Treatment of drug-resistant Aspergillus infection

Triazole antifungals are frontline drugs for the treatment and prophylaxis of infections due to Aspergillus species. Azole resistance is an emerging problem and is associated with treatment failure in several case series. The management of azole-resistant invasive aspergillosis remains a challenge and there are no guidelines with appropriate recommendations. The current clinical practice suggests that liposomal amphotericin B or a combination of voriconazole or posaconazole with an echinocandin may be effective. Although cross-resistance within the azoles seems to be common, the role of azoles in the management of azole-resistant aspergillosis remains unclear, but optimizing drug exposure is critical for treatment success.     

Invasive pulmonary aspergillosis due to Aspergillus lentulus in an adult patient: A case report and literature review

Aspergillus fumigatus is the commonest cause of pulmonary aspergillosis; however, a recently developed molecular genetic technique identified A. lentulus as a sibling species. Most of the isolates were found in solid organ recipients, often associated with a fatal outcome. Moreover, there is concern that A. lentulus has low susceptibility to multiple antifungal agents. Herein, we report an adult immunocompromised patient with proven invasive pulmonary aspergillosis (IPA) caused by A. lentulus, which was identified through molecular genetic analysis. The patient was diagnosed with IPA by bronchoscopy 3 weeks after initiating systemic corticosteroid therapy for anti-neutrophil cytoplasmic antibody-associated vasculitis. The clinical course of IPA due to A. lentulus showed improvement after treatment with the antifungal agent voriconazole. In summary, we report an adult immunocompromised patient without a history of transplantation who was diagnosed with IPA due to A. lentulus successfully treated with voriconazole, and we also report the findings of a literature review on IPA caused by A. lentulus.     

Antifungal prophylaxis following reduced-intensity stem cell transplantation

Reduced-intensity stem cell transplantation (RIST) has been developed to be a novel curative option for advanced hematologic diseases. Its minimal toxicity allows for transplantation in patients with advanced age or with organ dysfunction. Young patients without comorbidity can undergo RIST as outpatients. However, fungal infection remains an important complication in RIST. Given the poor prognosis of fungal infection, prophylaxis is critical in its management. The prophylactic strategy is recently changing with the development of RIST. Hospital equipment is important for fungal prophylaxis; however, the median day for the development of fungal infection is day 100, when most RIST patients are followed as outpatients. The focus of fungal management after RIST needs to shift from in-hospital equipment to oral antifungals. Various antifungals have recently been developed and introduced for clinical use. A major change in antifungal management will probably occur within several years.     

Systematic review and network meta-analysis of clinical outcomes associated with isavuconazole versus relevant comparators for patients with invasive aspergillosis

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.     

临床药师参与处置伏立康唑致血液系统肿瘤患者视觉障碍的临床实践

目的 通过临床药师参与一例血液系统肿瘤并粒细胞缺乏患者长期服用伏立康唑片剂后出现视觉障碍不良反应的临床实践过程,探讨临床药师的服务模式、药学监护内容及临床药师应具备的基础知识和技能.方法 对病例的病史、用药史、当前用药进行全面系统回顾,利用药品不良反应因果关系判别方法分析患者反应与用药间相互关系,考察药物浓度影响因素,提出改进用药的建议.结果 医师接受药学建议,减少合并用药奥美拉唑的剂量以减轻肝药酶抑制,降低对伏立康唑浓度干扰.10 d后患者视觉障碍症状缓解.结论 临床药师应具备灵活运用所学药学知识的能力,能通过独立思考判断与评估用药后可能产生的效益及风险,制定药学监护计划,减少或避免药源性损伤.     

Voriconazole therapeutic drug monitoring: focus on safety

Importance of the field: Voriconazole has been widely used for the treatment of invasive fungal diseases, particularly invasive aspergillosis. Drug–drug interactions are, however, the main drawback associated with voriconazole use, since this drug suffers from extensive hepatic metabolism.

Areas covered in this review: This article reviews the current literature on voriconazole therapeutic drug monitoring, with a special focus on drug safety.

What the reader will gain: An update on voriconazole metabolism, drug interactions, toxicity and the relation of these with voriconazole drug concentrations.

Take home message: Therapy with voriconazole may be better guided by measuring voriconazole concentrations in the plasma.     

Effect of voriconazole on the pharmacokinetics and pharmacodynamics of zolpidem in healthy subjects

AIMS: To assess the effect of voriconazole on the pharmacokinetics and pharmacodynamics of zolpidem. METHODS: In a randomized cross-over study with two phases, 10 healthy subjects ingested 10 mg of zolpidem with or without oral voriconazole pretreatment. The concentrations of zolpidem were measured in plasma up to 24 h and pharmacodynamic variables were monitored for 12 h. RESULTS: Voriconazole increased the peak plasma concentration of zolpidem by 1.23-fold [P < 0.05; 90% confidence interval (CI) 1.05, 1.45] and the area under the plasma zolpidem concentration-time curve by 1.48-fold (P < 0.001; 90% CI 1.29, 1.74). The time to peak plasma zolpidem concentration was unchanged by voriconazole but the half-life was prolonged from 3.2 to 4.1 h (P < 0.01; 95% CI on the difference 0.27, 1.45). The pharmacodynamics of zolpidem were unaffected by voriconazole. CONCLUSION: Voriconazole caused a moderate increase in exposure to zolpidem in healthy young subjects but no clear pharmacodynamic changes were observed between the groups.     

Monitoring plasma voriconazole levels may be necessary to avoid subtherapeutic levels in hematopoietic stem cell transplant recipients

BACKGROUND: Low voriconazole levels have been associated with a higher failure rate in patients with confirmed fungal infections. METHODS: Steady-state plasma trough voriconazole levels were measured after at least 5 days of therapy in 87 patients with hematologic malignancies on 201 separate occasions (1-5 levels per patient; median, 2). Most patients (90%) had undergone allogeneic hematopoietic stem cell transplantation. The daily voriconazole dose, administered in 2 divided doses, was 200 mg (n = 4), 400 mg (n = 151), 500 mg (n = 20), 600 mg (n = 18), and 800 mg (n = 8); corresponding to 2.0-16.3 (median, 5.4) mg/kg. Plasma voriconazole levels were 0-12.5 microg/mL (median, 1.2). Voriconazole was undetectable (<0.2 mug/mL) in 15%. RESULTS: The correlation between dose and levels was weak (r = 0.14; P = .045). The median absolute daily drug dose (400 mg) was identical in groups of patients with levels of 0, 0.2 to 0.5, >0.5 to 2.0, >2.0 to 5.0, and >5.0. Whereas the daily drug dose in mg/kg was significantly higher when the levels were >5.0 microg/mL, there was no consistent relation between dose and level below that threshold. In adult patients getting standard doses of voriconazole orally, the drug levels are highly variable. Based on limited available data, between a quarter and two-thirds of these levels could potentially be associated with a lower likelihood of response or a higher likelihood of failure. CONCLUSIONS: Future voriconazole studies should incorporate prospective therapeutic drug monitoring and consideration should be given to checking levels in patients receiving the drug for confirmed, life-threatening fungal infections.     

Antifungal Prophylaxis with Voriconazole or Itraconazole in Lung Transplant Recipients: Hepatotoxicity and Effectiveness

Invasive fungal infections (IFI) are common after lung transplantation and there are limited data for the use of antifungal prophylaxis in these patients. Our aim was to compare the safety and describe the effectiveness of universal prophylaxis with two azole regimens in lung transplant recipients.
This is a retrospective study in lung transplant recipients from July 2003 to July 2006 who received antifungal prophylaxis with itraconazole or voriconazole plus inhaled amphotericin B to compare the incidence of hepatotoxicity. Secondary outcomes include describing the incidence of IFI, clinical outcomes after IFI and mortality.
Sixty-seven consecutive lung transplants received antifungal prophylaxis, 32 itraconazole and 35 voriconazole and inhaled amphotericin B. There were no significant differences between groups in the acute physiology and chronic health evaluation (APACHE) score at the time of transplantation, demographic characteristics, comorbidities and concomitant use of hepatotoxic medications. Hepatotoxicity occurred in 12 patients receiving voriconazole and inhaled amphotericin B and in no patients receiving itraconazole (p < 0.001). There was no significant difference between groups with regard to the percentage of transplants with IFI, but one case of zygomycosis occurred in a transplant treated with voriconazole. Voriconazole prophylaxis after lung transplantation was associated with a higher incidence of hepatotoxicity and similar clinical effectiveness when compared to itraconazole.     

HPLC-MS/MS法测定伏立康唑的血药浓度及其在生物等效性研究中的应用

目的建立测定人血浆中伏立康唑的高效液相色谱-串联质谱法（HPLC-MS/MS）,研究2种伏立康唑片的相对生物利用度。方法血浆样品经酸化后用甲醇沉淀蛋白,经Waters Atlantis C18柱分离,流动相为乙腈-0.2%冰醋酸水溶液（内含20 mmol.L-1醋酸铵）（60∶40,v/v）,流速为0.2 mL.min-1;选择多反应离子检测（MRM）方式进行定量分析,用于监测的离子为质荷比m/z350.9→281.4（伏立康唑）和m/z307.9→220.3（内标氟康唑）。18名健康志愿者以随机交叉方式分别单次口服伏立康唑分散片T或伏立康唑片R 0.2 g后于不同时间点取血,样品以新建立的HPLC-MS/MS法测定,研究比较两制剂的药动学及相对生物利用度。结果伏立康唑与血浆中内源性杂质分离度好,伏立康唑浓度在27.35~3 500 ng.mL-1与峰面积比线性良好,最低定量浓度为27.35ng.mL-1。蛋白沉淀绝对回收率为86.2%~88.8%,相对回收率为97.9%~105.7%,日内精密度（RSD）〈9.8%,日间精密度（RSD）〈9.4%。单剂量口服伏立康唑分散片T和伏立康唑片R 0.2 g后2种制剂的Cmax为（717.9±325.1）、（671.8±243.3）μg.L-1;tmax为（1.1±0.5）、（1.1±0.4）h;AUC0~24为（3 729.1±1 887.7）、（3 811.2±1 836.6）μg.h.L-1;t1/2为（6.7±1.9）、（6.7±1.7）h。与R相比,T制剂相对生物利用度为（97.3±13.0）%。结论该方法简单快速,灵敏度高,可用于伏立康唑的体内过程研究。方差分析表明伏立康唑分散片T与伏立康唑片R中伏立康唑的主要药动学参数之间均无明显差异,双单侧t检验结果表明两制剂为生物等效制剂。