Antifungal Management Research Articles

Antifungal management after lung transplantation (TX): a survey of 37 transplant centers

Purpose: To provide data on antifungal management after lung TX, focusing on surveillance, prophylaxis.and pre-emptive therapy. Methods: All lung TX centers in the US were asked to participate. Participating centers filled out a survey document. Results: Thirty-seven of 69 active lung TX centers, accounting for 66% of all US lung transplants, responded, The median number of transplants performed per year was 14 (range1-52). and median age of the TX center was 9 years (range2-15 yrs). Pre-TX fungal surveillance was performed by 81% of centers with 67% surveying all patients and the rest just subsets. 72% of centers started antifungal treatment if Aspergillus was isolated before TX. Itraconazole was the preferred agent (86%). After TX, 76% of centers gave antifungal prophylaxis, although 24% did so only in selected patients. Prophylactic agents in order of preference were inhaled ampho B (61%), itraconazole (46%), parenteral ampho B (25%), and fluconazole (21%); many centers used more than one agent. Prophylaxis was started within 1 day in 71% of centers and by 7 days in all centers. Median duration was 3 mos. (range 1 mo. to life). All 37 centers gave antifungal therapy (median of 4.5 mos.) to patients colonized with Aspergillus and itraconazole was the preferred agent. Only 59% of centers treated patients colonized with Candida. Centers with larger volumes were less likely to treat pre-TX colonization with Candida and more likely to use itraconazole for post-TX colonization with Aspergillus (p 0.02). Only 14% of centers engaged in antifungal research at the time of the study. Conclusions: The majority of surveyed lung transplant programs actively manage fungal infection with prophylactic and/or pre-emptive strategies. Data from this survey may provide an impetus and basis for designing prospective studies.(supported by a grant from The Liposome Company).

KENDALA DALAM PENATALAKSANAAN KEILITIS EKSFOLIATIF (Laporan Kasus)

Exfoliative cheilitis is a rare chronic superficial inflammation disorder which affect vermilion border of the lips, especially lower lip. This disorder mostly happens in woman. The characteristics of this disease are a large amount production and desquamation of the keratin layers. The etiology and pathogenesis of exfoliative cheilitis is unknown. Diagnosis of exfoliative cheilitis can only be established if the conditions od the disease couldn’t be connected to others factors. Exfoliative cheilitis is very resistant to many treatment modalities, which gave a difficulty to determining a therapy with an optimum result. Topical steroid was the most effective therapy for the disease. Antifungal therapy can be used only if there is a secondarily infection caused by Candida . This case report is about an exfoliative cheilitis on 42 years-old women with unknown etiology backgrounds. On intra-oral examination we found out that there were several focus of infections that can delay the healing processes. The patient’s conditions were resolved after a few month of topical steroid therapy, a month of antifungal therapy and management of the focus of infections. An exact diagnosis, an appropriate management, good corporation between sections which are related to patient condition and patient corporation are very important on the healing of exfoliative cheilitis.

Framing the Future of Antifungals in Atopic Dermatitis

Atopic dermatitis (AD) is a frequent chronic inflammatory skin disease. Some fungal colonization or infection of the skin may exacerbate AD severity, particularly the so-called head and neck variant. In addition, excessive intestinal colonization by Candida albicans may represent an additional triggering factor. Hence, there is a rationale to use antifungals in selected AD patients. Early trials with topical ketoconazole in head and neck AD showed a decrease in Malassezia colonization, but no significant improvement was observed in the clinical severity. In contrast, clinical improvement and decreased serum IgE were obtained in patients with positive Malassezia radioallergosorbent tests (RASTs) who were treated by oral ketoconazole. Some preliminary data suggested that oral itraconazole treatment in AD patients reduced the need for topical corticosteroids, provided clinical improvement particularly in head and neck AD, reduced the cutaneous and intestinal fungal colonization that may trigger AD, reduced the percentage of positive Malassezia cultures and demonstrated a decrease in C. albicans and Malassezia RAST values. Furthermore, beside its antifungal action, itraconazole in part relieves pruritus and inflammation. In conclusion, oral itraconazole treatment can alleviate AD severity in selected patients. Fluconazole is also effective. Further research is warranted to identify whether the load in skin surface fungal agents, the fungal RAST values and specific prick testing should be assessed in order to optimize the antifungal management in AD patients.

Real-time antifungal susceptibility screening aids management of invasive yeast infections in immunocompromised patients.

We examined the utility of a semi-solid agar antifungal susceptibility screening (SAAS) test in real-time management of eight immunocompromised patients with invasive yeast infections. Tests of amphotericin B and fluconazole concentrations of 0.5 and 2 mg/L and 1, 8 and 40 mg/L, respectively, were performed on Candida albicans (two), Candida tropicalis (two), Candida krusei (one), Candida glabrata (one) and Trichosporon species (spp.) (two). All but the Trichosporon spp. and C. glabrata isolates were resistant to fluconazole at > or = 40 mg/L, and patients were successfully managed accordingly. Real-time antifungal susceptibility screening can assist in clinical management of invasive yeast infections.

Asthma induced by allergy to Trichophyton rubrum

The worldwide incidence of asthma and of allergic respiratory diseases is increasing (Akiyama K. ‘Environmental allergens and allergic diseases.’ Rinsho Byori 1997;45(1):13. D'Amato G, Liccardi G, D'Amato M. Environment and development of respiratory allergy. II. Indoors. Monaldi Arch Chest Dis 1994;49(5):412. Weeke AR. Epidemiology of allergic diseases in children. Rhinol Suppl 1992;13:5. Ulrik CS, Backer V, Hesse B, Dirksen A. Risk factors for development of asthma in children and adolescents: findings from a longitudinal population study. Respir Med 1996;90(10):623.) This has been attributed to several factors, including lifestyle changes and an expanding variety of potential causative allergens. Management of asthma entails preventive and acute medications, immunologic therapies, and removal of the identified allergen(s) from the patient's environment. Without the latter, patients may not experience full symptomatic relief. This case report describes a patient who developed bronchial asthma subsequent to an infection of tinea pedis and pedal onychomycosis; antifungal management resulted in full resolution of his tinea pedis, onychomycosis and asthma.

Asthma induced by allergy to Trichophyton rubrum

The worldwide incidence of asthma and of allergic respiratory diseases is increasing (Akiyama K. 'Environmental allergens and allergic diseases.' Rinsho Byori 1997;45(1):13. D'Amato G, Liccardi G, D'Amato M. Environment and development of respiratory allergy. II. Indoors. Monaldi Arch Chest Dis 1994;49(5):412. Weeke AR. Epidemiology of allergic diseases in children. Rhinol Suppl 1992;13:5. Ulrik CS, Backer V, Hesse B, Dirksen A. Risk factors for development of asthma in children and adolescents: findings from a longitudinal population study. Respir Med 1996;90(10):623.) This has been attributed to several factors, including lifestyle changes and an expanding variety of potential causative allergens. Management of asthma entails preventive and acute medications, immunologic therapies, and removal of the identified allergen(s) from the patient's environment. Without the latter, patients may not experience full symptomatic relief. This case report describes a patient who developed bronchial asthma subsequent to an infection of tinea pedis and pedal onychomycosis; antifungal management resulted in full resolution of his tinea pedis, onychomycosis and asthma.

Candidal colonization and oral candidiasis in patients undergoing oral and pharyngeal radiation therapy

Objectives. Radiotherapy-induced hyposalivation encourages oral candidal colonization that often leads to oral/pharyngeal candidiasis. The purpose of this study was to quantitate oral candidal colonization, assess signs, symptoms, and response to antifungal management, speciate Candida, and evaluate the influence of smoking and dentures. Study design. Forty-six patients undergoing radiation therapy for oral/pharyngeal squamous cell carcinoma were evaluated clinically and by Candidal cultures before, during, and after irradiation. Results. All patients complained of progressive xerostomia. There was a significant increase in the prevalence of positive candidal cultures ( p = < 0.0001): baseline 43%, completion of radiotherapy 62%, and follow-up timepoint 75%. Smoking and denture wearing were not statistically significant risk factors for increased candidal colonization ( p = 0.085 and p = 0.420, respectively). Eight patients developed clinical candidiasis. Although five responded clinically to systemic antifungal medication, all follow-up cultures remained positive. Candida albicans was the predominant species at baseline and completion of radiation (85% and 68%, respectively). Conclusions. When salivary glands are included in the field of radiation, xerostomia occurs, causing progressive increases in oral Candida colonization. Because 17.4% developed clinical candidiasis during radiotherapy and the question of fungal resistance remains speculative, a recommendation for the prophylactic use of antifungal medication is unresolved.

Clinical characteristics and management responses in 85 HIV-infected patients with oral candidiasis

Eighty-five consecutively seen HIV-positive persons with oral candidiasis were evaluated for clinical characteristics, staging of HIV disease, quantitation of candidal colony formation, and response to systemic antifungal treatment with Nizoral (ketoconazole). Fifty-five had CD4 counts less than 200. There was an inconsistent association between clinical signs, patient symptoms, CD4 counts, and candidal colony-forming units. However, there was a trend toward higher colony-forming unit counts (> 500) in patients with lower CD4 cells (< 200). Sixty-five patients had a complete clinical response to the ketoconazole treatment (200 mg daily for 7 days), even though 81% of posttreatment cultures remained positive. Nonsmokers were more likely to respond to antifungal treatment when compared with smokers, and there was a slight tendency for complete responses when colony-forming unit counts were low. The most common lesion presentation was a combination of the white (pseudomembranous) and red (erythematous) forms. Forty-nine percent had complaints of pain. The variable responses indicated the importance of flexible dose-time and drug considerations in antifungal management. Candida albicans was the predominant species.

Successful treatment of hepatosplenic candidiasis through repeated cycles of chemotherapy and neutropenia.

Hepatosplenic candidiasis (HSC) or chronic disseminated candidiasis is an increasingly recognized problem in patients with cancer. Whether patients with HSC should continue to receive antineoplastic therapy, which may cause neutropenia with the risk for progressive HSC or breakthrough fungemia, can be a major dilemma. Patients with HSC at the National Cancer Institute continue antineoplastic therapy, when possible during antifungal therapy for HSC, despite repeated bouts of neutropenia. Therefore, whether this strategy resulted in breakthrough fungemia or progression of HSC was investigated. All patients consecutively treated at the National Cancer Institute at the Warren-Grant Magnuson Clinical Center from 1982-1992 for HSC were prospectively studied for therapeutic and outcome variables of antifungal and antineoplastic management. Each case was summarized on a time-event line to quantify the duration of simultaneous periods of antineoplastic therapy and antifungal therapy (AFT). Sixteen patients (median age, 22 years) with HSC were studied. Eleven patients had relapsed tumor and 5 had newly diagnosed tumor. During antifungal therapy for HSC, 12 of 16 patients were neutropenic for a median of 10 days (range, 6-91 days) and 11 were profoundly neutropenic for a median of 13 days (range, 1-55 days). Hepatosplenic candidiasis was successfully treated with complete antifungal response in 12 patients and a partial response in 2; 2 patients continued to receive AFT. No patient had breakthrough fungemia and two patients had progression of HSC, only one episode of which occurred during neutropenia. Hepatosplenic candidiasis in patients with cancer may be treated successfully under careful observation through repeated courses of chemotherapy-induced neutropenia without progression of hepatosplenic candidiasis or breakthrough fungemia.