Antifungal Pharmacotherapy

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1 Interpreting Antifungal Susceptibility Testing: Science or Smoke and Mirrors A. W. F O T H E R G I L L, M A, M B A U N I V E R S I T Y O F T E X A S H E A L T H S C I E N C E C E N T E R S A N A N T O N I O, T E X A S A S S O C I A T E P R O F E S S O R, D E P A R T M E N T O F P A T H O L O G Y T E C H N I C A L D I R E C T O R, F U N G U S T E S T I N G L A B O R A T O R Y Antifungal Pharmacotherapy Current options for the treatment of systemic fungal infections are limited Amphotericin B Nystatin Fluconazole Itraconazole Voriconazole Posaconazole Caspofungin Micafungin Anidulafungin Combinations? Considerable confusion/disagreement regarding appropriate use of these agents Amphotericin B Antifungal Agents Standard Therapy for invasive, lifethreatening fungal infections. Works by attaching to sterols in cell wall Toxic Infusion related: chills, fever, headache Doselimiting nephrotoxicity Clinical efficacy poor in some settings Invasive aspergillosis in immunocompromised 3

2 Amphotericin B Lipid Formulations Chemical Differences from AMB Deoxycholate NONE Advantages Increased daily dose of parent drug High tissue concentration Fewer infusion related side effects Decreased nephrotoxicity Disadvantages Superior clinical efficacy not proven Extremely expensive 4 Amphotericin B Lipid Formulation Use Systemic mycoses, intolerant of or refractory to conventional AMB Renal dysfunction during treatment (Cr>.5) Severe/persistent infusionrelated side effects Disease progression after 500 mg total dose 5 Typically invasive aspergillosis in patients that are severely immunocompromised Azoles Favorable side effect profile Act by inhibition of ergosterol synthesis Ease of administration Limitations: Drug interactions Static rather than cidal activity Emergence of resistance, even during therapy, especially Candida spp. to FLU 6

3 Echinocandins Favorable side effect profile Inhibit fungal cell wall synthesis Glucan synthase inhibitors Broadly active in vitro Generally well tolerated Warning for coadministration with cyclosporine FDA approved for aspergillosis and candidiasis, refractory or AMB/ITRA intolerant 7 Antifungal Susceptibility Testing Methods 8 Macrobroth dilution Microbroth dilution Disk diffusion Agar diffusion Solid agar with wells CLSI (NCCLS) Publications 008 M7A3 Third edition 008 M38A Second edition 004 M44A Approved Standard 9 3

4 Previous Susceptibility Cutoffs for Candida spp. (µg/ml) S SDD I R NS 5FC <4 86 >3 FLU <8 63 >64 ITRA < > VORI < >4 ANID < > CAS < > MICA < > 0 M7A3 Approved Breakpoints Candida albicans, C. tropicalis, C. krusei Time S SDD I R AMB 4 H ANID 4 H < > CAS 4 H < > MICA 4 H < > FLU 4 H <* 4* >8* POS 4 H VORI 4/48 H < > ITRA 4/48 H 5FC 4/48 H *None for C. krusei M7A3 Approved Breakpoints Candida glabrata Time S SDD I R AMB 4 H ANID 4 H < > CAS 4 H < > MICA 4 H < > FLU 4 H <3 >64 POS 4 H VORI 4/48 H ITRA 4/48 H 5FC 4/48 H 4

5 M7A3 Approved Breakpoints Candida parapsilosis, C. guilliermondii Time S SDD I R AMB 4 H ANID 4 H < 4 >8 CAS 4 H < 4 >8 MICA 4 H < 4 >8 FLU 4 H <* 4* >8* POS 4 H VORI 4/48 H <* * >* ITRA 4/48 H 5FC 4/48 H *None for C. guilliermondii Reading MICs 4 AMB No visible growth Azoles/5FC 80% reduction in turbidity (macro) 50% reduction in turbidity (micro) 00% reduction in turbidity (moulds ITRA, POSA, VORI) Echinocandins 50% reduction in turbidity (yeast) Minimum Effective Concentration (mould) Macrobroth Procedure 5 5

6 Microtiter Method 6 Caspofungin: Minimum Effective Concentration (MEC) Growth Control 7 Increasing Concentration of Echinocandin Healthy Point of Transition: MEC Stubby Aberrant Sick Photomicrographs and definition of MEC: Kurtz et al., AAC 38:480, 994 Slide courtesy of John Rex, MD. Disk Diffusion 8 6

7 Provides NCCLS M44A Zone interpretive criteria for FLU & VORI QC ranges for FLU & VORI 9 R SDD S FLU 5µg <4mm 58mm >9mm VORIµg <3mm 46mm >7mm Sensititre Yeast One Panel 0 Etest Technical Manual 7

8 Etest Technical Manual Is Susceptibility Testing a Predictor of Clinical Response? 3 MIC is not a physical or chemical measurement Dependant upon testing variables Host factors are more predictive: Immune response, underlying disease Drainage/removal of infected foci Drug level to site of infection Susceptibility Testing Clinical Utility 4 Low MIC does not predict success High MIC does not predict failure In vitro resistance may select a population less likely to respond to a particular agent Other factors (host, drug) are more important as predictors of outcome Both antibacterial AND antifungal susceptibility testing share these limitations. 8

9 Antimicrobial Susceptibility Testing The 9060 Rule (expected correlation) General rules to guide interpretation of results Infections due to susceptible isolates respond appropriate therapy ~ 90% of the time Infections due resistant isolates (or infections treated with inappropriate therapy) respond ~ 60% of the time 5 to Rex and Pfaller CID 00; 35:989. Trends Toward Resistance? Reported trends toward resistance for azoles 6 Questionable trends toward resistance for candins Are moulds acquiring resistance? Resistance and Breakthrough Infections Antifungal Micafungin Description breakthrough infections among 649 BMT or SOT recipients receiving micafungin prophylaxis ( ) 9 isolates Candida isolates Micafungin MICs elevated: 5 of 7 C. parapsilosis (4 8 μg/ml) 5 of 6 C. glabrata (4 8 μg/ml) of 3 C. tropicalis ( μg/ml) C. glabrata & C. tropicalis crossresistance to caspofungin & anidulafungin (fks gene mutations) Micafungin 93 C. glabrata bloodstream infections (00 00). Resistance increased from 4.9% to.3% Risk factors for echinocandin resistance Solid organ transplantation Prior echinocandin exposure Pfeiffer et al. J Clin Microbiol 00; 48: Alexander et al. Clin Infect Dis 03; 56:

10 Increasing Echinocandin Resistance in C. glabrata Echinocandin resistance increasing in C. glabrata May vary based on region MDRresistance problem Azoles Percent Resistance Candida glabrata Atlanta (4.7%) Baltimore (4.0%) Knoxville (3.4%) Portland (0%) Of 340 isolates tested: 36.% of echinocandinresistant isolates also resistant to fluconazole Pfam et al. J Clin Microbiol 04; 58: Clinical Relevance of Azole / Echinocandin Link? Azole & echinocandin coresistance noted in ICU & nonicu patients with C. glabrata bloodstream isolates No coresistance detected in isolates collected from % of fluconazoleresistant C. glabrata isolates also resistant to one or more echinocandin in those collected from Pfaller et al. J Clin Microbiol 0; 50: Pfaller et al. Int J Antimicrob Agents 0; 38: Azole Resistance in Aspergillus Modification of Target Enzyme A. fumigatus has two distinct genes encoding for 4 demethylase (Cyp5p) Point mutations in CYP5A observed in clinical and laboratory isolates with azole resistance Position of point mutation determines azole resistance Azoles Affected Panazole Voriconazole Itraconazole & posaconazole Cyp5p amino acid changes G38, Y3C, G434C G448 G54, P6L, M0 Mann et al. Antimicrob Agents Chemother 003; 47: 557. Mellado et al. Antimicrob Agents Chemother 004; 48: 747. Howard et al. Emerg Infect Dis 009; 5: Seyedmousavi et al. Drug Resist Updat 04; 7:

11 Environmental Exposure to Azoles Azoleresistant IA identified in patients without prior azole exposure in parts of Europe Indoor environment in hospitals & direct proximity to medical centers Fields where azole fungicides used Tandem repeat in CYP5A promoter point mutation in gene TR 34 /L98H TR 46 /YF/T89A Snelders et al. Appl Environ Microbiol 009; 75: Chowdhary et al. PLoS One 0; 7: e587. van der Linder et al. Clin Infect Dis 03; 57: Chowdhary et al. J Antimicrob Chemother 04; 69: Chowdhary et al. J Antimicrob Chemother 04; 69: 69: Global Azole Resistance TR 3 /L98H & TR 46 /YF/T89A Belgium, Denmark, France, Germany, the Netherlands, Norway, UK, Spain Kuwait Iran China Tanzania India Australia Becoming a global issue Yeasts Antifungal Resistance Candida krusei fluconazole intrinsic Candida albicans fluconazole acquired Candida glabrata fluconazole acquired Candida albicans caspofungin acquired? Candida glabrata caspofungin acquired? Moulds Pseudallescheria boydii amphotericin B intrinsic Fusarium spp. ALL intrinsic Paecilomyces lilacinus amphotericin B intrinsic Aspergillus terreus amphotericin B intrinsic 33

12 Aspergillus fumigatus 34 AMB CAS VORI POSA N=50 N=39 N=48 N=59 MIC 50 MIC Aspergillus terreus 35 AMB CAS VORI POSA N=96 N=33 N=87 N=8 MIC MIC Candida albicans 36 AMB CAS FLU VORI N=385 N=73 N=3 N=780 MIC 50 <0.05 MIC

13 Candida glabrata 37 AMB CAS FLU VORI N=08 N=38 N=535 N=78 MIC MIC Candida lusitaniae 38 AMB CAS FLU VORI N=30 N=88 N=97 N=67 MIC MIC Epidemiological Cutoff Values 39 An endpoint described when there is a lack of clinical data Chosen by taking into account the MIC distribution of a species and the inherent variability in MIC testing methods 3

14 MIC Distribution and ECV for Azoles Against Aspergillus spp. 40 Drug Range µg/ml ECV µg/ml % < ECV Itraconazole Voriconazole Posaconazole RodriguezTudela et al AAC 008;5:4687 ECV for Candins Against Aspergillus spp. 4 Species Drug MEC Mode ECV A. fumigatus ANID MICA A. flavus ANID MICA A. niger ANID MICA A. terreus ANID MICA Pfaller et al, JCM 009; 47:3335 Antifungal Combinations 4 Rationale Expand/enhance the spectrum of activity Synergistic combinations may allow for the administration of lower doses of toxic agents such as amphotericin B 4

15 Checkerboard Dilutions 43 Fractional Inhibitory Concentration An algebraic or geometric determination The MIC of each drug in the combination expressed as a fraction of the MIC for each drug alone 44 MIC A within the CB MIC B within the CB MIC A alone MIC B alone FIC A FIC B = FICI (index) Antifungal Combinations Synergy (FICI = <) 45 A tube or 4fold decrease in the MIC of both drugs Additivism (FICI =.0) A tube or fold decrease in the MIC of either drug Indifference FIC A FIC B = FIC A OR FIC B No change in the MIC as a result of the combination Antagonism (FICI is >.0) An increase In the MIC of either drug as a result of the combination 5

16 Choosing the endpoint I I I I A A A I S A I I 46 Example of Indifference 47 Example of Additivism 48 6

17 Example of Synergism 49 Synergy 50 Examples of Antagonism 5 7

18 Antagonism 5 Antifungal Combinations 53 Theoretical basis for antagonism: Azole & polyene No theoretical basis for antagonism: Azole & 5FC Azole & echinocandin Polyene & 5FC Polyene & echinocandin Echinocandin & 5FC AzolePolyene Interaction 54 Several recently published studies have reported in vivo antagonism of the fungicidal activity of AMB when administered concurrently with FLU or ITRA Sugar et al., JID 998;77:6603 AMBITRA against C. albicans Louie et al., AAC 999;43:837 Louie et al., AAC 999;43:8340 AMBFLU against C. albicans 8

19 AzolePolyene Interaction 55 Discourage concomitant use of AMB and azole antifungals. A more rational approach may be to initiate therapy with AMB and step down to an intravenous or oral azole when appropriate. Summary Antifungal Susceptibility testing offers valuable information to assist with making treatment decisions Trends in resistance remain stable over the last 0 years New methods may make antifungal susceptibility testing routine in the microbiology laboratory 56 Questions? 57 9

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