Professional Documents
Culture Documents
Terapia Antifungica
Terapia Antifungica
Chapter
Antifungal therapy
Paul O. Gubbins, Elias J Anaissie
Wooley discovers
first azole
benzimidazole
Sporothrix discovered
and first C. immitis
cases in U.S. reported
Gruby and Remak
discover tinea favosa
in humans
1835
1896
1841
Amphotericin
B discovered
Zygomycosis
reported in U.S.
1837
1894
1918
1906
1944
1923
Gilchrist reports
blastomycosis in
humans in U.S.
Berg proves
fungal etiology
of thrush
Bassi discovers
muscardine in
silkworms
Miconazole and
Clotrimazole
introduced
Amphotericin
B introduced
1939
Griseofulvin
discovered
Cryptococal
meningitis
reported in U.S.
Darling discovers
Histoplasmosis
in Panama
1955
1950
Ketoconazole
introduced
1960
1957
1969
1964
Amphotericin B
First used
in humans
Itraconazole
introduced
5FC
developed
1981
1974
Micafungin
introduced
AmBisome
introduced
1992
1990
1995
Econazole
introduced
Fluconazole
introduced
2005
1997
2002
2006
First Echinocandin
(caspofungin)
and
Voriconazole
introduced
ABLC
introduced
Anidulafungin
and
Posaconazole
introduced
Table 7-1 Drugs approved for the treatment of systemic mycoses in the United States
Generic name
Brand name
Available
formulation
Amphotericin B
deoxycholate
Amphotericin B
lipid complex
Amphotericin B
colloidal dispersion
Amphotericin B liposomal
Fungizone
Abelcet (ABLC)
IV
Amphotec (ABCD)
IV
AmBisome (LAmB)
IV
Pyrimidine
Flucytosine (5FC)
Ancoban
Oral tablet
Azoles
Ketoconazole
Fluconazole
Nizoral
Diflucan
Itraconazole
Sporanox
Voriconazole
Posaconazole
Vfend
Noxafil
Oral tablet
IV, oral suspension,
oral tablet
Oral capsule, oral
solution
IV, oral tablet
Oral suspension
Caspofungin
Micafungin
Anidulafungin
Cancidas
Mycamine
Eraxis
IV
IV
IV
Class
Polyenes
Echinocandins
Mechanism
of action
of ergosterol. One such target in the ergosterol biosynthesis pathway is cytochrome P450 (CYP)-dependent 14demethylase, which catalyzes the demethylation of ergosterol
precursors. Certain azoles (i.e., ketoconazole, voriconazole)
may interact with secondary targets in the ergosterol biosynthesis pathway; 14-demethylase is the primary target
for this class of compounds.19,20,22,23 Inhibition of 14demethylase ultimately causes the depletion of ergosterol
and the accumulation of sterol precursors, including 14methylated sterols (lanosterol, 14-dimethyl lanosterol, and
163
Membrane function
Polyenes
bind to ergosterol
Antimicrobial peptides: defensins, the protegrins, gallinacini,
cecropin A, thanatin and the dermaseptins
Pradimicins and benanomicins:
bind to mannoprotein and cause a calcium-dependent alteration in
membrane permeability
Ergosterol synthesis
Azoles
inhibit cytochrome P450-dependent 14 --demethylase
Allylamines (naftifine and terbinafien) and thiocarbamates
(tolnaftate): inhibit squalene epoxidase
Morpholine (amorolfine): inhibit 14 -reductase, 7, 8-isomerase,
oxido-squalene cyclase, and 24 methyltransferase
Nuclear division
Griseofulvin
* Investigational
Potential target
Clinically available
Figure 7-2 Sites of action of antifungals.
CH3
CH3
CH3
CH3
Lanosterol
4. 14-dimethylzymosterol
CH3
CH3
HO
CH3
HO
HO
HO
CH3
Oblusifoliol
CH3
CH3
24-methylenedihydrolanosterol
HO
CH3
CH3
CH3
HO
14-methylfecosterol
HO
CH3
CH3
HO
HO
HO
Ergosterol
Figure 7-3 Pathway for sterol synthesis of ergosterol and blocks by azoles.
antifungal agents that have been studied.37 Their exact mechanism of action has not been defined.37 It remains to be seen
whether these and other targets that have or may be discovered in the fungal cell wall show promise for the development
of future antifungal agents; nonetheless, some are undergoing
clinical trials.
165
41
CH3
CH3
O
HO
CH3
42 O
O 43 44
19
OH
OH
OH
OH O
O
OH
OH
OH
18
16
CH3
OH
NH3
COO
OH
Usually Effective
(>60%)
Variably Effective
to Resistant
Candida albicans
Candida krusei
Candida lusitaniae
Candida rugosa
Candida tropicalis
Candida parapsilosis
Cryptococcus neoformans var.
neoformans/var. gattii
Histoplasma capsulatum var.
capsulatum/var. duboisii
Paracoccidioides brasiliensis
Blastomyces dermatitidis
Penicillium marneffei
Sporothrix schenckii
Fusarium spp.
Pseudallescheria boydii
Scedosporium prolificans
Various
Phaeohyphomycetes
Aspergillus spp.
Coccidioides immitis
Note that clinical response does not always correlate with in vitro response.
For example, Aspergillus species and Coccidioides immitis are usually
susceptible in vitro to amphotericin B, but clinical responses vary widely
because of other variables such as immune response.
168
0.075-0.17
0.045-0.08
Amphotericin B
colloidal dispersion
Liposomal
amphotericin B
Vd
Cmax
Cl
AUC
Brain
Bone
marrow
Liver
Fat a
Lung
Comments
Key: AmB, amphotericin B; m, microns; Cmax, maximum concentration; Vd, volume of distribution; Cl, clearance; AUC, area under the serum concentration time curve; Scr, serum creatinine; ABLC, amphotericin B
lipid complex; ABCD, amphotericin B colloidal dispersion; LAmB, liposomal amphotericin B; , increased; , decreased; , similar;
aall preparations demonstrate poor penetration;
bgreatest degree of penetration among formulations.
1.6-11
Molecular
size (m)
Amphotericin B
lipid complex
Formulation
Mean human
pharmacokinetic
parameters
Side view
Polar
interior
25A
Lipid
Amphotericin B
Membrane of associated complexes
A
Figure 7-5 Structure of lipid-associated forms of amphotericin B.
(A) Ablecet. (B) AmBisome.
depending on the population of patients.41 With repeated dosing, amphotericin B also causes glomerular vasospasm and
ischemia, resulting in decreases of glomerular filtration rate.
Risk factors for D-AmB induced nephrotoxicity include average
daily dose, concomitant nephrotoxin (particularly cyclosporine)
use, and elevated baseline serum creatinine.84,85
In some patient populations, glomerulotubular flow may be
augmented by acute infusion of isotonic saline before amphotericin B and may somewhat preserve renal function.86 However, the usefulness of saline hydration may be offset by fluid
restriction employed to manage the fluid status of critically ill
patients. As renal failure progresses, synthesis of erythropoietin diminishes, which leads to anemia.87 Most cases of D-AmB
induced nephrotoxicity are mild to moderate in nature and
reversible in patients at low risk for this complication.88 Severe
nephrotoxicity is uncommon but it too is often reversible.88
Although D-AmB is nephrotoxic, renal dysfunction does not
significantly impact its kinetics. Therefore, anephric patients
may be treated with dosages similar to those given to patients
with normal renal function. Initial decreases in renal function
caused by amphotericin B may be improved by occasional
interruption of therapy, switching to the lipid amphotericin B
169
Major reactions
Incidence
Management
Common
Local phlebitis
Common
Rare
Hypotension
Rare
Rare
Renal insufficiency
Common
Common
Electrolyte replacement
Rare
Common
Supportive care
Normochromic anemia
Rare
Rare
Toxicity The primary toxicities of flucytosine are myelosuppression, gastrointestinal intolerance, and hepatic toxicity.
The underlying mechanism of myelosuppression associated
with flucytosine is unknown. However, the conversion of
flucytosine to 5-fluorouracil is believed to be one possible
mechanism. Patients treated with flucytosine have detectable
171
Creatinine
clearance (ml/min)
Dose
(mg/kg)
Dosing
interval
>50
25
Every 6 hours
>25-50
25
Every 12 hours
10-25
25
Daily
<10
12.5
Daily
Notes:
1. Monitor renal function and adjust dose accordingly, particularly if
other nephrotoxins used (amphotericin B) and if flucytosine serum level
is not readily available. Keep peak 75 g/ml for cryptococcal or candidal
meningitis and 5075 g/ml for candidemia.
2. Monitor blood counts twice weekly and avoid combining flucytosine
with myelosuppressive agents.
Azoles
Fluconazole, itraconazole, voriconazole, posaconazole
(Fig. 7-6)
Mechanism of action The azoles exert a fungistatic effect by
dose-dependent inhibition of CYP-dependent 14-demethylase,
which ultimately depletes ergosterol and compromises cell
wall integrity. The first clinically useful azoles (clotrimazole,
ketoconazole) have excellent activity against Candida species.
Because of a lack of systemic effect, clotrimazole is used only
for mucosal infections. Ketoconazole, the first systemic azole,
has largely been supplanted by the other agents in the class
and is more commonly used in the developing nations,
where its low cost is a major advantage; thus it will not be
addressed in this chapter. The systemic azoles developed after
ketoconazole include fluconazole, itraconazole, voriconazole
and posaconazole.
Among species the systemic triazoles vary in their 14demethylase inhibition, which may in part explain the differences in antifungal activity in this class. The triazoles also
172
Cl
Cl
CH2 CH O CH2
Cl
Cl
Cl
Clotrimazole
Miconazole
N
N
N
Cl
CH2
O
Cl
CH2
Cl
O
CH2 O
N CH2 C CH2 N
OH
CH3 F
N
Fluconazole
Voriconazole
O
H
F
R
Posaconazole
N
N
Itraconazole
OH
Ketoconazole
CH3
CH2 O
NC CH3
Cl
N
O
s
s
Me
OH
Me
N N
N
Figure 7-6 Structures of azole antifungals. (A) Clotrimazole. (B) Miconazole. (C) Ketaconazole. (D) Itraconazole. (E) Fluconazole. (F) Voriconazole.
(G) Poscaconazole.
Species
Fluconazole
Itraconazole
Voriconazole
Posaconazole
C. albicans
++
++
++
++
Flu/itra resistant
C. glabrata
+/-
+/-
+?
+?
C. parapsilosis
++
++
++
++
C. tropicalis
++
++
++
++
C. lusitania-e
++
++
++
++
C. krusei
+/-
++
++
C. guilliermondii
+/-
++
++
Crytococcus
neoformans
++
++
++
++
Trichosporon asahii
++
++
++
++
Coccidiodes immitis
++
++
++
Histoplasma
capsulatum
+/-
++
++
NA
Blastomyces
dermatitidis
+/-
++
++
NA
Sporothrix schenckii
++
++
NA
Paracoccidioides
brasiliensis
++
NA
++
Penicillium marneffei
++
++
NA
Aspergillus spp.
++
++
++
Fusarium spp.
-*
-*
+/-*
+/-*
Zygomycetes
+/-**
+**
Scedosporium
apiospermum
+/-
++
++
NA
Scedosporium
prolificans
Phaeohyphomycetes
+/++
+/++
+/++
Yeasts
Candida species
Dimorphic fungi
Moulds
Key: + moderate activity; ++ excellent activity; +/- variable activity; - no clinical activity; flu/itra, fluconazole, itraconazole; NA, insufficient data on clinical
activity, probably effective.
*Fusarium solani is resistant to all azoles; variable susceptibility of other species.
**Variable susceptibility: species and organism dependent; Rhizopus spp. more susceptible than other species.
174
drug, its ability to inhibit CYP in vitro may not reflect its in
vivo inhibitory potential.
Dosage adjustment is necessary in patients with reduced
renal function. A 50% dose reduction is recommended for a
CrCl between 11 and 50 ml/mn. Patients undergoing hemodialysis should receive one dose after each dialysis session.
Itraconazole Itraconazole is available as 100 mg capsules and solubilized in a 40% HP-CD 10 mg/ml solution
for oral use. The IV formulation containing HP-CD has
been withdrawn from the marketplace. Itraconazole absorption from the capsule form is slow and incomplete, and the
drug undergoes significant first-pass metabolism in the
intestine and liver before reaching the systemic circulation. In
capsule form, absorption is variable and itraconazole is better
absorbed under acidic gastric conditions or in the fed state.142
In contrast, HP-CD significantly enhances the solubility of
itraconazole. The oral solution requires no dissolution so its
absorption is not influenced by gastric pH and is rapid.143
Thus, high concentrations of itraconazole are delivered to the
intestinal epithelium, which may cause transient saturation
of intestinal CYP3A4.144,145 The oral solution undergoes less
first-pass metabolism, and therefore produces higher and
more consistent serum concentrations. In this form, itraconazole is better absorbed in the fasting than the fed state.144
Higher peak plasma concentrations of itraconazole and its
primary metabolite, hydroxyitraconazole, are achieved more
rapidly following administration in the fasted state compared
to non-fasting conditions.144,145 Compared to the capsule, the
oral solution produces a pharmacokinetic profile with less
inter- and intrapatient variability.146 Although the oral solution is optimally absorbed under fasting conditions, even in
the fed state it produces higher serum concentrations than the
capsule. The absolute bioavailability of the oral solution is
higher than that of the capsule, but the two formulations are
considered bioequivalent.142,146
Itraconazole is highly lipophilic. In the serum it is highly
bound (99.8%) to albumin and consequently the unbound
concentrations in body fluids (i.e., CSF, saliva, urine) are very
low.147 Itraconazole distributes widely throughout the body
and has high affinity for tissues (i.e., vaginal mucosa, horny
layer of nails, etc.).147 It can persist in these tissues long after
the serum concentrations are undetectable.147 Increases in
itraconazole dosage produce disproportional (i.e., non-linear)
changes in drug levels. Itraconazole is extensively metabolized and several metabolites are sequentially formed only by
CYP3A4, including hydroxyitraconazole, ketoitraconazole,
and N-desalkyl-itraconazole.148 The principal metabolite,
hydroxyitraconazole, is formed primarily during gut wall
metabolism and is bioactive.142,148
Voriconazole Voriconazole is available as an IV and oral
formulation. The IV formulation consists of a powder for reconstitution containing 200 mg voriconazole solubilized with sulfobutyl ether -cyclodextrin (SE-CD). When reconstituted, the
final solution contains 10 mg/ml. The oral tablets contain either
50 or 200 mg of voriconazole. Voriconazole dissolution is not
affected by altered gastric pH. Following oral dosing, voriconazole absorption is rapid and nearly complete, with a relative
bioavailability approaching 90%.149 Peak serum concentrations are achieved within 2 hours of oral dosing. Voriconazole
is moderately bound to plasma proteins and is widely distributed throughout the body. In case reports, CSF concentrations
175
Itraconazole
Fluconazole
Cap
Soln
Voriconazole
Posaconazole
Rate
Rapid (13 h)
Slow
Rapid
Rapid
Slow
Bioavailability (%)
>93
30
55
96
Food effect
No
Yes
Yes
Yes
Yes
Increase ( )/
Decrease ( )
None
Moderate (60)
Significant (>95)
Absorption
Distribution
Protein binding (%)
Minimal (<10)
Significant (99.8)
VD (L/kg)
0.70.8
10.7
4.6
Very large
CNS/CSF
penetration
6080%
<1%
>50%
Yes (major)
Yes (mild)
Metabolism
CYP substrate
Yes (moderate)
Yes (major)
Isoform (s)
2C9/19; 3A4
3A4
3A4
CYP inhibitor
Yes
Yes
Yes
Yes
Isoform (s)
2C9/19; 3A4
3A4
3A4
Phase II substrate
No
No
Yes
Isoform
UGT1A4
Phase II inhibitor
Yes
No
Isoform
UGT2B7
Other pathway(s)
Transporters
P-gp substrate
No
Yes
No
Yes
P-gp inhibitor
No
Yes
No
Yes
Other transporters
Transport protein
BCRP (I)
No (<5%)
No (<14%)
Yes
Yes (77%)
Elimination
Urine
Yes (89%)
Bile/Feces
No
No (<1%)
Yes
Key: unknown/not applicable; Cap, capsule; Soln, solution; VD, volume of distribution; UGT, UDP-glucuronosyltransferase; COMT, catechol-Omethyltransferase; OATP, organic anion transporting polypeptide; BCRP (I), breast cancer resistance protein inhibitor.
176
Echinocandins
Caspofungin, micafungin, anidulafungin (Fig. 7-7)
Mechanism of action The echinocandins are synthetic
lipopeptides that are derived from fermentation products
from several different fungi. These compounds disrupt cell
wall synthesis by inhibiting a novel target, 1,3-d-glucan
synthase, which blocks 1,3-d-glucan synthesis.171 This enzyme is present in most fungal pathogens but is not present
NH3+
+)
2(OAC
NH
HO
O
NH
HN
N
H
O
OH
O HN
HO
H
NH
H O
O
HO
NH
N
NH3+
HO
O
HO
NH
H2N
OH
HO O H
OH
HO OH
O
OH
NH
HN
O
HN H
H O
NH
HO
HO
Caspofungin
HO OH
O
NH
N
H
HO
O
HO
Micafungin
OH
O HN
H
NH H
O
NH N
HO OH
O
NH
N
H
O
HN
O
H
HO O H
HO
O
OH
OH
O
HN
O
O HN H OH
H H
HO
NH H
O
O
OH
HO
NH N
OH
HO O
OH
HO
Cilofungin
Anidulafungin
Figure 7-7 Structures of echinocandins. (A) Caspofungin. (B) Micafungin. (C) Cilofungin (D) Anidulafungin.
178
(CH2)4CH3
OH
O O H
NaO3SO
N O
OH
in mammalian cells and its inhibition ultimately produces osmotic lysis of the cell. 1,3-d-glucans are critical components
of most fungal cell walls and provide morphology and structural integrity.
Spectrum of activity These agents bind rapidly and irre
versibly to 1,3-d-glucan synthase and cause rapid death
in certain pathogens. The echinocandins possess a narrow
antifungal spectrum that is restricted to Candida spp. and
Aspergillus spp. and there is little difference among the individual drugs. All the echinocandins exert fungicidal activity
against Candida spp.; however, in Aspergillus spp. these compounds do not usually cause complete inhibition of growth
but instead induce abnormal morphologic hyphal growth.172
Therefore these agents are considered to be fungistatic against
Aspergillus spp.
In vitro the echinocandins are highly active against
C. albicans, C. glabrata, C. tropicalis, C. dubliniensis,
and C. krusei.173-176 They are slightly less active against
C. parapsilosis, C. guilliermondii, and C. lusitaniae and MIC
values are typically higher for these pathogens than other
Caspofungin
Micafungin
Anidulafungin
Significant (97)
Significant (99)
Significant (84)
VD (l/kg)
0.15
0.4
0.6
CNS/CSF penetration
Minimal
Minimal
CYP substrate
No
No
No
Isoform(s)
CYP inhibitor
No
No
No
Isoform(s)
Phase II substrate
No
No
No
Isoform
Phase II inhibitor
No
No
No
Isoform
Other pathway(s)
N-acetylation Peptide
hydrolysis
Arylsulfatase COMT
ydroxylation
h
Chemical degradation
P-gp substrate
No*
No
No
P-gp inhibitor
No*
No
No
Other transporters
Yes
Transport protein
OATP1B1
Urine
Yes (41%)
No (<1%)
No (<1%)
Bile/Feces
Yes (35%)
Yes (71%)
No (<10%)
Distribution
Metabolism
Transporters
Elimination
179
degraded and excreted in the feces and bile. Very little anidulafungin is excreted in the feces or urine as unchanged drug.188
Toxicity The echinocandins are well tolerated and their use
is associated with very few significant adverse effects. Common
adverse effects include irritation at the injection site, phlebitis,
and transient transaminase abnormalities. Other less common
non-specific adverse effects include nausea, vomiting, diarrhea,
fever and headache.
Allylamines
Terbinafine
Mechanism of action Terbinafine reversibly inhibits squalene
epoxidase, an enzyme that acts early in the ergosterol synthesis pathway. This inhibition produces both the fungistatic and
fungicidal effects on fungal cells.
Spectrum of activity In vitro, terbinafine demonstrates
excellent fungicidal activity against many dermatophytes inclu
ding Trichophyton rubrum, T. mentagrophytes, T. tonsurans,
Microsporum canis and Epidermophyton floccosum.189 However, terbinafine demonstrates variable and somewhat poor in
vitro activity against many yeasts. It generally demonstrates
fungicidal activity against C. parapsilosis but it is fungistatic
against C. albicans and other Candida spp.189 The in vitro
spectrum of activity also includes Aspergillus spp., some
dimorphic fungi, S. schenckii, and others. Initial animal studies
in mice showed no activity in vivo against systemic pathogens,
and the drug was abandoned for these indications.
Pharmacokinetics Terbinafine is well absorbed after
oral administration, but it undergoes significant first-pass
metabolism and its resulting apparent bioavailability is only
45%.190,191 It is metabolized to ten metabolites by at least
seven different CYP enzymes, the most important apparently
being CYP2C9, CYP1A2, and CYP3A4.192 Terbinafine binds
extensively to plasma proteins.193 Of note, it distributes extensively to poorly perfused tissues (i.e., skin and ungual bed).189
Terbinafine is extensively metabolized by the liver and 15
metabolites have been identified.189
Toxicity Terbinafine produces few adverse reactions,
including perversion of taste perception and occasionally abnormal liver function.
Azoles
Due to their chemical properties, drug interactions associated
with the azoles result from several different mechanisms. All
azoles are weak bases and at elevated pH values, weakly basic
compounds dissolve more slowly. Therefore, the absorption
of the capsule form of itraconazole is influenced by alterations
in gastric pH. Many of the azoles are lipophilic and thus they
are subjected to interactions involving their biotransformation
and disposition. Fluconazole is hydrophilic and is highly soluble in water and therefore, compared to the other azoles, it
requires much less biotransformation to be eliminated from
the body.194 Itraconazole, voriconazole, and posaconazole are
highly lipophilic and have limited aqueous solubility.159,194
Therefore, these azoles must undergo extensive enzymatic conversion to more polar metabolites in order to be eliminated
from the body.
Interactions with biotransformation enzymes As discussed
above, all azoles are CYP substrates but the degree to which
they are metabolized by CYP proteins differs. This CYPmediated metabolism is carried out primarily in the liver and
intestine. The azoles and the itraconazole metabolites are potent
competitive or non-competitive inhibitors of CYP, although
they differ in their respective affinities for these enzymes.194,195
The azoles predominantly inhibit CYP3A4, which is the most
common CYP involved in drug metabolism. Fluconazole binds
non-competitively to CYP and inhibits several CYP enzymes.
Fluconazole strongly inhibits CYP2C9 and CYP2C19 but only
weakly inhibits CYP3A4.196 However, because it binds noncompetitively and circulates in the body primarily as unbound
drug, its in vitro inhibitory potential may not predict its inhibition potential in vivo. Itraconazole and its metabolites potently
inhibit only CYP3A4. Because itraconazole is a potent inhibitor of this enzyme and CYP3A4 is solely responsible for itraco-
Echinocandins
As a class the echinocandins interact very little, if at all, with
CYP or P-gp. Therefore, to date their use has been associated
with very few significant drug interactions. Caspofungin is a
substrate of the transport protein OATP1B1.183 This protein is
involved in the slow distribution of caspofungin into tissue and
it is believed that interactions with this protein by other drugs
may cause drug interactions with caspofungin.183
Terbinafine
Although terbinafine is metabolized by at least seven different CYP enzymes, it does not inhibit most CYP enzymes at
clinically relevant concentrations.192 However, terbinafine and
at least two of its metabolites do inhibit CYP2D6. 192 Unlike
CYP3A4, this enzyme does not represent a large portion of
hepatic CYP and it is involved in the metabolism of only a few
therapeutic drug classes.
Drug
Comments and
Recommended Actions
Benzodiazepines
Midazolam
Triazolam
Miscellaneous drugs
Phenytoin
Warfarin
Alfentanil
Ibuprofen
Sulfonylureas
Rifampin/Rifabutin
182
Drug
ITRA affects drug: monitor for clinical toxicity and for toxic-range blood levels. Adjust dose
Calcineurin inhibitors
cyclosporine
Tacrolimus
Sirolimus
Cmin (cyclosporine, tacrolimus) via inhibition of hepatic CYP3A4 and perhaps enteric P-gp. AUC,
Cmax (sirolimus) via inhibition of hepatic CYP3A4 and perhaps enteric P-gp. When starting ITRA,
reduce cyclosporine and tacrolimus dose by 50%. Closely monitor calcineurin inhibitor blood levels
and increase dose when discontinuing ITRA. Limited information on dose reduction with sirolimus.
Benzodiazepines
Midazolam
Triazolam
Diazepam
Cmax (midazolam, triazolam) tmax (triazolam) exposure and t (midazolam, triazolam, diazepam)
and bioavailability (midazolam).
clearance
Corticosteroids
Methylprednisolone
Dexametasone
Prednisolone
Statins
Lovastatin
Simvastatin
Atorvastatin
Miscellaneous drugs
Antineoplastics
Digoxin
Quinidine
Warfarin
Inhibition of CYP3A4 and/or P-gp may increase the exposure of certain antineoplastic agents resulting in
significant toxicity. See Table 7-13.
Phenytoin
Rifampin/Rifabutin
Protease inhibitors
Echinocandins
The echinocandins produce few significant drugdrug interactions. Clinically relevant interactions with caspofungin may
arise primarily from interactions with transport proteins. The
most notable interaction with caspofungin involves rifampin.
Caspofungin has no effect on the pharmacokinetics of rifampin
but a transient increase in caspofungin plasma concentrations
Drug
VORI affects drug: monitor for clinical toxicity and for toxic-range blood levels. Adjust dose
Calcineurin inhibitors
Cyclosporine
Tacrolimus
Sirolimus
Significant Cmin of calcineurin inhibitors via inhibition of hepatic CYP3A4; sirolimus AUC
and C max increased 510 fold.
When starting VORI, reduce cyclosporine and tacrolimus dose by 50% and 75% respectively. Closely
monitor calcineurin inhibitors blood levels and increase dose when discontinuing VORI.
VORI contraindicated with sirolimus.
Benzodiazepines
Midazolam (PO, IV)
Analgesics
Ibuprofen
Alfentanil
Methadone
Miscellaneous drugs
Antineoplastic agents
Glipizide
Warfarin
Phenytoin
Prednisolone
Rifabutin
Inhibition of CYP 3A4, 2C19 or 2C9 may increase the exposure of certain antineoplastic agents
metabolized by these enzymes resulting in serious toxicities. See Table 7-13.
pharmacodynamic effect (warfarin) via inhibition of hepatic CYP2C9.
Cmax (phenytoin, rifabutin) exposure (phenytoin, prednisolone, rifabutin) via inhibition of hepatic
CYP2C9 (phenytoin) and CYP3A4 (prednisolone).
The interaction with phenytoin and rifabutin is bidirectional.
VORI exposure
Protease inhibitors
and VORI
NNRTIs**
and VORI exposure via inhibition or induction of CYP3A4 by agent. Monitor for VORI toxicity and
lack of response to VORI.
Terbinafine
Terbinafine produces few significant drugdrug interactions.
Clinically relevant interactions with voriconazole result primarily
from interactions with CYP2D6.189 Drugs that can produce clinically significant interactions with terbinafine are CYP2D6 substrates including psychopharmacologic agents (i.e., thioridazine,
desipramine, nortriptyline, paroxetine, venlafaxine,codeine and
dextromethorphan) and cardiovascular drugs (metoprolol, encainide, flecainide, propafenone and mexilitine).217
Drug
POSA affects drug: monitor for clinical toxicity and for toxic-range blood levels. Adjust dose
Calcineurin inhibitors
cyclosporine
Tacrolimus
Benzodiazepines
Midazolam
Miscellaneous drugs
Antineoplastics
Glipizide
Rifabutin
As with other azoles, inhibition of CYP 3A4 may increase the exposure of certain
antineoplastic agents. Information on POSA and antineoplastic agents is limited.
Plasma glucose via inhibition of hepatic CYP3A4 by POSA. Monitor blood glucose.
Rifabutin Cmax and AUC via inhibition of hepatic CYP3A4 by POSA.
NB: Experience with POSA is relatively limited and additional drugdrug interactions are likely.
See also Table 7-13.
Key: Cmax, peak concentration; Cmin, trough concentration; AUC, area under the curve; CL, clearance; CYP, cytochrome pathway.
*Frequently monitor for adverse events and toxicity and reduce dose or discontinue drug in presence of symptoms.
Polyene resistance
Resistance to amphotericin B remains uncommon during treatment but reports of isolates exhibiting elevated MIC have
become more common.59 Resistance to polyenes is believed
185
186
Atenolol
Lidocaine
Sotalol
OK
OK
USE CAUTION
Posaconazole
AVOID
OK
Digoxin
Quinidine
Voriconazole
AVOID
USE CAUTION
Sotalol
OK
USE CAUTION
Fluconazole
AVOID
Amiodarone
Digoxin
Quinidine
Antiarrhythmics
USE CAUTION
Itraconazole
AVOID
Azole
Antifungal
Felodipine
Nifedipine
Amlodipine
Isradipine
Nifedipine
Verapamil
Felodipine
CalciumChannel
Blockers
Cardiovascular agents
Lovastatin
Atorvastatin
Lovastatin
Simvastatin
Fluvastatin
Pravastatin
Rosuvastatin
Atorvastatin
Lovastatin
Simvastatin
HMG Co-A
Reductase
Inhibitors
Statins
Alprazolam
Triazolam
Midazolam
St. Johns Wort
Diazepam
Midazolam
Triazolam
Bromazepam
Diazepam
Estazolam
Oxazepam
Temazepam
Alprazolam
Midazolam
Triazolam
Benzodiazepine
Hypnosedatives/
Anxiolytics
Zolpidem
Buspirone
Zolpidem
Buspirone
NonBenzodiazepine
Hypnosedatives/
Anxiolytics
Psychotropic agents
Pimozide
Amitryptiline
Chlomipramine
Fluoxetine
Clozapine
Chlomipramine
Nefazadone
Trazodone
Haloperidol
Pimozide
Risperidone
Anti-depressants/
Anti-psychotics
Phenytoin
Phenytoin
Carbamazepime
Phenobarbital
Phenytoin
Carbamazepime
Phenobarbital
Phenytoin
Antiepileptics
Cimetidine
Ranitidine
Omeprazole
Omeprazole
Esomeprazole
Lansoprazole
Pantoprazole
Rabeprazole
Antacids
H2-Receptor Antagonists
Omeprazole
Mycophenolate Mofetil
Sirolimus
Tacrolimus
Cyclosporine
Mycophenolate Mofetil
Prednisolone
USE CAUTION
OK
Voriconazole
AVOID
USE CAUTION
OK
Sirolimus
Cyclosporine
Ibuprofen
Vincristine
Vincristine
Vinblastine
Docetaxel
Indinavir
Indinavir
Lamivudine
Zidovudine
Didanosine
Indinavir
Saquinavir
Amprenavir
Nelfinavir
Ritonavir
Saquinavir
Zidovudine
Didanosine
NRTIs
Nelfinavir
Indinavir
Ritonavir
Saquinavir
Protease
Inhibitors
Delavirdine
Nevirapine
Efavirenz
Delavirdine
Nevirapine
NNRTIs
Antiretroviral agents
Rifabutin
Azithromycin
Erythromycin
Rifampin
Rifabutin
Clarithromycin
Rifabutin
Rifampin
Sulfamethoxazole
Clarithromycin
Erythromycin
Isoniazid
Rifabutin
Rifampin
Antibacterials/
ntimycotics
A
Glipzide
Sulfoylureas
Sildenafil
Nateglinide
S ulfonylureas
Certain BCPs
Warfarin
Ergot alkaloids
Losartan
Dapsone
Mestranol
Warfarin
Mestranol
Selegiline
Loperamide
Sucralfate
Oxybutnin
Sildenafil
Warfarin
EES
Fexofenadine
Levomethadyl
Others
Glipizide
Glyburide
Nateglinide
Pioglitazone
Repaglinide
Sulfoylureas
Oral Hypoglycemics
NB: Experience with posaconazole is relatively limited and additional drugdrug interactions are likely. See also Tables 7-9 to 7-12. Avoid, interaction confirmed by controlled study, generally considered
clinically significant, avoid combination if possible, or monitor closely; Use Caution, interaction noted in case report or can theoretically occur, generally not considered clinically significant, use combination
cautiously; OK, combination studied and no or minimal interaction observed, not clinically significant, combination can be used; HMG CoA, 3-hydroxy-3 methylglutaryl coenzyme A; H2, histamine-2; NRTIs,
nucleoside reverse transcriptase inhibitors; NNRTIs, non-nucleoside reverse transcriptase inhibitors; EES, ethynil estradiol.
OK
USE CAUTION
Tacrolimus
Ibuprofen
Sirolimus
Tacrolimus
Fluconazole
AVOID
Posaconazole
AVOID
Alfentanil
Celecoxib
Cyclosporine
OK
Alfentanil
Methadone
Gefitinib
Fentanyl
Sufentanil
Mycophenolate Mofetil
USE CAUTION
Cyclophosphamide
Paclitaxel
Etoposide
Docetaxel
Paclitaxel
Vinblastine
Alfentanil
Methadone
Antineoplastics
Dexamethasone
Sirolimus
Tacrolimus
Cyclosporine
Analgesics/
Anesthetics
Busulfan
Vincristine
Vinblastine
Cyclophosphamide
Steroids,
Immunosuppressants
Budesonide
Methylprednisolone
Prednisolone
Itraconazole
AVOID
Azole
Antifungal
187
Flucytosine resistance
As discussed above, flucytosine has a relatively narrow spectrum of activity, mainly against Candida spp. and C. neoformans.30 Monotherapy with this agent rapidly leads to clinical
resistance. Several mechanisms of resistance are possible given
the multiple intracellular enzymatic steps required for its
action. These include alterations in the target enzymes uridine
monophosphate pyrophosphorylase (most common), cytosine
permease, and cytosine deaminase, or increased production
of pyrimidines.30 In addition, C. albicans serotypes A and B
seem to have different sensitivities, with serotype A being susceptible and serotype B generally resistant to flucytosine.30,228
Prevalence of resistance in yeast isolates varies widely with
geographic location from 5% to 43%.228,229
Azole resistance
Development of the azole group of antifungal compounds
vastly improved the treatment of fungal infections and has led
to their widespread use. Consequently, with extensive use have
come reports of resistance to these agents, particularly fluconazole.56,230-237 Several excellent reviews on the subject have
been written.219,221,237-241
Azole resistance in Candida has been the most widely
observed and studied for fluconazole and C. albicans; however, azole resistance to other azoles among other Candida
spp. has been reported and studied. Resistance to the azoles
can result from quantitative or qualitative modifications of target enzymes, reduced access of the drug to the target enzyme or
by a combination of these mechanisms. Qualitative modifications in target enzymes result from point mutations in ERG11,
the gene responsible for producing 14-demethylase, which
is the principal target of the azoles. In certain Candida spp.
these mutations produce differential susceptibilities across the
azole class. As discussed above, this may be due to the differing affinities azoles have for secondary targets in the ergosterol
188
Echinocandin resistance
As a class, the echinocandins are the most recent addition to
the antifungal arsenal. Consequently, to date their use has
been too limited to assess whether significant resistance will
impact this class. Clinical reports of echinocandin-resistant
Candida spp. are rare and to date such reports for Aspergillus
spp. are lacking. Challenges in terms of developing standard in
vitro susceptibility tests and the lack of significant numbers of
resistance isolates to this class have hindered the establishment
of widely accepted susceptibility breakpoints for this class.
Therefore, compared to other classes, the understanding of
resistance mechanisms to this class is still evolving.
Isolates can demonstrate either intrinsic or acquired resistance to the echinocandins. Organisms that demonstrate
intrinsic resistance possess either insufficient target enzyme 1,3d-glucan synthase or a mutated form of the enzyme that precludes
echinocandin binding.57,250-252 Given the narrow spectrum of this
class, many organisms demonstrate intrinsic resistance, including but not limited to Cryptococcus, Trichosporon spp., Fusarium spp., and the agents of zygomycosis.253 Acquired resistance
to the echinocandins involves the mutation of the FKS1 gene,
which encodes a subunit of 1,3-d-glucan synthase.253 Although
most of the work done to date in this area has been with caspofungin, data suggest that the mutations in this gene may confer
reduced echinocandin susceptibility in a wide array of fungal
species.253
Terbinafine resistance
Terbinafine resistance appears to be a rare occurrence in dermatophytes and C. albicans.189 Data suggest that some pathogenic fungi appear to have the potential to develop resistance
to terbinafine and, like the azoles, resistance to terbinafine may
be mediated by an overexpression of multidrug efflux transporter, specifically the CDR genes.189 Nonetheless, to date
overexpression of CDR transport proteins has yet to develop
into a clinically significant problem.
References
Conclusion
The therapy of fungal infections, once limited and toxic,
has undergone an explosive period of development in recent
years. Since the middle of the 1990s, new agents with
novel mechanisms of action, enhanced potency, improved
pharmacokinetics, and substantially less toxicity have
reached the marketplace. The lipid amphotericin B formulations extended the life of this valuable agent by reducing
its notable toxicity. The azole group of compounds has provided excellent alternatives to amphotericin B in the treatment of most clinically important mycoses. Research into
the development of newer antifungal agents that focused on
novel targets yielded the echinocandins, which are the first
new class of compounds in several decades. This class provides another alternative in the treatment of candidiasis and
aspergillosis.
With all the choices, clinicians must be cognisant of differences in the spectrum of activity, pharmacokinetics and drug
interaction potential of antifungal agents so that they may
select the most appropriate drug for their patient. In addition,
antifungal drug resistance is also becoming increasingly recognized as an important clinical problem. Azole resistance,
especially to fluconazole, has been frequently reported. As
more antifungal agents become available, drug resistance will
likely continue to be a problem. Further advances in antifungal chemotherapy will be necessary to improve management of
invasive mycoses in the future.
References
1. Espinel-Ingroff A. History of medical mycology in the United
States. Clin Microbiol Rev 9:235, 1996
2. Gilchrist TC. Protozoan dermatitidis. J Cutaneous Dis 12:496,
1894
3. Mercurio MG, Elewski BE. Therapy of sporotrichosis. Semin
Dermatol 12:285, 1993
4. Sheehan DJ, Hitchcock CA, Sibley CM. Current and emerging
azole antifungal agents. Clin Microbiol Rev 12:40, 1999
5. Oxford AE, Raistrick H, Simonart P. Studies on the biochemistry of microorganisms 60. Griseofulvin, C17H17O6Cl,
ametabolic product of Penicillium griseofulvum Dierckx.
Biochem J33:240, 1939
6. Wooley DW. Some biological effects produced by benzimidazole and their reversal by purines. J Biol Chem 152:225, 1944
7. Elson WO. The antibacterial and fungistatic properties of
propamidine. J Infect Dis 76:193, 1945
8. Hazen EL, Brown R. Two antifungal agents produced by a soil
actinomycete. Science 112:423, 1950
9. Hazen EL, Brown R. Fungicidin, antibiotic produced by soil
actinomycete. Proc Soc Exp Biol Med 76:93, 1951
10. Schoenbach EB, Miller JM, Ginsberg M, Long PH. Systemic
blastomycosis treated with stilbamidine. JAMA 146:1317, 1951
11. Snapper I, McVay LV. The treatment of North American
blastomycosis with 2-hydroxystilbamidine. Am J Med 15:603,
1953
12. Gold WH, Stout A, Pagano JF, Donovick R. Amphotericin A
and B, antifungal antibiotics produced by a streptomycete. I.
In vitro studies of A. Antibiot Annu 3:579586, 19551956
13. Harrell ER, Curtis AC. The treatment of North American blastomycosis with amphotericin B. Arch Dermatol 76:561, 1957
14. Sawyer PR, Brogden RN, Pinder RM, et al. Clotrimazole.
Drugs 9:424, 1975
15. Heel RC, Brogden RN, Pakes GE, et al. Miconazole: a preliminary review of its therapeutic efficacy in systemic fungal
infections. Drugs 19:7, 1980
16. Burgess MA, Bodey GP. Clotrimazole (Bay b 5097): in vitro
and clinical pharmacological studies. Antimicrob Agents
Chemother 2:423, 1972
17. Fainstein V, Bodey GP. Cardiorespiratory toxicity due to
miconazole. Ann Intern Med 93:432, 1980
18. Espinel-Ingroff A, Shadomy S, Gebhart RJ. In vitro studies
with R 51211 (itraconazole). Antimicrob Agents Chemother
26:5, 1984
19. Ghannoum MA, Rice LB. Antifungal agents: mode of action,
mechanisms of resistance, and correlation of these mechanisms
with bacterial resistance. Clin Microbiol Rev 12:501, 1999
20. Georgopapadakou NH, Walsh TJ. Human mycoses: drugs and
targets for emerging pathogens. Science 264:371, 1994
21. Brajtburg J, Powderly WG, Kobayashi GS, Medoff G.
Amphotericin B: current understanding of mechanisms of
action. Antimicrob Agents Chemother 34:183, 1990
22. vanden Bossche H, Marichal P, Gorrens J, et al. Mode of
action studies: basis for the search of new antifungal drugs.
Ann NY Acad Sci 544:191, 1988
23. Sanati H, Belanger P, Rutilio F, Ghannoum M. A new triazole,
voriconazole (UK-109,496), blocks sterol biosynthesis in
Candida albicans and Candida krusei. Antimicrob Agents
Chemother 41:2492, 1997
24. Ryder NS. Squalene epoxidase as a target for the allylamines.
Biochem Soc Trans 19:774, 1991
25. Ryder NS. Specific inhibition of fungal sterol biosynthesis by
SF 86-327, a new allylamine antimycotic agent. Antimicrob
Agents Chemother 27:252, 1985
26. Ryder NS, Dupont MC. Inhibition of squalene epoxidase by
allylamine antimycotic compounds: a comparative study
of the fungal and mammalian enzymes. Biochem J 130:765,
1985
27. Ryder NS, Frank I, Dupont MC. Ergosterol biosynthesis
inhibition by the thiocarbamate antifungal agents tolnaftate
and tolciclate. Antimicrob Agents Chemother 29:858, 1986
28. Mercer EI. Morpholine antifungals and their mode of action.
Biochem Soc Trans 19:788, 1991
29. Haria M, Bryson HM. Amorolfine: a review of its pharmacological properties and therapeutic potential in the treatment of
onychomycosis and other superficial fungal infections. Drugs
49:103, 1995
30. Atkinson GW, Israel HL. 5-fluorocytosine treatment of meningeal and pulmonary aspergillosis. Am J Med 55:496, 1973
31. Hector RF. Compounds active against cell walls of medically
important fungi. Clin Microbiol Rev 6:1, 1993
32. Carillo-Munoz AJ, Giusiano G, Ezkurra PA. Antifungal agents:
mode of action in yeast cells. Rev Esp Quimoterap 19:130,
2006
33. Igarashi Y, Futamata K, Fujita T, et al. A novel antifungal
antibiotic produced by Streptomyces sp. TP-A0356. J Antibiot
(Tokyo) 56:107, 2003
34. Petraitiene R, Petraitis V, Kelaher AM, et al. Efficacy,
plasma pharmacokinetics, and safety of icofungipen, an
inhibitor of Candida isoleucyl-tRNA synthetase, in treatment of experimental disseminated candidiasis in persistently
neutropenic rabbits. Antimicrob Agents Chemother 49:2084,
2005
35. Gonzalbo D, Elorza MV, Sanjuan R, et al. Critical steps
in fungal cell wall synthesis: strategies for their inhibition.
Pharmacol Ther 60:337, 1993
36. Bulawa CE. Genetics and molecular biology of chitin synthesis
in fungi. Annu Rev Microbiol 47:505, 1993
37. Debono M, Gordee RS. Antibiotics that inhibit fungal cell wall
development. Annu Rev Microbiol 48:471, 1994
189
38. Dominguez JM, Kelly VA, Kinsman OS, et al. Sordarins: a new
class of antifungals with selective inhibition of the protein synthesis elongation cycle in yeasts. Antimicrob Agents Chemother
42:2274, 1998
39. Lodge JK, Jackson-Machelski E, Toffaletti DL, et al. Targeted
gene replacement demonstrates that myristoyl-CoA: protein
N-myristoyltransferase is essential for viability of Cryptococcus
neoformans. Proc Natl Acad Sci USA 91:12008, 1994
40. Georgopapadkou NH. New cell wall targets for antifungal
drugs. Expert Opin Investig Drugs 10:269, 2001
41. Gallis HA, Drew RH, Pickard WW. Amphotericin B: 30 years
of clinical experience. Rev Infect Dis 12:308, 1990
42. Herv M, Dubouzy JC, Borowski E, et al. The role of the
carboxyl and amino groups of polyene macrolides in their interactions with sterols and their selective toxicity. A 31 P-NMR
study. Biochim Biophys Acta 980:261, 1989
43. Brajtburg J, Powderly WG, Kobayashi GS, Medoff G.
Amphotericin B: current understanding of mechanisms of
action. Antimicrob Agent Chemother 34:183, 1990
44. Norman AW, Spielvogel AM, Wong RG. Polyene antibiotic
sterol interaction. J Infect Dis 149:986, 1984
45. Gruda I, Nadeau J, Brajtburg J, Medoff G. Application of
different spectra in the UV-visible region to study the formation of amphotericin B complexes. Biochim Biophys Acta
602:260, 1980
46. Vertut-Croquin A, Bolard J, Chabert M, Gary-Bobo C. Differences in the interaction of the polyene antibiotic amphotericin
B with cholesterol- or ergosterol-containing phospholipid vesicles. A circular dichroism and permeability study. Biochemistry
22:2939, 1983
47. Schell RE. Proton permeability of renal membranes: influence
of amphotericin B. Nephron 63:481, 1993
48. Hsu S-F, Burnette RR. The effect of amphotericin B on the
K-channel activity of MDCK cells. Biochim Biophys Acta
Protein Struct Mol Enzymol 1152:189, 1993
49. Velez JD, Allendoerfer R, Luther M, et al. Correlation of in
vitro azole susceptibility with in vivo response in a murine
model of cryptococcal meningitis. J Infect Dis 168:508, 1993
50. Graybill JR. The future of antifungal therapy. Clin Infect Dis
22(suppl 2):S166, 1996
51. Graybill JR, Sharkey PK. Fungal infections and their management. Br J Clin Pract 44(suppl 71):32, 1990
52. Graybill JR. The modern revolution in antifungal chemotherapy. In: Mycoses in AIDS. Plenum Press, New York, 1990,
p. 265
53. Cleary JD, Chapman SW, Nolan RL. Pharmacologic modulation of interleukin-1 expression by amphotericin B-stimulated
human mononuclear cells. Antimicrob Agents Chemother
36(5):977, 1992
54. Cha JKS, Pollack M. Amphotericin B induces tumor necrosis factor production by murine macrophages. J Infect Dis
159:113, 1989
55. Wilson E, Thorson L, Speert DP. Enhancement of macrophage
superoxide anion production by amphotericin B. Antimicrob
Agents Chemother 35:796, 1991
56. Spellberg BJ, Filler SG, Edwards JE. Current treatment strategies for disseminated candidiasis. Clin Infect Dis 42:244, 2006
57. Pfaller MA, Diekema DJ. Rare and emerging opportunistic fungal pathogens: concern for resistance beyond Candida albicans
and Aspergillus fumigatus. J Clin Microbiol 42:4419, 2004
58. Dick, JD, Rosengard RP, Merz WG, et al. Fatal disseminated
candidiasis due to amphotericin B resistant Candida guilliermondii. Ann Intern Med 102:67, 1985
59. Pfaller MA, Diekema DJ. Epidemiology of invasive candidiasis:
a persistent public health problem. Clin Microbiol Rev 20:133,
2007
60. Pfaller MA, Boyken L, Messer SA, et al. Evaluation of the Etest
method using Mueller-Hinton agar with glucose and methylene
190
References
77. Hiemenz JW, Walsh TJ. Lipid formulations of amphotericin B:
recent progress and future directions. Clin Infect Dis 22(suppl
2):S133, 1996
78. Groll AH, Giri N, Petraitis V, et al. Comparative efficacy
and distribution of lipid formulations of amphotericin B in
experimental Candida albicans infection of the central nervous
system. J Infect Dis 182:274, 2000
79. Groll AH, Mickiene D, Piscitelli SC, Walsh TJ. Distribution
of lipid formulations of amphotericin B into bone marrow
and fat tissue in rabbits. Antimicrob Agents Chemother
44:408, 2000
80. Wasan KM, Grossie VB Jr, Lopez-Berestein G. Concentrations in serum and distribution in tissue of free and liposomal
amphotericin B in rats during continuous intralipid infusion.
Antimicrob Agents Chemother 38:2224, 1994
81. Bratjburg J, Elberg S, Kobayashi GS, Medoff G. Effects of
serum lipoproteins on damage to erythrocytes and Candida
albicans cells by polyene antibiotics. J Infect Dis 153:623, 1986
82. Brajtburg J, Elberg S, Bolard J, et al. Interaction of plasma
proteins and lipoproteins with amphotericin B. J Infect Dis
149:986, 1984
83. Siegel EB. Measurement of polyene antibiotic-mediated
erythrocyte damage by release of hemoglobin and radioactive
chromium. Antimicrob Agents Chemother 11:675, 1977
84. Goodwin SD, Cleary JD, Walawander CA, et al. Pretreatment
regimens for adverse events related to infusion of amphotericin
B. Clin Infect Dis 20:755, 1995
85. Gubbins PO, Penzak SR, Polston S, et al. Characterizing and
predicting amphotericin B-associated nephrotoxicity in bone
marrow or peripheral blood stem cell transplant recipients.
Pharmacotherapy 22:961, 2002
86. Heidemann HT, Gerkens JF, Spickard WA, et al. Amphotericin
B nephrotoxicity in humans decreased by salt repletion. Am
J Med 75:476, 1983
87. MacGregor RR, Bennett JE, Ersley AJ. Erythropoietin concentration in amphotericin B induced anemia. Antimicrob Agents
Chemother 14:270, 1978
88. Luber AD, Maa L, Lam M, Guglielmo BJ. Risk factors for amphotericin B-induced nephrotoxicity. J Antimicrob Chemother
43:267, 1999
89. de Marie S, Janknegt R, Bakker-Woudenberg IAJM. Clinical
use of liposomal and lipid-complexed amphotericin B. J Antimicrob Chemother 33:907, 1994
90. Wong-Beringer A, Jacobs RA, Guglielmo BJ. Lipid formulations of amphotericin B: clinical efficacy and toxicities. Clin
Infect Dis. 27:603, 1998
91. Slain D. Lipid-based amphotericin B for the treatment of fungal
infections. Pharmacotherapy 19:306, 1999
92. Barrett JP, Vardulaki KA, Conlon C, et al. A systematic review
of antifungal effectiveness and tolerability of amphotericin B
formulations. Clin Ther 25:1295, 2003
92b. Wingard JR, White MH, Anaissie E, et al. L-Amph / ABLC
Collaborative Study Group. A randomized, double-blind
comparative trial evaluating the safety of liposomal amphotericin B versus amphotericin B lipid B complex in the empirical
treatment of febrile neutropenia. L-Amph/ABLC Collaborative
Study Group. Clin Infect Dis. 31:1155, 2000
93. White MH, Bowden RA, Sandler ES, et al. Randomized,
double-blind clinical trial of amphotericin B colloidal dispersion vs. amphotericin B in the empirical treatment of fever and
neutropenia. Clin Infect Dis 27:296, 1998
94. Ostrosky-Zeichner L, Marr KA, Rex JH, Cohen SH, Amphotericin B: time for a new gold standard. Clin Infect Dis
37:415, 2003
95. Polak A, Grenson M. Evidence for a common transport system
for cytosine, adenine and hypoxanthine in Saccharomyces
cerevisiae and Candida albicans. Eur J Biochem 32:276, 1973
96. Polak A, Scholer HJ. Mode of action of 5-fluorocytosine and
mechanisms of resistance. Chemotherapy 21:113, 1975
97. Waldorf AR, Polak A. Mechanisms of action of 5-fluorocytosine. Antimicrob Agents Chemother 23:79, 1983
98. Diasio RB, Bennett JE, Myers CE. Mode of action of 5-fluorocytosine. Biochem Pharmacol 27:703, 1978
99. Polak AM, Scholer HJ, Wall M. Combination therapy of
experimental candidiasis, cryptococcosis, and aspergillosis in
mice. Chemotherapy 28:461, 1982
100. Rex JH, Walsh TJ, Sobel JD, et al. Practice guidelines for
the treatment of candidiasis. Infectious Diseases Society of
America. Clin Infect Dis 30:662, 2000
101. Saag MS, Graybill RJ, Larsen RA, et al. Practice guidelines for
the management of cryptococcal disease. Infectious Diseases
Society of America. Clin Infect Dis 30:710, 2000
102. Cutler RE, Blair AD, Kelly MR. Flucytosine kinetics in subjects
with normal and impaired renal function. Clin Pharmacol Ther
24:333, 1978
103. Daneshmend TK, Warnock DW. Clinical pharmacokinetics of
systemic antifungal drugs. Clin Pharmacokinet 8:17, 1983
104. Muther RS, Bennett WM. Peritoneal clearance of amphotericin
B and 5-flucytosine. West J Med 133:157, 1980
105. Schnebeck J, Polak A, Fernex M, Scholer HJ. Pharmacokinetic studies on the oral antimycotic agent 5-fluorocytosine
in individuals with normal and impaired kidney function.
Chemotherapy 18:321, 1973
106. Vermes A, van der Sijs IH, Guchelaar HJ. Flucytosine: correlation between toxicity and pharmacokinetic parameters.
Chemotherapy 46, 86, 2000
107. Block ER, Bennett JE, Livoti LG, et al. Flucytosine and amphotericin B: hemodialysis effects on the plasma concentration and
clearance. Studies in man. Ann Intern Med 80:613, 1974
108. Vermes A, Matht RAA, van der Sijs IH, et al. Population
pharmacokinetics of flucytosine: comparison and validation of
three models using STS, NPEM, and NONMEM. Ther Drug
Monit 22:676, 2000
109. Perfect JR, Lindsay MH, Drew RH. Adverse drug reactions to
systemic antifungals. Prevention and management. Drug Safety
7:323, 1992
110. Lewis RE, Klepser ME, Pfaller MA. In vitro pharmacodynamic
characteristics of flucytosine determined by time-kill methods.
Diagn Microbiol Infect Dis 36:101, 2000
111. Diaso RB, Lakings DE, Bennett JE. Evidence for conversion of
5-fluorocytosine to 5-fluorouracil in humans: possible factor in
5-fluorocytosine clinical toxicity. Antimicrob Agents Chemother 14:903, 1978
112. Harris BE, Manning BW, Federle TW, Diasio RB. Conversion
of 5-fluorocytosine to 5-fluorouracil by intestinal microflora.
Antimicrob Agents Chemother 29:44, 1986
113. Stamm AM, Diasio RB, Dismukes WE, et al. Toxicity of amphotericin B plus flucytosine in 194 patients with cryptococcal
meningitis. Am J Med 83:236, 1987
114. Benson JM, Nahata MC. Clinical use of systemic antifungal
agents. Clin Pharm 7:424, 1988
115. Vermes A, Guchelaar HJ, Dankert J. Flucytosine: a review of
its pharmacology, clinical indications, pharmacokinetics, toxicity and drug interactions. J Antimicrob Chemother 46:171,
2000
116. Wheat J, Marichal P, Vanden Bossche H, et al. Hypothesis
on the mechanism of resistance to fluconazole in Histoplasma
capsulatum. Antimicrob Agent Chemother 41:410, 1997
117. Groll AH, Piscitelli SC, Walsh TJ. Antifungal pharmacodynamics: concentration-effect relationships in vitro and in vivo.
Pharmacotherapy 21:133S, 2001
118. Pfaller MA, Diekema DJ, Gibbs DL, et al. Global Antifungal
Surveillance Study. Results from the ARTEMIS DISK Global
Antifungal Surveillance study, 1997 to 2005: an 8.5-year
analysis of susceptibilities of Candida species and other yeast
species to fluconazole and voriconazole determined by CLSI
standardized disk diffusion testing. J Clin Microbiol 45:1735,
2007
191
119. Pfaller MA, Messer SA, Boyken L, et al. Global trends in the
antifungal susceptibility of Cryptococcus neoformans (1990 to
2004). J Clin Microbiol 43:2163, 2005
120. Ramani R, Chaturvedi V. Antifungal susceptibility profiles of
Coccidioides immitis and Coccidioides posadasii from endemic
and non-endemic areas. Mycopathologia 163:315, 2007
121. Supparatpinyo K, Chiewchanvit S, Hirunsri P, et al. Penicillium
marneffei infection in patients infected with human immunodeficiency virus. Clin Infect Dis 14:871, 1992
122. Norris S, Wheat J, McKinsey D, et al. Prevention of relapse of
histoplasmosis with fluconazole in patients with the acquired
immunodeficiency syndrome. Am J Med 96:504, 1994
123. Diaz M, Negroni R, Montero-Gei F, et al. A pan-American
5-year study of fluconazole therapy for deep mycoses in the
immunocompetent host. Clin Infect Dis 14(suppl 1):S68, 1992
124. Pappas PG, Bradsher RW, Chapman SW, et al. Treatment of
blastomycosis with fluconazole: a pilot study. Clin Infect Dis
20:267, 1995
125. Supparatpinyo K, Khamwan C, Baosoung V, et al. Disseminated Penicillium marneffei infection in southeast Asia. Lancet
344:110, 1994
126. Deng Z, Ribas J, Gibson DW, Connor DH. Infections caused
by Penicillium marneffei in China and southeast Asia. Review
of 18 published cases and report of four more cases. Rev Infect
Dis 10:640, 1988
127. Supparatpinyo K, Nelson KE, Merz WG, et al. Response to
antifungal therapy by human immunodeficiency virus-infected
patients with disseminated Penicillium marneffei infections
and in vitro susceptibilities of isolates from clinical specimens.
Antimicrob Agents Chemother 37:2407, 1993
128. Pfaller MA, Boyken L, Hollis RJ, et al. In vitro susceptibilities
of clinical isolates of Candida species, Cryptococcus neoformans, and Aspergillus species to itraconazole: global survey of
9,359 isolates tested by clinical and laboratory standards institute broth microdilution methods. J Clin Microbiol 43:3807,
2005
129. Gonzalez GM, Fothergill AW, Sutton DA, Rinaldi MG,
Loebenberg D. In vitro activities of new and established triazoles against opportunistic filamentous and dimorphic fungi.
Med Mycol 43:281, 2005
130. Almyroudis NG, Sutton DA, Fothergill AW, et al. In vitro suscepti
bilities of 217 clinical isolates of zygomycetes to conventional
and new antifungal agents. Antimicrob Agents Chemother
51:2587, 2007
131. Hostetler JS, Heykants J, Clemons KV, et al. Discrepancies in
bioassay and chromatography determinations explained by
metabolism of itraconazole to hydroxyitraconazole: studies of
interpatient variations in concentrations. Antimicrob Agents
Chemother 37:2224, 1993
132. Messer SA, Jones RN, Fritsche TR. International surveillance
of Candida spp. and Aspergillus spp.: report from the SENTRY
Antimicrobial Surveillance Program (2003). J Clin Microbiol
44:1782, 2006
133. Soczo G, Kardos G, McNicholas PM, et al. Correlation of
posaconazole minimum fungicidal concentration and time kill
test against nine Candida species. J Antimicrob Chemother
60:1004, 2007
134. Espinel-Ingroff A. Germinated and nongerminated conidial
suspensions for testing of susceptibilities of Aspergillus spp. to
amphotericin B, itraconazole, posaconazole, ravuconazole, and
voriconazole. Antimicrob Agents Chemother 45:605, 2001
135. Perfect JR, Cox GM, Dodge RK, Schell WA. In vitro and in
vivo efficacies of the azole SCH56592 against Cryptococcus
neoformans. Antimicrob Agents Chemother 40:1910, 1996
136. Pfaller MA, Messer SA, Hollis RJ, Jones RN. In vitro activities
of posaconazole (SCH 56592) compared with those of itraconazole and fluconazole against 3,685 clinical isolates of Candida spp. and Cryptococcus neoformans. Antimicrob Agents
Chemother 45:2862, 2001
192
137. Debruyne D, Ryckelynk JP. Clinical pharmacokinetics of fluconazole. Clin Pharmacokinet 24:10, 1993
138. Pelz RK, Lipsett PA Swoboda MS, et al. Enteral fluconazole
is well absorbed in critically ill surgical patients. Surgery
131:534, 2002
139. Summers KK, Hardin TC, Gore SJ, Graybill JR. Therapeutic
drug monitoring of systemic antifungal therapy. J Antimicrob
Chemother 40:753, 1997
140. Brammer KW, Coakley AJ, Jezequel SG, Tarbit MH. The
disposition and metabolism of [14C] fluconazole in humans.
Drug Metab Disp 19:764, 1991
141. Black DJ, Kunze KL, Wienkers LC, et al. Warfarin-fluconazole
II A metabolically based drug interaction: in vivo studies. Drug
Metab Disp 24:422, 1996
142. Heykants J, Van Peer A, Van de Velde V, et al. The clinical
pharmacokinetics of itraconazole: an overview. Mycoses
32(suppl 1):67, 1989
143. Johnson MD, Hamilton CD, Drew RH, et al. A randomized
comparative study to determine the effect of omeprazole on
the peak serum concentration of itraconazole oral solution.
JAntimicrob Chemother 51:453, 2003
144. Van de Velde VJS, Van Peer A, Heykants JJP, et al. Effect of
food on the pharmacokinetics of a new hydroxypropyl-cyclodextrin formulation of itraconazole. Pharmacotherapy
16:424, 1996
145. Barone JA, Moskovitz BL, Guarnieri J, et al. Food interaction
and steady-state pharmacokinetics of itraconazole oral solution
in healthy volunteers. Pharmacotherapy 18:295, 1998
146. Barone JA, Moskovitz BL, Guarnieri J, et al. Enhanced
bioavailability of itraconazole in hydroxypropyl--cyclodextrin
solution versus capsules in healthy volunteers. Antimicrob
Agents Chemother 42:1862, 1998
147. Poirier JM, Cheymol G. Optimization of itraconazole therapy
using target drug concentrations. Clin Pharmacokinet 35:461,
1998
148. Isoherranen N, Kunze KL, Allen KE, et al. Role of itraconazole
metabolites in CYP3A4 inhibition. Drug Metab Disp 32:1121,
2004
149. Pearson MM, Rogers PD, Cleary JD, Chapman SW. Voriconazole: a new triazole antifungal. Ann Pharmacother 37:420,
2003
150. Schwartz S, Milatovic D, Eckhard T. Successful treatment of
cerebral aspergillosis with a novel triazole (voriconazole) in a
patient with acute leukemia. Br J Haematol 97:663, 1997
151. Johnson LB, Kauffman CA. Voriconazole: a new triazole
antifungal agent. Clin Infect Dis 36:630, 2003
152. Hyland R, Jones BC, Smith DA. Identification of the
cytochrome P450 enzymes involved in the N-oxidation of
voriconazole. Drug Metab Disp 31:540, 2003
153. Walsh TJ, Karlsson MO, Driscoll T, et al. Pharmacokinetics
and safety of intravenous voriconazole in children after singleor multiple-dose administration. Antimicrob Agents Chemother
48:21662172, 2004.
154. Courtney R, Wexler D, Radwanski E, et al. Effect of food on
the relative bioavailability of 2 oral formulations of posaconazole in healthy adults. Br J Clin Pharmacol 57:218, 2004
155. Courtney R, Pai S, Laughlin M, et al. Pharmacokinetics, safety,
and tolerability of oral posaconazole administered in single and
multiple doses in healthy adults. Antimicrob Agents Chemother
47:2788, 2003
156. Ezzet F, Wexler D, Courtney R, et al. Oral bioavailability of
posaconazole in fasted healthy subjects: comparison between
three regimens and basis for clinical dosage recommendations.
Clin Pharmacokinet 44:211, 2005
157. Krieter P, Flannery B, Musick T, et al. Disposition of posaconazole following single-dose oral administration in healthy
subjects. Antimicrob Agents Chemother 48:3543, 2004
References
158. Ullmann AJ, Cornely OA, Burchardt A, et al. Pharmacokinetics, safety, and efficacy of posaconazole in patients with
persistent febrile neutropenia or with refractory invasive fungal
infection. Antimicrob Agents Chemother 50:658, 2006
159. Gubbins PO, Krishna G, Sansone-Parsons A, et al. Pharmacokinetics and safety of oral posaconazole in neutropenic stem cell
transplant recipients. Antimicrob Agents Chemother 50:1993,
2006
160. Ghosal A, Hapngama N, Yuan Y, et al. Identification of human UDP-glucuronosyltransferase enzyme(s) responsible for
the glucuronidation of posaconazole (noxafil). Drug Metab
Disp 32:267, 2004
161. Como JA, Dismukes WE. Oral azole drugs as systemic antifungal therapy. N Engl J Med 330:263, 1994
162. Boucher HW, Groll AH, Chiou CC, Walsh TJ. Newer systemic
antifungal agents. Drugs 64:1997, 2004
163. Pappas PG, Kauffman CA, Perfect J, et al. Alopecia associated
with fluconazole therapy. Ann Intern Med 123:354, 1995
164. Terrell CL. Antifungal agents. Part II. The azoles. Mayo Clin
Proc 74:78, 1999
165. Willems L, van der Geest R, de Beule K. Itraconazole oral solution and intravenous formulations: a review of pharmacokinetics and pharmacodynamics. J Clin Pharm Ther 26:159, 2001
166. Tan K, Brayshaw N, Tomaszewski K, et al. Investigation of the
potential relationships between plasma voriconazole concentrations and visual adverse effects or liver function test abnormalities. J Clin Pharmacol 46:235, 2006
167. Lazarus HM, Blumer JL, Yanovich S, et al. Safety and pharmacokinetics of oral voriconazole in patients at risk of fungal
infection: a dose escalation study. J Clin Pharmacol 42:395-402,
2002
168. Purkins L, Wood N, Ghahramani P, et al. Pharmacokinetics
and safety of voriconazole following intravenous- to oral-dose
escalation regimens. Antimicrob Agents Chemother 46:2546,
2002
169. Denning DW, Ribaud P, Milpied N, et al. Efficacy and safety
of voriconazole in the treatment of acute invasive aspergillosis.
Clin Infect Dis 34:563, 2002
170. Lutsar I, Hodges MR, Tomaszewski K, et al. Safety of voriconazole and dose individualization. Clin Infect Dis 36:1087,
2003
171. Hector RF. Compounds active against cell walls of medically
important fungi. Clin Microbiol Rev 6:1, 1993
172. Kurtz MB, Heath IB, Marrinan J, et al. Morphological effects
of lipopeptides against Aspergillus fumigatus correlate with
activities against (1,3)-beta-D-glucan synthase. Antimicrob
Agents Chemother 38:1480, 1994
173. Ostrosky-Zeichner L, Rex JH, Pappas PG, et al. Antifungal susceptibility survey of 2,000 bloodstream Candida isolates in the
United States. Antimicrob Agents Chemother 47:3149, 2003
174. Pfaller MA, Boyken L, Hollis RJ, et al. In vitro activities of
anidulafungin against more than 2,500 clinical isolates of
Candida spp., including 315 isolates resistant to fluconazole.
JClin Microbiol 43:5425, 2005
175. Pfaller MA, Diekema DJ, Messer SA, et al. In vitro activities of
caspofungin compared with those of fluconazole and itraconazole against 3,959 clinical isolates of Candida spp., including
157 fluconazole-resistant isolates. Antimicrob Agents Chemother 47:1068, 2003
176. Cuenca-Estrella M, Rodriguez D, Almirante B, et al, for the
Barcelona Candidemia Project Study Group. In vitro susceptibilities of bloodstream isolates of Candida species to
six antifungal agents: results from a population-based active
surveillance programme, Barcelona, Spain, 20022003.
J Antimicrob Chemother 55:194, 2005
177. Oakley KL, Moore CB, Denning DW. In vitro activity of the
echinocandin antifungal agent LY303,366 and comparison
with itraconazole and amphotericin B against Aspergillus spp.
Antimicrob Agents Chemother 42:2726, 1998
178. Bowman JC, Hicks PS, Kurtz MB, et al. The antifungal echinocandin caspofungin acetate kills growing cells of Aspergillus
fumigatus in vitro. Antimicrob Agents Chemother 46:
3001, 2002
179. Kurtz MB, Heath IB, Marrinan J, et al. Morphological effects
of lipopeptides against Aspergillus fumigatus correlate with
activities against (1,3)-beta-D-glucan synthase. Antimicrob
Agents Chemother 38:1480, 1994
180. Chiou CC, Mavrogiorgos N, Tillem E, et al. Synergy, pharmacodynamics, and time-sequenced ultrastructural changes of
the interaction between nikkomycin Z and the echinocandin
FK463 against Aspergillus fumigatus. Antimicrob Agents
Chemother 45:3310, 2001
181. Denning DW. Echinocandin antifungal drugs. Lancet
362:1142, 2003
182. Stone JA, Xu X, Winchell GA, et al. Disposition of caspofungin: role of distribution in determining pharmacokinetics in
plasma. Antimicrob Agents Chemother 48:815, 2004
183. Sandhu P, Lee W, Xu X, et al. Hepatic uptake of the novel
antifungal agent caspofungin. Drug Metab Disp 33:676,
2005
184. Balani SK, Xu X, Arison BH, et al. Metabolites of caspofungin
acetate, a potent antifungal agent, in human plasma and urine.
Drug Metab Disp 28:1274, 2000
185. Hebert MF, Smith HE, Marbury TC, et al. Pharmacokinetics
of micafungin in healthy volunteers, volunteers with moderate liver disease, and volunteers with renal dysfunction. J Clin
Pharmacol 45:1145, 2005
186. Cappelletty D, Eiselstein-McKitrick K. The echinocandins.
Pharmacotherapy 27:369, 2007
187. Joseph JM, Jain R, Danziger LH. Micafungin: a new echinocandin antifungal. Pharmacotherapy 27:53, 2007
188. Stogniew M, Pu F, Henkel T, Dowell J. Anidulafungin biotransformation in humans is by degradation not metabolism.
Clin Microbiol Infect 9(suppl):291, 2003
189. Darkes MJM, Scott LJ, Goa KL. Terbinafine: a review of its use
in onychomycosis in adults. Am J Clin Dermatol 4:39, 2003
190. Jensen JC. Clinical pharmacokinetics of terbinafine (Lamisil).
Clin Exp Dermatol 14:110, 1989
191. Kovarik JM, Kirkesseli S, Humbert H, et al. Dosepharmacokinetics of terbinafine and its N-demethylated
metabolite in healthy volunteers. Br J Dermatol 126:8, 1992
192. Vickers AE, Sinclair JR, Zollinger M, et al. Multiple cytochrome P-450s involved in the metabolism of terbinafine suggest a limited potential for drugdrug interactions. Drug Metab
Disp 27:1029, 1999
193. Ryder NS, Frank I. Interaction of terbinafine with human
serum and proteins. J Med Vet Mycol 30:451, 1992
194. Gubbins PO, Amsden JR. Drugdrug interactions of antifungal
agents and implications for patient care. Exp Opin Pharmacother 6:2231, 2005
195. Templeton IE, Thummel KE, Kharasch ED, et al. Contribution
of itraconazole metabolites to inhibition of CYP3A4 in vivo.
Clin Pharmacol Ther 83(1):77, 2008
196. Black DJ, Kunze KL, Wienkers LC, Warfarin-
fluconazole
II:
a metabolically based drug interaction: in vivo studies. Drug
Metab Disp 24:422, 1996
197. Muijser RBR, Goa KL, Scott LJ. Voriconazole in the treatment
of invasive aspergillosis. Drugs 18:2655, 2002
198. Wexler D, Courtney R, Richards W, et al. Effect of posaconazole on cytochrome P450 enzymes: a randomized, open-label,
two-way crossover study. Eur J Pharm Sci 21:645, 2004
199. Lin JH, Yamazaki M. Clinical relevance of P-glycoprotein in
drug therapy. Drug Metab Rev 35:417, 2003
200. Gubbins PO. Drugdrug interactions of antifungal agents and
implications for patient care. J Invasive Fungal Infect 1:144,
2007
193
194
222. Hamilton-Miller JM. Polyene resistance in yeasts: a consideration of physiological and biochemical mechanisms. Microbios
8:209, 1973
223. Nolte FS, Parkinson T, Falconer DJ, et al. Isolation and characterization of fluconazole- and amphotericin B-resistant Candida
albicans from blood of two patients with leukemia. Antimicrob
Agents Chemother 41:196, 1997
224. Lupetti A, Danesi R, Campa M, et al. Molecular basis of resistance to azole antifungals. Trends Mol Med 8:76, 2002
225. Vandeputte P, Tronchin C, Berges T, et al. Reduced susceptibility to polyenes associated with a missense mutation in the ERG6
gene in a clinical isolate of Candida glabrata with pseudohyphal
growth. Antimicrob Agents Chemother 51:982, 2007
226. Safe LM, Safe SH, Subden RE, Morris DC. Sterol content and
polyene antibiotic resistance in isolates of Candida krusei,
Candida parakrusei, and Candida tropicalis. Can J Microbiol
23:398, 1977
227. Geraghty P, Kavanagh K. Erythromycin, an inhibitor of mitoribosomal protein biosynthesis, alters the amphotericin B susceptibility of Candida albicans. J Pharm Pharmacol 55:179, 2003
228. Stiller RL, Bennett JE, Scholer HJ, et al. Susceptibility to
5-fluorocytosine and prevalence of serotype in 402 Candida
albicans isolates from the United States. Antimicrob Agents
Chemother 22(3):482, 1982
229. Weber S, Polak A. Susceptibility of yeast isolates from defined
German patient groups to 5-fluorocytosine. Mycoses 35:163,
1992
230. Redding S, Smith J, Farinacci M, et al. Resistance of Candida
albicans to fluconazole during treatment of oropharyngeal
candidiasis in a patient with AIDS: documentation by in vitro
susceptibility testing and DNA subtype analysis. Clin Infect Dis
18:240, 1994
231. He X, Tiballi RN, Zarins LT, et al. Azole resistance in oropharyngeal Candida albicans strains isolated from patients infected with
human immunodeficiency virus. Antimicrob Agents Chemother
38:2495, 1994
232. Thomas-Greber E, Korting HC, Bogner J, Goebel FD. Fluconazole-resistant oral candidosis in a repeatedly treated female
AIDS patient. Mycoses 37:35, 1994
233. Revankar SG, Kirkpatrick WR, McAtee RK, et al. Detection
and significance of fluconazole resistance in oropharyngeal
candidiasis in human immunodeficiency virus-infected patients.
J Infect Dis 174:821, 1996
234. Masia Canuto M, Gutierrez Rodero F. Antifungal drug resistance to azoles and polyenes. Lancet Infect Dis 2:550, 2002
235. Perea S, Patterson TF. Antifungal resistance in pathogenic
fungi. Clin Infect Dis 35:1073, 2002
236. Spanakis EK, Aperis G, Mylonakis E. New agents for the treatment of fungal infections: clinical efficacy and gaps in coverage.
Clin Infect Dis 43:1060, 2006
237. Rex JH, Rinaldi MG, Pfaller MA. Resistance of Candida species to fluconazole. Antimicrob Agents Chemother 39:1, 1995
238. Nguyen MH, Peacock JE Jr, Morris AJ, et al. The changing
face of candidemia: emergence of non-Candida albicans species
and antifungal resistance. Am J Med 100:617, 1996
239. Powderly WG. Resistant candidiasis. AIDS Res Hum Retroviruses 10:925, 1994
240. Hitchcock CA. Resistance of Candida albicans to azole
antifungal agents. Biochem Soc Trans 21:1039, 1993
241. Pfaller MA, Diekema DJ. Azole antifungal drug cross-resistance: mechanisms, epidemiology, and clinical significance.
JInvasive Fungal Infect 1:74, 2007
242. Xiao L, Madison V, Chau AS, et al. Three-dimensional models
of wild-type and mutated forms of cytochrome P-450 14alphasterol demethylases from Aspergillus fumigatis and Candida
albicans provide insights into posaconazole binding. Antimicro
Agents Chemother 48:568, 2004
References
243. White TC, Marr KA, Bowden RA. Clinical, cellular, and
molecular factors that contribute to antifungal drug resistance.
Clin Microbiol Rev 11:382, 1998
244. Sanglard D, Odds FC. Resistance of Candida species to
antifungal agents: molecular mechanisms and clinical
consequences. Lancet Infect Dis 2:73, 2002
245. Li X, Brown N, Chau AS, et al. Changes in susceptibility to
posaconazole in clinical isolates of Candida albicans
JAntimicrob Chemother 53:74, 2004
246. Marr KA, Lyons CN, Rustad TR, et al. Rapid transient
fluconazole resistance in Candida albicans is associated with
increased mRNA levels of CDR. Antimicrob Agents
Chemother 42:2584, 1998
247. Sanglard D, Kuchler K, Ischer F, et al. Mechanisms of
resistance to azole antifungal agents in Candida albicans
isolates from AIDS patients involve specific multidrug
transporters. Antimicrob Agents Chemother 39:2378, 1995
248. Sanglard D, Ischer F, Monod M, Bille J. Susceptibilities of
Candida albicans multidrug transporter mutants to various
antifungal agents and metabolic inhibitors. Antimicrob Agents
Chemother 40:2300, 1996
195