Serum posaconazole levels among haematological cancer patients taking extended release tablets is affected by body weight and diarrhoea: single centre retrospective analysis

The posaconazole extended release tablet formulation was developed to improve bioavailability relative to the oral suspension. Therapeutic drug monitoring has been used to optimise posaconazole dosing to achieve a target trough level ≥0.7 μg ml^?1. We retrospectively evaluated 28 patients with haematological malignancies who received posaconazole tablets for antifungal prophylaxis. Posaconazole serum trough levels were obtained 5 days after initiation of therapy. Mean trough level was 1.19 ± 0.63 μg ml^?1, and 71% achieved a trough level ≥0.7 μg ml^?1. Diarrhoea was associated with lower mean trough levels (0.65 ± 0.08 μg ml^?1 vs. 1.31 ± 0.13 μg ml^?1), P = 0.002. Mean trough levels were lower in patients ≥90 kg (0.74 ± 0.09 μg ml^?1) vs. <90 kg (1.32 ± 0.14 μg ml^?1), P = 0.002 and in patients with body mass index (BMI) ≥30 (0.89 ± 0.13 μg ml^?1) vs. BMI <30 (1.29 ± 0.14 μg ml^?1), P = 0.05. Posaconazole delayed release tablets attain appropriate trough levels in most patients, but patients with a higher weight and those experiencing diarrhoea are more likely to have lower levels.     

An anti‐Aspergillus protein from Escherichia coli DH5α: Putative inhibitor of siderophore biosynthesis in Aspergillus fumigatus

An antifungal protein designated as anti‐Aspergillus protein (AAP), produced by Escherichia coli DH5α, was purified and characterised. It exhibited a molecular weight of 60 kDa on Sodium dodecyl sulphate–polyacrylamide gel electrophoresis analysis and depicted 99% purity on ultra performance liquid chromatography. The purified protein manifested antimycotic potential against pathogenic isolates of Aspergillus spp., depicting a minimum inhibitory concentration in the range 15.62–31.25 μg ml^?1 and 5.0–10.0 μg per disc, using microbroth dilution, spore germination inhibition and disc diffusion assays respectively. In vitro toxicity tests demonstrated that it showed no toxicity against human erythrocytes at doses up to 1000 μg ml^?1. Matrix‐assisted laser desorption ionisation–Time‐of‐flight analysis of trypsin‐digested peptides of purified protein and subsequent Mascot search revealed that several peptides of AAP have identity with bacterial siderophore biosynthetic protein, i.e. non‐ribosomal peptide synthetase enzyme, involved in critical step of fungal siderophore biosynthesis. Siderophore‐based inhibition was further corroborated by Chrome azurol S assay. Hence, the antagonistic effect might be the result of impediment in siderophore‐mediated iron uptake and transport process which may cause critical consequences on Aspergillus growth and virulence.     

Cryptococcal meningitis due to Cryptococcus neoformans genotype AFLP1/VNI in Iran: a review of the literature

Cryptococcal meningitis is the most important opportunistic fungal infection with a high mortality in HIV‐patients in less developed regions. Here, we report a case of cryptococcal meningitis in a 49‐year‐old HIV‐positive female due to Cryptococcus neoformans (serotype A, mating‐type alpha, genotype AFLP1/VNI) in Sari, Iran. In vitro antifungal susceptibility tests showed MICs of isavuconazole (0.016 μg ml^?1), voriconazole (0.031 μg ml^?1), posaconazole (0.031 μg ml^?1), itraconazole (0.063 μg ml^?1), amphotericin B (0.125 μg ml^?1) and fluconazole (8 μg ml^?1). Despite immediate antifungal therapy, the patient died 4 days later due to respiratory failure. Cryptococcal infections have been infrequently reported from Iran and therefore we analysed all published cases of cryptococcosis in Iran since the first reported case from 1969.     

Molecular identification and susceptibility profile of Sporothrix schenckii sensu lato isolated in Argentina

We studied 23 clinical and environmental strains of Sporothrix schenckii sensu lato collected from 1984 to 2017 in Argentina. The molecular identification (partial sequencing of a fragment of the calmodulin gene) of the strains was performed. For the yeast and mycelial phases, the in vitro susceptibility testing by a microdilution reference method was determined against eight antifungal drugs. Strains studied were identified as S. schenckii sensu stricto 13 (56.5%), S. brasiliensis 8 (34.7%) and S. globosa 2 (8.7%). The most active antifungal drugs tested for the yeast and mycelial phases expressed as geometric mean (GM ) value of the minimal inhibitory concentration (MIC ) (μg mL^?1) were terbinafine (0.07 and 0.24), posaconazole (0.13 and 0.58), itraconazole (0.38 and 1.10) and ketoconazole (0.22 and 0.89), while fluconazole (110.10 and 131.92) and flucytosine (2.96 and 79.03) were the less active. For voriconazole and amphotericin B the GM ‐MIC values were acceptably low for the yeast phase (0.39 and 0.72 μg mL^?1), while the mycelial phase showed values ≥2‐fold higher (8.76 and 1.88 μg mL^?1), P  < .05. Here, we described S. schenckii sensu stricto, S. brasiliensis and S. globosa, these species were isolated from humans, animals and soil and are circulating in Argentina since at least 1984.     

Seventeen years of subcutaneous infection by Aspergillus flavus; eumycetoma confirmed by immunohistochemistry

Chronic subcutaneous infections caused by Aspergillus species are considered to be extremely rare. Because these fungi are among the most common laboratory contaminants, their role as eumycetoma causative agents is difficult to ascertain. Here, we report the first case of A. flavus eumycetoma confirmed by isolation, molecular identification and immunohistochemical analysis. Patient was a 55‐year‐old male from Sudan suffering from eumycetoma on his left foot for a period of 17 years. He developed swelling, sinuses and white grain discharge was observed. He has been operated nine times and was treated with several regimens of ketoconazole and itraconazole without improvement. Initial diagnosis based on histology and radiology was Scedosporium eumycetoma. However, examination of the biopsy revealed A. flavus, which was identified by molecular analysis and MALDI‐TOF MS. Immunohistochemistry using antibody directed against Aspergillus species was positive. Because of the earlier treatment failures with ketoconazole and itraconazole, therapy with voriconazole was initiated. However, in vitro susceptibility testing yielded a lower Minimum Inhibitory Concentration (MIC) value for itraconazole (0.25 μg ml^?1) than for voriconazole (1 μg ml^?1). Based on the presented results, A. flavus can be considered as one of the agents of white‐grain eumycetoma.     

Anti‐inflammatory activity of lanoconazole,a topical antifungal agent

Topical antifungal agents which have anti‐inflammatory effects have the potential to provide additional clinical benefits. Therefore, an anti‐inflammatory activity of lanoconazole (LCZ), a topical antifungal agent, was investigated against in vitro and in vivo models of inflammation. The release of interleukin‐8 (IL‐8) from human epidermal keratinocytes stimulated by the addition of 100 μg ml^?1 β‐glucan of Saccharomyces cerevisiae was significantly inhibited by LCZ at the concentration of 10^?5 mol l^?1. The release of interferon‐γ and IL‐2 from human peripheral blood mononuclear cells stimulated by the addition of 30 and 100 μg ml^?1 phytohemagglutinin was significantly inhibited by LCZ at the concentrations of 10^?7 and 10^?6 mol l^?1, respectively. The increase in the ear thickness induced by topical application of 0.01% 12‐O‐tetradecanoyl phorbol‐13‐acetate and 1% 2,4,6‐trinitrochlorobenzene (TNCB) after sensitisation with 3% TNCB were established as the mouse models of irritant and contact dermatitis, respectively. Application of 1% and 3% LCZ showed a significant anti‐inflammatory activity against both the irritant and contact dermatitis models. These findings suggest that LCZ possesses an anti‐inflammatory activity, which may be partially helpful in the treatment of dermatomycoses.     

In vitro susceptibility patterns of clinically important Trichophyton and Epidermophyton species against nine antifungal drugs

Despite the common, worldwide, occurrence of dermatophytes, little information is available regarding susceptibility profiles against currently available and novel antifungal agents. A collection of sixty‐eight clinical Trichophyton species and Epidermophyton floccosum were previously identified and verified to the species level by sequencing the internal transcribed spacer (ITS) regions of rDNA. MICs of amphotericin B, fluconazole, itraconazole, voriconazole, posaconazole, isavuconazole, terbinafine and MECs of caspofungin and anidulafungin were performed based on CLSI M38‐A2. The resulting MIC₉₀s of all strains were, in increasing order, as follows: terbinafine (0.063 mg l^?1); posaconazole (1 mg l^?1); isavuconazole and anidulafungin (2 mg l^?1); itraconazole, voriconazole, amphotericin B, and caspofungin (4 mg l^?1) and fluconazole (>64 mg l^?1). These results confirm that terbinafine is an excellent agent for treatment of dermatophytosis due to T. rubrum, T. mentagrophytes, T. verrucosum, T. schoenleinii and E. floccosum. In addition, the new azoles POS and ISA are potentially useful antifungals to treat dermatophytosis. However, the clinical effectiveness of these novel antifungals remains to be determined.     

Susceptibility profile and epidemiological cut‐off values of Cryptococcus neoformans species complex from Argentina

Epidemiological cut‐off values (ECVs) based on minimal inhibitory concentration (MIC) distribution have been recently proposed for some antifungal drug/Cryptococcus neoformans combinations. However, these ECVs vary according to the species studied, being serotypes and the geographical origin of strains, variables to be considered. The aims were to define the wild‐type (WT) population of the C. neoformans species complex (C. neoformans) isolated from patients living in Argentina, and to propose ECVs for six antifungal drugs. A total of 707 unique C. neoformans isolates obtained from HIV patients suffering cryptococcal meningitis were studied. The MIC of amphotericin B, flucytosine, fluconazole, itraconazole, voriconazole and posaconazole was determined according to the EDef 7.2 (EUCAST) reference document. The MIC distribution, MIC₅₀, MIC₉₀ and ECV for each of these drugs were calculated. The highest ECV, which included ≥95% of the WT population modelled, was observed for flucytosine and fluconazole (32 μg ml^?1 each). For amphotericin B, itraconazole, voriconazole and posaconazole, the ECVs were: 0.5, 0.5, 0.5 and 0.06 μg ml^?1 respectively. The ECVs determined in this study may aid in identifying the C. neoformans strains circulating in Argentina with decreased susceptibility to the antifungal drugs tested.     

Evaluation of improvement of onychomycosis in HIV‐infected patients after initiation of combined antiretroviral therapy without antifungal treatment

Onychomycosis in HIV‐infected patients has a prevalence of 20–44% and is more frequently seen with CD4⁺ T cell counts ≤450 cel μl^?1. There are case reports of improvement in onychomycosis after initiation of combined antiretroviral therapy (cART), but there are no prospective studies that prove the existence and frequency of this phenomenon. The aim of this study was to evaluate if HIV‐infected patients with onychomycosis who begin cART improve and/or cure without antifungal treatment. We included HIV‐infected patients with onychomycosis who had not started cART and nor received antifungal therapy during 6 months prior to the study. We evaluated affected the nails with the Onychomycosis Severity Index (OSI); nail scrapings were collected and direct microscopy with potassium hydroxide (KOH) as well as mycological culture were performed. We repeated these procedures at 3 and 6 months to assess changes. CD4 T cell counts and HIV viral load were obtained. A total of 16 patients were included, with male gender predominance (68.7%); distal and lateral subungual onychomycosis (DLSO) was the most common form (31.3%). Trichophyton rubrum was the most frequently isolated microorganism. OSI decreased 21.5% at 3 months and 40% at 6 months after initiation of antiretrovirals (P = 0.05). We found a non‐significant tendency towards improvement with higher CD4⁺ T cell counts and with viral loads <100 000 copies ml^?1. This could be due to the increase in CD4⁺ T cells, decreased percentage of Treg (CD4⁺CD25⁺) among CD4⁺ Tcells and/or a decreased viral load; further studies are necessary to prove these hypothesis.     

Comparative in vitro fungicidal activity of echinocandins against Candida albicans in peritoneal dialysis fluids

The peritoneal dialysis (PD)‐associated peritonitis caused by fungi is a relatively rare, but very serious disease. PD fluids (PDFs) affect inhibitory efficacy on the microorganisms' growth, which may compromise the affectivity of some antimicrobials. The purpose of this study was to investigate in vitro the fungicidal effectiveness of echinocandins in diverse PDFs. The fungicidal efficacy of caspofungin (CAS), anidulafungin (ANA), micafungin (MYC) against five clinical isolates of Candida albicans was studied in the different PDFs using time‐kill curves. As control substance amphotericin B was used. Echinocandins showed slower and reduced killing of C. albicans in PDFs when compared with the time‐kill curves in control bouillon. At concentration of 8 × minimal inhibitory concentration (MIC) the greatest reduction in the growth of C. albicans was seen by ANA in lactate‐buffered Nutrineal PD4^® with 1.1% amino acid (2.33 ± 0.52 log₁₀ CFU ml^?1), and by CAS and MYC in lactate‐buffered Dianeal PD4^® with 1.36% glucose (2.36 ± 0.89 log₁₀ CFU ml^?1 and 2.36 ± 0.99 log₁₀ CFU ml^?1 respectively). Using high concentration of 128 × MIC echinocandins achieved fungicidal effect in all PDFs. PDFs may significantly impair the activities of echinocandins, but fungicidal activity of drugs can be achieved at high concentration of 128 × MIC.     

In vitro biofilms and antifungal susceptibility of dermatophyte and non‐dermatophyte moulds involved in foot mycosis

Tinea pedis and onychomycosis are among the commonest fungal diseases in the world. Dermatophytes and, less frequently, non‐dermatophyte moulds are aetiological agents of foot mycosis and are capable of forming biofilms. Fungal biofilm has demonstrated increasing drug resistance. This work aims to evaluate, in vitro, the ability to form biofilm and the susceptibility to antifungal drugs of sessile dermatophytes and non‐dermatophyte moulds involved in foot mycosis. Thirty‐six dermatophytes and non‐dermatophyte moulds isolated from Tunisian patients with foot mycoses, and identified with MALDI ‐TOF have been tested. MIC s of fluconazole, econazole, itraconazole, terbinafine and griseofulvin were carried out using CLSI broth microdilution method. The ability to form biofilm and antifungal activities of drugs against fungal biofilm formation has been quantified by Crystal Violet and Safranin Red staining. Biomass quantification revealed that all species studied were able to form biofilms in vitro after 72 hours. Fluconazole, econazole, itraconazole and terbinafine inhibited fungal growth with MIC values ranging from 0.031 to >64 μg mL^?1. The best antifungal activity has been obtained with terbinafine against Fusarium solani . Econazole showed the highest activity against fungal biofilm formation. These findings can help clinicians to develop the appropriate therapy of foot mycosis.     

In vitro activity of colistin as single agent and in combination with antifungals against filamentous fungi occurring in patients with cystic fibrosis

Because published reports indicate that the antibiotic colistin (COL) has antifungal properties, this study investigated the antifungal in vitro activity of COL as single agent and in combination with the antifungal compounds voriconazole (VRC), caspofungin (CAS) and amphotericin B (AMB) against Scedosporium/Pseudallescheria spp., Exophiala dermatitidis and Geosmithia argillacea. In total, susceptibility was determined for 77 Scedosporium/Pseudallescheria spp., 82 E. dermatitidis and 17 G. argillacea isolates. The minimal inhibitory concentrations (MICs) of COL and the antifungals as single compound and in combination were determined with MIC test strips. Drug interactions were detected by crossing the MIC test strips at a 90º angle. The fractional inhibitory concentration index was used to categorise the drugs’ interaction. The MIC₅₀ value of COL was 12 μg ml^?1 for S. prolificans, 16 μg ml^?1 for P. apiosperma, 16 μg ml^?1 for P. boydii, 12 μg ml^?1 for E. dermatiditis and 6 μg ml^?1 for G. argillacea. VRC was the most active drug in combination without any antagonism with the exception of few P. boydii isolates. COL as single agent and in most combinations with antifungals exhibits in vitro antifungal activity against filamentous ascomycetes occurring in cystic fibrosis patients and may offer a novel therapeutic option, especially for multidrug‐resistant S. prolificans.     

Investigation of minor species Candida africana,Candida stellatoidea and Candida dubliniensis in the Candida albicans complex among Yaoundé (Cameroon) HIV‐infected patients

Minor species of the Candida albicans complex may cause overestimation of the epidemiology of C. albicans, and misidentifications could mask their implication in human pathology. Authors determined the occurrence of minor species of the C. albicans complex (C. africana, C. dubliniensis and C. stellatoidea) among Yaoundé HIV‐infected patients, Cameroon. Stool, vaginal discharge, urine and oropharyngeal samples were analysed by mycological diagnosis. Isolates were identified by conventional methods and mass spectrometry (MS; carried out by the matrix‐assisted laser desorption–ionisation time‐of‐flight MS protocol). Candida albicans isolates were thereafter submitted to the PCR amplification of the Hwp1 gene. The susceptibility of isolates to antifungal drugs was tested using the Clinical and Laboratory Standards Institute M27‐A3 protocol. From 115 C. albicans obtained isolates, neither C. dubliniensis nor C. stellatoidea was observed; two strains of C. africana (422PV and 448PV) were identified by PCR electrophoretic profiles at 700 bp. These two C. africana strains were vaginal isolates. The isolate 448PV was resistant to ketoconazole at the minimal inhibitory concentration of 2 μg ml^?1, and showed reduced susceptibility to amphotericin B at 1 μg ml^?1. This first report on C. africana occurrence in Cameroon brings clues for the understanding of the global epidemiology of this yeast as well as that of minor species of the C. albicans complex.     

Effects of ambroxol on Candida albicans growth and biofilm formation

Typically, the onset of candidiasis is characterised by the appearance of a biofilm of Candida albicans, which is associated with several diseases including oral candidiasis in young and elderly people. The objective of this work was to investigate the in vitro fungicidal activity as well as the antibiofilm activity of ambroxol (AMB) against C. albicans growth. In the present investigation, the fungicidal activity of AMB was established using the cell viability 3‐(4,5‐dimethylthiazol‐2‐yl)‐2,5‐diphenyltetrazolium bromide (MTT) assay. Also the minimum inhibitory concentration (MIC) of AMB required to inhibit the fungal growth was determined. Simultaneously, the antibiofilm activity of AMB was evaluated using fluorescence microscopy. The study revealed that 2 mg ml^?1 of AMB exhibited higher fungicidal activity than 3.3 mg ml^?1 of terbinafine, one of most common commercial antifungals. A MIC of 1 mg ml^?1 was determined for AMB to interfere with C. albicans growth. Furthermore, AMB was found to be effective in inhibiting the biofilm formation of C. albicans and exerted its fungicidal activity against the fungal cells interspersed in the preformed biofilm. The study suggests a potential role of the mucolytic agent, AMB, as an interesting therapeutic alternative in the treatment of oral candidiasis.     

Serum posaconazole levels during acute myeloid leukaemia induction therapy: correlations with breakthrough invasive fungal infections

The usefulness of posaconazole therapeutic drug monitoring (TDM) is still a matter of debate. A correlation between posaconazole serum levels and breakthrough invasive fungal infections (IFI) has not been clearly demonstrated so far. We analysed posaconazole serum levels in patients with acute myeloid leukaemia (AML) during induction therapy and correlated them with the incidence of breakthrough IFI and the need of systemic antifungal therapy. Overall, 77 AML patients receiving posaconazole were evaluated for serum levels; breakthrough IFI were observed in five with at least one posaconazole TDM (6.5%). Median serum level was 534 ng ml^?1 (IQ range: 298.5–750.5 ng ml^?1) and did not change significantly over time. Four of the 40 patients with median posaconazole levels <500 ng ml^?1 developed IFI, as compared with only 1 of the 37 patients with median levels ≥500 (10% vs. 2.7%, P = 0.19). Median posaconazole levels on day 7 were 384.5 ng ml^?1 (IQ range: 207–659 ng ml^?1) and 560.5 ng ml^?1 (IQ range: 395–756 ng ml^?1) in patients requiring or not systemic antifungal treatment respectively (P = 0.067). These results seem to confirm that higher median serum levels of posaconazole correlate with higher prophylactic efficacy against proven/probable IFI and with lesser need of systemic antifungal therapy.     

The Mediterranean red alga Asparagopsis taxiformis has antifungal activity against Aspergillus species

The red algae Asparagopsis taxiformis collected from the Straits of Messina (Italy) were screened for antifungal activity against Aspergillus species. EUCAST methodology was applied and extracts showed antifungal activity against A. fumigatus, A. terreus and A. flavus. The lowest minimum inhibitory concentrations observed were <0.15 mg ml^?1 and the highest were >5 mg ml^?1 for Aspergillus spp. tested. Agar diffusion assays confirmed antifungal activity of A. taxiformis extracts in Aspergillus species.     

Efficacy of oleylphosphocholine (OlPC) in vitro and in a mouse model of invasive aspergillosis

Invasive aspergillosis (IA) has become increasingly common and is characterised by high morbidity and mortality. Upcoming resistance threatens treatment with azoles and highlights the continuous need for novel therapeutics. This laboratory study investigated the in vitro and in vivo potential of the alkylphospholipid oleylphosphocholine (OlPC) against Aspergillus. In vitro activities of OlPC, miltefosine, posaconazole and voriconazole were determined for Aspergillus fumigatus, A. niger, A. terreus and A. flavus. In vivo efficacy of OlPC was evaluated in a systemic A. fumigatus mouse model, adopting a short‐term and long‐term oral or intraperitoneal dosing regimen. OlPC showed good in vitro activity against A. fumigatus (IC₅₀ = 1.04 μmol l^?1). Intraperitoneal administration of 50 mg kg^?1 day^?1 OlPC significantly reduced the fungal organ burdens at 4 days post‐infection (dpi). Although 5‐ and 10‐day OlPC treatment improved survival, organ burdens were not affected at 10 and 15 dpi. While this study showed excellent in vitro activity of OlPC against Aspergillus spp., its therapeutic efficacy in an acute mouse model for IA was less convincing. Given the limited therapeutic options in the current antifungal market for invasive infections, OlPC activity should be assessed in a less stringent in vivo model, potentially in combination treatment with other already marketed antifungal drugs.     

Evolution of procalcitonin,C‐reactive protein and fibrinogen levels in neutropenic leukaemia patients with invasive pulmonary aspergillosis or mucormycosis

Unlike bacterial infections, the value of procalcitonin (PCT) in detecting fungal infections in leukaemia patients is not clear. To determine whether the monitoring of PCT coupled with C‐reactive protein (CRP) and fibrinogen (Fib) could be helpful in the management of pulmonary aspergillosis (IPA) or mucormycosis (PM), we retrospectively analysed the evolution of PCT, CRP and Fib levels in 94 leukaemia patients with proven/probable IPA (n = 77) or PM (n = 17) from D?12 to D12 relative to IFI onset defined as D0. Overall, 2140 assays were performed. From D?12 to D0, 12%, 5% and 1.4% of patients had PCT >0.5, 1 and 1.5 μg l^?1, respectively, while CRP was >50, 75 and 100 mg l^?1 in 84%, 70% and 57% and Fib was >4, 5 and 6 g l^?1 in 96%, 80% and 61% of cases respectively (P < 10^?7). The same trends were observed from D1 to D12. Overall, between D?12 and D12, only 6.4% of patients had PCT >1.5 μg l^?1, while CRP >100 mg l^?1 and Fib >6 g l^?1 were observed in 80% and 75% of cases respectively (P < 10^?7). In leukaemia patients, IPA or PM was accompanied by a significant increase in CRP and Fib while PCT remained low.     

Tintelnotia,a new genus in Phaeosphaeriaceae harbouring agents of cornea and nail infections in humans

Phaeosphaeriaceae is a family in the order Pleosporales containing numerous plant pathogens, endophytes, lichenised fungi, and environmental saprobes. A novel genus, Tintelnotia is introduced containing two species, one of which caused an eye infection and several nail infections in humans. All species of Tintelnotia produce conidia in soft pycnidia with a wide ostiole. The generic type species is T. opuntiae causing necrotic spots on cactus plants. The isolates of the human opportunist T. destructans showed variable susceptibility pattern to a panel of common antifungal agents. The MICs of amphotericin B, voriconazole, posaconazole and itraconazole were 1 μg/mL, complemented by an in vitro MEC of 16 μg/mL against caspofungin; the MIC of terbinafine was 0.125 μg/mL. The latter compound contributed to the successful therapy in the ocular mycosis refractory to standard antifungal therapy, the benefit of terbinafine should be highlighted as a therapeutic option especially in difficult‐to‐treat fungal keratitis.