlì "Villa Igea", Department of Ophthalmology, Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy
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Maertens JA, Rahav G, Lee DG, Ponce-de-León A, Ramírez Sánchez IC, Klimko N, Sonet A, Haider S, Diego Vélez J, Raad I, Koh LP, Karthaus M, Zhou J, Ben-Ami R, Motyl MR, Han S, Grandhi A, Waskin H. Posaconazole versus voriconazole for primary treatment of invasive aspergillosis: a phase 3, randomised, controlled, non-inferiority trial. Lancet 2021; 397:499-509. [PMID: 33549194 DOI: 10.1016/s0140-6736(21)00219-1] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/04/2020] [Accepted: 12/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Voriconazole has been recommended as primary treatment for patients with invasive aspergillosis. Intravenous and tablet formulations of posaconazole that have improved systemic absorption could be an effective alternative to voriconazole. We aimed to assess non-inferiority of posaconazole to voriconazole for the primary treatment of invasive aspergillosis. METHODS We did a randomised, prospective, double-blind, double-dummy, controlled trial comparing posaconazole (intravenous or oral posaconazole 300 mg twice on day 1, followed by 300 mg once a day for days 2-84) with voriconazole (6 mg/kg intravenous or 300 mg oral twice on day 1 followed by 4 mg/kg intravenously or 200 mg orally twice a day for days 2-84) for 12 weeks or less in the primary treatment of invasive aspergillosis. Participants were from 91 study sites in 26 countries, were aged 13 years or older, weighed at least 40 kg, and met criteria for proven, probable, or possible fungal disease. Participants were randomly assigned (1:1) via a computer-generated randomisation schedule with stratification by risk status. The primary endpoint was cumulative all-cause mortality up until day 42 in the intention-to-treat (ITT) population (defined as randomly assigned participants who received ≥1 dose of study drug), with a 10% non-inferiority margin. The ITT population was also evaluated for safety. This study is registered with ClinicalTrials.gov, NCT01782131, and EudraCT, 2011-003938-14. FINDINGS Between Oct 25, 2013, and Sept 10, 2019, of 653 individuals assessed for eligibility, 575 ITT participants were randomly assigned and received one or more doses of study drug (n=288 [50%] posaconazole, n=287 [50%] voriconazole). Mortality up until day 42 was 15% (44 of 288) in the posaconazole group and 21% (59 of 287) in the voriconazole group (treatment difference -5·3% [95% CI -11·6 to 1·0]; p<0·0001). Mortality up until day 42 in the full-analysis-set subpopulation (ITT participants with proven or probable invasive aspergillosis) supported this conclusion: 31 (19%) of 163 participants in the posaconazole group and 32 (19%) of 171 participants in the voriconazole group (treatment difference 0·3% [95% CI -8·2 to 8·8]). The most frequently reported treatment-related adverse events (incidence >3%) were increased aspartate aminotransferase (AST) or alanine aminotransferase (ALT), nausea, hypokalaemia, and vomiting in the posaconazole group and increased ALT, AST, or alkaline phosphatase, hallucination, increased γ-glutamyltransferase peptidase, nausea, and blurred vision in the voriconazole group. The overall incidence of treatment-related adverse event rates in the ITT population was 30% for posaconazole and 40% for voriconazole (treatment difference -10·2% [95% CI -17·9 to -2·4]). INTERPRETATION Posaconazole was non-inferior to voriconazole for all-cause mortality up until day 42 in participants with invasive aspergillosis. Posaconazole was well tolerated, and participants had fewer treatment-related adverse events than in the voriconazole group. This study supports the use of posaconazole as a first-line treatment for the condition. FUNDING Merck Sharp & Dohme, a subsidiary of Merck & Co, Inc.
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Affiliation(s)
- Johan A Maertens
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; Department of Hematology, University Hospitals Leuven, Leuven, Belgium.
| | - Galia Rahav
- Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Alfredo Ponce-de-León
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, México
| | | | - Nikolay Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia
| | - Anne Sonet
- CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Shariq Haider
- Juravinski Hospital and Cancer Center, McMaster University, Hamilton, ON, Canada
| | | | - Issam Raad
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liang-Piu Koh
- National University Cancer Institute, National University Health System, Singapore
| | | | - Jianying Zhou
- Department of Respiratory Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ronen Ben-Ami
- Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mary R Motyl
- Department of Clinical Microbiology, Merck & Co, Inc, Kenilworth, NJ, USA
| | - Seongah Han
- Department of Diabetes/NASH, Merck & Co, Inc, Kenilworth, NJ, USA
| | - Anjana Grandhi
- Department of Biostatistics, Merck & Co, Inc, Kenilworth, NJ, USA
| | - Hetty Waskin
- Department of Infectious Disease, Merck & Co, Inc, Kenilworth, NJ, USA
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Kaur R, Dennison SR, Burrow AJ, Rudramurthy SM, Swami R, Gorki V, Katare OP, Kaushik A, Singh B, Singh KK. Nebulised surface-active hybrid nanoparticles of voriconazole for pulmonary Aspergillosis demonstrate clathrin-mediated cellular uptake, improved antifungal efficacy and lung retention. J Nanobiotechnology 2021; 19:19. [PMID: 33430888 PMCID: PMC7798018 DOI: 10.1186/s12951-020-00731-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/07/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Incidence of pulmonary aspergillosis is rising worldwide, owing to an increased population of immunocompromised patients. Notable potential of the pulmonary route has been witnessed in antifungal delivery due to distinct advantages of direct lung targeting and first-pass evasion. The current research reports biomimetic surface-active lipid-polymer hybrid (LPH) nanoparticles (NPs) of voriconazole, employing lung-specific lipid, i.e., dipalmitoylphosphatidylcholine and natural biodegradable polymer, i.e., chitosan, to augment its pulmonary deposition and retention, following nebulization. RESULTS The developed nanosystem exhibited a particle size in the range of 228-255 nm and drug entrapment of 45-54.8%. Nebulized microdroplet characterization of NPs dispersion revealed a mean diameter of ≤ 5 μm, corroborating its deep lung deposition potential as determined by next-generation impactor studies. Biophysical interaction of LPH NPs with lipid-monolayers indicated their surface-active potential and ease of intercalation into the pulmonary surfactant membrane at the air-lung interface. Cellular viability and uptake studies demonstrated their cytocompatibility and time-and concentration-dependent uptake in lung-epithelial A549 and Calu-3 cells with clathrin-mediated internalization. Transepithelial electrical resistance experiments established their ability to penetrate tight airway Calu-3 monolayers. Antifungal studies on laboratory strains and clinical isolates depicted their superior efficacy against Aspergillus species. Pharmacokinetic studies revealed nearly 5-, 4- and threefolds enhancement in lung AUC, Tmax, and MRT values, construing significant drug access and retention in lungs. CONCLUSIONS Nebulized LPH NPs were observed as a promising solution to provide effective and safe therapy for the management of pulmonary aspergillosis infection with improved patient compliance and avoidance of systemic side-effects.
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Affiliation(s)
- Ranjot Kaur
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Sarah R Dennison
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Andrea J Burrow
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK
| | | | - Rajan Swami
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
| | - Varun Gorki
- Department of Zoology, Panjab University, Chandigarh, India, 160 014
| | - O P Katare
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
| | - Anupama Kaushik
- Dr SSB University Institute Chem Engineering and Technology, Panjab University, Chandigarh, India, 160 014
| | - Bhupinder Singh
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India.
- UGC Centre for Excellence in Nano-Biomedical Applications, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160 014, India.
| | - Kamalinder K Singh
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK.
- UCLan Research Centre for Smarts Materials, University of Central Lancashire, Preston, PR1 2HE, UK.
- UCLan Research Centre for Drug Design and Development, University of Central Lancashire, Preston, PR1 2HE, UK.
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Olum R, Baluku JB, Kazibwe A, Russell L, Bongomin F. Tolerability of oral itraconazole and voriconazole for the treatment of chronic pulmonary aspergillosis: A systematic review and meta-analysis. PLoS One 2020; 15:e0240374. [PMID: 33052954 PMCID: PMC7556473 DOI: 10.1371/journal.pone.0240374] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 09/24/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chronic pulmonary aspergillosis (CPA) requires prolonged treatment with itraconazole or voriconazole. However, adverse events (AEs) are common with the use of these agents, with the need to discontinue the offending drug in a significant proportion of the patients. The aim of this study was to evaluate the frequency of adverse events of itraconazole and voriconazole for the treatment of CPA. METHODS We searched Embase and Medline to select clinical studies providing information on AEs to itraconazole or voriconazole for the treatment of CPA from inception to May 2020. Reviews, single case reports, and case series reporting less than 10 patients were excluded. Random effect meta-analysis was performed using STATA 16.0. RESULTS We included 9 eligible studies with an overall total of 534 CPA patients enrolled. Of these, 69% (n = 366) were treated with voriconazole and 31% (n = 168) with itraconazole. The median daily dose of both itraconazole and voriconazole used was 400mg. In a pooled analysis, AEs were observed in 36% (95% CI: 20-52%, N = 366) of patients on voriconazole and 25% (95% CI: 18 to 31%, N = 168) in those treated with itraconazole. Discontinuation rate due to AEs was the same for both drugs; 35% (47/366) and 35% (15/168) for voriconazole and itraconazole, respectively. There were 70 AEs reported with itraconazole use, the commonest being cardiotoxicity (29%). Skin AEs (28%) were the most frequent among the 204 AEs reported with voriconazole use. None of the studies compared the tolerability of itraconazole head-to-head with voriconazole. CONCLUSIONS AEs due itraconazole and voriconazole are common and may lead to discontinuation of treatment in a significant proportion of patients. This information can be used to educate patients prior to commencement of these antifungal therapies. PROSPERO REGISTRATION NUMBER CRD42020191627.
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Affiliation(s)
- Ronald Olum
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Baruch Baluku
- Department of Programs, MildMay Uganda, Wakiso, Uganda
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Andrew Kazibwe
- The AIDS Support Organisation, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Laura Russell
- Medical Library, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Felix Bongomin
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
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Wang J, Zhou M, Xu JY, Zhou RF, Chen B, Wan Y. Comparison of Antifungal Prophylaxis Drugs in Patients With Hematological Disease or Undergoing Hematopoietic Stem Cell Transplantation: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2020; 3:e2017652. [PMID: 33030550 PMCID: PMC7545296 DOI: 10.1001/jamanetworkopen.2020.17652] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Several antifungal drugs are available for antifungal prophylaxis in patients with hematological disease or who are undergoing hematopoietic stem cell transplantation (HSCT). OBJECTIVE To summarize the evidence on the efficacy and adverse effects of antifungal agents using an integrated comparison. DATA SOURCES Medline, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials were searched to collect all relevant evidence published in randomized clinical trials that assessed antifungal prophylaxis in patients with hematological disease. Sources were search from inception up to October 2019. STUDY SELECTION Studies that compared any antifungal agent with a placebo, no antifungal agent, or another antifungal agent among patients with hematological disease or undergoing HSCT were included. Of 39 709 studies identified, 69 met the criteria for inclusion. DATA EXTRACTION AND SYNTHESIS The outcome from each study was estimated using the relative risk (RR) with 95% CIs. The Mantel-Haenszel random-effects model was used. The reliability and validity of the networks were estimated by addressing inconsistencies in the evidence from comparative studies of different treatments. Data were analyzed from December 2019 to February 2020. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Network Meta-analysis (PRISMA-NMA) guideline. MAIN OUTCOMES AND MEASURES The primary outcomes were invasive fungal infections (IFIs) and mortality. The secondary outcomes were fungal infections, proven IFIs, invasive candidiasis, invasive aspergillosis, fungi-related death, and withdrawal owing to adverse effects of the drug. RESULTS We identified 69 randomized clinical trials that reported comparisons of 12 treatments with at total of 14 789 patients. Posaconazole was the treatment associated with the best probability of success against IFIs (surface under the cumulative ranking curve, 86.7%; mean rank, 2.5). Posaconazole treatment was associated with a significant reduction in IFIs (RR, 0.57; 95% CI, 0.42-0.79) and invasive aspergillosis (RR, 0.36; 95% CI, 0.15-0.85) compared with placebo. Voriconazole was associated with a significant reduction in invasive candidiasis (RR, 0.15; 95% CI, 0.09-0.26) compared with placebo. However, posaconazole was associated with a higher incidence of withdrawal because of the adverse effects of the drug (surface under the cumulative ranking curve, 17.5%; mean rank, 9.2). In subgroup analyses considering efficacy and tolerance, voriconazole might be the best choice for patients undergoing HSCT, especially allogenic HSCT; however, posaconazole was ranked as the best choice for patients with acute myeloid leukemia or myelodysplastic syndrome. CONCLUSIONS AND RELEVANCE These findings suggest that voriconazole may be the best prophylaxis option for patients undergoing HSCT, and posaconazole may be the best prophylaxis option for patients with acute myeloid leukemia or myelodysplastic syndrome.
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Affiliation(s)
- Jing Wang
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- The Pq Laboratory of Micro/Nano BiomeDx, Department of Biomedical Engineering, Binghamton University – SUNY, Binghamton, New York
| | - Min Zhou
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Jing-Yan Xu
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Rong-Fu Zhou
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Bing Chen
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Yuan Wan
- The Pq Laboratory of Micro/Nano BiomeDx, Department of Biomedical Engineering, Binghamton University – SUNY, Binghamton, New York
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Zhou HX, Chen X, Ji HJ. Two methods for therapeutic drug monitoring of voriconazole: act according to circumstances. Eur J Hosp Pharm 2020; 27:248. [PMID: 32587087 PMCID: PMC7335621 DOI: 10.1136/ejhpharm-2020-002290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hua Xiao Zhou
- Department of Nephrology, Yancheng Third people's Hospital, Yancheng, Jiangsu, China
| | - Xin Chen
- Department of Nephrology, Affiliated Yancheng Hospital of Southeast University Medical College, Yancheng, Jiangsu, China
| | - Hong Jian Ji
- School of Pharmacy, The Yancheng Third People's Hospital, Yancheng, Jiangsu, China
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Takatsuka H, Yamazaki S, Watanabe A, Yokoyama I, Suzuki T, Kamei K, Ishii I. Successful treatment of Aspergillus empyema using combined intrathoracic and intravenous administration of voriconazole: A case report. J Infect Chemother 2020; 26:847-850. [PMID: 32414688 DOI: 10.1016/j.jiac.2020.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/06/2020] [Accepted: 03/20/2020] [Indexed: 11/19/2022]
Abstract
Aspergillus empyema is treated with either systemic administration of antifungal drugs or surgery, but the mortality rate is very high. Here, we report a case of Aspergillus empyema successfully treated using combined intrathoracic and intravenous administration of voriconazole (VRCZ). Treatment success was achieved by monitoring VRCZ plasma trough concentration. The patient was a 71-year-old Japanese woman diagnosed with Aspergillus empyema whom we started on intravenous administration of VRCZ. Although penetration of VRCZ into the pleural effusion was confirmed, the level was below 1 μg/mL, which is the minimum inhibitory concentration for Aspergillus fumigatus determined by antifungal susceptibility testing in pleural effusion culture. Therefore, we initiated combination therapy with intrathoracic and intravenous administration of VRCZ. VRCZ 200 mg was first dissolved in 50-100 mL of saline and administered into the thoracic cavity via a chest tube. The chest tube was clamped for 5-6 h, and then VRCZ solution was excreted though the chest tube. When a single dose of the VRCZ was administered into the intrathoracic space, the plasma concentration before intravenous administration increased from 1.45 μg/mL on day 27 to 1.53 μg/mL on day 28. Although intravenous administration was continued, the VRCZ plasma trough concentration decreased to 1.36 μg/mL on day 29. We therefore decided on an intrathoracic administration schedule of 2-3 times a week. Intrathoracic administration was performed 14 times in total until fenestration surgery on day 64. Our case suggests that combined intrathoracic and intravenous administration of VRCZ may be a valid treatment option for Aspergillus empyema.
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Affiliation(s)
| | | | - Akira Watanabe
- Divison of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | | | - Takaaki Suzuki
- Division of Pharmacy, Chiba University Hospital, Japan; Graduate School of Pharmaceutical Sciences, Chiba University, Japan.
| | - Katsuhiko Kamei
- Divison of Clinical Research, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Itsuko Ishii
- Division of Pharmacy, Chiba University Hospital, Japan; Graduate School of Pharmaceutical Sciences, Chiba University, Japan
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Lempers VJ, Meuwese E, Mavinkurve-Groothuis AM, Henriet S, van der Sluis IM, Hanff LM, Warris A, Koch BCP, Brüggemann RJ. Impact of dose adaptations following voriconazole therapeutic drug monitoring in pediatric patients. Med Mycol 2019; 57:937-943. [PMID: 30759261 DOI: 10.1093/mmy/myz006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/08/2019] [Accepted: 01/11/2019] [Indexed: 12/16/2022] Open
Abstract
Voriconazole is the mainstay of treatment for invasive aspergillosis in immunocompromised pediatric patients. Although Therapeutic Drug Monitoring (TDM) of voriconazole is recommended, it remains unknown if TDM-based dose adaptations result in target attainment. Patients <19 years from two pediatric hematologic-oncology wards were retrospectively identified based on unexplained high voriconazole trough concentrations (Cmin > 6 mg/l). Patient demographics, clinical characteristics, treatment, voriconazole dosing information, voriconazole Cmin before and after adjustment based on TDM were obtained. Twenty-one patients, median (range) age 7.0 (1.2-18.5) years, were identified in two centers. First Cmin (3.1 mg/l [0.1-13.5]) was obtained after 3 days (1-27) of treatment. The median of all Cmin (n = 485, median 11 per patient) was 2.16 mg/l (0.0 (undetectable)-28.0), with 24.1% of Cmin < 1 mg/l, 48.9% 1-4 mg/l, 9.3% 4-6 mg/l, and 17.7% > 6 mg/l. Intrapatient variability was large (94.1% for IV, 88.5% for PO). Dose increases at Cmin < 1 mg/l resulted in an increased Cmin in 76.4%, with 60% between 1 and 4 mg/l. Dose decreases at Cmin > 6 mg/l resulted in a decreased Cmin in 80%, with 51% between 1 and 4 mg/l. Overall, in 45% of the cases (33 out of 55 and 12 out of 45) therapeutic targets were attained after dose adjustment. Fifty-five percent of initial Cmin was outside the therapeutic target of 1-4 mg/l, with multiple dose adaptations required to achieve therapeutic concentrations. Only 60% and 51% of dose adaptations following sub- and supra-therapeutic Cmin, respectively, did result in target attainment. Intensive and continuous TDM of voriconazole is a prerequisite for ensuring adequate exposure in pediatric patients.
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Affiliation(s)
- Vincent J Lempers
- Radboud university medical center, Department of Pharmacy and Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Edmé Meuwese
- Erasmus Medical Center, Department of Pharmacy, Rotterdam, The Netherlands
| | | | - Stefanie Henriet
- Radboud university medical center, Department of Pediatric Infectious Diseases & Immunology, Nijmegen, The Netherlands
| | - Inge M van der Sluis
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Erasmus Medical Center-Sophia Children's Hospital, Department of Pediatric Haematology-Oncology, Rotterdam, The Netherlands
| | - Lidwien M Hanff
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Adilia Warris
- MRC Centre for Medical Mycology, Aberdeen Fungal Group, Institute of Medical Sciences, University of Aberdeen, United Kingdom
| | - Birgit C P Koch
- Erasmus Medical Center, Department of Pharmacy, Rotterdam, The Netherlands
| | - Roger J Brüggemann
- Radboud university medical center, Department of Pharmacy and Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
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11
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Resztak M, Kosicka K, Zalewska P, Krawiec J, Główka FK. Determination of total and free voriconazole in human plasma: Application to pharmacokinetic study and therapeutic monitoring. J Pharm Biomed Anal 2019; 178:112952. [PMID: 31708268 DOI: 10.1016/j.jpba.2019.112952] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 01/15/2023]
Affiliation(s)
- Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Str., 60-781 Poznań, Poland.
| | - Katarzyna Kosicka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Str., 60-781 Poznań, Poland.
| | - Paulina Zalewska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Str., 60-781 Poznań, Poland.
| | - Justyna Krawiec
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Str., 60-781 Poznań, Poland.
| | - Franciszek K Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Str., 60-781 Poznań, Poland.
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12
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Abstract
Scedosporium genus as a significant emerging opportunist causes a broad spectrum of disease in not only immunosuppressed but also immunocompetent patients. The lung is one of the most commonly encountered sites of Scedosporium infection. Due to its very high levels of antifungal resistance, surgery has been recommended as an important part in the treatment of pulmonary Scedosporium spp infection, even in immunocompetent cases. However, whether lung surgery could help to reduce the risk of death in immunocompetent patients is not clear.We retrospectively retrieved the records of pulmonary infections with Scedosporium species in immunocompetent patients through a comprehensive literature search. The association of surgery on all-cause mortality was explored using binary logistic regression (BLR). Receiver operating characteristic (ROC) curve analysis was carried out to evaluate the capability of the model.The comprehensive searching strategy yielded 33 case reports and 3 case series in total, with 40 individual patients being included. The overall mortality was 12.50%. The fatality rate was 9.09% (2/22) in cases with surgery and 16.67% (3/18) in cases without surgery (odds ratio, 0.50; 95% confidence interval, 0.07-3.38; P = .48). Consistently, BLR analysis identified no statistical association between surgery and reduced mortality (odds ratio, 1.19; 95% confidence interval, 0.09-15.64; P = .89), after adjusting for age, gender, and antifungal chemotherapy. The area under the ROC curve was 0.88.For immunocompetent patients with pulmonary Scedosporium spp infection, surgical therapy may not be associated with reduced mortality. Surgical excision could be considered but is not imperative in this group of patients.
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13
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Fujioka K, Nagai T, Kinoshita Y, Urushihara M, Hamasaki Y, Shishido S, Kagami S. Successful treatment with voriconazole combined with amphotericin B-liposome for fluconazole-resistant pulmonary cryptococcosis after renal transplantation. CEN Case Rep 2019; 8:261-265. [PMID: 31161376 DOI: 10.1007/s13730-019-00403-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 05/23/2019] [Indexed: 11/26/2022] Open
Abstract
Cryptococcosis is an invasive fungal infection that is common among organ transplant recipients, and it is challenging to treat among these patients because of their immunocompromised status. Fluconazole (FLCZ) is recommended as a first-line treatment modality for pulmonary cryptococcosis in organ transplant recipients. However, cases of FLCZ resistance among Cryptococcus neoformans isolates have been reported from the Asia Pacific region. Previous studies have reported the efficacy of voriconazole (VRCZ) in patients with FLCZ-resistant fungal infections. Herein, we report a case of FLCZ-resistant pulmonary cryptococcosis after renal transplantation that was successfully treated with VRCZ combined with amphotericin B-liposome (L-AMB). The patient was a-23-year-old woman who underwent living-donor kidney transplantation at age 20 years. She has attended our hospital since before for mental retardation, epilepsy, and dilated cardiomyopathy. At age 23 years, she presented to our hospital with fever and cough. She was diagnosed with pulmonary cryptococcosis based on positive-serum cryptococcal antigen. Chest radiography showed bilateral consolidations. Fosfluconazole (F-FLCZ) was administered, and her condition improved. However, she developed cough and fever again on day 60 of hospitalization. Cryptococcosis recurrence was suspected due to the high degree of cryptococcal antigen titers showed (1:2048) taken on the same day. Therefore, L-AMB was added, and F-FLCZ was substituted with VRCZ. Her condition improved, but L-AMB was discontinued due to hyponatremia, hypokalemia, and elevated serum creatinine. This indicates that VRCZ caused the remission. She was discharged after 6 months of admission. In conclusion, this case shows the efficacy of VRCZ combined with L-AMB for refractory pulmonary cryptococcosis.
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Affiliation(s)
- Keisuke Fujioka
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan.
| | - Takashi Nagai
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan
| | - Yukiko Kinoshita
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan
| | - Maki Urushihara
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Shoji Kagami
- Department of Pediatrics, Institute of Biochemical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Tokushima, 770-8503, Japan
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14
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Villanueva-Lozano H, Treviño-Rangel RDJ, Téllez-Marroquín R, Bonifaz A, Rojas OC, Hernández-Rodríguez PA, González GM. In vitro inhibitory activity of sertraline against clinical isolates of Sporothrix schenckii. Rev Iberoam Micol 2019; 36:139-141. [PMID: 31171430 DOI: 10.1016/j.riam.2019.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/31/2018] [Accepted: 01/04/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sertraline (SRT) is an antidepressant that has proven its activity in vitro against Cryptococcus, Coccidioides, Trichosporon and other fungi. Disseminated sporotrichosis, although rare, has a high mortality and its treatment is difficult and prolonged, often relying in combining two or more antifungals. AIMS In our study we evaluate the antifungal activity of SRT, alone and in combination with itraconazole (ITC), voriconazole (VRC) and amphotericin B (AMB), against 15 clinical isolates of Sporothrix schenckii. METHODS We used the broth microdilution method as described by the CLSI to test the susceptibility to antifungals, and the checkerboard microdilution method to evaluate drug interactions. RESULTS The minimum inhibitory concentration (MIC) with SRT was in the range of 4-8μg/ml, while for AMB, VRC and ITC were 0.5-4μg/ml, 0.5-8μg/ml and 0.125-2μg/ml, respectively. In addition, SRT showed synergy with ITC in one strain, mainly additivity with VRC, and indifference with AMB in others. CONCLUSIONS The MIC values with SRT for the isolates studied show the potential role of this drug as an adjuvant in the treatment of sporotrichosis, especially in disseminated or complicated cases.
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Affiliation(s)
- Hiram Villanueva-Lozano
- Department of Microbiology, School of Medicine, Universidad Autonoma de Nuevo Leon, Nuevo Leon, Mexico
| | | | - Ricardo Téllez-Marroquín
- Infectious Diseases Service, Department of Internal Medicine, University Hospital "Dr. José E. Gonzalez", Universidad Autonoma de Nuevo Leon, Nuevo Leon, Mexico
| | - Alexandro Bonifaz
- Dermatology Service & Mycology Department, Hospital General de Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Olga C Rojas
- Department of Microbiology, School of Medicine, Universidad Autonoma de Nuevo Leon, Nuevo Leon, Mexico; Vice-rectory Health Sciences, Department of Basic Science, Universidad de Monterrey, Nuevo Leon, Mexico
| | - Pedro A Hernández-Rodríguez
- Infectious Diseases Service, Department of Internal Medicine, University Hospital "Dr. José E. Gonzalez", Universidad Autonoma de Nuevo Leon, Nuevo Leon, Mexico
| | - Gloria M González
- Department of Microbiology, School of Medicine, Universidad Autonoma de Nuevo Leon, Nuevo Leon, Mexico.
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15
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Haider G, Shamim MS, Khan MF, Bari ME, Enam SA. Pre-operative Voriconazole in patients undergoing surgery for Central Nervous System fungal infections: Special Report. J PAK MED ASSOC 2019; 69:103-107. [PMID: 30623922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Fungal infections of the central nervous system (CNS) are uncommon. Despite several advancements in diagnosis and treatment of these infections, the mortality rates remain high. The current retrospective study was planned to define the demographic and clinical features of patients with CNS fungal infections. Conducted at Aga Khan University Hospital, Karachi, and comprising CNS fungal infections operated between January 2000 and December 2015. The study analysed whether a short course of pre-operative anti-fungal therapy may improve outcomes in these patients. There were 47 cases confirmed on histopathology and/or microbiology. Outcome measures used were Glasgow coma score (GCS), Glasgow outcome score (GOS) and Karnofsky performance score (KPS). The overall 30-day mortality was 20(42.5%). Fungal infections of the CNS can occur in both immune-compromised and immune-competent patients. Early diagnosis, radical surgery, pre-operative anti-fungal therapy for at least 2 weeks, pre- and postoperative Voriconazole therapy results in more favourable outcomes.
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Affiliation(s)
- Ghani Haider
- Section of Neurosurgery, Department of Surgery, Aga Khan University, Karachi. Pakistan
| | | | - Muhammad Faheem Khan
- Section of Neurosurgery, Department of Surgery, Aga Khan University, Karachi. Pakistan
| | - Muhammad Ehsan Bari
- Section of Neurosurgery, Department of Surgery, Aga Khan University, Karachi. Pakistan
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, Aga Khan University, Karachi. Pakistan
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16
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Miao Q, Tang JT, van Gelder T, Li YM, Bai YJ, Zou YG, Wang LL, Shi YY. Correlation of CYP2C19 genotype with plasma voriconazole exposure in South-western Chinese Han patients with invasive fungal infections. Medicine (Baltimore) 2019; 98:e14137. [PMID: 30653146 PMCID: PMC6370172 DOI: 10.1097/md.0000000000014137] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to investigate the correlation between CYP2C19 genotype and dose-adjusted voriconazole (VCZ) trough concentrations (C0/dose).We analyzed the correlation between CYP2C192(681G>A), CYP2C193(636G>A), and CYP2C1917(-806C>T) genetic polymorphisms and the dose-corrected pre-dose concentration (C0/dose) in 106 South-western Chinese Han patients.The frequencies of variant alleles of CYP2C192, 3, and 17 were 29.7%, 4.25%, and 0.92%. For 49.3% of the VCZ samples, the therapeutic window between 1.5 and 5.5 μg/ml was reached. Following the first dose VCZ measurement, in subsequent samples the proportion of VCZ C0 within the therapeutic window increased, suggesting effective therapeutic drug monitoring (TDM) (P = .001). The VCZ C0 was significantly different (P = .010) between patients with normal metabolism (NMs), intermediate metabolism (IMs), and poor metabolism (PMs). The VZC C0/dose was 12.2 (interquartile range (IQR), 8.33-18.2 μg·ml/kg·day), and 7.68 (IQR, 4.07-16.3 μg·ml/kg·day) in PMs and IMs patients, respectively, which was significantly higher than in NMs phenotype patients (4.68; IQR, 2.51-8.87 μg·ml/kg·day, P = .008 and P = .014).This study demonstrated that the VCZ C0/dose was significantly influenced by the CYP2C19 genotype in South-western Chinese Han patients. In this patient population, more over-exposure was observed in patients with a CYP2C19 genotype associated with poor or intermediate metabolism. CYP2C19 genotype-based dosing combined with TDM will support individualization of VCZ dosing, and potentially will minimize toxicity and maximize therapeutic efficacy.
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Affiliation(s)
- Qiang Miao
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jiang-Tao Tang
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Ya-Mei Li
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yang-Juan Bai
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan-Gao Zou
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lan-Lan Wang
- Department of Laboratory Medicine, Research Centre of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yun-Ying Shi
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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17
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Abstract
The oomycete Pythium and the protozoan Acanthamoeba can cause fulminant and recalcitrant keratitis, respectively. These infections are not only sight-threatening but can also threaten the structural integrity of the eye. A high index of suspicion is required to identify Pythium keratitis given its uncommon occurrence. Acanthamoeba keratitis is most commonly associated with contact lens wear. However, its coexistence with Pythium has not been reported. We present the successful management of a case of contact lens-related keratitis, coinfected with Pythium and Acanthamoeba.
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Affiliation(s)
- Anita Raghavan
- Cornea and Refractive Services, Aravind Eye Hospital Coimbatore, Coimbatore, Tamil Nadu, India
| | - Prathyusha Bellamkonda
- Cornea and Refractive Services, Aravind Eye Hospital Coimbatore, Coimbatore, Tamil Nadu, India
| | - Leonel Mendoza
- Microbiology, Michigan State University, East Lansing, Michigan, USA
| | - Ram Rammohan
- Microbiology, Aravind Eye Hospital Coimbatore, Coimbatore, Tamil Nadu, India
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18
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Herbrecht R, Kuessner D, Pooley N, Posthumus J, Escrig C. Systematic review and network meta-analysis of clinical outcomes associated with isavuconazole versus relevant comparators for patients with invasive aspergillosis. Curr Med Res Opin 2018; 34:2187-2195. [PMID: 30022696 DOI: 10.1080/03007995.2018.1502659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Voriconazole, amphotericin B (AmB) formulations, and isavuconazole are all included in guideline recommendations for treatment of patients with invasive aspergillosis (IA) but the relative efficacy of isavuconazole versus AmB formulations has not been directly compared. We aimed to estimate the relative efficacy of isavuconazole compared with AmB deoxycholate (AmB-D), liposomal AmB (L-AmB), and voriconazole for the treatment of patients with proven/probable IA. METHODS Nine literature databases were screened for randomized controlled trials comparing treatments with any of voriconazole, AmB-D, L-AmB and isavuconazole for treatment of proven/probable IA. Articles meeting the criteria were included in a meta-analysis to determine the efficacy of AmB-D, L-AmB and voriconazole relative to isavuconazole based on all-cause mortality (ACM) and overall response using a fixed-effects model. RESULTS Four articles were identified that compared L-AmB with AmB-D (Study 1), standard-dose L-AmB (3-5 mg/kg/day) with high-dose L-AmB (10 mg/kg/day; Study 2), voriconazole with AmB-D (Study 3), and isavuconazole with voriconazole (Study 4). In the network meta-analysis, isavuconazole was statistically superior to AmB-D on both ACM (odds ratio [95% credible intervals] shown as natural log, 1.00 [0.26, 1.74]) and overall response (-1.39 [-2.21, -0.63]). Differences between isavuconazole, and standard-dose L-AmB, high-dose L-AmB and voriconazole were not statistically significant for either ACM (0.18 [-1.17, 1.53], 0.50 [-1.11, 2.13] and 0.32 [-0.19, 0.84], respectively) or overall response (-0.99 [-2.21, 0.29], -0.89 [-2.41, 0.65] and 0.06 [-0.43, 0.57], respectively). CONCLUSIONS This data suggests that the efficacy of isavuconazole for treatment of IA is superior to AmB-D and comparable with both L-AmB and voriconazole.
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Affiliation(s)
- Raoul Herbrecht
- a Département d'Oncologie et d'Hématologie , Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, University of Strasbourg , Inserm, UMR-S1113/IRFAC, Strasbourg , France
| | - Daniel Kuessner
- b Basilea Pharmaceutica International Ltd , Basel , Switzerland
| | | | - Jan Posthumus
- b Basilea Pharmaceutica International Ltd , Basel , Switzerland
| | - Cesar Escrig
- b Basilea Pharmaceutica International Ltd , Basel , Switzerland
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19
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Mangal N, Hamadeh I, Arwood MJ, Cavallari LH, Samant TS, Klinker KP, Bulitta J, Schmidt S. Optimization of Voriconazole Therapy for the Treatment of Invasive Fungal Infections in Adults. Clin Pharmacol Ther 2018; 104:957-965. [PMID: 29315506 PMCID: PMC6037619 DOI: 10.1002/cpt.1012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 11/10/2022]
Abstract
Therapeutic concentrations of voriconazole in invasive fungal infections (IFIs) are ensured using a drug monitoring approach, which relies on attainment of steady-state pharmacokinetics. For voriconazole, time to reach steady state can vary from 5-7 days, not optimal for critically ill patients. We developed a population pharmacokinetic/pharmacodynamic model-based approach to predict doses that can maximize the net benefit (probability of efficacy-probability of adverse events) and ensure therapeutic concentrations, early on during treatment. The label-recommended 200 mg voriconazole dose resulted in attainment of targeted concentrations in ≥80% patients in the case of Candida spp. infections, as compared to only 40-50% patients, with net benefit ranging from 5.8-61.8%, in the case of Aspergillus spp. infections. Voriconazole doses of 300-600 mg were found to maximize the net benefit up to 51-66.7%, depending on the clinical phenotype (due to CYP2C19 status and pantoprazole use) of the patient and type of Aspergillus infection.
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Affiliation(s)
- Naveen Mangal
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
| | - Issam Hamadeh
- Levine Cancer Institute, Department of Cancer Pharmacology, Charlotte, NC
| | - Meghan J. Arwood
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | | | - Kenneth P. Klinker
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL
| | - Jurgen Bulitta
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
| | - Stephan Schmidt
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL
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20
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Veloso DFMC, Benedetti NIGM, Ávila RI, Bastos TSA, Silva TC, Silva MRR, Batista AC, Valadares MC, Lima EM. Intravenous delivery of a liposomal formulation of voriconazole improves drug pharmacokinetics, tissue distribution, and enhances antifungal activity. Drug Deliv 2018; 25:1585-1594. [PMID: 30044149 PMCID: PMC6060385 DOI: 10.1080/10717544.2018.1492046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/13/2018] [Accepted: 06/19/2018] [Indexed: 12/21/2022] Open
Abstract
Voriconazole (VCZ), a triazole with a large spectrum of action is one of the most recommended antifungal agents as the first line therapy against several clinically important systemic fungal infections, including those by Candida albicans. This antifungal has moderate water solubility and exhibits a nonlinear pharmacokinetic (PK) profile. By entrapping VCZ into liposomes, it is possible to circumvent certain downsides of the currently available product such as a reduction in the rate of its metabolization into an inactive form, avoidance of the toxicity of the sulfobutyl ether-beta-cyclodextrin (SBECD), vehicle used to increase its solubility. PKs and biodistribution of VCZ modified by encapsulation into liposomes resulted in improved antifungal activity, due to increased specificity and tissue penetration. In this work, liposomal VCZ resulted in AUC0-24/MIC ratio of 53.51 ± 11.12, whereas VFEND® resulted in a 2.5-fold lower AUC0-24/MIC ratio (21.51 ± 2.88), indicating favorable antimicrobial systemic activity. VCZ accumulation in the liver and kidneys was significantly higher when the liposomal form was used. Protection of the drug from biological degradation and reduced rate of metabolism leads to a 30% reduction of AUC of the inactive metabolite voriconazole-N-oxide (VNO) when the liposomal drug was administered. Liposomal VCZ presents an alternative therapeutic platform, leading to a safe and effective treatment against systemic fungal infections.
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Affiliation(s)
- Danillo F. M. C. Veloso
- Faculty of Pharmacy, Laboratory of Pharmaceutical Technology – FamaTec, Federal University of Goiás, Goiânia, Brazil
| | - Naiara I. G. M. Benedetti
- Faculty of Pharmacy, Laboratory of Pharmaceutical Technology – FamaTec, Federal University of Goiás, Goiânia, Brazil
| | - Renato I. Ávila
- Faculty of Pharmacy, Laboratory of Celullar Toxicology and Pharmacology – FarmaTec, Federal University of Goiás, Goiânia, Brazil
| | | | - Thaísa C. Silva
- Laboratory of Micology, Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, Brazil
| | - Maria R. R. Silva
- Laboratory of Micology, Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, Brazil
| | - Aline C. Batista
- Laboratory of Oral Pathology, Dental School, Federal University of Goiás, Goiânia, Brazil
| | - Marize C. Valadares
- Faculty of Pharmacy, Laboratory of Celullar Toxicology and Pharmacology – FarmaTec, Federal University of Goiás, Goiânia, Brazil
| | - Eliana M. Lima
- Faculty of Pharmacy, Laboratory of Pharmaceutical Technology – FamaTec, Federal University of Goiás, Goiânia, Brazil
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21
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Khalid M, Ali SA. Fungal osteomyelitis in a patient with chronic granulomatous disease: Case report and review of the literature. J PAK MED ASSOC 2018; 68:1387-1390. [PMID: 30317271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Chronic granulomatous disease (CGD) is the most common of the primary immunodeficiency in children. It is caused by single gene defect resulting in dysfunctional nicotinamide adenine dineucleotide phosphate (NADPH) oxidase complex causing recurrent bacterial and fungal infections. Here we present the case of a 9 year old boy who was a known case of CGD since three years of age. He presented with recent history of fever, left sided pain in the scapular region and difficulty in breathing. Chest imaging revealed developing left upper lobe consolidation and erosion of the 3rd posterior rib. The child underwent video assisted thoracoscopic surgery (VATS) and biopsy of the lesion. Histopathology revealed fungal hyphae which were confirmed to be Aspergillus nidulans on staining. He was successfully treated with voriconazole therapy. We will also review the literature on fungal osteomyelitis in CGD patients.
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22
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Oldenburg CE, Prajna NV, Krishnan T, Rajaraman R, Srinivasan M, Ray KJ, O’Brien KS, Glymour MM, Porco TC, Acharya NR, Rose-Nussbaumer J, Lietman TM. Regression Discontinuity and Randomized Controlled Trial Estimates: An Application to The Mycotic Ulcer Treatment Trials. Ophthalmic Epidemiol 2018; 25:315-322. [PMID: 29718751 PMCID: PMC5980795 DOI: 10.1080/09286586.2018.1469156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/20/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE We compare results from regression discontinuity (RD) analysis to primary results of a randomized controlled trial (RCT) utilizing data from two contemporaneous RCTs for treatment of fungal corneal ulcers. METHODS Patients were enrolled in the Mycotic Ulcer Treatment Trials I and II (MUTT I & MUTT II) based on baseline visual acuity: patients with acuity ≤ 20/400 (logMAR 1.3) enrolled in MUTT I, and >20/400 in MUTT II. MUTT I investigated the effect of topical natamycin versus voriconazole on best spectacle-corrected visual acuity. MUTT II investigated the effect of topical voriconazole plus placebo versus topical voriconazole plus oral voriconazole. We compared the RD estimate (natamycin arm of MUTT I [N = 162] versus placebo arm of MUTT II [N = 54]) to the RCT estimate from MUTT I (topical natamycin [N = 162] versus topical voriconazole [N = 161]). RESULTS In the RD, patients receiving natamycin had mean improvement of 4-lines of visual acuity at 3 months (logMAR -0.39, 95% CI: -0.61, -0.17) compared to topical voriconazole plus placebo, and 2-lines in the RCT (logMAR -0.18, 95% CI: -0.30, -0.05) compared to topical voriconazole. CONCLUSIONS The RD and RCT estimates were similar, although the RD design overestimated effects compared to the RCT.
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Affiliation(s)
| | | | | | | | | | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
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23
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Lin X, Li Z, Yan M, Zhang B, Liang W, Wang F, Xu P, Xiang D, Xie X, Yu S, Lan G, Peng F. Population pharmacokinetics of voriconazole and CYP2C19 polymorphisms for optimizing dosing regimens in renal transplant recipients. Br J Clin Pharmacol 2018; 84:1587-1597. [PMID: 29607533 PMCID: PMC6005582 DOI: 10.1111/bcp.13595] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 03/13/2018] [Accepted: 03/18/2018] [Indexed: 12/15/2022] Open
Abstract
AIMS The aims of the present study were to characterize the pharmacokinetics of voriconazole in renal transplant recipients and to identify factors significantly affecting pharmacokinetic parameters. We also aimed to explore the optimal dosing regimens for patients who developed invasive fungal infections. METHODS A total of 105 patients (342 concentrations) were included prospectively in a population pharmacokinetic analysis. Nonlinear mixed-effects models were developed using Phoenix NLME software. Dosing simulations were performed based on the final model. RESULTS A one-compartment model with first-order absorption and elimination was used to characterize voriconazole pharmacokinetics. Population estimates of clearance, volume of distribution and oral bioavailability were 2.88 l·h-1 , 169.3 l and 58%, respectively. The allele frequencies of cytochrome P450 gene (CYP) 2C19*2, *3 and *17 variants were 29.2%, 5.2% and 0.5%, respectively. CYP2C19 genotype had a significant effect on the clearance. Voriconazole trough concentrations in poor metabolizers were significantly higher than in intermediate metabolizers and extensive metabolizers alike. The volume of distribution increased with increased body weight. The oral bioavailability was substantially lower within 1 month after transplantation but increased with postoperative time. Dosing simulations indicated that during the early postoperative period, poor metabolizers could be treated with 150 mg intravenously or 250 mg orally twice daily; intermediate metabolizers with 200 mg intravenously or 350 mg orally twice daily; and extensive metabolizers with 300 mg intravenously twice daily. CONCLUSIONS Using a combination of CYP2C19 genotype and postoperative time to determine the initial voriconazole dosing regimens followed by therapeutic drug monitoring could help to advance individualized treatment in renal transplantation patients with invasive fungal infections.
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Affiliation(s)
- Xiao‐bin Lin
- Department of Pharmacy, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
- Institute of Clinical PharmacyCentral South UniversityChangshaHunan410011China
- Department of Pharmacythe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouGuangdong510080China
| | - Zi‐wei Li
- Department of Pharmacy, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
- Institute of Clinical PharmacyCentral South UniversityChangshaHunan410011China
- Department of PharmacyRuijin Hospital Shanghai Jiaotong University School of MedicineShanghai200025China
| | - Miao Yan
- Department of Pharmacy, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
- Institute of Clinical PharmacyCentral South UniversityChangshaHunan410011China
| | - Bi‐kui Zhang
- Department of Pharmacy, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
- Institute of Clinical PharmacyCentral South UniversityChangshaHunan410011China
| | - Wu Liang
- Beijing Dryas Pharma‐Tech Co. LTD.Beijing100085China
| | - Feng Wang
- Department of Pharmacy, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
- Institute of Clinical PharmacyCentral South UniversityChangshaHunan410011China
| | - Ping Xu
- Department of Pharmacy, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
- Institute of Clinical PharmacyCentral South UniversityChangshaHunan410011China
| | - Da‐xiong Xiang
- Department of Pharmacy, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
- Institute of Clinical PharmacyCentral South UniversityChangshaHunan410011China
| | - Xu‐biao Xie
- Department of Urological Organ Transplantation, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
| | - Shao‐jie Yu
- Department of Urological Organ Transplantation, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
| | - Gong‐bin Lan
- Department of Urological Organ Transplantation, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
| | - Feng‐hua Peng
- Department of Urological Organ Transplantation, the Second Xiangya HospitalCentral South UniversityChangshaHunan410011China
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Wang T, Yan M, Tang D, Xue L, Zhang T, Dong Y, Zhu L, Wang X, Dong Y. Therapeutic drug monitoring and safety of voriconazole therapy in patients with Child-Pugh class B and C cirrhosis: A multicenter study. Int J Infect Dis 2018; 72:49-54. [PMID: 29793038 DOI: 10.1016/j.ijid.2018.05.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The purpose of this study was to investigate the pharmacokinetic profile and safety of voriconazole treatment in patients with Child-Pugh class B and C cirrhosis. METHODS Liver cirrhosis patients who had received the recommended voriconazole maintenance dose (group A) or halved maintenance dose (group B), orally or intravenously, were included. Voriconazole-related adverse events (AEs) were defined according to the Common Terminology Criteria for Adverse Events. RESULTS A total of 110 trough plasma concentrations of voriconazole (Cmin) were measured in 78 patients. There was a significant difference in voriconazole Cmin between group A and group B (Cmin, 6.95±3.42mg/l vs. 4.02±2.00mg/l; p<0.001). No significant difference in voriconazole Cmin between Child-Pugh class B and C cirrhosis patients was observed in either of the two groups. The international normalized ratio and co-medication with a CYP2C19 inhibitor had a significant effect on voriconazole Cmin in group B. The incidence of AEs in group A was 26.5% and in group B was 15.9%, and 87.5% of AEs developed within 7days after starting voriconazole treatment. CONCLUSIONS These results suggest that the recommended dose and halved maintenance dose may be inappropriate in patients with Child-Pugh class B and C cirrhosis due to the high Cmin, and that voriconazole Cmin should be monitored earlier to avoid AEs.
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Affiliation(s)
- Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| | - Miao Yan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Dan Tang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, China.
| | - Ling Xue
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China.
| | - Tao Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| | - Yuzhu Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| | - Li Zhu
- Department of Infectious Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| | - Xinggang Wang
- Department of Pharmacy, Pulmonary Hospital of Lanzhou, Lanzhou 730046, China.
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
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Bongomin F, Harris C, Hayes G, Kosmidis C, Denning DW. Twelve-month clinical outcomes of 206 patients with chronic pulmonary aspergillosis. PLoS One 2018; 13:e0193732. [PMID: 29634721 PMCID: PMC5892866 DOI: 10.1371/journal.pone.0193732] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 02/16/2018] [Indexed: 11/18/2022] Open
Abstract
There is a paucity of evidence surrounding the optimal antifungal therapy for use in chronic pulmonary aspergillosis (CPA) and the duration of therapy remains unclear. We retrospectively evaluated treatment outcomes, including change in quality of life scores (St George’s Respiratory Questionnaire (QoL)), weight and Aspergillus IgG at 6 and 12 months following initiation of therapy in a cohort of 206 CPA patients referred to the UK National Aspergillosis Centre (NAC), Manchester between April 2013 and March 2015. One hundred and forty-two patients (69%) were azole naïve at presentation and 105 (74%) (Group A) were commenced on itraconazole, 27 (19%) on voriconazole, and 10 (7%) were not treated medically. The remainder (64 patients, 31%) had previously trialled, or remained on, azole therapy at inclusion (Group B) of whom 46 (72%) received itraconazole, 16 (25%) voriconazole, and 2 (3%) posaconazole. Initial therapy was continued for 12 months in 78 patients (48%) of those treated; the azole was changed in 62 (32%) patients and discontinued in 56 (29%) patients for adverse reactions (32, 57%), azole resistance (11, 20%), clinical failure (8, 14%) or clinical stability (5, 9%). Azole discontinuation rates were higher in Group B than in Group A (42% vs. 22%, p = 0.003). For all patients who survived, weight increased (median of 62.2Kg at baseline, to 64.8 at 12 months), mean Aspergillus IgG declined from 260 (baseline) to 154 (12 months) and QoL improved from 62.2/100 (baseline) to 57.2/100 (12 months). At 12 months, there was no difference in median survival between Groups A and B (95% vs. 91%, p = 0.173). The rate of emergence of resistance during therapy was 13% for itraconazole compared to 5% for voriconazole. Bronchial artery embolization was done in 9 (4.4%) patients and lobectomy in 7 (3.2%). The optimal duration of azole therapy in CPA is undetermined due to the absence of evidenced based endpoints allowing clinical trials to be undertaken. However we have demonstrated itraconazole and voriconazole are modestly effective for CPA, especially if given for 12 months, but fewer than 50% of patients manage this duration. This suggests extended therapy may be required for demonstrable clinical improvement.
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Affiliation(s)
- Felix Bongomin
- The National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Chris Harris
- The National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Gemma Hayes
- The National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Chris Kosmidis
- The National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- The Manchester Academic Health Service Centre, Manchester, United Kingdom
| | - David W. Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- The Manchester Academic Health Service Centre, Manchester, United Kingdom
- * E-mail:
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Pal RS, Spalgais S, Murar AK, Ojha UC. Invasive Aspergillus Pseudomembranous and Obstructive Tracheo-bronchitis in an Immuno-competent Patient. J Assoc Physicians India 2017; 65:92-93. [PMID: 29322720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A 19 year female, presented with life threatening haemoptysis and cough with minimum expectoration for 3 months. Bronchoscopy showed multiple nodules in airway. The direct microscopy and culture of sputum revealed fungal elements and Aspergillus flavus respectively. Serum Galactomannan was positive. Thus diagnosis of invasive aspergillus tracheo-bronchitis made. She responded to voriconazole. Aspergillus tracheo-bronchitis is a rare form of invasive pulmonary aspergillosis in immuno-competent host. Aspergillus spp in respiratory samples should not be routinely discarded as colonization.
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Abstract
RATIONALE Central nervous system (CNS) aspergillosis has the characteristics of multifocality, polymorphism, and coexistence of pathological types, and missed diagnosis and misdiagnosis frequently occur at the initial stage. The thesis reports a rare case of infant infection of CNS aspergillosis with the first-episode of intracranial hemorrhage. PATIENT CONCERNS An 11-month-old female infant suffered convulsion and coma two days after the onset of fever and emesis. Its cranial computed tomography (CT) displayed subdural hemorrhage in the left tentorium cerebelli and tests indicated normal cerebrospinal fluid (CSF). Three days after being hospitalized, the infant had difficulty breathing and its CT presents consolidation in the right lung. However, treatment with ceftriaxone (ivgtt) had no effect on the baby. DIAGNOSIS The patient's bronchoalveolar lavage fluid (BALF) was cultured into Aspergillus spp, its galactomannan (GM) antigen in CSF counted 3.0, higher than that in BALF which counted 2.6, and cranial magnetic resonance imaging (MRI) revealed multiple ring reinforced tubercles in sulci. Hence it was clinically diagnosed with CNS aspergillosis. INTERVENTIONS Voriconazole for intravenous injection. After the intravenous injection, its trough concentration was 4.2 μg/mL, and it was within the recommended range. OUTCOMES After one week's treatment with voriconazole, the infant's consciousness was improved. Four weeks later, with normothermia and clear consciousness, the patient was discharged. With oral administration of voriconazole up to 16 weeks, its physical state suggests no relapse and cranial MRI indicated disappearance of nodules in sulci. LESSONS CNS aspergillosis with first-episode of intracranial hemorrhage probably leads to misdiagnosis and GM test combined with cranial MRI can augment its accuracy in the early diagnosis.
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Affiliation(s)
- Yang Wang
- Department of Pediatric
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Deyuan Li
- Department of Pediatric
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lina Qiao
- Department of Pediatric
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Fumin Zhao
- Department of Radiology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Liu X, Su H, Tong J, Chen J, Yang H, Xiao L, Hu J, zhang L. Significance of monitoring plasma concentration of voriconazole in a patient with liver failure: A case report. Medicine (Baltimore) 2017; 96:e8039. [PMID: 29049191 PMCID: PMC5662357 DOI: 10.1097/md.0000000000008039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
RATIONALE Invasive pulmonary aspergillosis is associated with significant morbidity and mortality in patients with liver failure. Voriconazole (VRCZ) is recommended as a primary therapeutic agent for the treatment of invasive aspergillosis and metabolized in the liver. Now, data are still lacking on the safety and appropriate dosage of VRCZ in patients with liver failure. Here, we report a representative case of invasive pulmonary fungal infection in a patient with liver failure who was treated with low-dose VRCZ. PATIENT CONCERNS A 21-year-old man, presented with subacute liver failure caused suspected by viral infection, was admitted on June 22, 2014. Liver function was not improved by the treatment of gancicolovir and methylprednisolone. The patient presented with fever, cough, and hyperpyrexia on July 14. Laboratory tests revealed raised neutrophil percentage (82.1%, normal range [NR] 50-70), international normalized ratio (INR) (2.32, NR 0.8-1.2) and levels of serum lactic acid (4.308 mmol/L, NR 0.6-2.2), alanine transaminase (165 U/L,NR 0-40), aspartate transaminase (99 U/L, NR 8-40), and total bilirubin (654 mmol/L, NR 3.4-20.5). Furthermore, CD4+ T cell, CD8+T cell, and B cell count were low (169, 221, and l8/mL, respectively). Sputum smear microscopy for bacteria was negative, but the direct observation for fungal elements was positive. Thoracic CT scan revealed bilateral pulmonary high-density shadow. Sputum cultures were positive 2 days later with the presence of Aspergillus fumigatus. DIAGNOSES Therefore, this patient diagnosed with suspected pulmonary a spergillosis. INTERVENTIONS VRCZ was used on July 15th and its dosage was 400 mg twice on day 1 followed by a maintenance dose of 100 mg twice daily according to drug usage instruction. However, some side effects, such as tremors, lips twitching, and hair loss, occurred. Plasma VRCZ trough concentration was 8.1 mg/mL which was much higher than the recommend level. Therefore, VRCZ dosage was adjusted according to its plasma concentration. VRCZ plasma concentration fluctuated between 2.5 to 4.7 mg/mL when its dosage was 100 mg once daily and side effects disappeared. OUTCOMES VRCZ was administered for 2 months. This patient's symptoms and liver function were improved. A follow-up CT scan performed at the end of VRCZ therapy indicated that the high-density shadow had diminished. LESSONS This case demonstrated that low-dose VRCZ (maintenance dose, 100 mg/day) can achieve effective plasma concentration and reduce side effects without liver damage. We believe that VRCZ is safe to be administered in patients with liver failure, but its plasma concentration should be carefully monitored.
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Saeed A, Alsarkhy A, Asmi MA, Mouzan ME, Hamid Y, Assiri A. Ileocolonic Basidiobolomycosis in a Child: An Unusual Fungal Infection. J Coll Physicians Surg Pak 2017; 27:508-510. [PMID: 28903846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 07/11/2017] [Indexed: 06/07/2023]
Abstract
Systemic basidiobolomycosis is a rare fungal infection caused by Basidiobolus rararum (B. rararum). The clinical presentation is non-specific and is similar to many gastrointestinal conditions such as Crohn's disease (CD). The most consistent findings of basidiobolomycosis are recurrent abdominal pain, weight loss, fever and peripheral eosinophilia. Most of the patients are diagnosed on surgical resection of the involved region along with compatible histopathological findings like transmural inflammation, granulomas with eosinophilic infiltration (Splendore-Hoeppli phenomenon) and more specifically detection of fungal hyphae on fungal stains. Effective and curative treatment for systemic basidiobolomycosis is available, if diagnosed and managed properly in time. We report here a Saudi boy who had ileo-caecal basidiobolomycosis, but diagnosed after a prolonged course of illness.
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Affiliation(s)
- Anjum Saeed
- Department of Pediatric, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
- Prince Abdullah Bin Khalid Celiac Disease Research Chair, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed Alsarkhy
- Department of Pediatric, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mona Al Asmi
- Department of Pediatric, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohammad El Mouzan
- Department of Pediatric, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Yasin Hamid
- Department of Pediatric, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Asaad Assiri
- Department of Pediatric, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
- Prince Abdullah Bin Khalid Celiac Disease Research Chair, King Saud University Medical City, Riyadh, Saudi Arabia
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Uyhazi KE, Kolomeyer AM, Gray IN, Traband A, Kohli AA, O'Brien JM, Maguire AM. Management of Presumed Endogenous Fungal Endophthalmitis in a Child With Acute Lymphoblastic Leukemia. J Pediatr Ophthalmol Strabismus 2017; 54:e42-e46. [PMID: 28665443 DOI: 10.3928/01913913-20170531-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/18/2017] [Indexed: 11/20/2022]
Abstract
The authors describe a case of presumed endogenous fungal endophthalmitis in an immunocompetent pediatric patient with acute lymphoblastic leukemia. A 15-year-old boy with a history of high-risk B-cell acute lymphoblastic leukemia status post-chemotherapy presented with acute changes in vision in his left eye. Fundus examination revealed a white bi-lobed chorioretinal lesion with overlying vitritis and associated subretinal fluid. Magnetic resonance imaging of the brain revealed small ring-enhancing lesions in the right parietal and left occipital lobes. Blood, cerebrospinal fluid, aqueous, and vitreous cultures were all negative. Bone marrow and vitreous cytology were negative for malignant cells. The patient was treated for presumed fungal endophthalmitis with systemic and intravitreal voriconazole, followed by pars plana vitrectomy with intravitreal voriconazole and amphotericin B injections. The chorioretinal lesion resolved and visual acuity recovered to 20/20. Chorioretinal infiltrates in a patient with leukemia may require treatment even in the absence of a definitive diagnostic test result. Intervention should be guided by risk analysis and clinical judgment. [J Pediatr Ophthalmol Strabismus. 2017;54:e42-e46.].
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Imburgia C, Buscemi C, Corrao S. Pulmonary infiltrate with characteristic "reversed halo" and "air crescent" signs. Eur J Intern Med 2017; 41:e3-e4. [PMID: 27979669 DOI: 10.1016/j.ejim.2016.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/07/2016] [Indexed: 01/15/2023]
Affiliation(s)
- Claudia Imburgia
- 2(nd) Internal Medicine Department and Infectious Disease Unit, National Relevance Hospital Trust, ARNAS Civico, Di Cristina e Benfratelli, Palermo, Italy.
| | - Calogero Buscemi
- 2(nd) Internal Medicine Department and Infectious Disease Unit, National Relevance Hospital Trust, ARNAS Civico, Di Cristina e Benfratelli, Palermo, Italy
| | - Salvatore Corrao
- 2(nd) Internal Medicine Department and Infectious Disease Unit, National Relevance Hospital Trust, ARNAS Civico, Di Cristina e Benfratelli, Palermo, Italy; Centre of Research for Effectiveness and Appropriateness in Medicine (CREAM), Biomedical Department of Internal Medicine and Subspecialties [DiBiMIS], University of Palermo, Italy
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32
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Affiliation(s)
- Karim Ladak
- Clinical Fellow, Hospital for Special Surgery, Rheumatology Department, New York, New York, USA
| | - Laurence Rubin
- Professor of Medicine, University of Toronto, Rheumatology Department, Toronto, Canada
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Silva F, Navea D, Saias C, Torres JP, Catalán P, Morales J. [Analysis of voriconazole serum concentrations and safety profile in pediatric oncology patients]. Rev Chilena Infectol 2017; 33:127-34. [PMID: 27314989 DOI: 10.4067/s0716-10182016000200001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 02/22/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Voriconazole (VCZ) serum drug levels (SDL) vary widely and are associated with increased mortality when they are below the therapeutic range for invasive aspergillosis (IA). AIM To describe VCZ SDL in oncology pediatric patients in order to reach adequate concentrations for prophylaxis (≥ 0.5 mg/L) and treatment (≥ 1.0 y 2.0 mg/L) for IA and their relationship with toxicity. PATIENTS AND METHODS Retrospective analysis of VCZ SDL and toxicities recorded in oncology pediatric patients between February 2013 and November 2014. The daily dosage and SDLs were analyzed according to administration route: intravenous (IV) and oral (PO), type of therapy (prophylaxis and treatment) and patient age (< 12 y ≥ 12 years old). RESULTS 112 through levels from 26 patients were analyzed and the average age was 9.3 years-old. The SDL obtained from the IV route were 43.7%. There were more SDL ≥ 0.5 mg/L and ≥ 1.0 mg/L with the IV route than the PO route (p < 0.05). Patients younger than 12-years-old received a higher dosage than those ≥ 12 years old (median 18.6 and 9.2 mg/kg/d, respectively, p < 0.05). To reach SDL ≥ 0,5 mg/L with the PO route, a dosage of 200 mg every 12 hours showed the best results for all patients (80-100% SDL ≥ 0.5 mg/L). With an IV dosage between 14 and 20 mg/kg/day in patients > 12-years-old, 80% of the SDL were ≥ 1 mg/L and ≥ 2 mg/L. In patients younger than 12-year-old, dosages between 8-30 mg/ kg/day showed similar results (50-63% of SDL ≥ 1 mg/L and 36-40% of SDL ≥ 2 mg/L). Eight patients (30.8%) presented an adverse drug reaction and no relationship with the SDL was found. Conclusión: A VCZ standard dosage of 200 mg every 12 hours PO showed the best results for IA prophylaxis in all patients. Patients younger than 12-years-old would require higher dosages than the doses used in this study to attain adequate SDL for IA treatment. No relation with SDL and adverse reactions was found.
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Ceccarelli G, Ghezzi MC, Raponi G, Brunetti G, Marsiglia C, Fallani S, Novelli A, Venditti M. Voriconazole treatment of Candida tropicalis meningitis: persistence of (1,3)-β-D-glucan in the cerebrospinal fluid is a marker of clinical and microbiological failure: A case report. Medicine (Baltimore) 2016; 95:e4474. [PMID: 27495087 PMCID: PMC4979841 DOI: 10.1097/md.0000000000004474] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Infections are still the most common complications of cerebral shunt procedures. Even though fungal etiologies are considered to be rare, they are associated with significant morbidity and mortality. Due to their uncommonness, diagnostic procedures and optimal therapy are poorly defined. We report a case of Candida tropicalis infection of ventriculo-peritoneal cerebrospinal fluid (CSF) shunt in a 49-year-old immune competent male treated with voriconazole (VOR). METHODS Microbiological and CSF markers (1,3-b-D-glucan-BDG) of fungal infection, biofilm production capacity, sensitivity of serial isolates of the pathogen, and the concentration of the antifungal drug have been monitored and related to the clinical course of this infection. RESULTS Despite appropriate treatment with VOR, in terms of adequate achieved CSF drug concentrations and initial effective therapeutic response, loss of VOR susceptibility of the C tropicalis and treatment failure were observed. CONCLUSION Biofilm production of the C. tropicalis isolate might have had a significant role in treatment failure. Of interest, clinical and microbiological unfavorable outcome was anticipated by persistence of BDG in CSF. Rising titers of this marker were associated with relapse of fungal infection.
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Affiliation(s)
- Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases. University of Rome “Sapienza”, Azienda Policlinico Umberto I, Rome
| | - Maria Cristina Ghezzi
- Department of Public Health and Infectious Diseases. University of Rome “Sapienza”, Azienda Policlinico Umberto I, Rome
| | - Giammarco Raponi
- Department of Public Health and Infectious Diseases. University of Rome “Sapienza”, Azienda Policlinico Umberto I, Rome
| | - Grazia Brunetti
- Department of Public Health and Infectious Diseases. University of Rome “Sapienza”, Azienda Policlinico Umberto I, Rome
| | - Carolina Marsiglia
- Department of Public Health and Infectious Diseases. University of Rome “Sapienza”, Azienda Policlinico Umberto I, Rome
| | - Stefania Fallani
- Department of Health Sciences (DSS), Section of Clinical Pharmacology and Oncology, Università degli Studi, Florence, Italy
| | - Andrea Novelli
- Department of Health Sciences (DSS), Section of Clinical Pharmacology and Oncology, Università degli Studi, Florence, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases. University of Rome “Sapienza”, Azienda Policlinico Umberto I, Rome
- Correspondence: Mario Venditti, Department of Public Health and Infectious Diseases, University of Rome “Sapienza”, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy (e-mail: )
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Siafaka PI, Üstündağ Okur N, Mone M, Giannakopoulou S, Er S, Pavlidou E, Karavas E, Bikiaris DN. Two Different Approaches for Oral Administration of Voriconazole Loaded Formulations: Electrospun Fibers versus β-Cyclodextrin Complexes. Int J Mol Sci 2016; 17:282. [PMID: 26927072 PMCID: PMC4813146 DOI: 10.3390/ijms17030282] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 01/24/2016] [Accepted: 02/19/2016] [Indexed: 12/03/2022] Open
Abstract
In this work, a comparison between two different preparation methods for the improvement of dissolution rate of an antifungal agent is presented. Poly(ε-caprolactone) (PCL) electrospun fibers and β-cyclodextrin (β-CD) complexes, which were produced via an electrospinning process and an inclusion complexation method, respectively, were addressed for the treatment of fungal infections. Voriconazole (VRCZ) drug was selected as a model drug. PCL nanofibers were characterized on the basis of morphology while phase solubility studies for β-CDs complexes were performed. Various concentrations (5, 10, 15 and 20 wt %) of VRCZ were loaded to PCL fibers and β-CD inclusions to study the in vitro release profile as well as in vitro antifungal activity. The results clearly indicated that all formulations showed an improved VRCZ solubility and can inhibit fungi proliferation.
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Affiliation(s)
- Panoraia I Siafaka
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, 54 124 Thessaloniki, Greece.
| | - Neslihan Üstündağ Okur
- School of Pharmacy, Department of Pharmaceutical Technology, Istanbul Medipol University, Beykoz, 34810 Istanbul, Turkey.
| | - Mariza Mone
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, 54 124 Thessaloniki, Greece.
| | - Spyridoula Giannakopoulou
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, 54 124 Thessaloniki, Greece.
| | - Sevda Er
- School of Pharmacy, Department of Microbiology, Istanbul Medipol University, Beykoz, 34810 Istanbul, Turkey.
| | - Eleni Pavlidou
- Department of Physics, Aristotle University of Thessaloniki, 54 124 Thessaloniki, Greece.
| | | | - Dimitrios N Bikiaris
- Laboratory of Polymer Chemistry and Technology, Department of Chemistry, Aristotle University of Thessaloniki, 54 124 Thessaloniki, Greece.
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Maertens JA, Raad II, Marr KA, Patterson TF, Kontoyiannis DP, Cornely OA, Bow EJ, Rahav G, Neofytos D, Aoun M, Baddley JW, Giladi M, Heinz WJ, Herbrecht R, Hope W, Karthaus M, Lee DG, Lortholary O, Morrison VA, Oren I, Selleslag D, Shoham S, Thompson GR, Lee M, Maher RM, Schmitt-Hoffmann AH, Zeiher B, Ullmann AJ. Isavuconazole versus voriconazole for primary treatment of invasive mould disease caused by Aspergillus and other filamentous fungi (SECURE): a phase 3, randomised-controlled, non-inferiority trial. Lancet 2016; 387:760-9. [PMID: 26684607 DOI: 10.1016/s0140-6736(15)01159-9] [Citation(s) in RCA: 570] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Isavuconazole is a novel triazole with broad-spectrum antifungal activity. The SECURE trial assessed efficacy and safety of isavuconazole versus voriconazole in patients with invasive mould disease. METHODS This was a phase 3, double-blind, global multicentre, comparative-group study. Patients with suspected invasive mould disease were randomised in a 1:1 ratio using an interactive voice-web response system, stratified by geographical region, allogeneic haemopoietic stem cell transplantation, and active malignant disease at baseline, to receive isavuconazonium sulfate 372 mg (prodrug; equivalent to 200 mg isavuconazole; intravenously three times a day on days 1 and 2, then either intravenously or orally once daily) or voriconazole (6 mg/kg intravenously twice daily on day 1, 4 mg/kg intravenously twice daily on day 2, then intravenously 4 mg/kg twice daily or orally 200 mg twice daily from day 3 onwards). We tested non-inferiority of the primary efficacy endpoint of all-cause mortality from first dose of study drug to day 42 in patients who received at least one dose of the study drug (intention-to-treat [ITT] population) using a 10% non-inferiority margin. Safety was assessed in patients who received the first dose of study drug. This study is registered with ClinicalTrials.gov, number NCT00412893. FINDINGS 527 adult patients were randomly assigned (258 received study medication per group) between March 7, 2007, and March 28, 2013. All-cause mortality from first dose of study drug to day 42 for the ITT population was 19% with isavuconazole (48 patients) and 20% with voriconazole (52 patients), with an adjusted treatment difference of -1·0% (95% CI -7·8 to 5·7). Because the upper bound of the 95% CI (5·7%) did not exceed 10%, non-inferiority was shown. Most patients (247 [96%] receiving isavuconazole and 255 [98%] receiving voriconazole) had treatment-emergent adverse events (p=0·122); the most common were gastrointestinal disorders (174 [68%] vs 180 [69%]) and infections and infestations (152 [59%] vs 158 [61%]). Proportions of patients with treatment-emergent adverse events by system organ class were similar overall. However, isavuconazole-treated patients had a lower frequency of hepatobiliary disorders (23 [9%] vs 42 [16%]; p=0·016), eye disorders (39 [15%] vs 69 [27%]; p=0·002), and skin or subcutaneous tissue disorders (86 [33%] vs 110 [42%]; p=0·037). Drug-related adverse events were reported in 109 (42%) patients receiving isavuconazole and 155 (60%) receiving voriconazole (p<0·001). INTERPRETATION Isavuconazole was non-inferior to voriconazole for the primary treatment of suspected invasive mould disease. Isavuconazole was well tolerated compared with voriconazole, with fewer study-drug-related adverse events. Our results support the use of isavuconazole for the primary treatment of patients with invasive mould disease. FUNDING Astellas Pharma Global Development, Basilea Pharmaceutica International.
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Affiliation(s)
- Johan A Maertens
- Department of Hematology, Universitaire Ziekenhuizen Leuven, KU Leuven, Belgium
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kieren A Marr
- Department of Medicine, John Hopkins University, Baltimore, MD, USA; Department of Oncology, John Hopkins University, Baltimore, MD, USA
| | - Thomas F Patterson
- The University of Texas Health Science Center San Antonio and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Oliver A Cornely
- Department of Internal Medicine, Clinical Trials Centre Cologne, ZKS Köln, Center for Integrated Oncology CIO Köln Bonn, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), German Centre for Infection Research, University of Cologne, Cologne, Germany
| | - Eric J Bow
- Departments of Medical Microbiology and Infectious Diseases, and Internal Medicine, the University of Manitoba, Winnipeg, Canada; Infection Control Services, CancerCare Manitoba, Winnipeg, Canada
| | - Galia Rahav
- The Chaim Sheba Medical Center, Tel-Hashomer, and Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Dionysios Neofytos
- Division of Infectious Diseases, John Hopkins University, Baltimore, MD, USA
| | - Mickael Aoun
- Division of Infectious Diseases, Jules Bordet Institute, Brussels, Belgium
| | - John W Baddley
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Michael Giladi
- Infectious Disease Unit, Tel Aviv Sourasky Medical Center and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Werner J Heinz
- University of Würzburg Medical Center, Würzburg, Germany
| | - Raoul Herbrecht
- Department of Oncology and Hematology, Hôpitaux Universitaires de Strasbourg and Université de Strasbourg, France
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Meinolf Karthaus
- Klinik für Hämatologie und Onkologie, Klinikum Neuperlach, Munich, Germany
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Olivier Lortholary
- Université Paris Descartes, Centre d'Infectiologie Necker Pasteur, Hôpital Necker Enfants Malades, IHU Imagine and Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Vicki A Morrison
- University of Minnesota and Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Ilana Oren
- Infectious Diseases Unit, Rambam Health Care Campus, and the Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Shmuel Shoham
- Department of Medicine, John Hopkins University, Baltimore, MD, USA
| | | | - Misun Lee
- Astellas Pharma Global Development, Northbrook, IL, USA
| | | | | | | | - Andrew J Ullmann
- Julius-Maximilians-University, Department of Internal Medicine II, Infectious Diseases, Würzburg, Germany.
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Motta I, Calcagno A, Baietto L, D'Avolio A, De Rosa FG, Bonora S. A probable drug-to-drug interaction between voriconazole and haloperidol in a CYP2C19 poor metabolizing patient. [corrected]. Infez Med 2015; 23:367-369. [PMID: 26700090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We present a case of Aspergillus fumigatus renal abscess treated with voriconazole. Following haloperidol treatment we observed an unexpected increase in voriconazole--trough concentrations and liver function tests. CYP2C19*2 loss of function allele was stated and the introduction of haloperidol, a weak CYP3A4 inhibitor, probably explains this interaction. [corrected]. Therapeutic drug monitoring and CYP2C19 genotyping may be suggested when administering voriconazole to complex patients.
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Affiliation(s)
- Ilaria Motta
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Lorena Baietto
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | | | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
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El-Sayed Ahmed MM, Almanfi A, Aftab M, Singh SK, Mallidi HR, Frazier OH. Aspergillus Mediastinitis after Orthotopic Heart Transplantation: A Case Report. Tex Heart Inst J 2015; 42:468-70. [PMID: 26504444 DOI: 10.14503/thij-14-4732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 55-year-old woman was admitted for orthotopic heart transplantation. Her medical history was notable for multiple cardiovascular problems, including ischemic cardiomyopathy that necessitated circulatory support with a left ventricular assist device. Five weeks after undergoing orthotopic heart transplantation, she developed Aspergillus calidoustus mediastinitis, for which she underwent a prolonged course of antifungal treatment that comprised (in sequence) posaconazole for 11 days, voriconazole for 10 days, and amphotericin B for 42 days. During this period, she also underwent repeated mediastinal drainage and sternal débridement, followed by sternal wiring and coverage with bilateral pectoralis advancement flaps. Four months postoperatively, she was discharged from the hospital with a successfully controlled infection and a healed sternum. To our knowledge, only 3 previous cases of Aspergillus mediastinitis after orthotopic heart transplantation have been reported in the literature, none of which was Aspergillus calidoustus.
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Cha SA, Kim MH, Lim TS, Kim HH, Chang KY, Park HS, Kim HW, Wie SH, Jin DC. Invasive Primary Colonic Aspergillosis in the Immunocompetent Host without Classical Risk Factors. Yonsei Med J 2015; 56:1453-6. [PMID: 26256995 PMCID: PMC4541682 DOI: 10.3349/ymj.2015.56.5.1453] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/19/2014] [Accepted: 09/22/2014] [Indexed: 11/27/2022] Open
Abstract
Invasive aspergillosis (IA), generally considered an opportunistic infection in immunocompromised hosts, is associated with high morbidity and mortality. IA commonly occurs in the respiratory tract with isolated reports of aspergillosis infection in the nasal sinuses, central nervous system, skin, liver, and urinary tract. Extra-pulmonary aspergillosis is usually observed in disseminated disease. To date, there are a few studies regarding primary and disseminated gastrointestinal (GI) aspergillosis in immunocompromised hosts. Only a few cases of primary GI aspergillosis in non-immunocompromised hosts have been reported; of these, almost all of them involved the upper GI tract. We describe a very rare case of IA involving the lower GI tract in the patient without classical risk factors that presented as multiple colon perforations and was successfully treated by surgery and antifungal treatment. We also review related literature and discuss the characteristics and risk factors of IA in the immunocompetent hosts without classical risk factors. This case that shows IA should be considered in critically ill patients, and that primary lower GI aspergillosis may also occur in the immunocompetent hosts without classical risk factors.
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Affiliation(s)
- Seon Ah Cha
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Mi Hee Kim
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Tae Seok Lim
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Hyun Ho Kim
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Kyung Yoon Chang
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Hoon Suk Park
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea.
| | - Hyung Wook Kim
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Seong Heon Wie
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Dong Chan Jin
- Department of Internal Medicine, School of Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
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Mason NT, Bell GC, Quilitz RE, Greene JN, McLeod HL. Budget impact analysis of CYP2C19-guided voriconazole prophylaxis in AML. J Antimicrob Chemother 2015; 70:3124-6. [PMID: 26233624 DOI: 10.1093/jac/dkv224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 06/26/2015] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The objective of this study was to determine the economic impact of proactive, CYP2C19 genotype-guided voriconazole prophylaxis in AML. METHODS An Excel-based model was created to project the cost of treating a simulated cohort of severely neutropenic AML patients undergoing antifungal prophylaxis. The model compares (i) standard prophylactic dosing with voriconazole and (ii) CYP2C19 genotyping of all AML patients to guide voriconazole dosing and prescribing. RESULTS Based on the model, genotype-guided dosing of voriconazole conservatively spares 2.3 patients per year from invasive fungal infections. Implementing proactive genotyping of all AML patients in a simulated 100 patient cohort is expected to save a total of $41467 or $415 per patient. CONCLUSIONS The model, based on the robust literature of clinical and economic data, predicts that proactive genotype-guided voriconazole prophylaxis is likely to yield modest cost savings while improving patient outcomes. The primary driver of savings is the avoidance of expensive antifungal treatment and extended hospital stays, costing $30 952 per patient, in patients succumbing to fungal infection.
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Affiliation(s)
- Neil T Mason
- H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., MRC-CANCONT, Tampa, FL 33612, USA
| | - Gillian C Bell
- H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., MRC-CANCONT, Tampa, FL 33612, USA
| | - Rod E Quilitz
- H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., FOB-3 BMT PROG, Tampa, FL 33612, USA
| | - John N Greene
- H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., FOB-3 BMT PROG, Tampa, FL 33612, USA
| | - Howard L McLeod
- H. Lee Moffitt Cancer Center, 12902 Magnolia Dr., MRC-CANCONT, Tampa, FL 33612, USA
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Matsumoto K. [Voriconazole dosage optimization in adult patients based on different CYP2C19 genotypes]. Jpn J Antibiot 2015; 68:243-247. [PMID: 26625537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Okazaki T, Shiraishi S, Iwasa N, Kitamura E, Mizutani T, Hanada Y, Yanagihara T. [Extended voriconazole theraphy and long term survival of a patient with invasive central aspergillosis causing stroke]. Rinsho Shinkeigaku 2015; 55:472-477. [PMID: 26041392 DOI: 10.5692/clinicalneurol.cn-000668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Central nervous system (CNS) aspergillosis with stroke has a high mortality and poor prognosis generally. We report a 78-years-old woman with diabetes mellitus, who developed invasive paranasal sinus aspergillosis with the orbital apex syndrome on the right side and cerebral infarction caused by intracranial occlusion of the right internal carotid artery. Based on the presence of a mass lesion in the ethmoid sinus extending to the orbital apex on the right side with cranial CT, the mass lesion was surgically removed and the pathological examination of the surgical specimen revealed aspergillus mold. Immediately after surgery, we initiated treatment with voriconazole 200 mg × 2/day intravenously for 38 days, and then via feeding tube for 86 days until the galactomannan-aspergillus antigen level in the cerebrospinal fluid became negative at 132 days. She is alive now for almost two years without relapse of aspergillosis. There is no definitive guideline for management of patients with CNS aspergillosis concerning the length of drug treatment and the method for monitoring the response for treatment. We believe that measurement of the galactomannan-aspergillus antigen level in the cerebrospinal fluid might be a useful way of monitoring the efficacy of treatment for CNS aspergillosis.
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Liao S, Ge T, Zhu L, Zhao Y, Yang J, Xu G. A pharmacokinetic/pharmacodynamic analysis of a standard voriconazole regimen in different CYP2C19 genotypes by Monte Carlo simulation. Pharmazie 2015; 70:306-309. [PMID: 26062298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the standard voriconazole dosage regimen (maintenance dose was 200 mg bid orally) against Aspergillus infections in different CYP2C19 genotypes from a pharmacokinetic/pharmacodynamic (PK/PD) perspective. METHOD Monte Carlo simulation (MCS) was applied to simulate 5,000 patients by integrating published pharmacokinetic (PK) parameters, variability of PK parameters on CYP2C19 genotypes and microbiological data. RESULTS The standard dosage regimen for poor metabolizers (PM) with Aspergillus infections was effective except A. versicolor, for heterozygous extensive metabolizers (HEM), Aspergillus fumigatus, A. terreus and A. nidulans infections could be treated effectively with the standard dosage regimen; for extensive metabolizers (EM), the standard voriconazole dosage regimen failed to achieve the best outcome for the six Aspergillus spp. Increasing dose (e.g. 300 mg bid) or even changing the antifungal drug was needed for EM and most HEM patients with Aspergillus infection. CONCLUSION Instead of using a standard dosage regimen for all patients, the voriconazole dosage regimen needs to be optimized for patients with different CYP2C19 genotypes.
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Mazzaferri F, Adami I, Tocco P, Cazzadori A, Merighi M, Forni A, Storato S, Ferrari S, Concia E. [Thalamo-mesencephalic aspergillus abscess in a heart transplant subject: a case report and literature review]. Infez Med 2015; 23:51-55. [PMID: 25819052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Cerebral aspergillosis is a rare and highly fatal infection that mainly affects immunocompromised patients. We report on a case of a heart transplanted Caucasian man, who arrived at our hospital because of the onset of diplopy. We performed a broad diagnostic work-up: the brain MRI showed a single ring-enhancing thalamo-mesencephalic area suggestive of abscess lesion; cerebrospinal fluid (CSF) analysis disclosed galactomannan and beta-D-glucan antigens. Thus the antifungal therapy was immediately started. We decided to discontinue the therapy 16 months later because of severe hepatic toxicity, given that the patient was persistently asymptomatic, brain imaging showed a progressive resolution of the abscess area and CSF antigen analysis was persistently negative. The follow-up at three months was unchanged.
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Affiliation(s)
- Fulvia Mazzaferri
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
| | - Irene Adami
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
| | - Pierluigi Tocco
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
| | - Angelo Cazzadori
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
| | - Mara Merighi
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
| | - Alberto Forni
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
| | - Silvia Storato
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
| | - Sergio Ferrari
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
| | - Ercole Concia
- Sezione di Malattie Infettive, Dipartimento di Patologia, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Neurologia Clinica, Dipartimento di Scienze Neurologiche e del Movimento, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico G.B. Rossi; Sezione di Cardiochirurgia, Dipartimento Cardiovascolare e Toracico, Azienda Ospedaliera Universitaria Integrata di Verona, Ospedale Civile Maggiore, Verona, Italy
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Lekhanont K, Nonpassopon M, Nimvorapun N, Santanirand P. Treatment with intrastromal and intracameral voriconazole in 2 eyes with Lasiodiplodia theobromae keratitis: case reports. Medicine (Baltimore) 2015; 94:e541. [PMID: 25674759 PMCID: PMC4602755 DOI: 10.1097/md.0000000000000541] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To report the clinical presentation and the role of intrastromal and intracameral voriconazole injection in the management of rare cases of fungal keratitis caused by Lasiodiplodia theobromae.Two eyes of 2 patients with Lasiodiplodia keratitis unresponsive to topical and oral antifungal medications were included in this study. Diagnosis of Lasiodiplodia keratitis was confirmed by microbiological analysis, including culture-based (case 1 and 2) and DNA sequencing techniques (case 2 only).The first patient presented with multiple satellite lesions and one of these infiltrates spread deeply into the cornea, forming a stromal abscess. Another patient had a large full-thickness corneal infiltrates with several fungal balls in the anterior chamber, requiring a limbus-to-limbus therapeutic penetrating keratoplasty. Despite aggressive topical therapy, the stromal abscess continued to worsen in the first case and recurrent keratitis was observed postoperatively in the second case. Voriconazole 50 μg/0.1 mL was administered intracamerally and intrastromally around the fungal abscess as adjuncts to topical antimycotics in the first case. The second patient who needed therapeutic keratoplasty was treated with an intracameral injection of 50 μg/0.1 mL voriconazole at the end of surgery. Postoperatively, 100 μg/0.1 mL voriconazole was also injected intracamerally after the recurrence of infection was noted in the graft. Reinjections were given 48 hours apart in both cases. After the injections, all corneal and anterior chamber lesions were reduced in size and density and completely resolved within 4 weeks.Intrastromal and intracameral voriconazole injections may offer safe and effective treatment options for L theobromae keratitis.
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Affiliation(s)
- Kaevalin Lekhanont
- From the Department of Ophthalmology (KL, MN, NN); and Department of Pathology (PS), Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Hamada Y, Kawasumi N, Hirai J, Yamagishi Y, Mikamo H. [Evaluation of voriconazole oral dosage in Japan]. Jpn J Antibiot 2014; 67:279-284. [PMID: 25566590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Voriconazole (VRCZ), a broad-spectrum triazole, is served in two dosage forms-injection and oral. VRCZ is difference dosage of oral and intravenous administration writing a medical package insert in Japan. 6 mg/kg intravenous injection (IV) twice daily for first day as initial loading dose, followed by 3-4 mg/kg IV twice daily between meals is recommended. 300 mg orally twice daily for first day as initial loading dose, followed by 150-200 mg orally twice daily between meals is recommended. Patients weighing over 40 kg, 200 mg orally twice daily between meals is recommended. Patients weighing under 40 kg, 100 mg orally twice daily between meals is recommended, increase to 150 mg twice daily if inadequate response. This study evaluated VRCZ trough concentration and oral dosage in the 23 cases which administered VRCZ to analysis for TDM in Aichi University Hospital. Spearman rank correlation coefficient was calculated to examine relationships among variables. The level of statistical significance was set at p=0.05. All data were analyzed and processed on JMP 8 (SAS Institute Japan). There was a significant positive correlation between VRCZ trough concentration and dose/weight (r=0.47 p<0.05). In this result, VRCZ oral dosage is appropriate to administer dose/weight (mg/kg) twice a day as same as IV.
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Affiliation(s)
- Yukihiro Hamada
- Department of Infection Control and Prevention, Aichi Medical University Hospital
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Hu B, Li S, Hu H, Chen T, Guo X, Zhang Z, Dong F, Li Z, Wang Q, Yao K, Liu G. [Central nervous system infection caused by Exophiala dermatitidis in a case and literature review]. Zhonghua Er Ke Za Zhi 2014; 52:620-624. [PMID: 25224242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To summarize the clinical features, imaging characteristics, diagnosis and treatment of a case with central nervous system infection caused by Exophiala dermatitidis, as well as to review the related literature. METHOD Associated literature and clinical data of an 8-year-old boy who was diagnosed as central nervous system infection caused by Exophiala dermatitidis in Beijing Children's Hospital Affiliated to Capital Medical University and hospitalized twice from 2012 to 2014 were analyzed retrospectively. RESULT The boy was 8 years old with the chief complaint of dizziness for 2 months, intermittent fever for 1 month accompanied with spasm twice. He was diagnosed as bile ducts space-occupying lesions 2 years ago, when the pathological diagnosis was fungal infection. The boy was treated with irregular anti-fungal therapy. Then the boy developed nervous symptoms, impaired consciousness and abnormal physical activity that developed gradually. After hospitalization the cerebral MRI of the boy showed space-occupying lesions accompanied with edema of surrounding area. Filamentous fungi was found by brain biopsy, which was culture positive for Exophiala dermatitidis. After diagnosis the boy was treated with amphotericin B (AMB), voriconazole and 5-Fu, as well as symptomatic treatment. The state of the boy was improved gradually. Two months later, the boy could communicate with others normally and move personally. The lesions and edema seen on the MRI was decreased moderately. Accordingly, the boy was treated with oral voriconazole maintenance treatment for about 1 year and 4 months after discharge. During this period, the state of him was stable without symptoms. The lesions shown by MRI did not disappear but decreased on regular examination. However, recently the disease of the boy progressed again, with dizziness, neck pain, headache and progressive nervous symptoms (intermittent spasm, inability to cough, and impaired consciousness). The boy died at last, even with the active treatment at the second hospitalization. Exophiala dermatitidis was culture-positive again in his CSF, and was confirmed by PCR successfully. CONCLUSION The central nervous system infection caused by Exophiala dermatitidis is rare. Clinical features of this disease were similar to those of other fungal CNS infection, cerebral MRI of which could show the similar lumpy lesions. Diagnosis of the disease should be based on pathology and culture.
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Affiliation(s)
- Bing Hu
- Division of Infectious Diseases, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
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Zhuo J, Sun H. [Caspofungin and voriconazole combination therapy for invasive pulmonary aspergillosis in patients with liver failure: a report of two cases]. Zhonghua Gan Zang Bing Za Zhi 2014; 22:239-240. [PMID: 24919229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Bal AM, Shankland GS, Scott G, Imtiaz T, Macaulay R, McGill M. Antifungal step-down therapy based on hospital intravenous to oral switch policy and susceptibility testing in adult patients with candidaemia: a single centre experience. Int J Clin Pract 2014; 68:20-7. [PMID: 24341299 DOI: 10.1111/ijcp.12231] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 06/07/2013] [Indexed: 11/29/2022] Open
Abstract
AIMS Echinocandins are recommended for the treatment of candidaemia in moderately severe to severely ill patients. Step-down or de-escalation from echinocandin to fluconazole is advised in patients who are clinically stable but data in relation to step-down therapy are sparse. Using our hospital intravenous to oral switch therapy (IVOST) policy to guide antifungal de-escalation in patients with candidaemia, we aimed to determine what proportion of patients are de-escalated to fluconazole, the timescale to step-down, associated reduction in consumption of echinocandins and antifungal cost savings. METHODOLOGY Patients with candidaemia were followed from April 2011 to March 2013. RESULTS A total of 37 episodes of candidaemia were documented during the study period. Twenty-seven patients were commenced on an echinocandin or voriconazole and 19 (70.3%) were de-escalated to fluconazole based on the IVOST policy. The mean and median number of days to de-escalation of therapy was 4.6 and 5 days, respectively. One patient whose therapy was de-escalated relapsed. The overall 30 day crude mortality was 37.1%. The step-down approach led to significant saving in antifungal drug cost of £1133.88 per candidaemic episode and £2208.08 per de-escalation. CONCLUSION Implementation of IVOST policy led to streamlining of antifungal therapy.
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Affiliation(s)
- A M Bal
- Department of Microbiology, University Hospital Crosshouse, Kilmarnock, UK
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Baka S, Tsouma I, Kouskouni E. Fatal lower limb infection by Trichosporon asahii in an immunocompetent patient. Acta Dermatovenerol Croat 2013; 21:241-244. [PMID: 24476611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Trichosporon (T.) asahii can cause superficial skin infections and can be an opportunistic pathogen that produces potentially fatal systemic infections in immunocompromised hosts. We report a case of lower limb infection due to T. asahii in an immunocompetent patient who displayed no evidence of underlying disease. There is a strong possibility that our patient had been colonized at the infection site as part of the normal skin flora. After one-month bed rest due to an accidental fall and fracture of the right shoulder blade, a 61-year-old woman experienced severe edema and redness in the right lower limb and received topical treatment with iodine solution and antibiotics without improvement. She presented at our Outpatient Clinic with cellulitis and lymphedema. Samples collected from the affected areas revealed T. asahii and the patient was referred to a hospital for infectious diseases for appropriate therapy. The patient was treated with wound dressings until she was admitted to our intensive care unit when her general condition abruptly deteriorated. Despite in vitro susceptibility results, therapy with liposomal amphotericin and voriconazole could not change the fatal outcome. Nowadays, physicians must suspect this emerging difficult-to-treat fungal pathogen and treatment must start promptly in these infections.
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Affiliation(s)
- Stavroula Baka
- Assist. Prof. Stavroula Baka, MD, 3, Blessa Street, Papagou, 15669 Athens, Greece;
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