Ontwikkeling en validatie van een hoge druk
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Transcript Ontwikkeling en validatie van een hoge druk
Pharmacotherapy of
antifungal drugs
Isabel Spriet
Pharmacy Dpt, UZ Leuven
The fungal ‘players’
Opportunistic fungi
– Normal flora
Candida spp.
– Ubiquitious in our environment
Aspergillus spp.
Cryptococcus spp.
Mucor spp.
Newly emerging fungi
- Fusarium
- Scedosporium
Endemic geographically restricted
- Blastomyces spp.
- Coccidiodes spp.
- Histoplasma spp.
Invasive fungal infections Incidence
Solid organ transplant: 5-42%
Bone marrow transplant: 15-25%
ICU: 17%
Singh N. Clin Infect Dis 2000;31:545-53
Vincent JL. Intens Care Med 1998; 24:206-216
Candidemia – Mortality rate
Pathogen
% Isolated
% Mortality
CNS
31.9
21
S aureus
15.7
25
Enterococci
11.1
32
Candida spp.
7.6
38
E. Coli
5.7
24
Klebsiella spp.
5.4
27
Enterobacter spp.
4.5
28
Pseudomonas spp.
4.4
33
Serratia spp.
1.4
26
S. viridans
1.4
23
Hospital acquired pathogens and their associated mortality
Edmond et al. CID 1999; 29:239-44.
Invasive Aspergillosis – Mortality Rate
Review of 1941 Patients from 50 Studies
Case Fatality Rate (%)
100
80
60
40
20
0
Overall (1941)
BMT (285)
Leuk/Lymph (288)
Pulm (1153)
CNS/Dissem (175)
Lin S-J et al, CID 2001; 32:358-66
Risk factors for fungal disease
Candidiasis
Aspergillosis
-Broad
-Granulocytopenia
-Decreased neutrophil number
-Decreased function
-T-cell dysfunction
-Hematologic malignancies
-Organ allograft recipients
-Immunosuppressants
-Corticosteroids
-AIDS
spectrum antibiotics
-Intravascular catheters
-Abdominal surgery
-Neoplastic diseases
-Chemotherapy
-Immunosuppressants
Fungal infections today
A major change in the
occurence,
diagnosis and
management
of invasive fungal infections has arisen in
the recent years.
Licensed antifungals:
a dynamic drug class
To be expected:
Posaconazole
isovuconazole – anidulafungin –
micafungin …
Voriconazole
Caspofungin
Lipid amphotericin
products
Itraconazole
Fluconazole
Ketoconazole
Amphotericin B
1950
1960
Flucytosine
1970
1980
1990
2000
Outline
Product Overview
Spectrum
Therapeutic indications
Recommended dosages
Pharmacokinetics
Pharmacokinetic difficulties and problems
Tolerability and safety
Therapeutic drug monitoring?
An ideal antifungal agent has…
Broad spectrum of activity (yeasts and moulds)
Rapidly and highly fungicidal, stable to resistance
Potent in vivo activity (even in neutropenia)
Good pharmacokinetics (AUC)
Both oral and parenteral formulations
Good penetration into all tissue compartments
Low toxicity, minimal drug-drug interactions
Cost effective
Polyenes
Amphotericin B
Target: fungal cell membrane
Ampho B binds ergosterol in the cell membrane
• depolarisation: leakage of monovalent and divalent cations
cell death
• stimulates host immune response
Amphotericin B
Spectrum and Recommended dosage
Spectrum:
– very broad range of activity: most Candida and Aspergillus spp.
– active against most fungi except A. terreus, Fusarium spp.
Fungicidal
Amphotericin B: 1 mg/kg IV (after a test dose of 1 mg)
Lipid-based Amphotericin B
– amphotericin B Lipid Complex: 5 mg/kg IV
– liposomal amphotericin B: 3 mg/kg IV
Amphotericin B
Pharmacokinetics
Low oral bioavailability: only IV administration
Extensive distribution
– High concentrations in liver, spleen, bone marrow
No metabolism
Renal excretion
– Halflife: about 5 days
Amphotericin B
Tolerability and Safety
chills, rigors, fever (during infusion)
nausea, vomiting
cardio/respiratory reactions
phlebitis
can be explained by mode of action: ampho B
stimulates host immune response with release of
inflammatory cytokines
Amphotericin B
Tolerability and Safety
Nephrotoxicity: incidence: 49-65%
Hypokalemia
can be explained by mode of action: ampho B binds cholesterol
in distal tubular membrane leading to wasting of Na+, K+ and
Mg++
Amphotericin B
Tolerability and Safety
Nephrotoxicity has been shown to significantly increase:
• Length of hospital stay
• Treatment costs
Prevention of nephrotoxicity
•
•
•
•
•
Fluids: saline, sodium bicarbonate
Low-dose vasoconstrictors (e.g. dopamine)
Alternate day dosing
Infusion rates (conventional ampho B: at least 6 hrs)
Lipid formulations
Bates DW. CID 2001; 32: 686-93.
Cagnoni PJ. J Clin Oncol 2000; 18: 2476-83.
Greenberg RN. J Med Economics 2002; 2: 109-18.
Azoles
The azoles
Target: fungal cell membrane
Azoles inhibit ergosterol synthesis by inhibiting 14-α-demethylase
toxic sterol intermediates accumulate in the cell membrane leading to
enhanced cellular permeability and inhibition of fungal growth
Inhibits also human
CYP450-dependent
enzymes playing an
important role in
human hormone
synthesis or drug
metabolism
DRUG
INTERACTIONS!!!
Fluconazole
Fluconazole
Spectrum, therapeutic indications, dosage
Spectrum: Candida spp. except C. krusei (C. glabrata:
reduced susceptibility), Cryptococcus spp.
Indications and dosage:
Prophylaxis in neutropenic patients: fluco 200 mg
Treatment of Candida-infections:
Candidemia in nonneutropenic patients
Fluco 400 mg + remove IV catheter
! C. glabrata-I: fluco 800 mg
! C. glabrata-R: caspofungin
Invasive candidiasis
(intra-abdominal/
postoperative)
Fluco 400 mg (+ surgical drainage)
Alternative caspofungin 70/50 mg IV
Charlier C. JAC 2006; 57:384-410.
Fluconazole
Pharmacokinetics
Bio-availability
- > 90%
- not dependent of gastric pH or food: IV-PO switch
possible!
Distribution
-
Metabolism
-
Excretion
-
extensive: Vd 0.7-1.0 L/kg
- protein binding: 11%
- CSF levels: 70% of plasma levels
- good penetration in bone
not metabolised
60-75% glomerular filtration: dose adjustments in
decreased renal clearance
- 8-10% feces
- halflife: 27-34 hrs: OD administration, LD required
- removed by dialysis
Charlier C. JAC 2006; 57:384-410.
Fluconazole
Pharmacokinetics
Pharmacokinetic problems?
Majority unchanged renal excretion
glomerular filtration+ tubular reabsorption
Dose adjustments in severe renal failure
Removed by dialysis: 100 mg extra dose after IHD
Drug interactions:
Inhibits CYP2C9, CYP2C19 and CYP3A4
cyclosporin – nephrotoxicity: TDM
midazolam: excessive sedation
phenytoin: TDM
tacrolimus – nephrotoxicity, neurotoxicity: TDM
warfarin: INR
Rifampicin induces fluconazole metabolism:
increase fluco dose with 25%
Charlier C. JAC 2006; 57:384-410.
Fluconazole
Tolerability and Safety
Generally very well tolerated: no adverse events
Side effects only occur in high doses (>400 mg/day)
– Common: headache, nausea, abdominal pain
– Elevated AST/ALT levels: generally mild
Reported in 10% of leukemia patients with fluco prophylaxis
Reported in 20% of ICU patients with fluco prophylaxis
– Rare: case reports of fulminant hepatitis
– Very rare:
neurotoxicity (high doses > 1200 mg/day),
prolongation of the QT interval
Charlier C.
JAC 2006; 57:384-410.
Fluconazole
Therapeutic drug monitoring?
No routine indications for measuring fluco levels
- Predictable fluconazole PK and serum concentrations
Charlier C. JAC 2006; 57:384-410.
Voriconazole
Voriconazole
Spectrum of activity
Invasive aspergillosis
• fungicidal activity as great as ampho B
Invasive candidiasis
• C. glabrata?
Fusarium, Penicillium, Scedosporium
Cryptococcus
• in vitro activity > flucytosine or fluconazole
! Zygomycetes: resistant to voriconazole
• Breakthrough infections
Mashmeyer G et al. Future Microbiol 2006; 1: 365-85.
Voriconazole
Recommended dosage
Loading dose: 2 x 6mg/kg
Maintenance dose: 2 x 4 mg/kg
• Infusion over 1hr
Adult Patients < 40 kg
• Loading dose idem
• Maintenance dose: 2 x 2 mg/kg or 2 x 100 mg
Child A and B cirrhosis (Child C: no data)
• Loading dose idem
• Maintenance dose: 2 x 2 mg/kg or 2 x 100 mg
Children (2-12 yrs)
• 2 x 7 mg/kg
Voriconazole
Pharmacokinetics
Bio-availability
96%
Steady state
-
Distribution
-
Metabolism
-
extensive (Vd: 4.6 L/kg)
- CSF concentration: 50% of plasma concentration:
dosage increase by 50%
- protein binding 58%
-
Elimination
5-6 days
loading dose necessary!
CYP2C9, CYP2C19, CYP3A4
major metabolite (72%): N-oxide
-80%
via urine
-20% via feces
Voriconazole
Pharmacokinetics
Voriconazole serum levels: high interindividual variability!
!Difficult pharmacokinetics!
Non-linear kinetics: saturable metabolism!
Disproportional increase in plasma levels if dosage increased
Half-life = dose dependent
In children: linear pharmacokinetics: higher metabolising capacity
– Dosage 7 mg/kg bid
Genetic polymorphism CYP2C19
3 genotypes: extensive metabolizers, heterozygous extensive
metabolizers, poor metabolizers
PM especially in Asian population: 18-23%
PM in Caucasion population: 3-5%
Plasma levels up to 2-fold (HEM) or 4- fold (PM) higher!
Purkins L et al. AAC 2002; 46:2546-53.
Voriconazole
Pharmacokinetics
Extensive CYP-metabolism: drug interactions!
Other drugs affecting voriconazole plasma levels
– Contra-indicated with potent inducers
Rifampicin, ritonavir, carbamazepine, phenobarbital
– Dose adjustments needed if combined with phenytoin (5
mg/kg bid)
Voriconazole affecting plasma levels of others (inhibition)
– Contra-indicated with sirolimus, terfenadines, astemizole,
cisapride, …
– Dose adjustments needed if combined with
Cyclosporin (- 50% ): if not, risk of nephrotoxicity
Tacrolimus (- 66%): if not, risk of nephrotoxicity
Voriconazole
Pharmacokinetics
Oral bio-availability affected if taken with food
reduction oral bio-availability with > 20%!
no studies if administered with enteral feeding on
ICU
– Stop enteral feeding 1hr before up to 2 hrs after
administration
– Administration 2x daily: 6 hrs without calory intake!
Purkins L et al. Br J Clin Pharmacol 2003; 56 (S1): 17-23
Voriconazole
Safety
Visual disturbances: (20%)
• Altered perception of light, photophobia, blurred vision, color
vision changes: mechanism unknown
• transient, infusion related
• more in patients with higher levels - how to assess in sedated
patients?
Hepatotoxicity (13%)
• AST, ALT, alkaline phosphatase, bilirubin elevations
• AST, ALP and BILI abnormalities correlating with higher
vorico plasma levels
Phototoxicity (6%): erythema, Steven-Johnson syndrome, toxic
epidermal necrolysis
Neurological changes: confusion and hallucinations
Voriconazole
Safety
Adverse effects of voriconazole
– French pharmacovigilance database
4 year registration period
detailed registration of cases
causality assessment
Results
–
–
–
–
LFT abnormalities in 23% patients
Visual disturbances in 18% of patients
Skin rashes in 17% of patients
Cardiovascular events (10%), hematologic disorders
(8%) renal disturbances (4%)
Eiden C. Ann Pharmacother 2007; 41:755-63
Voriconazole
Tolerability and Safety
Nephrotoxicity of SBECD
– IV vials contain SBECD, a solubilizer
in patients with moderate to severe renal failure (CrCl < 50
ml/min): accumulation of SBECD with potential
nephrotoxicity (vacuolization of urinary epithelium)
frequent problem in ICU patients: switch to oral formulation?
Or other product?
Von Mach MA et al. BMC Clin Pharamacol 2006; 6:6
Voriconazole
Therapeutic drug monitoring?
Complex pharmacokinetics
High inter and intra- individual variability!!
Serum levels correlated with efficacy/safety?
FDA report
- no correlation
Smith. AAC 2006; - 28 patients, random plasma samples
50:1570-2.
- progressive disease in 18 patients with levels < 2.05 µg/ml
Trifilio S. BMT
2007; 40:451-6.
-
Denning D. CID
2002; 34: 56371.
-
71 patients, trough plasma levels
- 6 candidiasis cases in patients with levels < 2 µg/ml
Herbrecht study
- liver failure or liver toxicity in 6 out of 22 patients with levels >
6 µg/ml
Optimal serum levels: 2-6 µg/ml
– Well above MIC of Aspergillus/Candida spp.
Voriconazole
Therapeutic drug monitoring?
TDM voriconazole
– 52 adult patients: 181 samples
– 25%: levels < 1mg/L
Correlated with oral therapy
Lack of response more frequent in this group
– 31%: levels > 5.5 mg/L
Correlated with omeprazole comedication
5 patients with neurotoxicity
– 4 of 5 treated intravenously
– TDM improves efficacy and safety
– Proposed therapeutic interval 1-5.5 µg/ml
Pascual A. CID 2008;46:201-211.
Voriconazole
Therapeutic drug monitoring?
TDM …
– in all patients?
in patients with progressive disease?
in patients exhibiting significant visual or hepatic toxicity?
– in patients at risk of fluctuating plasma levels?
drug interactions?
changing hepatic and renal function?
treated by mouth?
ICU?
– daily (cost-effectiveness)?
– method?
– dose adjustments?
non-lineair kinetics!
Goodwin M et al. JAC 2007. Epub
Posaconazole
Posaconazole
Spectrum, therapeutic indication and dosage
Spectrum: Candida spp. (less active C. glabrata),
Aspergillus spp., C. neoformans, H. capsulatum,
Zygomycetes
Indications:
Prophylaxis of invasive fungal infections in high-risk patients
(SCTx – GvHD, AML-MDS)
Treatment of IA, fusariosis, chromoblastosis, mycetoma,
coccidiomycosis refractory to ampho B or itra
Dosage: 200 mg 3 - 4x/day
– Only available as oral suspension
Posaconazole
Pharmacokinetics
Bio-availability
-52-100%
-Dependent
on dosing frequency and intake with/without
meal
-Saturation in absorption if daily dose > 800 mg
Distribution
-Extensive
(Vd: 2447L)
-Tissue penetration: limited data
- crosses BBB
- distributes into bone and eye
-Protein
binding > 98%
Metabolism
-Primarily
unchanged excretion
-<30% metabolised as glucuronide conjugates (UGT 1A4)
Elimination
-Majority
via feces as unchanged drug
-Minimal renal elimination (14%)
-Halflife 20 hr
Schiller D et al. Clin Ther 2007; 29: 1862-1886
Posaconazole
Pharmacokinetics
Posaconazole levels: high interindividual variability!
!Difficult pharmacokinetics!
Absorption
2.6-4-fold higher if taken with a meal
High-fat meals enhance absorption
Cimetidine: gastric pH: 40% decrease in posaconazole AUC
and Cmax
Avoid concomitant use of histamine 2-blockers
or PPIs!
Mucositis?
Schiller D et al. Clin Ther 2007; 29: 1862-1886
Goodwin M et al. JAC 2007. Epub.
Posaconazole
Pharmacokinetics
Drug interactions
Posaconazole inhibits CYP3A4 (not a substrate of CYP3A4)
Tacrolimus: dose reduction with 66%
Cyclosporine: dose reduction with 25%
Increase in serum concentrations of benzodiazepines,
calcium channel blockers, statines, TCA, nevirapine…
Posaconazole is substrate of UGT 1A4
Induction by phenytoin: contra-indicated!
Induction by rifabutin: contra-indicated!
Schiller D et al. Clin Ther 2007; 29: 1862-1886
Goodwin M et al. JAC 2007. Epub.
Posaconazole
Pharmacokinetics
Dosing in patients with hepatic impairment?
posaconazole should be used with caution
not studied using Child score
Dosing in patients with renal impairment?
Dose adjustment not necessary
Use with caution in severe renal failure
Schiller D et al. Clin Ther 2007; 29: 1862-1886
Goodwin M et al. JAC 2007. Epub.
Posaconazole
Tolerability and Safety
Gastro-intestinal side effects
- Abdominal pain, diarrhea, vomiting: 3-7%
Elevated liver function tests
Rash
- Not correlated with elevated posa serum levels
Schiller D et al. Clin Ther 2007; 29: 1862-1886
Goodwin M et al. JAC 2007. Epub.
Posaconazole
Therapeutic drug monitoring?
Limited data available
FDA approved product information:
– association between posa levels and efficacy
Proven (6%) or probable (3.8%) IFI if levels < 0.7 µg/ml
Proven (1.8%) or probable (0%) IFI if levels > 0.7 µg/ml
lower concentrations correlate with treatment
failure
– recommendations:
ensurance of adequate plasma levels:
– Administration of posaconazole with a meal
– Avoidance of drug inducing agents
– Monitoring for breakthrough infections
Goodwin M et al. JAC 2007. Epub.
Posaconazole
Therapeutic drug monitoring?
TDM in patients with:
– Progressive disease
– Suspected poor oral absorption (nausea, vomiting,
mucositis, compliance)
– Levels > 1.25 mg/L
Goodwin M et al. JAC 2007. Epub.
Caspofungin
The echinocandins
Target: fungal cell wall
Echinocandines inhibit 1,3-beta-glucan synthase
• depletion of glucan polymers: weak cell wall
Caspofungin
Spectrum of activity and indications
Candida spp. (ex. C. parapsilosis) and Aspergillus spp.
Not Cryptococcus as its cell wall does not contain ßD-glucan
Not Fusarium spp., Zygomycetes
Empirical therapy for presumed fungal infections in
febrile, neutropenic patients
Candidemia, intra-abdominal abscess, peritonitis
Invasive aspergillosis if refractory or intolerant to other
therapies
Caspofungin
Measurement of in vitro activity?
– Candida spp.: minimal inhibitory
concentration (MIC)
Macroscopic growth inhibition
Lowest concentration of the drug that
results in inhibiting growth in 24 hours
– Aspergillus spp.: minimal effective
concentration (MEC)
Microscopic endpoint
Lowest concentration of the drug that
results in formation of aberrantly growing
hyphal tips
Caspofungin
Recommended dosage
Loading dose: 70 mg
Maintenance dose: 50 mg
– Patients > 80 kg: 70 mg
Child B liver cirrhosis
– Loading dose: 70 mg
– Maintenance dose: 35 mg
Mistry GC. J Clin Pharmacol 2007; 47: 951.
Caspofungin
Pharmacokinetics
Bio-availability
<2%: only IV
Distribution
-Vd
4.5L
- high levels in liver, spleen, kidney
- equal levels in lung tissue
- low levels in heart, skeletal muscle, brain
-distribution
phase determines clearance
-protein binding: 96%: no elimination via IHD
Metabolism
- hydrolysis and N-acetylation: no active metabolites
- not CYP450 dependent
Excretion
-via
PK
linear: 3 phases
urine and faeces (only 2% unchanged)
-distribution phase
-elimination phase of 8 hrs
-additional elimination phase with longer halflife of 27 hrs
Caspofungin
Pharmacokinetics
Pharmacokinetic problems?
Elimination based on tissue distribution
No dose adjustments in renal insufficiency
No CYP-mediated metabolism
– No CYP-mediated drug interactions
– No genetic polymorphisms
Uptake via hepatic transporter: OATP
OATP= organic anion transporting polypeptide
Reduced uptake in patients with hepatic insufficiency
– Dose reduction in Child B liver cirrhosis
– No recommendations in Child C
Drug interactions mediated by OATP?
Sandhu P et al. DMD 2005; 33: 676-82.
Caspofungin
Pharmacokinetics
OATP = organic anion
transporting
polypeptide
• drug uptake
transporter
•Basolateral membrane
of hepatocytes
•Contributes to overall
elimination of
caspofungin
• Cyclosporin and
rifampicin are also
substrates for OATP1B1
Caspofungin
Pharmacokinetics
Co-administration with cyclosporin
– AUC caspo + 25%
– Competitive inhibition at OATP?
Co-administration with rifampicin
– Inhibition and induction effect on caspo
– First days: rifa blocks OATP
– After continued dosing: rifa induces OATP
Net effect: AUC caspo ↓: increase MD to 70mg/day
Other inducers: efavirenz, nevirapine, dexamethasone,
phenytoin, carbamazepin
– Increase MD to 70 mg/day
Caspofungin
Tolerability and Safety
Excellent safety and tolerability
can be explained by mode of action: human cells do
not have a cell wall
Adverse events = unspecific drug reactions
– Histamine-mediated: headache, fever, nausea
– Elevation of hepatic enzyme levels
AST, ALT and ALP
< 5-fold ULN
Caspofungin
TDM in critically ill patients
Caspofungin plasma concentrations in surgical intensive
care units
C24hr concentrations
40 SICU patients
Altered drug plasma concentrations due to altered PK?
Results:
Trough levels: 0.52-4.08 µg/ml
Literature (Stone studies): 1.12-1.78 µg/ml
Higher in patients with low body weight (< 75 kg)
Higher in patients with albumin concentration > 23.6 g/L
! Patients’ body weight varied from 48 – 108 kg >< every patient
got LD 70 mg/ MD 50 mg!
Nguyen TH et al. JAC 2007; 60:100-106.
Anidulafungin - Micafungin
Anidulafungin - Micafungin
Spectrum, therapeutic indications and
recommended dosage
Anidulafungin
Micafungin
Spectrum
-Candida spp.
-Aspergillus spp.
-Candida spp.
-Aspergillus spp.
Indications
-Invasive candidiasis
-Esophageal candidiasis
-Prophylaxis for Candida
infections in HSCT
-Esophageal candidiasis
Dosage
LD: 200 mg
MD: 100 mg
-prophylaxis: 50 mg OD
-treatment: 150 mg OD
No
Dose adjustement
in hepatic impairment
No
Weight based dose
adjustments
No
No
Anidulafungin - Micafungin
Pharmacokinetics
Anidulafungin
Micafungin
Bioavailability
Low, only IV administration
Low, only IV administration
Distribution
-Rapid
distribution halflife
-Vd: 0.57 L/kg
-Protein binding: 99%
-No specific tissue distribution
studies done
-Vd:
Metabolism
-No
hepatic metabolism
-No CYP involvement
-Metabolism by slow nonenzymatic, chemical
degradation
-No
Elimination
-
Halflife : 24hrs
- Via feces
- Halflife: 13 hrs
- Via feces, > 90% unchanged
PK
linear
linear
0.39 L/kg
-- Protein binding: 99%
- poor CNS penetration
hepatic metabolism
-No CYP involvement
-Breakdown by arylsulfatase
and COMT
Anidulafungin- Micafungin
Pharmacokinetics
anidulafungin
micafungin
Dose adjustments in
hepatic insufficiency?
No
Studied in Child A,B,C:
no increase in plasma
levels
No
Not studied in Child C
Dose adjustments in
renal
insufficiency/dialysis?
No
No
No
Small increase in
anidula levels if
combined with
cyclosporine
No
Possibly mild inhibition
of CYP3A with small
increase in cyclosporin,
sirolimus and nifedipin
levels
Drug interactions?
Anidulafungin-Micafungin
Tolerability and Safety
Adverse reactions = mild
Infusion (histamine-mediated) related reactions
(especially at high infusion rates): flushing, pruritis,
rash, urticaria
Coagulopathy
Diarrhoea, vomiting, nausea
Hepatic enzyme elevation: ALT, ALP, bilirubin
In 5-10% of patients
Usually < 3-fold ULN
Micafungin
Warning EMEA – risk hepatocellular tumour formation
• discontinuation if persistent elevation ALT/AST
• consider alternative in patients with severe liver function impairment
or chronic liver diseases or concomitant hepatotoxic therapy
http://www.emea.europa.eu/humandocs/PDFs/EPAR/mycamine/H-734-PI-en.pdf
Case report
CASE I
Man, 49 yrs old, 65 kg
Medical history:
– diabetes, insuline dependent
– abuse: nicotine, ethyl (10 U/day)
– weight loss: - 25 kg/2 months
Admitted because of
– hyperglycemia
– fever, hypotension, leucopenia, thrombopenia
Rx thorax: bilateral infiltrates
Diagnosis: CAP: start Cefuroxim – amikacin
– Elevated liver function tests (bili: 3.38 mg/dL): cirrhosis?
– On day 8: high fever: switch AB into meropenem – fluconazol
– Transfer UZ Leuven
CASE I
Man, 49 yrs old, 65 kg
Admitted upon ICU
– high fever, severe hypotension, respiratory distress:
Intubation + mechanical ventilation
Fluid resuscitation, noradrenalin, antibiotics
New cultures
Day 10 and 11: BA Aspergillus +
Day 12: BAL Aspergillus +/ galactoBAL: 8.3
Serum galactomannan day 11: 3.2
Diagnosis: Invasive aspergillosis
start Vfend IV LD 400 mg on day 11
Stop Diflucan
CASE I
Man, 49 yrs old, 65 kg
At the same day:
Decrease of renal function: start CVVH
! Vfend IV: accumulation of SBECD: switch PO?
Auramin stain: + : tuberculosis!
– Start TB therapy: ethambutol, pyrazinamid, moxifloxacin
and rifampicin
! Vfend + Rifampicin = contra-indicated!
Switch Cancidas
Interaction with rifampicin!
Dosage: LD 70 mg – MD 70 mg
CASE II
Female, 49 yrs old, 80 kg
Medical history:
– Henoch-Schönlein vasculitis
R/ Medrol 64 mg during 1 month
Hospital admission because of
– anorexia, chills, sputa, respiratory insufficiency
Suspicion of pneumonia: Augmentin
CRP ↑: switch to Tazocin
BAL: A. fumigatus/ serum GM 4.8:
R/ Vfend tablets 2x400mg LD, 200 mg PO
IHD - terminal renal insufficiency
CASE II
Female, 49 yrs old, 80 kg
Day 6: Transfer to UZ Leuven - MICU
Serum GM: 0.7/BA: fungi
CT brain: cerebral aspergillosis – multiple lesions
Ocular Aspergillus invasion
Diagnosis: Pulmonary, cerebral, ocular IA
Switch Vfend PO → IV + increase dose based on body weight:
2 x 320 mg
Vfend intravitreal injection
Switch Tazocin into Meronem (follow up GM)
CASE II
Female, 49 yrs old, 80 kg
Day 12:
switch Vfend IV → PO (suspension)
Association of L-AmB high dose: 5 mg/kg
Day 14:
serum GM: 0.1
CT brain: worsening cerebral lesions
CASE II
Female, 49 yrs old, 80 kg
Discussion
– CNS aspergillosis
Voriconazole = first line – standard dose or higher dose
(penetration 50%)?
Combination with L-AmB?
– Initial Vfend dose: too low?
Tablets vs. oral suspension (weight based dosing)?
– Vfend IV vs. PO?
PO ↔ critically ill patient, enteral feeding: absorption?
IV ↔ accumulation of SBECD in patient with IHD
– Encephalopathy due to brain accumulation of SBECD?
– Encephalopathy due to high vorico levels?
Final Remarks
How to choose?
Spectrum
Likely or documented pathogen
Site of infection
Patient-specific factors
Concomitant diseases
Hepatic/renal function
Toxicities
Drug interactions with concomitant therapy
IV/PO
Cost/ Reimbursement criteria
Conclusion
Despite development of new antifungals
during last decade
mortality of IFI remains very high
– optimalisation of diagnostics
– improvement of knowledge on
pharmacokinetics – role of TDM?
avoid toxicity
warrant effective drug concentrations