An evaluation of ibrexafungerp for the treatment of invasive candidiasis: the evidence to date.

INTRODUCTION: Invasive fungal infections, especially candidemia and invasive candidiasis, cause significant morbidity and mortality. The epidemiology of candida infections have changed dramatically due to an increase in risk factors associated with the development of infection and the emergence of resistant isolates such as C. glabrata and C. auris. This has prompted the search for novel and effective antifungals. AREAS COVERED: The results of in vitro studies evaluating the activity of ibrexafungerp against Candida species are reviewed and the pharmacokinetic/pharmacodynamic properties are highlighted. Available results and safety data from limited clinical studies are discussed. EXPERT OPINION: Ibrexafungerp demonstrates potent in vitro activity against susceptible and resistant Candida species, including echinocandin-resistant C. glabrata and multidrug-resistant C. auris. It also offers the flexibility of a parenteral and an oral preparation, minimal adverse effects, and low drug-drug interactions. In Phase 2/3 clinical trials, ibrexafungerp appears to have excellent clinical activity in patients with candidemia, invasive candidiasis, and mucosal candidiasis. Although there are several ongoing clinical trials, ibrexafungerp appears to be a promising agent and an important addition to the antifungal armamentarium necessary to treat emerging and resistant pathogens, including several of the Candida species.

Toxin production, growth kinetics and molecular characterization of Ostreopsis cf. ovata isolated from Todos os Santos Bay, tropical southwestern Atlantic.

The toxin profile and hemolytic activity of a strain of Ostreopsis cf. ovata (UFBA013) isolated from Todos os Santos Bay (northeastern Brazil) were evaluated under different levels of N and P. Phylogenetic analyses based on ITS rDNA region (ITS1-5.8S-ITS2) placed UFBA013 within the Atlantic/Mediterranean/Pacific clade of O. cf. ovata. Growth experiments were conducted in f/2 medium modified by adding N and P (P: 0-36 µM; N: 0-882 µM). The growth kinetics was adequately described by logistic equations. The best growth (highest Gm) was recorded under levels of N/P = 0/18, 129/5 and 441/36, while one of the lowest Gm was obtained under P-depletion. The maximum and specific maximum growth rates (as vm; cells mL-1 d-1 and µm; d-1) were achieved with N limitation (N/P = 441/36) and P-limitation/depletion (753/5.3 and 441/0) and are the highest values reported in the literature, most similar to isolates from Pacific and Mediterranean areas. The control experiment (N/P = 441/18) also yielded similar values to those from some Mediterranean isolates, but higher than formerly reported for Brazilian isolates. In all conditions assayed, no palytoxin (PLTX) was detected. The ovatoxins (OVTXs) a, b, c, d and e did not show significant differences in cell quota between exponential and stationary phases. A significant relationship was detected between OVTXs concentration and hemolytic activity.

Toxicity of spill-treating agents and oil to sea urchin embryos.

The aim of this study was to assess the joint toxicity of a Maya crude oil and four spill-treating agents (STAs) (CytoSol, Finasol OSR51, Agma OSD569 and OD4000). The acute toxicity of the binary mixtures of the water accommodated fractions (WAFs) obtained independently for the oil and each STA was assessed. The toxicity of the chemically enhanced WAF (CEWAF) of oil and Finasol OSR51 at several dispersant to oil ratios (1:2, 1:10 and 1:100) was also evaluated. The toxicity (EC50) obtained for the WAFs of the STAs was: CytoSol (15.1 mL/L)

Toxicity of binary mixtures of oil fractions to sea urchin embryos.

The assumption of additive toxicity for oil compounds is related to a narcotic mode of action. However, the joint toxicity of oil fractions has not been fully investigated. A fractionation of Maya crude oil into aliphatics, aromatics and polars was performed, fractions were dissolved in dimethyl sulfoxide (DMSO) and subsequently toxicity of single fractions and binary mixtures was assessed using the sea urchin embryo test. The descriptive ability of Concentration Addition (CA), Independent Action (IA) and modifications of both models for describing the joint toxicity of mixtures has also been evaluated. The hydrocarbon content extractable with dichloromethane of the fractions dissolved in DMSO was: 12.0 ± 1.8 mg mL(-1), 39.0 ± 0.5 mg mL(-1) and 20.5 ± 2.5 mg mL(-1) for aliphatics, aromatics and polars, respectively. The toxicity of the extracts in DMSO of the fractions as EC50 (µLL(-1)) was: aliphatics (165.8-242.3)

Inhibition kinetics of lipid oxidation of model foods by using antioxidant extract of fermented soybeans.

Fermentation by using Aspergillus oryzae has been reported to increase antioxidant activity of soybeans significantly. The effectiveness of the extract from fermented soybeans was studied in 3 model foods with different complexities, i.e., linoleic acid emulsion, sunflower oil emulsions and bulk sunflower oil. For the emulsion systems, oxidation at two different pH values (4.5 and 7) was also compared. A reparameterised logistic equation was used to describe and to predict the experimental data. In general, a good agreement between experimental trends and simulated data from the model was found. A crude antioxidant extract (5 mg/g) showed a comparable antioxidant activity to 0.26 mg/g of butylated hydroxytoluene (BHT) in the linoleic acid emulsions. The extract exhibited a better capability to retard primary products in the linoleic acid systems than the secondary products. The opposite effect was observed in the bulk sunflower oil and its emulsion systems.

Dose-response modelling with two agents: application to the bioassay of oil and shoreline cleaning agents.

Single and joint effects of hydrocarbons and a shoreline cleaning agent (SCA) were studied by measuring the inhibition of the larval growth of sea urchin. Different dosage methods of hydrophobic compounds were compared. The results obtained in the evaluation of CytoSol toxicity revealed that the method of variable dilution of water accommodated fraction (WAF) led to the more conservative toxicological approach. Regarding to Libyan oil, the use of DMSO as carrier allowed us the evaluation of its potential toxicity in comparison with the limitations imposed to the use of WAF method. A reparametrised form of the Weibull equation was slightly modified to be useful for dose-response analysis. This was the basis for modelling single sigmoid responses, which were used to simulate biphasic profiles with addition of effects and to describe both the concentration addition (CA) and independent action (IA) hypotheses. In all cases, its descriptive ability was graphically and statistically satisfactory. The IA model was the best option to explain the combined experimental responses obtained.

Randomized, comparative, double-blind, double-dummy, multicenter trial of miconazole buccal tablet and clotrimazole troches for the treatment of oropharyngeal candidiasis: study of miconazole Lauriad® efficacy and safety (SMiLES).

BACKGROUND: Oropharyngeal candidiasis (OPC) is the most common opportunistic infection among persons infected with human immunodeficiency virus (HIV). Once-daily miconazole 50 mg buccal tablet (MBT) is a novel delivery system using an extended-spectrum azole with potent in vitro activity against many Candida species, including some that may be resistant to other azoles. METHODS: This phase 3, double-blind, double-dummy, multicenter trial evaluated 578 randomized patients with HIV infection and OPC. The study compared the efficacy and safety of MBT once daily with clotrimazole 10 mg troches (CT) 5 times daily for 14 days. The co-primary efficacy endpoints were clinical cure at test of cure (TOC) visit (days 17-22) in the intent-to-treat (ITT) and per protocol (PP) populations. RESULTS: Clinical cure rate at TOC visit for MBT-treated patients was statistically noninferior to CT-treated patients in both the ITT (61% vs 65%) and PP (68% vs 74%) populations. Secondary endpoints, safety, and tolerability were similar between treatment groups. CONCLUSIONS: In this large trial, once-daily MBT was shown to be noninferior to CT 5 times daily in the treatment of OPC in HIV-positive patients. MBT offers an effective, safe, and well-tolerated topical treatment option for OPC administered as a convenient once-daily dose.

Acute toxicity of a shoreline cleaner, CytoSol, mixed with oil and ecological risk assessment of its use on the Galician Coast.

The application of embryo-larval bioassay with the purple sea urchin Paracentrotus lividus and the mussel Mytilus galloprovincialis at 48 hours, and with neonates of the mysid Siriella armata at 96 hours, was used to evaluate the acute toxicities of the following preparations: (1) the shoreline cleaning agent CytoSol; (2) the water-accommodated fraction of CytoSol plus a light crude oil; and (3) the runoff from a pilot-scale treatment with CytoSol of a rocky coastal substrate impregnated with residues from the Prestige oil spill (which occurred on November 19, 2002). The mussel was the most sensitive organism to CytoSol and runoff effects (EC(50) = 8.0 microL/L and 64.3 mL/L, respectively), and the mysid was the least sensitive to the runoff (EC(50) > 200 mL/L). The predicted no-effect environmental concentration (PNEC) was calculated from the no observed-effect concentration of the species most sensitive to the runoff. The predicted environmental concentration (PEC) was estimated from a simple and reasonable dilution model, and the PEC/PNEC ratio was calculated according to the area treated and the values of the variables considered in the model. Implications for the management of the treatment operations are discussed.

Combination antifungal therapy: the new frontier.

The past decade has seen a significant increase in the incidence of invasive fungal infections. The antifungal armamentarium for the treatment of serious fungal infections remains limited. A possible approach to overcoming antifungal drug resistance and high mortality rates seen in severe fungal infections is to combine two or three classes of antifungals, especially if the drugs have different mechanisms of action. Combinations of new agents along with more traditional antifungals have now been shown to possess some synergistic or at least additive activity against many fungi in in vitro and animal studies. On the other hand, caution is still needed since some antifungal combinations have also demonstrated antagonistic activity. Well-controlled clinical trials are still required to define the most efficacious antifungal regimen. Furthermore, these trials should also evaluate the side-effect potential of combination regimens and the pharmacoeconomic impact these regimens may have.

Anidulafungin: a novel echinocandin.

Until recently, the treatment available for serious fungal infections was composed of amphotericin B and azoles, and each class demonstrated significant limitations. Echinocandins are a new class of drugs that have shown promising results in treating a variety of fungal infections. Of these, anidulafungin is a novel echinocandin that appears to have several advantages over existing antifungals. It is unique because it slowly degrades in humans, undergoing a process of biotransformation rather than being metabolized. It has potent in vitro activity against Aspergillus and Candida species, including those resistant to fluconazole or amphotericin B. Results of several clinical trials indicate that anidulafungin is effective in treating esophageal candidiasis, including azole-refractory disease. The results of a recent study comparing fluconazole versus anidulafungin demonstrated the superiority of anidulafungin in the treatment of candidemia and invasive candidiasis (IC). Studies evaluating the concomitant use of anidulafungin and either amphotericin B, voriconazole, or cyclosporine did not demonstrate significant drug-drug interactions or adverse events. To date, anidulafungin appears to have an excellent safety profile. On the basis of early clinical experience, it appears that anidulafungin will be a valuable asset in the management of serious and difficult-to-treat fungal infections.

A multicenter randomized trial evaluating posaconazole versus fluconazole for the treatment of oropharyngeal candidiasis in subjects with HIV/AIDS.

BACKGROUND: Oropharyngeal candidiasis is the most common opportunistic infection among persons infected with human immunodeficiency virus (HIV). Use of some agents is hampered by lack of efficacy, emergence of resistance, adverse events, and need for intravenous administration. Posaconazole is an extended-spectrum triazole with potent in vitro activity against Candida species, including Candida albicans, Candida glabrata, and Candida krusei (including fluconazole-resistant strains). METHODS: This multicenter, randomized, evaluator-blinded study of subjects with HIV infection and oropharyngeal candidiasis compared efficacy of posaconazole with that of fluconazole. Subjects received either 200 mg of posaconazole or fluconazole oral suspension on day 1, followed by 100 mg/day for 13 days. The primary study end point--clinical success (cure or improvement) on day 14--was evaluated for 329 subjects. Durability of clinical success was evaluated on day 42. RESULTS: Three hundred fifty subjects received posaconazole (n = 178) or fluconazole (n = 172). Clinical success occurred in 155 (91.7%) of 169 posaconazole recipients and in 148 (92.5%) of 160 fluconazole recipients (95% confidence interval, -6.61% to 5.04%), indicating that posaconazole was not inferior to fluconazole. On day 14, mycological success was 68% in both arms, but by day 42, significantly more posaconazole recipients than fluconazole recipients continued to have mycological success (40.6% vs. 26.4%; P=.038). Fewer posaconazole recipients than fluconazole recipients experienced clinical relapse (31.5% vs. 38.2%). Adverse events were similar between treatment arms. CONCLUSIONS: Results demonstrate that posaconazole was as effective as fluconazole in producing a successful clinical outcome. However, posaconazole was more effective in sustaining clinical success after treatment was stopped.

Anidulafungin: a new echinocandin with a novel profile.

BACKGROUND: Until recently, available treatment for serious fungal infections comprised amphotericin B and azoles, which have limitations. Renal toxicity is a major concern with amphotericin B, while drug-drug interactions, hepatotoxicity, and skin rashes are the primary concerns with the azole medications. The development of the echinocandins, including caspofungin, has helped to fill the need for more efficacious antifungals that are useful across different patient populations and have a good safety profile. Anidulafungin is an echinocandin being developed to treat mucosal and invasive fungal infections. OBJECTIVE: The aim of this report was to describe the pharmacodynamic and pharmacokinetic (PK) properties of anidulafungin. METHODS: Data were identified using MEDLINE and National Library of Medicine Gateway searches for English-language literature (key words: anidulafungin, esophageal candidiasis, echinocandin, caspofungin, ravuconazole, voriconazole, posaconazole, micafungin, and fluconazole; years: 1996-2004), and from meeting abstracts of the American Society for Blood and Marrow Transplantation (Arlington Heights, Illinois), European Congress of Clinical Microbiology and Infectious Diseases (Basel, Switzerland), International Conference on Antimicrobial Agents and Chemotherapy (Washington, DC), and Infectious Diseases Society of America (Arlington, Virginia). RESULTS: Anidulafungin has potent in vitro activity against Aspergillus and Candida spp, including those resistant to either fluconazole or amphotericin B. Results of several clinical trials imply that anidulafungin is effective in treating esophageal candidiasis (EC), candidemia, and invasive candidiasis (IC). In a Phase III, randomized, blinded clinical trial evaluating anidulafungin (50 mg/d) versus fluconazole (100 mg/d) for the treatment of EC, 97.2% and 98.9% of patients who received anidulafungin and fluconazole, respectively, showed evidence of cure or improvement (treatment difference, -1.6%; 95% CI, -4.1 to 0.8). In a Phase II study of candidasis and candidemia, anidulafungin showed success rates of 72%, 85%, and 83% in patients receiving the drug at dosages of 50, 75, or 100 mg/d, respectively. Studies evaluating the concomitant use of anidulafungin and either amphotericin, voriconazole, or cyclosporine did not show clinically significant drug-drug interactions or altered adverse-event (AE) profiles (P < 0.05). A population PK analysis showed no significant effect of age, race, concomitant medications, or renal or hepatic insufficiency on the PK properties of anidulafungin (P < 0.05). CONCLUSIONS: Anidulafungin may offer a new option to treat serious fungal infections, such as EC, azole-refractory EC, candidemia, and IC. In addition, anidulafungin has been associated with no clinically significant drug-drug interactions and few treatment-related AEs. Anidulafungin may offer a new option in the management of serious and difficult-to-treat invasive fungal infections.

Multiechinocandin- and multiazole-resistant Candida parapsilosis isolates serially obtained during therapy for prosthetic valve endocarditis.

Echinocandins are approved for the treatment of candidal infections. In vitro they have been shown to be less potent against strains of Candida parapsilosis than against other Candida spp. This is the first case report describing the development of a secondary multidrug (echinocandin-azole)-resistant Candida strain during therapy.

Efficacy of alcohol-based and alcohol-free melaleuca oral solution for the treatment of fluconazole-refractory oropharyngeal candidiasis in patients with AIDS.

PURPOSE: To evaluate the efficacy of alcohol-based and alcohol-free melaleuca oral solution in patients with AIDS and fluconazole-refractory oropharyngeal candidiasis. METHOD: We performed a prospective, single-center, open-label study in a university-based inner city HIV/AIDS clinic. The study included 27 patients with AIDS and oral candidiasis clinically refractory to fluconazole. Patients were randomized 1:1 to receive either alcohol-based or alcohol-free melaleuca oral solution four times daily for 2-4 weeks. Thirteen patients were enrolled into cohort 1, and 14 patients were enrolled into cohort 2. The main outcome measure was resolution of clinical lesions of oral candidiasis. Evaluations were performed at 2 and 4 weeks for clinical signs and symptoms of oral candidiasis and quantitative yeast cultures. RESULTS: All C. albicans isolates showed some degree of in vitro resistance to fluconazole. Overall, using a modified intent-to-treat analysis, 60% of patients demonstrated a clinical response to the melaleuca oral solution (7 patients cured and 8 patients clinically improved) at the 4-week evaluation. CONCLUSION: Both formulations of the melaleuca oral solution appear to be effective alternative regimens for patients with AIDS suffering from oropharyngeal candidiasis refractory to fluconazole.

Vaginitis due to Candida krusei: epidemiology, clinical aspects, and therapy.

Twelve women with vaginal Candida krusei infection were evaluated. In vitro antifungal susceptibility testing and molecular typing were performed. Patients infected with C. krusei frequently had refractory vulvovaginal signs and symptoms that were otherwise indistinguishable from vaginitis due to other yeasts. Patients were 32-63 years old and had previously received multiple courses of antimycotic agents, including fluconazole and miconazole. The most active azole in vitro was clotrimazole, with a 90% minimum inhibitory concentration of 0.25 microg/mL. Four of 6 patients treated with boric acid had clinical and mycological cure. Two dominant genotypes of C. krusei were identified via contour-clamped homogenous electrical field analysis. No major genotypic change was observed in successive isolates from the same patient in most cases, suggesting that these refractory cases were relapses. C. krusei is a rare but important cause of refractory vaginitis and is unique because of its intrinsic resistance to fluconazole.