Beruflich Dokumente
Kultur Dokumente
• http://www.doctorfungus.org
• http://mycology.adelaide.edu.au/mycoses
• http://mycology.cornell.edu/
• http://www.mycology.net/
Lecture outline
• Clinical significance of fungal infection
• Fungal cell structure and targets
• Antifungal agents and mechanism of action
• Antifungal drug interactions & nephrotoxicity
• Mechanisms of antifungal resistance
• Combination antifungal therapy
Medical Problems Caused by Fungi
1) Allergic disease
2) “Mushroom” poisoning
3) Mycotoxins
Secondary metabolites
--many have industrial uses
--Fusarium mycotoxin -- USSR after WWII
--A. flavus “aflatoxin”
150
primary human
fungal pathogens
100,000
Validly described species
of fungi
150
primary human
fungal pathogens
100,000
Validly described species
of fungi
150 Candida,
Aspergillus,
primary human Crypto, Blasto, Histo,
Cocci, Dermatophytes
fungal pathogens
100,000
Validly described species
of fungi
c. Mobile population.
i. People commonly travel through areas of endemic mycoses, which
presents diagnostic challenges.
Advances in research:
a. New antifungal agents and treatment options
Mannoproteins
β-(1,6)-glucan
β-(1,3)-glucan
Chitin
Phospholipid bilayer
of cell membrane
β-(1,3)-glucan synthase
Ergosterol
Ergosterol
Synthesis DNA/RNA Synthesis
Pathway
Squalene
ANTIFUNGAL DRUGS
targets
• Membrane disrupting agents • Glucan synthesis
Amphotericin B, nystatin inhibitors
• Ergosterol synthesis inhibitors Echinocandins
Azoles, allylamines, morpholine
• Nucleic acid inhibitor • Chitin synthesis
Flucytosine inhibitor
• Anti-mitotic (spindle disruption) Nikkomycin
Griseofulvin
• Protein synthesis inhibitors
Sordarins, azasordarins
Lecture outline
• Clinical significance of fungal infection
• Fungal cell structure and targets
• Antifungal agents and mechanism of action
• Antifungal drug interactions & nephrotoxicity
• Mechanisms of antifungal resistance
• Combination antifungal therapy
ANTIFUNGAL DRUGS
classes
• POLYENES • ECHINOCANDINS
Amphotericin B, nystatin Caspofungin,
• AZOLES
anidulafungin,
Imidazoles: Ketoconazole..
micafungin
Triazoles: Fluconazole,
itraconazole,
voriconazole, • PEPTIDE-NUCLEOSIDE
posaconazole, Nikkomycin Z
ravuconazole
• ALLYLAMINES • TETRAHYDROFURAN
Terbinafine, butenafine DERIVATIVES
• MORPHOLINE Sordarins, azasordarins
Amorolfine
• FLUORINATED PYRIMIDINE
• OTHER
Flucytosine
Griseofulvin
Polyenes
OH
OH
H3C O OH
HO O OH OH OH OH O
CH3 COOH
H
H3C
O O CH3
amphotericin B OH
NH2
OH
OH
OH
H3C O OH
HO O OH OH OH OH O
CH3 COOH
H3C
Nystatin A1 O CH3
OH
OH NH2
Amphotericin B
Ergosterol
Cell membrane
Binding to ergosterol, Ca
Ca++
++ Ca
Ca++
++
Intercalation of cell membrane Na
Na++
Na
Na++ K
K++
K
K++
O
N F
O
N
N N O O
N H3C H Cl Cl
N N
OH F
ketoconazole
fluconazole N
N
N
CH3
N O
O
H3C
N
N N N O O
N N N
H Cl Cl
N N F
OH
itraconazole
N
F CH3
N
F H3C
N
O
O
H3C
voriconazole N
N N N O
HO N
H F F
posaconazole
Azole
Cell membrane
Ergosterol
Ergosterol
Synthesis
Pathway
Squalene
Accumulation of
toxic sterols in
cell membrane
Toxic sterols
Inhibition of
14-alpha-demethylase
Azoles
• Mechanism: block ergosterol synthesis via inhibition
of cytochrome P450 14α-demethylase
terbinafine
CH3
O CH3
N
H3C
butenafine
Allylamines, morpholines
• Mechanism: block ergosterol synthesis via inhibition
of squalene epoxidase (allylamines), sterol reductase
and isomerase activity (morpholines)
HO O
O
NH
H3C
NH
H2N N O
O N
HN OH
O O
HO NH O CH3
H2N O N
H
HO N
NH OH
OH
O OH
S O
O OH
O
HO O
NH O O
H
O
N
H
HO micafungin
H2N N
OH
O HN H3C
H3C
H
H CH3 CH3
CH3
NH O HO OH
HO
H H O
O H HO O
N
OH OH NH
H3C
NH
O
OH N O
H3C O HN OH
HO NH O CH3
HO
caspofungin O
H
N O
HO N
H3C
OH
O
OH
anidulafungin
HO
Mannoproteins
ß(1,6)-glucan
ß(1,3)-glucan
Chitin
Phospholipid bilayer
of cell membrane
Inhibition of
ß(1,3) glucan synthase
This AIDS patient failed fluconazole,
amphotericin B, and itraconazole…
Echinocandins: No cross-
resistance
OCH3
O OCH3
H
N O
N
O
F H3CO
H3C
Cl
NH2
flucytosine griseofulvin
Cytosine
Cytosine permease
permease
5-FC
5-FC
Cytosine
Cytosine deaminase
deaminase
5-FC
5-FU
Phosphorylation
Phosphorylation FdUMP FdUMP
Conversion
Conversion to
to FUTP
dUMP
deoxynucleosides
deoxynucleosides
dTMP
Substitution
Substitution for
for uracil
uracil
Inhibition
Inhibition of
of Protein
Protein Synthesis
Synthesis
Inhibition
Inhibition of
of thymidylate
thymidylate synthase
synthase
Inhibition
Inhibition of
of DNA
DNA synthesis
synthesis
Immunocompromised
“Non-immunocompromised”
(transplant, BMT, AIDS)
Start echinocandin
Start fluconazole,
or (lipid) polyene, wait
Endemic mycosis Candida wait for ID and
for ID and
monitor response
monitor response
If good response
Continue (lipid) polyene
complete 14 days from first If no response
Until stable, then consider If good response No response or
negative culture, may switch to other agent
fluconazole complete 14 days from clearly resistant
Switch to fluconazole or from the
or itraconazole first negative culture isolate
voriconazole if above classes
as appropriate
stable and susceptible
Portal vein
Liver
CYP Absorption
To feces
Gut wall
Metabolism
Antifungal drug interactions
• Pharmacokinetic interactions: changes in absorption or elimination of
interacting drug and the antifungal
• Interactions of drug absorption
• Ketoconazole, itraconazole require low pH for absorption (avoid antacids, vitamin
supplements)
• Pre-systemic clearance via membrane transporters (P-gp) & metabolic enzymes. Azoles can
be both substrates and inhibitors of P-gp
• Interactions of drug metabolism
• Oxidation, reduction, hydrolysis, conjugation of lipophilic compounds
• Interactions with cytochrome P450
• Azoles are metabolized by CYP P450 system
• Azoles are also reversible inhibitors of P450 enzymes
• Co-administered metabolites are a concern
Proportion of Drugs Metabolized by CYP
P450
Antifungal drug interactions
• Pharmacokinetic interactions: changes in absorption or elimination of
interacting drug and the antifungal
• Interactions of drug absorption
• Ketoconazole, itraconazole require low pH for absorption (avoid antacids, vitamin
supplements)
• Pre-systemic clearance via membrane transporters (P-gp) & metabolic enzymes. Azoles can
be both substrates and inhibitors of P-gp
• Interactions of drug metabolism
• Oxidation, reduction, hydrolysis, conjugation of lipophilic compounds
• Interactions with cytochrome P450
• Azoles are metabolized by CYP P450 system
• Azoles are also reversible inhibitors of P450 enzymes
• Co-administered metabolites are a concern
Inducers of CYP 3A4
Reduction in levels
Glomerulus
Tubular-glomerular feedback:
Further constriction of arterioles
Lecture outline
• Clinical significance of fungal infection
• Fungal cell structure and targets
• Antifungal agents and mechanism of action
• Antifungal drug interactions & nephrotoxicity
• Mechanisms of antifungal resistance
• Combination antifungal therapy
Fungal Virulence
• Fungal determinants of virulence
Number and physical size of fungal inoculum; conditions of exposure
Virulence factors (adhesins, proteases, toxins, interference with host
defenses)
Morphology of fungal cells in vivo
Regulatory and signal transduction pathways
• Host defenses, cellular & humoral immunity
Non-specific (innate) defense
Cell-mediated immunity
Phagocytic and tissue response
Predisposing factors (age, gender, heredity, pathophysiological state,
cellular immunodeficiency)
Opportunism
Clinical Resistance is a
Multifactorial Issue
• FUNGUS
• HOST Initial MIC
Cell type: Yeast/hyphae..
Immune status
Genomic stability
Site of infection
Biofilm production
Severity of infection Population bottlenecks
Foreign devices • DRUG
Noncompliance with drug Fungistatic nature
regimen Dosing
Pharmacokinetics
Drug-drug interactions
Resistance to Amphotericin B
RESISTANCE TO FLUCONAZOLE
PRIMARY C. krusei
Aspergillus
C. glabrata
C. norvegensis...
SECONDARY C. albicans
C. dubliniensis...
Mechanisms of Resistance to
Azoles
• Alteration of lanosterol (14-alpha) demethylase
• Mechanism: (?)
CDR1-mediated efflux (possible)
Resistance to Flucytosine
• SECONDARY C. albicans
C. neoformans
Block Proc Soc Exp Biol Med 142;476, ’73; Te Dorsthorst AAC 46:2982, ’02; Bennett NEJM 301:126, 1979; van der Horst
NEJM 337:15, ’97; Saag CID 28:291, ’99; Saag CID 30:710, ’00; Te Dorsthorst AAC 46:2982, ’02; Martin AAC 38:1331,
’94; Barbaro Chest 110:1507, ’96; Polak Chemotherapy 33:381, ’87; Verweij Infection 22:81, ’94; Sllling Mycoses 42
(S2):101, ’99; Denning RID 12:1147, ‘90
Useful lesson: Dose matters
Ding AAC 41:1589, ’97; Allendoerfer AAC 35:726, ’91; Barchiesi AAC 44:2435, ‘00
Dead
Franzot AAC 41:331, ’97; Flattery ICAAC #J-61, ’98; Smith EJCMID 10:588, ’91; unpublished data (Rex);
Sugar AAC 35:2128, ’91; Roling DMID 43:13, ‘02
Polyenes plus azoles
• Histoplasma: BAD
• Higher lung & spleen CFU with FLU + AmB
• Trichosporon: GOOD
• FLU + AmB was better than AmB alone
Barchiesi AAC 44:2435, ’00; LeMonte JID 182;545, ’00; Louie ICAAC J-1619, ‘01
AmB + Azoles: Bottom Line
• Very confusing
• Many negative trends, but many surprises
• Cryptococcus: Combination often positive
• Candida: A wild range of results
• The one human trial was NOT negative
• Can do if needed. This strategy pursued to get better
spectrum. Candins should render moot.
• Aspergillus
• Start w/AmB, switch to azole, may overlap
Clinical Implications
• Cryptococcus
• Adding 5FC is generally good. +FLU is better?
• Candida
• Can combine fluconazole with AmB
• But, probably should avoid in endocarditis
• Candins may render this idea moot
• Aspergillus
• Candin-based combos look like the way to go
Future Directions to Avoid
Development of Resistance
• Proper dosing strategies
• Combination therapies
• Restricted and well-defined indications for
prophylaxis with azoles