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Description : Check out this medical titled "Antifungal agents”.

This medical is about antifungal agents, a group of drugs that are used to treat fungal infections. Fungal infections can affect different parts of the body, including the skin, nails, respiratory tract, and bloodstream.

Several classes of antifungal agents include Polyenes, Azoles, Echinocandins, Allylamines, and Griseofulvin.

Antifungal agents can be administered in various ways, including topical application, oral administration, or intravenous infusion, depending on the location and severity of the infection. It is important to use antifungal agents as directed by a healthcare provider and complete the full course of treatment, even if symptoms improve, to prevent the recurrence of the infection.

Tags : Antifungal agents, fungal infections, Polyenes, Azoles, Echinocandins, Allylamines, Griseofulvin, Infectious Disease

Published on : Jun 01, 2023 | Views : 1140 | Downloads : 0

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Slide 1-

ANTIFUNGAL AGENTS subhash k. mohan UHN – TML & Mount Sinai Hospital
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Subhash K. Mohan 2 What are they? Empirical UseAntifungal Susceptibility Testing Interpretation antifungal agents
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Subhash K. Mohan 3 antifungal agents Griseofulvin Polyenes Azoles 5-FC Terbinafine Echinocandins What are they?
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Subhash K. Mohan 4 antifungal agents Griseofulvin binds microtubule proteins, inhibit cell wall synthesis Terbinafine is an ergosterol inhibitor useful for systemic mycosis Echinocandins target their action on fungal cell wall 5FC converts to 5FU, incorporated into RNA, abnormal proteins Mode of action Amphotericin B binds to plasma membrane creating pores Azoles inhibits cytochrome P450 enzymes in the fungal cell
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Subhash K. Mohan 5 antifungal agents Griseofulvin Source Penicillium griseofulvum Produced in 1939 Not used until 1958 Spectrum Dermatophytes Gentles first used orally in guinea pigs prior to its use in humans Anti-inflammatory properties Inhibits keratolytic action
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Subhash K. Mohan 6 antifungal agents Polyenes Amphotericin B Nystatin Polyenes are produced from Streptomyces Natamycin Mepartricin Cyclic molecules Broad spectrum VERY TOXIC
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Subhash K. Mohan 7 antifungal agents Amphotericin B Yellow powder, water insoluble Bile salt allows solubility (weak association) Floats free in the aqueous medium, causes toxic effects Broad spectrum, binds to sterol in the cell membrane Fungicidal activity @ 3 h with 1 µg/ml Amphotericin B and 5FC gives synergy Azole-amphotericin B is never synergistic Candida lusitaniae is usually resistant to Amphotericin B
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Subhash K. Mohan 8 antifungal agents Amphotericin B early intolerance reaction thrombophlebitis nephrotoxicity hematotoxic effects Toxicity The liposomal preparation of Amphotericin B reduces the risk of nephrotoxicity
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Subhash K. Mohan 9 antifungal agents Azole Derivatives Water insoluble except fluconazole Preferentially inhibit cytochrome P450 enzymes Fungistatic, Modify cytochrome P450 enzyme A chemical pentacyclic structure with 2 nitrogen atoms Clotrimazole requires high doses – poorly tolerated First generation Imidazoles: Parenteral dosages no longer available for Miconazole Clotrimazole & Miconazole
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Subhash K. Mohan 10 antifungal agents CYP is vital to the formation of cholesterol & steroids NADPH + H+ + O2 + RH ==> NADP+ + H2O + R-OH CYP is a host of enzymes that use iron to oxidize things Cytochrome P 450 (CYP 450) CYP disposes harmful substances by making them water-soluble CYP is something like a hydroxyl group P450-mediated oxidation is referred to as "Phase I metabolism” CYP in man is found in the liver, small intestine
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Subhash K. Mohan 11 Fungal plasma membranes have nonpolar sterol (ergosterol) Amphotericin B binds to ergosterol permitting rapid leakage Cytochrome P450 catalyzes synthesis of ergosterol Azole antifungal agents interfere with cytochrome P450 antifungal agents CYP 450 …..
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Subhash K. Mohan 12 antifungal agents Ketoconazole Orally well absorbed imidazole of second generation Hepatotoxicity restricts its use Also interacts with other molecules CSF penetration is very weak Ketoconazole is the only imidazole for systemic use
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Subhash K. Mohan 13 antifungal agents Itraconazole Voriconazole Fluconazole Third generation azoles Satisfactory tolerability, Suitable for systemic use Posaconazole Revuconazole Triazole derivatives (contain three nitrogen atoms)
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Subhash K. Mohan 14 antifungal agents Fluconazole has been extensively used for yeast infections Useful for systemic infections Itraconazole is used to treat aspergillus infections Entirely metabolized in the liver Eliminated in the feces and urine Readily and completely absorbed by gastrointestinal tract Distributed equally in different organs and tissue Fluconazole & Itraconazole Candida krusei Intrinsically resistant to fluconazole
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Subhash K. Mohan 15 antifungal agents Voriconazole is a modified fluconazole A broad spectrum antifungal agent Rapid absorption after oral administration Distributes in tissues and body fluids Metabolized in the liver Eliminated in the urine in unchanged form Azoles carry some side effects Hepatotoxicity, gastrointestinal and endocrine toxicity Skin rash, pruritis and other hypersensitivity
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Subhash K. Mohan 16 antifungal agents Clinical Indication Miconazole has poor tolerability given by intravenous Ketoconazole used for endemic & superficial mycosis Fluconazole useful for C. albicans and Cryptococcus neoformans Itraconazole is used to treat bronchopulmonary aspergillosis Voriconazole & Posaconazole have similar spectrum as other azole Adverse effects: gastrointestinal, hypersensitivity & hepatotoxicity
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Subhash K. Mohan 17 antifungal agents Echinocandins Caspofungin Micafungin and Anidulafungin – are under investigation Caspofungin is semisynthetic, synthesized from Glarea lozyensis Whitish powder, water & methanol soluble, fungicidal Fungicidal against, Aspergilli, Candida and P. carinii No cross resistance amongst strains resistant to Ampho B or azoles No activity against Cryptococcus neoformans, Fusarium & Rhizopus Effective against Pneumocystis carinii
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Subhash K. Mohan 18 antifungal agents Terbinafine Terbinafine belongs to allylamines, synthetic, highly lipophilic Oral and topical (cream) formulations Terbinafine inhibits ergosterol biosynthesis Adverse reactions to terbinafine are in general transient and mild Used to treat superficial mycosis Also useful against systemic mycosis (yeast & other fungi)
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Subhash K. Mohan 19 antifungal agents Antifungal susceptibility testing Macrodilution Microdilution Disk diffusion E test Agar dilution Based on NCCLS M27-A document Variables: inoculum, medium, PH, incubation & temperature, MIC
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Subhash K. Mohan 20 antifungal agents Macrodilution read after 48h – more stable – useful for low volume Microdilution read after 24h (high values @ 48h) Colorimetric method better for Azoles Spectrophotometer reading micro plates is useful after agitated Major problem “trailing point” Blank disks soaked in antifungals applied on agar surface E-test based on diffusion of concentration gradient - investigational Redox reaction of Alamar blue eliminates trailing point Colorimetric MIC high for Itraconazole and low for Fluconazole Useful for isolates being resistant to Amphotericin B Agar dilution faster – more data needed for evaluation
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Subhash K. Mohan 21 antifungal agents Medium RPMI 1640 buffered, pH 7.0 Inoculum 0.5 McFarland (1 x 103 to 5 x 103 CFU/ml) Drug dilution 10x macrodilution, 2x microdilution Range Fluconazole 0.12 to 64 µg/ml, others 0.03 to 16 µg/ml Macrodilution 0.9 ml inoculum & 0.1 ml of 10x drug Microdilution 100 µl inoculum & 100 µl of 2x drug Growth control Macrodilution 0.9 ml inoculum & 0.1 ml drug free medium Microdilution 100 µl inoculum & 100 µl drug free medium Interpretation Amphotericin B – lowest concentration prevents growth 5-FC & Azoles 80% inhibition macrodilution & 50% microdilution
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Subhash K. Mohan 22 antifungal agents Interpreting antifungal test results (MIC: mg/L) Antifungal Susceptible Susceptible – dose dependent Intermediate Resistant Fluconazole = or < 8 16 - 32 = or > 64 Itraconazole = or < 0.125 0.25 – 0.5 = or > 1 5-FC = or < 4 8 - 16 = or > 32 Voriconazole* Guidelines have not been established for Amp. B and Ketoconazole = or < 1 2 = or > 4 * Tentative approval
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Subhash K. Mohan 23 antifungal agents Question Does empiric use of antifungal agents trigger resistance? Are we going to hit MRSA like situation in mycology? Antifungals show resistance more than they did in the past Some fungi become resistant after exposure to antifungals Highly unlikely Antifungals are not over prescribed as antibiotics