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Amphotericin- Amphotericin- or or
Echinocandin-Based Echinocandin-Based Antifungal Prophylaxis Antifungal Prophylaxis
ApproachesApproaches
Jo-Anne Young, MD, FACP, FIDSA
Disclosures
Clinical Trials funding support (antifungal agents): Pfizer, Astellas, Merck, Schering-Plough
Clinical Trials funding support (outside of mycology): Glaxo, ViroPharma, Advanced Biologics, Adamas
Not a Consultant
Not on a Speaker’s Bureau
Objectives
Amphotericin as antifungal prophylaxisMerits, Problems
Echinocandins as antifungal prophylaxisMerits, Problems
Undefined areas in practice
Amphotericin routes
OralICU Selective digestive tract decontamination
Radiotherapy lung cancer patients
Nebulization or nasal sprayLung transplant
HSCT
IV
Standard care SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics.
Nonrandomized study of lung cancer consecutive patients20 patients 67 Gy (range 61-80 Gy) AmB QID from day 8 to the end of radiotherapy
Trend toward higher esophageal volumesOlderWorse median Karnofsky Index More often received induction chemotherapyStart of symptoms day 21 (median, range 14-44) 5 patients developed esophagitis grade 1
20 patients 60 Gy (range 51-67.5 Gy) control groupStart of symptoms day 18 (median, range 10-32) 14 patients showed esophagitis grade 1 and 2 patients grade 2 (p < 0.05).
Nasal
Bottle design to prevent aspiration of nasal secretions back into the bottleEach nostril 5x/day
Compliance a problemIrritating to nasal mucosa: tolerance a problem
Reduction in surveillance CFUs, but not in invasive disease
Bronchial Anastamosis
Courtesy of Jordan Dunitz, MD
6 single and 6 double lung recipients
One 7-ml (35 mg) nebulized dose labeled with Technetium
Selected system: AeroEclipse nebulizer & DeVilbiss compressor
3.9 + 1.6 mg allograft, 2.1 + 1.1 mg native
2.8 + 0.8 mg Left, 4.0 + 1.3 mg Right
271 patients 407 neutropenic episodes. Some adverse effects, but none serious, in the liposomal amphotericin B group were reported, most frequently coughing (16 patients vs. 1 patient; P=.002).
Prophylactic inhalation of liposomal amphotericin B significantly reduced the incidence of IPA.
Intent-to-treat analysis18 of 132 patients in the placebo group developed IPA6 of 139 patients in the liposomal amphotericin B groupodds ratio, 0.26; 95% CI, 0.09-0.72; P=.005
On-treatment analysis13 of 97 patients receiving placebo developed IPA 2 of 91 receiving liposomal amphotericin B odds ratio, 0.14; 95% CI, 0.02-0.66; P=.007
Nebulization: meritsDirected delivery to the lungs, good distribution throughout lung airways
Achieves high local concentrationHalf-life in lung of 4.8 days
Not associated with a decline in PFTs
Avoids undesirable systemic effects and drug interactions
Lipid formulations Penetrate the lung better
Have a longer half-life
Administer at long intervals
No demonstrated resistance
Nebulization: problemsSome increased risk of
Transient cough
Nausea
Aftertaste
Deoxycholate detergent may have adverse effects on surfactant
Breakthrough invasive disease Pulmonary
Cerebral
Nebulization: undefined areas
Many type of nebulizersOnly a few dosages studiedNo data regarding
Long term efficacyRepeated use efficacyComparison to systemic antifungalsSynergy with systemic antifungals
Lack of standardization of administration procedures and dosesThese are not treatment data
IV
Potential systemic toxicityAmphotericin accumulates in the reticulo-endothelial system Even a single dose may proved tissue depots for prophylaxis in at-risk pts such as liver transplantIntermittent high dosing of lipid ampho may be an option to daily azoles or candins
Enrollment was discontinued in the SCT group as recommended by the independent data review committee in accordance with the 10% limit of AEs (CTC grade 3-4) fixed by the protocol.
Yeasts Yeasts MoldsMolds
Randomized, double-blind Phase III study
72 centers in the US and Canada
Patient population: HCT candidates 6 months of age
Autologous HCT for heme malignancies only
CID 2004;39:1407-16 (van BurikCID 2004;39:1407-16 (van Burik et al. et al.))
Treatment success
Treatment difference
Micafungin
340 / 425
(80%)
+6.5%
P=0.03 (95% CI, 0.9% to 12%)
Fluconazole
336 / 457
(73.5%)
Assess non-inferiority of micafungin to fluconazole over 10% Treatment success
Absence of suspected, proven, or probable invasive fungal infection through the end of prophylaxis periodAbsence of a proven or probable invasive fungal infection through the end of the 4-week post-treatment period
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 10 20 30 40 50 60 70
Micafungin (N=425)Fluconazole (N=457)
Time to Treatment Failure P
ropo
rtio
n of
Pat
ient
s w
ith T
reat
men
t Suc
cess
P-Value (2 tailed) = 0.025
Days Since First Dose of Study Drug
Breakthrough fungal infection
Aspergillus*ProvenProbable
CandidaFusariumZygomycetes
Death
Death due to FI
Micafungin7/425 (1.6%)
101411
18/425 (4.2%)
1 (Zygomycetes)
Fluconazole11/457 (2.4%)
743220
26 / 457 (5.7%)
2 (Pulmonary aspergillosis)
P=0.07 Micafungin compared with Fluconazole
HSCT candidates 6 months of age
Micafungin Fluconazole
Pediatric <16 yrs 69% (27/39) 53% (24/45)
Adult 16-64 yrs 81% (313/386) 76% (312/412)
Adult > 64 yrs97% (32/33) 70% (16/23)
High dose micafungin
Adult patients Micafungin 150 mg (n = 52) orFluconazole 400 mg (n = 52)Success 94 vs. 88% Empirical antifungal therapy (P = 0.06)2/50 (4.0%) micafungin 6/50 (12.0%) fluconazole arm
Int J Hematol. 2008 Dec;88(5):588-95
Liver transplant Open-label trial of 71 adult liver transplant recipients
Caspofungin for at least 21 days
2 IFI: Mucor and Candida albicans surgical wound infections
6 discontinued: drug-related altered liver function
8 patients died, 6 during caspofungin administration and 2 during follow-up period, but none were attributed to IFI or caspofungin toxicity
Transplantation 2009 Feb 15;87(3):424-35
Echinocandins: undefined areasLimited amount of published data:
Randomized trials
Observational cohorts
Specific patient populationsBy disease
By age
Can trials with one drug be extrapolated to other drugs
Dosage
Summary
Amphotericin as antifungal prophylaxisMerits, Problems
Echinocandins as antifungal prophylaxisMerits, Problems
Undefined areas in practice