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From a total of 109 strains, 59 belonged to non-C. albicans Candida species: 25 Candida parapsilosis complex, 14 Candida glabrata complex, 13 Candida tropicalis, 4 Candida krusei, 1 Candida lipolytica, 1 Candida membranaefaciens, and 1 Candida pulcherrima. The most common risk factor in adults and children was catheter use. It was observed that 8.5% of those non-C.albicans strains were resistant to fluconazole.
The present prospective observational study was conducted in the Department of Microbiology at a tertiary care teaching hospital during one year June 2011-July 2012. Blood samples were collected from 1376 patients clinically suspected to have fungal septicaemia, out of which 100 (7.2%) Candida isolates obtained, were speciated by conventional methods. Antifungal susceptibility testing of all the isolates was done against fluconazole, voriconazole as per NCCL (M27-A2) and against olive oil and cinnamon oil by agar well diffusion method.
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Aspergillus, a nosocomial agent, is the most common fungal cause of suppurative thyroiditis. Most patients with Aspergillus thyroiditis have disseminated infection, primarily with lung compromise. Late diagnosis and treatment, severity of immunosuppressive state and thyroid hormone overload contribute to extremely high mortality rates.
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Drug interactions were assessed by a checkerboard microdilution method that also included the determination of the MIC of each drug alone according to CLSI (Clinical and Laboratory Standards Institute) document M38-A2, 2008.
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The first study was a randomized, double-blind, double dummy, two-period crossover study. Subject received either 1000 mg fosfluconazole or 800 mg FLCZ once daily for 14 days in random order. The second study was an open label, randomized parallel group study. Subjects received one of three fosfluconazole once daily treatments: 500 mg for 10 days (no loading dose), a loading dose of 1000 mg on day 1 followed by 500 mg for 9 days (one loading dose), or loading doses of 1000 mg on days 1 and 2 followed by 500 mg for 8 days (two loading doses).
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69 patients (54 men and 15 women, aged 55.8 [range 18-87] years) of 364 patients of the anaesthesiological intensive care unit (ICU) of the University Hospital of Heidelberg in 1991 and 1992 were selected for the study. None of the 69 patients was suffering from proven invasive candidiasis according to the gold-standard criteria of positive histology, blood culture, or isolation from a sterile compartment. However, 35 of the 69 patients were systemically treated with fluconazole (on average 295 mg per day for 10.2 days intravenously). 34 patients did not receive any antifungal therapy. Retrospectively we analysed the course of the disease in both groups of patients. Furthermore, 173 serum samples of these patients were available for investigations by Western blot for anti-Candida antibodies of the immune globulin classes M and G.
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We have partially mapped by country systemic generic antifungal drug registration, availability and daily cost for intravenous deoxycholate amphotericin B (50 mg), flucytosine (5 g), oral fluconazole (750-800 mg) and oral itraconazole (400 mg).
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Drug resistance among yeasts and mycelial fungi remains a serious problem when therapy for deep mycoses is chosen. The generic variety of fungal cultures obtained from the sputa of 148 patients with various bronchopulmonary diseases in 1998-2008 was assessed. Most (n = 113) isolates were yeasts of the genus Candida and 39 isolates were mycelial fungi of the genus Aspergillus. The fungi of the genera Geotrichum, Rhodotorula, Saccharomyces, Kluyveromyces, Penicillium, Cryptococcus, and Mucor were much less common. The sensitivity of the obtained Candida isolates was monitored. It has been found that in the past decade there has been reduced sensitivity to azole drugs, such as ketoconazole, clotrimazole, fluconazole, and itraconazole. At the same time, the sensitivity of yeast cultures to pimafucin has increased. Comparison of the sensitivity of cultures of various genera has shown that the azole drugs are much less active against Aspergillus than Candida. The sensitivity of mycelial fungi to lamisil and pimafucin is higher than that of yeasts.
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An observational pharmaco-epidemiological database study was performed in a university hospital setting with 3884 patients with T2DM.
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In Candida albicans, the ERG11 gene encodes lanosterol demethylase, the target of the azole antifungals. Mutations in ERG11 that result in an amino acid substitution alter the abilities of the azoles to bind to and inhibit Erg11, resulting in resistance. Although ERG11 mutations have been observed in clinical isolates, the specific contributions of individual ERG11 mutations to azole resistance in C. albicans have not been widely explored. We sequenced ERG11 in 63 fluconazole (FLC)-resistant clinical isolates. Fifty-five isolates carried at least one mutation in ERG11, and we observed 26 distinct positions in which amino acid substitutions occurred. We mapped the 26 distinct variant positions in these alleles to four regions in the predicted structure for Erg11, including its predicted catalytic site, extended fungus-specific external loop, proximal surface, and proximal surface-to-heme region. In total, 31 distinct ERG11 alleles were recovered, with 10 ERG11 alleles containing a single amino acid substitution. We then characterized 19 distinct ERG11 alleles by introducing them into the wild-type azole-susceptible C. albicans SC5314 strain and testing them for susceptibilities to FLC, itraconazole (ITC), and voriconazole (VRC). The strains that were homozygous for the single amino acid substitutions Y132F, K143R, F145L, S405F, D446E, G448E, F449V, G450E, and G464S had a ≥ 4-fold increase in FLC MIC. The strains that were homozygous for several double amino acid substitutions had decreased azole susceptibilities beyond those conferred by any single amino acid substitution. These findings indicate that mutations in ERG11 are prevalent among azole-resistant clinical isolates and that most mutations result in appreciable changes in FLC and VRC susceptibilities.
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Intravascular catheter placement carries the risk of a life-threatening systemic fungal infection. In addition to antifungal therapy, removal of the catheter is often considered to be an important part of management.
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EFA was -0.30 ± 0.11 log CFU/day calculated over the first 2 weeks of treatment, with no reduction in the rate of clearance between days 5 and 14. There was no grade IV hypokalemia or elevated creatinine, and no grade III or IV anemia or elevation of ALT. AmB or high dose fluconazole were not stopped early in any patient. Mortality was 23% at 2, and 28% at 10 weeks.
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A single dose of 750 mg of fluconazole was safe, well tolerated, and as effective as the standard 14-day fluconazole therapy in patients with HIV infection and acquired immunodeficiency syndrome who had oropharyngeal candidiasis coinfection.
Adjusted CLSI CBPs for FLU and C. albicans, C. parapsilosis, C. tropicalis (S, ≤ 2 mcg/ml; SDD, 4 mcg/ml; R, ≥ 8 mcg/ml), and C. glabrata (SDD, ≤ 32 mcg/ml; R, ≥ 64 mcg/ml) should be more sensitive for detecting emerging resistance among common Candida species and provide consistency with EUCAST CBPs.
Cryptococcus neoformans var. grubii (serotype A) was isolated from 12 soil samples mixed with pigeon droppings (16.9%) from 71 soil samples in Barcelona and rural areas of Catalonia. C. neoformans was not isolated from indoor dust and Eucalyptus debris. PCR fingerprinting was performed in 22 representative isolates and all of them corresponded to the VNI pattern. Susceptibility testing for the 22 isolates of C. neoformans var. grubii showed that all of them were susceptible to amphotericin B. Three isolates presented MICs (Minimal Inhibitory Concentrations) > or = 1 microg/ml to Itraconazole, five MICs > or = 1 microg/ml to ketoconazole and four were fluconazole resistant, (MICs > or = 64 microg/ml), while three of them were shown to have MICs > or = 1 microg/ml to voriconazole. In spite that all isolates presented the same DNA fingerprinting pattern, the susceptibility to antifungals is very variable. The possibility of acquiring cryptococcosis infection with primarily resistant environment strains is feasible.
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Anidulafungin is a new echinocandin antifungal agent recently approved in Spain by the Spanish Drug Agency. As other echinocandins, it inhibits a selective target, 1,3- beta-D-glucan synthesis, a major structural component of the fungal cell wall which is not present in mammalian cells, this avoiding toxicity problems. It has fungicidal activity against many Candida spp., including fluconazole-resistant, and fungistatic activity against other yeast and moulds such as Aspergillus spp. Clinical trials have shown non-inferiority of anidulafungin to fluconazole for invasive, including candidemia, and non-invasive Candida infections. It is well-tolerated, and no drug-related serious adverse events have been reported. Anidulafungin, which has a very long half life, is slowly degraded by human peptidases and proteases and has a low drug-drug interaction profile based on its lack of interaction with the cytochrome P450 system. Thus, dosing adjustments of anidulafungin based on age, gender, body weight, disease status, concomitant therapy or renal or hepatic insufficiency is not necessary. As it does not interact with amphotericin B and voriconazole, cyclosporine, tacrolimus and other drugs, it can be used in combination with other antifungal agents and co-administered with immunosuppressant drugs. It is generally well-tolerated in clinical trials. Its most frequent adverse events are nausea, vomiting, moderate diarrhea, transient elevation of hepatic enzymes and headache. Some of the patients have mild, passing reactions such as facial blushing, nausea and dyspnea related with rapid intravenous perfusion. Its antifungal activity, clinical efficacy, safety profile, and pharmacokinetic characteristics make it a suitable alternative antifungal compound for therapy of mucosal candidiasis, candidemia and invasive candidiasis, above all in patients with some degree of renal and hepatic insufficiency.
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In this metaanalysis of randomized controlled trials (RCTs) we aimed to compare the in vivo and in vitro activity and the safety of per os itraconazole and fluconazole treatment of uncomplicated acute vaginal/vulvovaginal candidiasis in nonpregnant women. We used PubMed, Scopus, Web of Science, and Cochrane Library to identify the studies that were relevant to our metaanalysis RCTs. Six RCTs were included in this study that comprised 1092 enrolled patients with signs and symptoms of vaginal/vulvovaginal candidiasis that was confirmed by microscopy and/or microbiologic cultures that were obtained from the ectocervix and/or vaginal fundus. Overall, there was no difference between itraconazole and fluconazole regarding clinical cure and improvement at the first and second scheduled visit assessments (pooled odds ratio [OR], 0.94 [95% CI, 0.6-1.48] and 1.09 [95% CI, 0.68-1.75], respectively), mycologic cure at the first and second scheduled visit assessments (OR, 0.73 [95% CI, 0.31-1.7] and 0.71 [95% CI, 0.49-1.03], respectively), withdrawal of patients because of severe adverse events (OR, 0.72 [95% CI, 0.16-3.32]), and adverse events noted from the nervous and digestive systems (OR, 1.07 [95% CI, 0.42-2.73] and 1.84 [95% CI, 0.3-11.27], respectively). In conclusion, effectiveness and safety of oral itraconazole and fluconazole in the treatment of acute uncomplicated vaginal/vulvovaginal candidiasis are similar.
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Cytochrome P-45061 (CYP61) was a cytochrome P-450 revealed during the yeast genome project when chromosome XIII was sequenced. Here we report on the properties of this second microsomal P-450 of vegetatively growing yeast. The enzyme kinetics associated with its endogenous role in sterol Delta22-desaturation revealed a Km of 20.4 microM and a Vmax of 2.9nmol/min/nmol CYP61. The affinity of the enzyme for antifungal drugs was characterized to investigate its potential role in determining tolerance to these sterol 14alpha-demethylase (CYP51) inhibitors. Drug binding induced a type II spectral change, which became saturated at equimolar concentrations of azole drug and P-450. Fluconazole exhibited slightly reduced affinity in comparison to ketoconazole as indicated by carbon monoxide displacement. These and Ki determination for fluconazole (0.14 nM) revealed CYP61 to have a similar affinity to azole drugs when compared with data available for CYP51, and the implications for antifungal treatment were considered.
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Ninety-eight patients were included. Among them, 10 patients were "proven" in whom the positive rate of BALF G test was 90.0%; 29 patients the results were considered as "probable" in whom the positive rate of BALF G test was 82.8%; in 32 patients the results were "possible" IPFI in whom the positive rate of BALF G test was 71.9%, 27 patients were "non-IPFI" in whom the positive rate of BALF G test was 7.4%. The positive rate of BALF G test was 84.6% (33/39), the positive rate of serum G test was 59.0% (23/39), the positive rate of culture of BALF was 41.0% (16/39), the positive rate of microscopic examination of BALF was 38.5% (15/39) in "proven" cases and "probable" cases. G test (cut-off ≥20 ng/L) of BALF had shown to have sensitivity, specificity, positive predictive value (PPV) of 84.6% (33/39), 92.6% (25/27), 94.3% (33/35), respectively, and negative predictive value (NPV) of 80.7% (25/31). The G test detection (cut-off ≥20 ng/L) in serum had shown to have sensitivity, specificity, PPV of 58.9% (23/39), 88.9% (24/27), 88.5%(23/26), respectively, and NPV of 60.0% (24/40), and the differences in sensitivity were statistically significant (P < 0.05). BALF G test assay tended to become positive earlier than the culture for 2-8 days with mean of (5.35 ± 2.26) days.Forty out of 56 G test positive patients were given preemptive antifungal therapy for 2 weeks, and there was a good response in 31 patients, but no response in 9 cases with 22.5% mortality. After treatment, the result of G test (ng/L) was lowered in patients with a good response in treatment group (BALF: 245.13 ± 43.84, 174.00 ± 13.01, 28.52 ± 7.38; serum: 93.26 ± 18.75, 72.15 ± 12.90, 37.37 ± 10.45, all P < 0.05). On the other hand, an elevated value suggested an unsatisfactory result in ineffective group (BALF: 267.58 ± 54.63, 309.71 ± 82.47, 486.72 ± 98.21; serum: 101.58 ± 12.75, 98.07 ± 27.45, 112.07 ± 19.21, all P < 0.05). There were significantly differences in the results of G tests on 7th day and 14th day between BALF G test and serum G test in both groups (all P < 0.05).
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The prophylaxis was successful in seven of 18 cases (39%) in the FLCZ group and 15 of 21 cases (71%) in the MCFG group, indicating that the success rate was significantly higher in the latter group.
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Candida albicans forms two types of biofilm in RPMI 1640 medium, depending upon the configuration of the mating type locus. In the prevalent a/α configuration, cells form a biofilm that is impermeable, impenetrable by leukocytes, and fluconazole resistant. It is regulated by the Ras1/cyclic AMP (cAMP) pathway. In the a/a or α/α configuration, white cells form a biofilm that is architecturally similar to an a/α biofilm but, in contrast, is permeable, penetrable, and fluconazole susceptible. It is regulated by the mitogen-activated protein (MAP) kinase pathway. The MTL-homozygous biofilm has been shown to facilitate chemotropism, a step in the mating process. This has led to the hypothesis that specialized MTL-homozygous biofilms facilitate mating. If true, then MTL-homozygous biofilms should have an advantage over MTL-heterozygous biofilms in supporting mating. We have tested this prediction using a complementation strategy and show that minority opaque a/a and α/α cells seeded in MTL-homozygous biofilms mate at frequencies 1 to 2 orders of magnitude higher than in MTL-heterozygous biofilms. No difference in mating frequencies was observed between seeded patches of MTL-heterozygous and MTL-homozygous cells grown on agar at 28°C in air or 20% CO2 and at 37°C. Mating frequencies are negligible in seeded patches of both a/α and a/a cells, in contrast to seeded biofilms. Together, these results support the hypothesis that MTL-homozygous (a/a or α/α) white cells form a specialized "sexual biofilm."
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Mechanism-based pharmacokinetic-pharmacodynamic (PK-PD) models describing the fungistatic activity of fluconazole and the fungicidal activity of caspofungin were developed using dynamic in vitro models. Antifungal-drug pharmacokinetics was simulated in vitro, assuming a one-compartment model with an elimination half-life of 3 h and using a wide (1 to 10,000) range of initial concentrations. The number of CFUs over time was determined for up to 31 h and used for PK-PD modeling. A model incorporating first-order natural growth and natural death, plus a maximum number of viable Candida cells, was used to characterize Candida growth in the absence of a drug. Fluconazole was considered to inhibit Candida growth and caspofungin to stimulate Candida death according to an Emax pharmacodynamic model. The data were analyzed with Nonmem, using a population approach. A good fit of the data was obtained with satisfactory estimates of PK-PD parameters, especially with drug concentrations producing 50% of the maximal effect: 50% inhibitory concentrations for fluconazole growth inhibition and 50% effective concentrations for caspofungin death stimulation. In conclusion, mechanistic PK-PD models were successfully developed to describe, respectively, the fungistatic and fungicidal activities of fluconazole and caspofungin in vitro. These models provide much better information on the drug effects over time than the traditional PK-PD index based on MICs. However, they need to be further characterized.
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A 67-year-old man with pulmonary emphysema was admitted to the hospital because of left back pain. Chest roentgenography revealed an infiltrate in the left upper lobe, with cavitation, Mycetoma-like shadows were seen in the cavities about 3 weeks later, and a test for the precipitating antibody to Aspergillus fumigatus was positive. Chronic necrotizing pulmonary aspergillosis (CNPA) was diagnosed, and fluconazole was given. A chest roentgenogram taken 4 weeks later showed resolution of both the mycetoma-like shadows and much of the infiltrate. Systemic immunosuppression was highly unlikely: the patient had not been undergoing corticosteroid therapy, and had no predisposing conditions, such as a chronic debilitating illness or diabetes mellitus. In that sense, this case is similar to another reported recently, in which CNPA was associated with chronic obstructive pulmonary disease in an immunocompentent patient.
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Midazolam is a short-acting benzodiazepine hypnotic extensively metabolized by CYP3A4 enzyme. Orally ingested azole antimycotics, including fluconazole, interfere with the metabolism of oral midazolam during its absorption and elimination phases. We compared the effect of oral and intravenous fluconazole on the pharmacokinetics and pharmacodynamics of orally ingested midazolam.
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From January 2010 to June 2011, all patients with newly diagnosed AML were consecutively registered and prospectively monitored at 30 Italian hematological centers. Our analysis focused on adult patients who received intensive chemotherapy and a mold-active AFP for at least 5 days. To determine the efficacy of prophylaxis, invasive fungal disease (IFD) incidence, IFD-attributable mortality, and overall survival were evaluated.
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Multicentre open study.
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Multidrug resistance-associated proteins (MRPs) and organic anion transporters (OATs) are expressed on the blood-brain barrier (BBB) and blood-cerebrospinal fluid barrier (BCSFB), preventing the entry of or the pumping out of numerous molecules. Fluconazole is widely used to treat fungal meningoencephalitis. The effect of these transporters on the distribution of fluconazole in the brain is unclear. We used microdialysis to compare the distribution of fluconazole in the rat brain with and without co-administration of probenecid, a MRP and OAT inhibitor. Additionally, we also observed the difference in fluconazole distribution between the two barriers. The results showed that probenecid increased the penetration of fluconazole into the BBB but did not alter the penetration of fluconazole into the BCSFB of rats. The penetration of the BBB and BCSFB by fluconazole did not statistically differ according to physiological condition. These results demonstrate that transporters that can be inhibited by probenecid may be involved in fluconazole resistance at the BBB and provide a laboratory basis for predicting brain extracellular fluid (ECF) concentration using the cerebrospinal fluid (CSF) concentration of fluconazole.