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------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0116.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Diagnosis of Mycoses
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Diagnosis of Systemic Mycoses and New Therapeutic Options
Mahmoud A. Ghannou= m, Ph.D.
Professor and Director
Center for Medical Mycology
Case Western Reser= ve University
Cleveland, Ohio, U= SA
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This Lecture Will Cover:
<= span style=3D'font-size:94%'>•Epidemiology of fungal infections
<= span style=3D'font-size:94%'>•Susceptibility pattern of fungal isolates
<= span style=3D'font-size:94%'>•Mortality due to fungal infections
<= span style=3D'font-size:94%'>•Difficulty in diagnosis
•Need for new broad spectrum antifungals to = respond to the changes
<= span style=3D'font-size:94%'>•Review of voriconazole, the new triazole
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Fun= gal Infections as Emerging Diseases
•Recent years have witnessed an increase in fungal infections = •Predisposing factors:  use of broad-spectr= um antibiotics, immunosuppressive agents, indwelling catheters and hospitalization •Increase first documented in the 80’s by Wey et al. (Arch. Intern. Med. 148:2642-2645, 1999) •More recently by Edmond et al. (Clin. Infect. Dis. 29:239-244, 1999)
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Sur= veillance and Control of Pathogens of Epidemiologic Importance
•49 hospitals across the U.S. (geographic diversity= ) = surveyed over a 3-year period •Cases of nosocomial bloodstream infections were <= span style=3D'font-size:94%'>surveyed •A nosocomial bloodstream infection was defined as occurring in critically ill patient when one or= more cultures of blood drawn at least 48 hours = after admission yielded a pathogenic organism.
Edmond et al.  Clin. Infect. Dis.  (1999) 29:239-244
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Rank order of nosocomial bloodstream pathogens and the associated crude mortality among the 49 hos= pitals
•         = ;         No. of         = ;          = ;   Crude
•  Ran= k Pathogen         = ;         isolates        = ;  %        mortality (%)
•    1        Coagulase-negative staphylococci     3,908         31.9 21
•    2 staphylococcus aureus         = ;            &n= bsp; 1,928        = ;  15.7      25 <= /div>
•    3 Enterococci     1,354         = ;  11.1   32
•    <= b>4 Candida species        934=         = ;    7.6     &= nbsp;     40
•    5 Escherichia coli        700=         = ;   5.7        24
•    6 Klebsiella species        662=         = ;   5.4 27
•    7 Enterobacter species        557=         = ;   4.5 28
•    8 Pseudomonas species        542=         = ;   4.4 33
•    9 Serratia species        177=         = ;   1.4 26
•  10<= span style=3D'mso-tab-count:1;width:5.64%'> Viridans streptococci        173=         = ;    1.4 23
Edmond et al.  Clin. Infect. Dis.  (1999).  29:239-244
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Distribution of nosocomial bloodstream infections due to Candida species by geographic region among the 49 hospitals
•        = ;            &n= bsp;   Northeast    Northwest    Southeast    Southwest =
•Candida species      (n =3D 288)     (n =3D 121)      (n =3D 351)    (n =3D 164)&#= 13;
•
•C. albicans        = ;            46        = ;      56        = ;         51        = ;        70
•C. glabrata        = ;           26        = ;       17        = ;         18        = ;        15
•C. krusei        = ;            &n= bsp;    4        = ;         3        = ;           4        = ;          1
•C. parapsilosis        = ;       8        = ;        12        = ;        13        = ;          5
•C. tropicalis        = ;          16        = ;       10        = ;        23        = ;          9
•Other        = ;            &n= bsp;          1        = ;         3        = ;          4        = ;          1
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Surveillance and Control of Pathogens of Epidemiologic Importance
•Yeasts continue to be important causes of <= /span>nosocomial bloodstream infections. •Importantly, they are associated with the highest mortality (40%). •Sizeable fraction of infections are caused by Candida spp. other than Candida albicans. <= /i>•The proportion of Candida= isolates other than C. albicans varied with geographic region.
Conclusions:
Edmond et al.  Clin. Infect. Dis.  (1999)  29:239-244
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Epid= emiology of Fungal Infections
•    Meis et al.  Diag. Microbiol. Infect. Dis.  39 (2000) 215-223, 26 Countries globally, 40 Institutions, 1997-1998, 20900 Isolates
Distribution of yeast isolates globally
C. albicans, 68.7%
C. glabrata, 9.9%
C. tropicalis, 4.16%
C. parapsilosis, 3.6%
C. krusei, 1.6%
C. species, 4.8%
Other yeast, 7%
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9
Species distribution of Candida= bloodstream isolates: Different regions of the world
•C. albicans 55         60        = ;          45        = ;           58
•C. glabrata        = ;             21a        = ;            &n= bsp; 12        = ;            6        = ;           10
•C. parapsilosis        = ;       11        = ;        16        25b 19b
•C. tropicalis   9          6          16c   7
•C. krusei   2          2        = ;             1        = ;            1
•Candida spp.   2        = ;          4     &nb= sp;            =    7        = ;            5
        = ;            &n= bsp;            = ;            &n= bsp;         % Isolates by geographic area&= #13;
   Species        = ;            &n= bsp;   U.S.        = ;   Canada    &nbs= p; Latin America   &nb= sp; Europe
         (n =3D 589)      (n =3D 161)        (n =3D 132)         (n =3D302) =
a P £ 0.01 compared to prevalence in other geographic areas.
bP £ 0.001 compared to prevalence in the United States= .
cP £ 0.03 compared to prev= alence in other geographic areas.
Pfaller et al.  SENTRY Program, 1997 to 1999
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10
Epid= emiology of Fungal Infections
•Rex= et al.  39th IDSA, 2000.  39 US Centers, 1995-1999, 2000 Is= olates
Distribution of yeast isolates
C. albicans, 37.5%
C. glabrata, 22.9%
C. tropicalis, 14.8%
C. parapsilosis, 3.6%
C. krusei, 2.6%
C. Lusitaniae, 0.9%<= b>
C. species, 2%
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11
Antifungal Susceptibility Survey of 2,000 Bloodstream Candida Isolates from the US
•Species (n)        AMB=   5FC  FLU  ITR  VOR  POS  CFG  MFG  AFG
•
•C. albicans (733)      0.25*    1       2     0.5    0.06   0.13   0.5    0.03    0.03
•C. glabrata <= /i>(458)       0.5=     0.13    32     4        1        2        1     0.06    0.13=
•C. krusei (50)          0.5     32     >64    1        1      0.5     &= nbsp; 2     0= .25    0.13
•C. lusitaniae= (20)       0.5=     0.13     2    0.25   0.06   0.13     2        2      0.25
•C. parapsilos= is (391) 0.5    0.13     2    0.25   0.06   0.13     2        2     &nb= sp;   2
•C. tropicalis= (307)     0.5     0.5     16      1        2        1     &nb= sp; 1     0.06    0.13=
Rex et al.  39th IDSA (2001).  San Francisco
*MIC in m= g/ml
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12
Tren= ds in Molds Other Than Aspergillu= s
•Fungi other than Aspergillus accounted for 37% of all molds and 43% of all deaths among organ transplant recipients with mold = infections. •Mortality among patients with infections due to mycelial fungi other than Aspergillus species exceeds that associated with invasive = aspergillosis.
Singh et al.  ICAAC (2000), Toronto
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Trends in Epidemiology of Opportunistic Fungal Infections
•11,000 autopsies were reviewed at a University = Hospital in Europe between 1978-1992. <= /span>
•Documented an increase in invasive fungal <= /span><= span style=3D'font-size:94%'>infections.
•This increase was largely due to a rise in = <= span style=3D'font-size:94%'>Aspergillus infections (P < 0.001).
•The incidence of invasive aspergillosis among transplant patients increased from 6% in 1983-= 1987 to 11% in 1988-1992.
Groll et al.  J. Infect. (1996)  33:23-32
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14
Invasive Aspergillosis
Etiologic Agen= ts and Site of Infection
•Examined a large cohort of patients treated for invasive aspergillosis to establish epidemiology <= /span>= and clinical outcome
•1994-1995
•89 physicians representing a diverse geographic area of the US, Canada and also included 3 = = participants from Western Europe
•595 cases were submitted for review
•74% had definite aspergillosis and 22% had = probably aspergillosis
Patterson et al.  Medicine (2000)  79:250-260.
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15
Invas= ive Aspergillosis Etiologic Agents
A. fumigatus, 66%  =
 <= /i>A. flavus, 14%
A. niger, 7%
Species not identified/reported, 7%
A. terreus, 4%
Other species, 2%*
*A. nidula= ns, A. versicolor (n=3D2), A. oryzae (n=3D1) and A. glaucus<= span style=3D'font-size:92%'> (n=3D1)
Patterson et al.  Medicine (2000) 79:250-260.
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16
Summ= ary of Fungal Epidemiology
<= span style=3D'font-size:94%'>•There is an increase in fungal infections
•Non-albicans Candida that are resistant to currently used antifungals are increasing (e.g. glabrata, lusitaniae, parapsilosis)
•Non-Aspergillus molds are increasing
•Non-fumiga= tus Aspergillus with resistance to amphotericin B are encountered clinically (e.g. = A. terreus).
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Mort= ality Due to Fungal Infections
•There is a dramatic increase in mortality due to all mycoses
•
•3.4 fold increase from 1980 to 1997
•    (0.7 to 2.4 death/100= ,000 population)
•<= /span>
McNeil et al.  Clin. Infect. Dis. (2001) 33:641-= 647
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18
Ranking of underlying causes of deaths due to infectious diseases in the US in 1980 and 1997<= /b>
•      1980 =      1997 = ;
•Rank Type of infection  # of deaths  Type of infection   # of deaths
•1         Respiratory tract      56,966   Respiratory tract      87,181= 3;
•2         Septicemia         = ;   9438   Septicemia        = ;       22,396
•3         Kidney/UTI         = ;   8006   HIV/AIDS         = ;   16,524
•4         Heart         = ;   2486     =   Kidney/UTI         = ;   13,413
•5         Tuberculosis         = ;   2333   Tuberculosis         = ;     5577
•6         Bacterial meningitis  = 1402   Hepatobiliary        = ;     4596
•7         Gastrointestinal         1377   Mycoses 2370
•8         Hepatobiliary         = ;   1277   Tuberculosis 1259
•9         Perinatal         = ;   1035     =   Gastrointestinal   =        1053
•10         Mycoses         = ;    828        Perinatal         = ;      820
UTI, urinary tract infection.
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19
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20
Why is this increase in mortality
 in spite of therapy?
<= span style=3D'mso-special-format:bullet;color:yellow;mso-color-index:3;position= :absolute; left:-4.31%'>•Poor diagnosis
•Increase in the incidence of innately resistant= organisms (lusitaniae, glabrata, terreus, non-Aspergillus molds,= e.g. zygomycetes, fusarium) which are difficult to treat
<= span style=3D'mso-special-format:bullet;color:yellow;mso-color-index:3;position= :absolute; left:-4.31%'>•Physicians do not think fungus
<= span style=3D'mso-special-format:bullet;color:yellow;mso-color-index:3;position= :absolute; left:-4.31%'>•Delay in institution of treatment
------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0061.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Diagnosis of Mycoses
21
Early Diagnosis of
Invasive Fungal Infections
R= 26;Obstacles
•Because of immunosuppression, typical signs and symptoms of infection are frequently absent
•Few clinical features are uniquely specific for sy= stemic fungal infection
•Sputum and blood cultures are frequently negative&= #13;
•Invasive procedures
–May be necessary for definitive diagnosis
–Are often contraindicated in severely immunocompromised patients
------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0061_image039.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlh2gECAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAQDY AQEAgAAAAP//AAIUjI+py+0Po5y02ouz3rz7D4biUgAAOw== ------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0061_image040.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhZAACAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAQBj AAEAgAAAAP//AAIIjI+py+0PIysAOy== ------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0062.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Diagnosis of Mycoses
22
Early Diagnosis of
Invasive Fungal Infections (continued)
•Benefits
•Early diagnosis permits therapy of maximal = effectiveness
<= span style=3D'font-size:91%;visibility:hidden'>•
•Early intervention with antifungal therapy may help decrease the high mortality rate associated with <= /span>serious systemic mycoses
------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0062_image041.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhVwACAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAABV AAEAgAAAAP//AAIIjI+py+0PVwEAOw== ------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0062_image042.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlh2gECAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAADY AQEAgAAAAP//AAIUjI+py+0Po5y02ouz3rz7D4biUgAAOw== ------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0055.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Diagnosis of Mycoses
23
•Retrosp= ective Analysis of Early Antifu= ngal  Therapy†
Reports of Invasive Aspergillosis*
90% Crude Mortality
87% Survival<= /div>
*Pannuti C, Gingrich R, Pfaller MA, Kao C,  Wenzel RP.  Cancer. 1992;69:2653-2662
Morrison VA, Haake RJ, Weisdorf DJ. Am J = Med. 1994;96:497-503
†Burch PA, Ka= rp JE, Merz WG, Kuhlman JE, Fishman EK.  J Clin Oncol. 1987;5:1985-1993.
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24
•Is there= a need for new antifungals?
•Treatment cure rates with current antifungals do n= ot <= span style=3D'font-size:88%'>exceed the 50% mark.
•Poor Diagnosis
•Mortality is still unacceptably high. <= /span>
•The answer is YES.
•
•The antifungals should be:
•Safe, possess broad spectrum activity, and availab= le as <= span style=3D'font-size:88%'>oral and IV.
•
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25
Voriconazole
N
N
N
N
N
Me
HO
F
F
F
Fluconazole
N
N
N
N
HO
F
F
N
N
Voriconazole: A New Third Generation Azole =
Vori= conazole is a broad-spectrum, triazole antifungal, with close structural similarity to fluconazole.
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26
Stages of Preclinical Evaluation
•In vitro activity (Minimum Inhibitory and Minimum Fungicidal Concentrations, MIC and MFC).
<= span style=3D'mso-special-format:bullet;color:yellow;position:absolute;left:-5.= 29%'>•Growth Inhibitory Studies.
•Effect of Voriconazole on the Fungal Morphology and Sterol Pattern.
<= span style=3D'mso-special-format:bullet;color:yellow;position:absolute;left:-5.= 29%'>•In  Vivo Efficacy Studies.
<= span style=3D'visibility:hidden'>•
------=_NextPart_01C2D2AB.B6ECAD80 Content-Location: file:///C:/15195993/Diagnosis_files/slide0067.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Diagnosis of Mycoses
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Voriconazole: Pre-clinical Evaluation: in vitro
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=
=
=
Organism
=
=
Candida <= /i>spp 3664 Voriconazole <0.03 – >16 = ;
Fluconazole 0.5 – >128
Amphotericin B 0.12 – 2 <= /div>
Itraconazole 0.12 – >8
Ketoconazole &po= und;0.12 – 4
Flucytosine &po= und;0.12 – 4
Cryptococcus 673 Voriconazole 0.06 – 0.25
neoforman= s Fluconazole 8 – 16
Amphotericin B 1.0
Itraconazole 0.5 – 1
Ketoconazole 0.25
Flucytosine 8
Yeastlike fungi = 79 Voriconazole <0.03 – 4*
Fluconazole 2 – 64*
Amphotericin B 0.5 – 2*
Itraconazole 0.25 – >8*
Ketoconazole NR
Flucytosine NR
=
=
=
No. of Isolates
=
=
=
Antifungal Agent  
=
=
=
MIC90 <= b>Range (µg/mL)*
Summary of Published MIC90 Ranges of Voriconazole versus Established Agents, by NCCLS M27A Method
=
=
=
*Geometric mean.
NR, not reported
Espinel-Ingroff A, et al. Mycopathologica. <= span style=3D'font-family:Arial;font-size:42%'>2001:150:101-115.
Vori= conazole in vitro Activity
Voriconazole has= in vitro activity against Candida spp, Cryptococcus neoformans, and yeastlike fungi.

The in vitro = activity of voriconazole is similar or superior to the activities of fluconazole, amphotericin B, and itraconazole against the same species.
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29
=
=
  Aspergillus spp     308 Voriconazol= e 0.25 – 8        = ;            &n= bsp;     0.5 – 32
Amphotericin B 0.5 – 4        = ;            &n= bsp;       0.12 – 16
Itraconazole 0.25 – 2        = ;            &n= bsp;     0.12 – 32
  Fusarium spp 84 Voriconazole 2 (10.5)*        = ;            &n= bsp;            = ;       2 – 16=
Amphotericin B 1.0 (7.13)1*        = ;            &n= bsp; 0.15 – 8
Itraconazole 0.5 – 16*
Flucytosine >801        = ;            &n= bsp;            = ;            &n= bsp;   NR
  Dimorphic fungi 521 Voriconazole 0.25 – >16        = ;            &n= bsp; <0.03 – 32
Amphotericin B 0.5 – 4        = ;            &n= bsp;       <0.03 – 4
Itraconazole 0.06 – 4        = ;            &n= bsp;     <0.03 –  >16
Flucytosine         = ;            &n= bsp;            = ;      NR
  Zygomycetes 33 Voriconazole 16        = ;            &n= bsp;            = ;  8 – 16
Amphotericin B 0.25        = ;            &n= bsp;           0.12 – 2
Itraconazole 0.5 – 2        = ;            &n= bsp;       0.5 – >16
  Dematiaceous 483 Voriconazole 0.05 – 7.4*        = ;            &n= bsp;             <0.03 = 211; 16
    fungi Amphotericin B 0.01 – 8.6*        = ;            &n= bsp;            0.25 – >16
Itraconazole 0.03 – 14.87*        = ;            &n= bsp;      0.06 – >16
Organism
=
=
=
 &nbs= p; No. of Isolates
=
=
=
Antifungal Agent
MIC90 Range (µg/mL)*
=
=
=
MFC Range µg/mL
Summary of Published MIC90 and MFC Ranges of Voric