Indian Pediatrics 2003; 40:545-550 

Treatment of Neonatal Candidiasis with Liposomal Amphotericin B (L-AMP-LRC-1): Phase II Study

Manuscript received: February 2, 2001; Initial review completed: March 7, 2001;
Revision accepted: January 7, 2003.

Abstract: A liposomal amphotericin B preparation (L-AMP-LRC-1) has been developed and tested successfully in adults by us. This preparation was administered to 23 neonates with candidiasis in an open phase II study. All the 14 assessable patients responded completely to the L-AMP-LRC-1 therapy given at 1 mg/kg for 28 days. Compared to AmBisome, another liposomal formulation of amphotericin B, L-AMP-LRC-1 was effective at lower dose in neonatal candidiasis. Thus L-AMP-LRC-1 appears to be an effective and low cost drug for the treatment of candidiasis.

Key words: Amphotericin B, Candidiasis, Liposomal, Newborn.

Candida species is a common cause of oral mucous membrane (thrush) and perineal skin infections in newborn infants(1). With improved survival of very low birth weight infants, disseminated fungal infections are occurring more frequently. Amphotericin B (amp B) is the drug of choice for systemic candidiasis. However it needs to be given as an infusion over 4-6 hrs. Nephrotoxicity is fairly common. Flucytosine is often given with amphotericin(2).

In BALB/c mice, LD50 of a liposomal amphotericin B preparation (L-AMP-LRC-1) developed by us, was 17.35 mg/kg in comparison with conventional amphotericin B having 1.2 mg/kg. Efficacy of L-AMP-LRC-1 with respect to percent survival was >70% compared to conventional ampho-tericin B, which was 20% in aspergillus mouse model(3). The mean particle size of L-AMP-LRC-1 is 0.1009 ± 0.014 (unpublished data).

L-AMP-LRC-1 differs from the existing formulation AmBisome. L-AMP-LRC-1 is made from neutral lipids, needs no reconstitution and is neutral in charge, while AmBisome is a lyophilized formulation and the negative charge. LD50 of AmBisome reported in mice is >17.5 mg/kg in compari-son with that of conventional amphotericin B having 2.3 mg/kg tested in mice(4).

L-AMP-LRC-1 has been tested success-fully in Phase I study in adults(5). This preparation was administered to 23 neonates with candidiasis in an open Phase II study. Our observations are reported here.

Subjects and Methods

Neonates with positive fungal culture from blood, cerebrospinal fluid, supra-pubically aspirated urine or joint aspirate, with clinical and laboratory evidence of sepsis/systemic candidiasis were included. For blood culture sample was collected from two sites. The study was carried out after obtaining permission from ethics committee of the hospital and Drug Controller General of India and informed consent of parents of infants to be included in the study. Liposomal amphotericin B (L-AMP-LRC-1) passing quality control tests as specified before was used in this study(3). It was administered intravenously after test doses of 0.1 and 0.4 mg/kg on day one and two. The daily dose of 1 mg/kg was diluted with 10-20 mL normal saline and infused over one hour. The duration of treatment was 28 days or for one week after 2 cultures of samples drawn one week apart were found to be negative. Patients were followed up for 8 weeks.

Patients were assessed daily clinically. Samples were collected for fungal culture weekly from the site of primary infection. Response was graded as complete, 2when two consecutive fungal cultures done at 7 days interval were negative and a complete resolution of disease as confirmed on clinical, radiological and/or microbiological criteria occurred for more than 8 weeks after stopping the treatment. In case patient died before completion of the treatment of amphotericin B and the weekly culture or histopathology had revealed no fungus then such patients were also considered to have responded completely provided the postmortem in these patients showed no evidence of fungal elements. The response was considered partial, when only partial resolution of disease occurred or recurrence of disease was observed within 2 months. Failure of response was defined when no response to drug therapy was observed.

Blood biochemistry and hematology was done before and repeated at least once a week and more frequently if required i.e., daily in the first 1-2 weeks during treatment and at the end of treatment. In case of fall in hemoglobin or potassium, blood transfusion and oral or intravenous potassium supplements were given. The biochemical and hematological pretreatment and post treatment results were compared using students paired t test.

Results

Twenty-three infants age ranging from D-1 to D-53 were included in the study. Their primary diagnosis, sites from which fungal culture was obtained, dose used, outcome and adverse reactions are given in Table I. In twenty three patients C. albicans was grown from blood and additionally from other sites in 12 patients.

TAB LE I
Details of Neonates Undergoing L-AMP-LRC-1 Therapy

Sr. No.	Sex	Age	Wt. (Kg)	Primary Diagnosis	Treatment for underlying disease	Candida growth by culture observed from	Total dose of L-AMP LRC-1 (mg)	Resp-onse	ADR and comments
1	F	D33	2.3	Birth asphyxia convulsion, respiratory distress	IV fluids, oxygen, gardenal, antiboitics	Blood, urine, joint aspirate	29.2	NA	AMA, all in PCV, 4 BT
2	F	D18	0.8	Preterm, IUGR, Apnea, hypoglycemia	oxygen, antibiotics	blood	1.44	NA	Received less than 8 doses, expired
3	M	D28	1.1	Preterm, apnea, hyperbilirubinemia	Ventilator, exchange transfusion, antibiotics	blood, urine, joint fluid	34.1	CR	Fall in PCV, 7 BT
4	M	D29	1.17	Preterm, hypoglycemia, apneic spells	Dextrose, hydrocortisone	Blood, urine	39.07	CR	fall in PCV, 8 BT
5	M	D16	1.16	Preterm, hypoglycemia, hyperbilirubinemia	Dextrose, hydrocortisone, phototherapy, exhange transfusion	Blood, urine	31.98	CR	Fall in PCV, 5BT hypokalemia, received oral potassium
6	M	D22	1.25	Birth asphyxia, hepatosplenomegaly	antibiotics	Blood	8.75	NA	Received  less than 8 doses, expired
7	M	D27	1.5	Preterm,s epticemia, hyperbilirubinemia, tachypnea, respiratory distress	Antibiotics, phototherapy, oxygen	Blood, urine	42.7	CR	Fall in PCV, 8BT, hypokalemia, received oral potassium
8	M	D20	1.2	Preterm, IUGR	Antibiotics	Blood, urine	21	CR	Fall in PCV, $ BT, hypokalemia, received oral potassium, expired after 19 days, post morterm revealed no fungus
9	F	D12	1.2	Preterm	-	Blood	0.12	NA	Received less than 8 doses, AMA
10	F	D23	1.1	Preterm	-	Blood	2.75	NA	Received less than 8 doses, expired
11	F	D18	1.45	Preterm, hypoglycemia, hypoxia	Oxygen, ventilator	Blood, urine	19.575	CR	Fall in PCV, 2 BT, Expired after 15 doses, PM: no fungus
12	F	D15	1.25	Preterm, apneic spells, hyperbilirubinemia	exchange transfusion, aminophylline, oxygen	Blood, urine	38.125	CR	Fall in PCV, 8BT
13	M	D21	1.31	Preterm, pletoric, hyperbilirubinemia	Exchange transfusion, antibiotics	Blood, urine	37.335	NA	Fall in PCV, 8 BT
14	F	D15	1.1	Preterm, apneic spells, hypoglycemia	Ventilator, dextrose, Antibiotics	Blood, urine	3.85	NA	Received less than 8 doses, expired.
15	M	D14	1.75	Preterm, icteric, apneic spells	Exchange, transfusion	Blood, urine	49.875	CR	Fall in PCV, 8BT, hypokalemia, received oral K
16	F	D17	1.31	Preterm, Respiratory distress, hyperbilirubinemia	Vetilator, exchange transfusion	Blood, urine	37.3	CR	NIL
17	M	D18	1.65	Preterm, tachypnea, distress, septicemia	Antibiotics	Blood	0.16	NA	Received less than 8 doses, expired.
18	M	D20	2.25	Bilateral renal polycystic disease, bladder outlet obstruction, oligohydrammnios	Catheterization	Blood, urine CSF	73.125	CR	Drowsiness (1), vomiting (3), Fall in PCV, required 3 BT
19	M	D53	1.13	Preterm, birth asphyxia	ventilator	Blood	1.6	NA	Received less than 8 doses, expired.
20	M	D17	1.2	Preterm, hyperbilirubinemia	Exchange transfusion phototherapy	Blood, urine	34.2	CR	Fall in PCV, 2 BT
21	F	D16	1.25	Preterm, septicemia	Antibiotics	Blood	34.375	CR	Fall in PCV, 3 BTG, hypokalemia, received oral K
22	F	D20	2.25	Asphyxia, Acute renal failure	Peritoneal dialysis	Blood, urine	66.37	CR	Nil
23	F	D1	1.2	Preterm		Blood	3.0	NA	Received less than 8 doses, expired

BT: Blood transfusion, PCV: Packed Cell Volume, AMA: Against Medical Advice,
PM: Post Morterm, K : Potassium NA: Non-assessable CR: Complete Response

Fall in PCV was noted in 12 patients and fall in serum potassium in five patients. These were treated with 2 to 9 blood transfusions and potassium supplements. Three patients had serum creatinine above normal before onset of treatment. There was no rise during or after treatment in creatinine in any patient, values were (mean ± SD) 0.76 ± 0.46 and 0.73 ± 0.25 mg % pre and post treatment respectively. Pre and post treatment BUN and serum potassium values were 12.76 ± 6.07, 9.3 ± 4.6 mg % and 4.0 ± 0.57, 4.08 ± 0-.47 meq/L respectively.

Liposomal amphotericin B was injected through peripheral vein or a central vein. No thrombophlebitis was noted in any infant. No rigor, fever, bronchospasm occurred in any patient.

Complete response was noticed in 14 infants. Of these two died due to causes other than fungal infection or adverse drug reaction. Nine patients were non-assessable; seven expired before completing 8 doses of treatment and two were discharged against medical advice. Fungal culture from sample collected at 1 week was negative in all (assessable) patients. In one baby that expired on day 19, no fungal growth was seen in autopsy samples. One patient died on day 16 due to fluid aspiration.

The pre- and post-treatment hemoglobin values (g/dL, mean ±SD) were 12.83 ± 3.09 and 10.62 ± 1.82 respectively. A marked rise in SGOT and SGPT was noted in 1 patient who responded completely; and an isolated rise in SGOT was noted in another patient, who was discharged against medical advice, but was negative for fungal culture at the time. The dose of L-AMP-LRC-1 was not reduced for either patient. The mean pre and post treatment SGOT values were (mean ± SD) 68.75 ± 47.16 µ/L and 95.55 ± 70.89 µ/L; and the corresponding SGPT values were 45.06 ± 45.12 µ/L and 61.09 ± 33.59 µ/L respectively.

Discussion

A mortality of 26.3% in the 38 infants with systemic candidiasis treated with ampho-tericin is reported(6). It was their impression that favorable outcome depended on prompt initiation of therapy coupled with rapid escalation of amphotericin dosage. In the present study with L-AMP-LRC-1 mortality of 13.3% was noted in patients given 1 mg/kg/d for 28 days. All the 14 assessable cases were negative for the fungal culture (response rate 100%).

Efficacy of another liposomal ampho-tericin B formulation AmBisome in neonates has been reported. AmBisome was given with a median dose of 2.66 mg/kg/d for median 28 days (range 11 to 79 days) with median cumulative dose of 71.0 mg/kg. All the patients recovered clinically(7). In another study, median cumulative dose of 45.2% was effective in 72.7% of the patients(8). L-AMP-LRC-1 was effective in this study at dose of 28.5 mg/kg. It is also expected to cost less than AmBisome. L-AMP-LRC-1 would be an important addition to drugs available to pediatricians and neonatologists, especially in the treatment of life threatening systemic fungal infections in neonates.

Contributors: RNK was responsible for manufacture and quality control of drug and drafting of paper. PVB was responsible for manufacturng and dispensing of L-AMP-LRC-1. BG was responsible for manufacturing, dispensing and data collection. LPM and USA were involved in patient care, follow up and adverse event monitoring. NAK was responsible for supervision of drug manufacture, drug administration, study design and manuscript preparation and will act as the guarantor for the paper.

Funding: Department of Biotechnology, Government of India, New Delhi. (BT/02/012/89-R&D).

Competing Interests: None stated.

 References