Pediatric pharmacology of antifungal agents

Pediatric age groups display important differences in host biology, predisposing conditions, epidemiology, and presentation of fungal infections relative to the adult population. Over the past decade, major advances have been made in the field of medical mycology. Most importantly, an array of new antifungal agents has entered the clinical arena. Although pediatric approval of several of these agents remains to be established, the pediatric development of antifungal agents is moving forward. Invasive fungal infections will remain important causes for morbidity and mortality in immunocompromised pediatric patients. Although the availability of new therapeutic options is an important advance, antifungal therapy has become increasingly complex, and a thorough understanding of the available antifungal armamentarium is essential for the successful management of individual patients.     

Primary and Secondary Antifungal Prophylaxis in the Immunocompromised Child: Where do we Stand?

Invasive opportunistic fungal infections are important causes of morbidity and mortality in immunocompromised children undergoing chemotherapy or haematopoietic stem cell transplantation (HSCT). Primary and secondary chemoprophylaxis of invasive fungal infections targets high risk disease-related patients with acute myeloid leukaemia, high risk acute lymphoblastic leukaemias, recurrent leukaemias and those following allogeneic HSCT. The rationale for antifungal prophylaxis in high risk patients comes from two different aspects. On the one hand, is the difficulty of instant diagnosis and, on the other hand, the consequences of morbidity and mortality by invasive infectious diseases. Although we have limited pediatric data concerning antifungal prophylaxis, it has become part of infectious disease supportive care schemes in most of paediatric leukaemia and HSCT centres. This review has insights on the evidence concerning primary and secondary antifungal prophylaxis in immunocompromised children. Although our knowledge comes from large adult studies concerning antifungal agents, there is a great need for evidence of primary or secondary antifungal prophylaxis in large pediatric clinical trials in order to have a consensus in primary and secondary antifungal prophylaxis in immunocompromised children.     

New Antifungal Agents and New Formulations Against Dermatophytes

A variety of oral and topical antifungal agents are available for the treatment of superficial fungal infections caused by dermatophytes. This review builds on the antifungal therapy update published in this journal for the first special issue on Dermatophytosis (Gupta and Cooper 2008;166:353–67). Since 2008, there have not been additions to the oral antifungal armamentarium, with terbinafine, itraconazole, and fluconazole still in widespread use, albeit for generally more severe or recalcitrant infections. Griseofulvin is used in the treatment of tinea capitis. Oral ketoconazole has fallen out of favor in many jurisdictions due to risks of hepatotoxicity. Topical antifungals, applied once or twice daily, are the primary treatment for tinea pedis, tinea corporis/tinea cruris, and mild cases of tinea unguium. Newer topical antifungal agents introduced include the azoles, efinaconazole, luliconazole, and sertaconazole, and the oxaborole, tavaborole. Research is focused on developing formulations of existing topical antifungals that utilize novel delivery systems in order to enhance treatment efficacy and compliance.     

Delivery of Antifungal Agents from Bone Cement

Fungal osteoarticular infections, including prosthetic joint infections and osteomyelitis, are rare yet present a therapeutic challenge with no guidelines to direct optimal treatment. When these infections occur, the majority are due to Candida species. In addition to systemic therapy, adjunctive antifungal-loaded bone cement has been utilized to successfully treat these infections. Amphotericin B is used most commonly, but cases utilizing voriconazole, fluconazole, and itraconazole have been reported as well. In vitro data suggest better elution of voriconazole from bone cement while there is minimal elution of amphotericin B. Unfortunately, a lack of consistency in the methods of both in vitro studies and case reports makes it difficult to determine if the addition of an antifungal agent in bone cement improves outcomes in fungal osteoarticular infections. This article provides an overview of bone cement as a delivery system for antifungal agents in vitro and in clinical reports.     

Pharmacology, in vitro activity, and in vivo efficacy of new antifungal agents

Invasive fungal infections remain significant clinical challenges and are associated with high morbidity and mortality in immunocompromised patients. Despite the availability of new antifungal agents, response rates against many of these infections remain suboptimal. In addition, many of the clinically available agents have limited oral bioavailability, are associated with adverse effects due to similarities between fungal and mammalian cells, or have significant drug-drug interactions. For these reasons, there is great interest in developing new antifungal drugs, including those with novel mechanisms of action. This article reviews the pharmacology, in vitro activity, and in vivo effectiveness of new antifungal agents, including members of new classes with novel mechanisms of action and at various stages of preclinical and clinical development. These agents include the triazole isavuconazole, the echinocandin aminocandin, the histone deacetylase inhibitor MGCD290, and the sordarin derivative FR290581.     

Potential applications of microbial surfactants in biomedical sciences

The main commercial use of biosurfactants is in pollution remediation because of their ability to stabilize emulsions. This enhances the solubility and availability of hydrophobic pollutants, thus increasing their potential for biodegradation. One useful property of many biosurfactants that has not been reviewed extensively is their antimicrobial activity. Several biosurfactants have strong antibacterial, antifungal and antiviral activity. Other medically relevant uses of biosurfactants include their role as anti-adhesive agents to pathogens, making them useful for treating many diseases and as therapeutic and probiotic agents. Here, we discuss some of the new and exciting applications and related developments of various microbial surfactants in the field of biomedical sciences.     

Antifungal Therapy in Pediatric Patients

Invasive fungal infections still play a major role in morbidity and mortality in pediatric patients, especially in children undergoing therapy for an underlying malignancy and in preterm infants. Relative to the adult population, pediatric age groups display important differences not only in host biology, predisposing conditions, epidemiology, and presentation of fungal infections, but also in the disposition and clearance of antifungal compounds. During the past decade, several new antifungal agents have been developed. Although not all of these agents are yet approved for children, the pediatric development of antifungal agents has moved forward in an exemplary manner, which is essential for the successful management of the individual patient. This article reviews the current data on pharmacokinetics, safety, and dosing of antifungal agents in pediatric patients.     

Genome sequence of Streptomyces sp. strain Tü6071

Streptomyces sp. Tü6071 is a soil-dwelling bacterium which has a highly active isoprenoid biosynthesis. Isoprenoids are important precursors for biopharmaceutical molecules such as antibiotics or anticancer agents, e.g., landomycin. Streptomyces sp. Tü6071 produces the industrially important terpene glycosides phenalinolactones, which have antibacterial activity against several Gram-positive bacteria. The availability of the genome sequence of Streptomyces sp. Tü6071 allows for understanding the biosynthesis of these pharmaceutical molecules and will facilitate rational genome modification to improve industrial use.     

Stability of Organoleptic Agents in Pharmaceuticals and Cosmetics

Organoleptic agents constitute an important niche in the field of pharmaceutical excipients. These agents encompass a range of additives responsible for coloring, flavoring, sweetening, and texturing formulations. All these agents have come to play a significant role in pharmaceuticals and cosmetics due to their ability to increase patient compliance by elevating a formulation’s elegance and esthetics. However, it is essential to review their physical and chemical attributes before use, as organoleptic agents, similar to active pharmaceutical ingredients (APIs), are susceptible to physical and chemical instability leading to degradation. These instabilities can be triggered by API-organoleptic agent interaction, exposure to light, air and oxygen, and changes in pH and temperature. These organoleptic agent instabilities are of serious concern as they affect API and formulation stability, leading to API degradation or the potential for manifestation of toxicity. Hence, it is extremely critical to evaluate and review the physicochemical properties of organoleptic agents before their use in pharmaceuticals and cosmetics. This literature review discusses commonly used organoleptic agents in pharmaceutical and cosmeceutical formulations, their associated instabilities, and probable approaches to overcoming them.     

Promising antifungal agents: A minireview

In the recent past, prevalence of life threatening fungal diseases have increased rapidly in immune-compromised cases such as acquired immunodeficiency syndrome (AIDS), cancer, organ transplant etc. Side by side, the appearance of drug resistance to the presently available antifungal therapeutics is on a rapid rise. It has become a top priority for the academia and pharmaceutical industries to develop new antifungal agents able to combat this resistance, and at the same time, possess potential broad spectrum of activity and minimum toxicity. An understanding of the pharmacological interactions between antifungal agents and their targets offers opportunities for design of new therapeutics. This review discusses the various methodology of drug design, structure activity relationships (SARs), and mode of action of variety of new antifungal agents.     

Pros and Cons of Extrapolating Animal Data on Antifungal Pharmacodynamics to Humans

Both the incidence of invasive fungal infections and the number of antifungal agents available to clinicians have expanded significantly over the past two decades. Successes with pharmacokinetic and pharmacodynamic evaluations of other antimicrobial agents in animal models and their clinical correlations with patient outcomes have led to an increased number of studies evaluating both old and new antifungal agents. Recently, animal models have successfully defined target pharmacodynamic indices for many antifungal agents and fungal infections, but validation of these targets in human studies is frequently lacking. This article evaluates the potential pros and cons of extrapolating to humans the animal data on antifungal pharmacodynamics.     

用聚类法分析受抗真菌物质处理后的酵母细胞全基因表达谱

微阵列DNA芯片技术可以并行分析成千上万个基因的表达情况,它为研究药物的作用机制提供了一个新的高效技术平台.用9种已知和未知作用机理的抗真菌化合物处理酵母细胞,并得到酵母细胞的全基因表达谱,然后对其进行聚类分析.结果表明作用机制类似的化合物具有相近的聚类关系.两性霉素B和制霉菌素、酮康唑和克霉唑都是已知的作用机制类似的抗真菌药物.通过对基因表达谱进行聚类分析,发现前一组和后一组分别被聚类在一起.另外已知澳洲茄胺抑制的是细胞膜上麦角固醇的合成,聚类分析表明它与酮康唑,克霉唑的聚类很靠近.对微阵列DNA芯片产生的基因表达谱进行聚类分析,由于作用机制相似的药物会被聚类在一起,因此根据未知药物和已知药物的聚类关系,可以了解未知药物的作用机制,这对于加速新药开发的步伐具有十分重要的意义.     

In Vitro Antifungal Activity of Dihydroxyacetone Against Causative Agents of Dermatomycosis

Dihydroxyacetone (DHA), a three-carbon sugar, is the browning ingredient in commercial sunless tanning formulations. DHA preparations have been used for more than 50 years and are currently highly popular for producing temporary pigmentation resembling an ultraviolet-induced tan. In this work, the in vitro antifungal activity of dihydroxyacetone was tested against causative agents of dermatomycosis, more specifically against dermatophytes and Candida spp. The antifungal activity was determined by the broth microdilution method according to the Clinical and Laboratory Standards Institute guidelines for yeasts and filamentous fungi. The data obtained show that the fungicidal activity varied from 1.6 to 50 mg ml⁻¹. DHA seems to be a promising substance for the treatment of dermatomycosis because it has antifungal properties at the same concentration used in artificial suntan lotions. Therefore, it is a potential low-toxicity antifungal agent that may be used topically because of its penetration into the corneal layers of the skin.     

Cardiopulmonary exercise testing in congenital heart disease: (contra)indications and interpretation

Cardiopulmonary exercise testing (CPET) in paediatric cardiology differs in many aspects from the tests performed in adult cardiology. Children's cardiovascular responses during exercise testing present different characteristics, particularly oxygen uptake, heart rate and blood pressure response, which are essential in interpreting haemodynamic data. Diseases that are associated with myocardial ischaemia are rare in children. The main indications for CPET in children are evaluation of exercise capacity and the identification of exercise-induced arrhythmias. In this article we will review the main indications for CPET in children with congenital heart disease, the contraindications for exercise testing and the indications for terminating an exercise test. Moreover, we will address the interpretation of gas exchange data from CPET in children with congenital heart disease. (Neth Heart J 2009;17:385–92.)     

Novel antifungal drugs.

There have been many new developments in antifungal therapy in the past few years. Some antifungal drugs have been reformulated to reduce toxicity (e.g. new lipid formulations of polyenes), and new derivatives of drugs have been developed to enhance potencies. The search for unique drug targets will be enhanced by the availability of sequencing data from whole genome sequencing projects.     

Will genomics revolutionize antimicrobial drug discovery?

Utilizing genome sequence data from bacterial and fungal pathogens for the discovery of new antimicrobial agents has received considerable attention, both practical and critical, from the pharmaceutical and biotechnological communities. Although no new drugs derived from genomics-based discovery have been reported to be in a development pipeline, the utilization of genomics has revolutionized many aspects of drug discovery. The application, utility, opportunity, and challenges afforded by many of these new approaches are discussed.     

Immunomodulatory Agents as Adjunctive Therapy for the Treatment of Resistant Candida Species

Invasive Candida infections have increased fivefold over the past 20 years. During this time, the incidence of antifungal resistance and infection due to non-albicans species has risen with the increasing use of broad spectrum antifungals. As few new antifungal agents are in development, strategies to improve outcomes in the treatment of Candida infections are sorely needed. The use of immunotherapy to augment the host immune response as an adjunctive treatment for Candida infections is a potentially robust and promising approach. The purpose of this review is to focus on new developments in the use of adjunctive immunotherapy for the treatment of Candida infections, and discuss the potential impact of antifungal resistance on the host immune response.     

Raising the Barriers to Access to Medicines in the Developing World – The Relentless Push for Data Exclusivity

Since the adoption of the WTO‐TRIPS Agreement in 1994, there has been significant controversy over the impact of pharmaceutical patent protection on the access to medicines in the developing world. In addition to the market exclusivity provided by patents, the pharmaceutical industry has also sought to further extend their monopolies by advocating the need for additional ‘regulatory’ protection for new medicines, known as data exclusivity. Data exclusivity limits the use of clinical trial data that need to be submitted to the regulatory authorities before a new drug can enter the market. For a specified period, generic competitors cannot apply for regulatory approval for equivalent drugs relying on the originator's data. As a consequence, data exclusivity lengthens the monopoly for the original drug, impairing the availability of generic drugs. This article illustrates how the pharmaceutical industry has convinced the US and the EU to impose data exclusivity on their trade partners, many of them developing countries. The key arguments formulated by the pharmaceutical industry in favor of adopting data exclusivity and their underlying ethical assumptions are described in this article, analyzed, and found to be unconvincing. Contrary to industry's arguments, it is unlikely that data exclusivity will promote innovation, especially in developing countries. Moreover, the industry's appeal to a property rights claim over clinical test data and the idea that data exclusivity can prevent the generic competitors from ‘free‐riding’ encounters some important problems: Neither legitimize excluding all others.     

广谱抗病毒抑制剂研究进展

研制广谱抗病毒制剂是病毒学前瞻性方向,也是国际医药界倍受瞩目的热点之一.近年来,广谱抗病毒制剂相关研究获得长足进展,突破了抗病毒制剂单一宿主的瓶颈与限制,以及广谱类制剂活性相对较弱的原有思维,部分成果已面向临床应用.本文基于病毒侵染以及宿主细胞防御两个层面,全面综述新型广谱抗病毒抑制剂的研究进展与应用潜力,讨论现存的挑战,并展望了未来研究趋势.