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Antimicrobial Agents and Chemotherapy, December 1998, p. 3092-3096, Vol. 42, No. 12
0066-4804/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
Efficacious Topical Treatment for Murine Cutaneous
Leishmaniasis with Ethanolic Formulations of Amphotericin B
Shoshana
Frankenburg,1,*
Dvora
Glick,2
Sidney
Klaus,1 and
Yechezkel
Barenholz2
Department of Dermatology, Hadassah Medical
Organization,1 and
Department of Medical
Biochemistry, Hebrew University-Hadassah Medical
School,2 Jerusalem, Israel
Received 28 May 1998/Returned for modification 6 August
1998/Accepted 22 September 1998
 |
ABSTRACT |
The goal of the present study was to evaluate the antileishmanial
effects of topically applied lipid-based formulations containing amphotericin B (AmB) in CBA mice as a model for human cutaneous leishmaniasis. Such treatment, if efficacious, is expected to be
superior to systemic treatments since, by acting in a localized manner,
it will require lower, and therefore less toxic, drug dosages. Three
preparations of AmB complexed to polar lipids were tested: Fungizone
(mixed micelles composed of AmB and deoxycholate), Amphocil (AmB and
cholesteryl sulfate complex), and ABPLC (AmB and phospholipid complex).
All these formulations killed parasites in vitro with similar
efficacies but were ineffective when they were applied topically.
However, Amphocil and ABPLC, but not Fungizone, when dispersed in an
aqueous solution containing 5 to 25% ethanol, induced a statistically
significant improvement in lesion size from week 2 or 3 onward (a total
of 15 mg of AmB per kg of body weight was applied over 3 weeks). AmB
biodistribution measurements following topical application of Amphocil,
determined by high-pressure liquid chromatography, showed that AmB was
detectable in the skin but not in the internal organs. Application of
at least 10 times more drug was necessary to obtain detectable levels
of AmB in the internal organs. After application of therapeutic doses
of ABPLC, very low levels of AmB were detected in the internal organs. These experiments show for the first time that AmB administered topically as a complex either with cholesteryl sulfate or with phospholipids and in the presence of ethanol can penetrate the skin and
kill sensitive organisms in a localized manner by using very low total
drug concentrations.
| |
INTRODUCTION |
Amphotericin B (AmB), a polyene
antibiotic, is a potent antifungal and antiparasitic agent with a broad
spectrum of activity against organisms that have ergosterol in their
membranes. It is commonly used as a systemic agent, administered
intravenously, with high levels of activity against leishmania
infection. However, because AmB is highly toxic, particularly
nephrotoxic, when it is given systemically, it is thus generally used
for the treatment of leishmaniasis only after other treatments have
failed (13).
Toxic side effects are typically greatly reduced when a drug is
administered topically, since much lower doses can generally be used
and a very small amount of the drug reaches sensitive internal organs
such as the kidneys. The topical use of AmB preparations on mucous
membrane surfaces, such as those of the eye, mouth, and respiratory and
digestive passages, often in combination with other agents, has been
described (1, 5, 18, 22).
The skin, however, is a very effective barrier for substances with
molecular masses greater than a few hundred daltons. For example,
topical treatment of cutaneous leishmaniasis (CL), a widespread and
potentially disfiguring protozoal infection of the skin, with
paromomycin, an aminoglycoside antibiotic, has been shown to be
effective in some cases (10) but not in others (4, 15,
19). Cutaneous Leishmania major lesions in mice
used as an experimental model for CLwere also unresponsive to a topical preparation of AmB in soft white paraffin containing 12%
methylbenzethonium chloride (9), although the drug is
effective against leishmaniasis when it is administered systemically.
In order to obtain effective drug penetration through the skin,
therefore, an efficacious drug-carrier system is required.
The data presented here show that formulations of AmB-cholesteryl
sulfate and AmB-phospholipid complex, but not AmB-deoxycholate complex,
when dispersed in nonviscous solutions containing 5 to 25% ethanol and
then administered topically, induced significant improvements in lesion
size with very low drug concentrations.
| |
MATERIALS AND METHODS |
Drugs and formulations.
Fungizone (Bristol Myers Squibb,
Princeton, N.J.) is composed of AmB and sodium deoxycholate (mixed
micelle formulation in a 54:94 [by mole] ratio); Amphocil (SEQUUS
Pharmaceuticals, Menlo Park, Calif.) is a colloidal dispersion composed
of AmB and cholesteryl sulfate (a 1:1 colloidal complex); ABPLC
(AmB-phospholipid complex) is a 1:3 molar complex of AmB with a 7:3
mole mixture of dimyristoyl phosphatidylcholine (DMPC) and dimyristoyl
phosphatidylglycerol (DMPG) and was prepared as described previously
(11). For more details on the formulations, see the report
by Barenholz and Cohen (3).
Quantification of AmB.
The amount of AmB was quantified by
high-pressure liquid chromatography (HPLC; Pump 420, Autosampler 460, Detector 430, and Data system 450; Kontron, Zürich, Switzerland).
Quantification was obtained by using an Econosphere C18
(3-µm particle size) plus guard column (100 by 4.6 mm; Alltech,
Deerfield, Ill.) with a mobile phase of acetonitrile and 0.02 M EDTA
(pH 4.5) in H2O in a ratio of 110 to 90 by volume. The
injection volume was 80 µl, and the flow rate was 1 ml/min. The
quantification was based on the absorbances at 405 and 386 nm recorded
with the Kontron 430 detector. Spectral snapshots in the range of 300 to 500 nm were taken to verify the identity of the analyte as AmB. Mean size and size distribution were measured by photon correlation spectroscopy by Coulter submicroparticle analysis (Coulter N4SD submicroparticle analyzer; Coulter Electronics Ltd., Luton, England). In some formulations the particles were too large to be measured in
this way. Therefore, these preparations were measured with a multisizer
(Multisizer II; Coulter), which measures particle sizes from 0.8 to 30 µm. The levels of AmB in body tissues after topical application or
intravenous (i.v.) injection of various formulations were measured by
HPLC. Levels in skin, spleen, liver, and kidney were measured 1 day
after administration was terminated; the level in the skin (at the site
of application) was in some cases also measured 1 h after
administration was terminated.
Tissue extractions.
The animals were killed 1 or 24 h
after the last drug application or injection, and the organs were
removed, dried with filter paper, weighed, and kept frozen in a
"wet" freezer until extraction. For skin, enzymatic digestion was
performed with tissue cut into small pieces, before tissue extraction,
by using 0.25% trypsin, 25 U of collagenase, and 0.1 mg of DNase I
(Sigma Chemical Co.) per ml of phosphate-buffered saline with overnight
digestion at 37°C.
For AmB extraction of the organs, the tissue was homogenized with
methanol (3 ml/g of tissue) by using a Polytron CH-6010 (Kinematika
GmbH, Luzern, Switzerland) high-speed homogenizer. The homogenate was
incubated for 1 h at room temperature; the sample was then
vortexed, transferred to polypropylene Eppendorf centrifuge tubes, and
centrifuged for 10 min. Eighty microliters of the supernatant was
injected into the chromatograph; it was found that the sensitivity
based on this volume was 40 ng/ml, i.e., 3 ng of AmB per analysis.
Assay validation.
Assay validation was performed in order to
assess the degree and reproducibility of the extraction recovery from
the tissues. This was accomplished by spiking experiments in which an
aliquot of AmB from each of the formulations was injected into
homogenates of various organs, followed by the addition of methanol and
extraction as described above. The value of the aliquot injected into
water was used as a measurement of 100% extraction efficiency. The
results showed >95% reproducible extraction over a broad range of concentrations.
Parasites.
Leishmania major WR1045 parasites were
isolated from BALB/c mice (Harlan Laboratories, Jerusalem, Israel) and
were maintained in RPMI 1640 culture medium supplemented with 20%
fetal calf serum (Biological Industries, Beth Haemek, Israel) at 28°C
for no more than 2 months.
In vivo experiments.
Female CBA mice (age, 6 to 10 weeks;
Harlan Laboratories, Indianapolis, Ind.) were injected subcutaneously
in the base of the tail with 3 × 106 stationary-phase
promastigotes (9, 24); eight mice were included in each
experimental group. From 24 h after injection onward and for the
next 3 weeks, 10 µl of each preparation (concentration, 2 mg/ml) was
applied daily to the base of the tail. Each mouse received a total of
15 drug applications, representing approximately 300 µg of AmB. Two
investigators independently measured the lesion sizes weekly. To
determine the diameter, the average was taken between the longest
distance across the lesion and the length of the line bisecting this
distance at a 90° angle. Mice were kept in a sterile pathogen-free
animal facility throughout the experiments.
Healthy mice were given 1 mg of Fungizone, Amphocil, or ABPLC per kg of
body weight by i.v. injection for 5 consecutive days.
In vitro experiments.
L. major promastigotes (5 × 106/ml) were incubated at 28°C in RPMI 1640 medium.
AmB formulations were added, and the number of viable (moving)
parasites was counted with a Neubauer hemocytometer after 24 h.
The results obtained were expressed as percent death of parasites in
treated cultures [100 
(number of viable parasites in treated
cultures divided by number of viable parasites in untreated cultures)].
Statistical methods.
The paired Student t test
was used for statistical analysis.
| |
RESULTS |
Characterization of AmB-cholesteryl sulfate formulations.
Various formulations that were based on Amphocil, a complex of
amphotericin B and cholesteryl sulfate which is available as a
colloidal dispersion, were prepared. This preparation, which is
normally administered by injection, contains small (approximately 120 nm) diskoid particles (3) composed of AmB and cholesteryl sulfate at a 1:1 mole ratio. Amphocil reconstituted with water to 5 mg/ml contains 5% glucose. Dispersion of Amphocil was prepared in
various media that are commonly used to enhance percutaneous absorption. Amphocil dispersed easily in aqueous solutions of 5%
glucose or 5 to 25% ethanol. Particle size distribution, measured by
photon correlation spectroscopy (Table 1),
demonstrates that the size of Amphocil particles increases somewhat
with an increase in the ethanol concentration, from 122 nm without
ethanol to 259 nm in the presence of 25% ethanol. To obtain a
dispersion in propylene glycol or glycerol, strong vortexing and
ultrasonic irradiation were necessary. Particle size, which was much
larger (4 to 15 µm), was measured with a Coulter multisizer.
Effect of AmB formulations on the course of disease.
Initially, dispersions of Amphocil in glycerol, propylene glycol, 10%
ethanol in double-distilled water (DDW), and 5% glucose in DDW
were topically applied for 3 weeks on the site of L. major injection. Lesion size was measured weekly. The effects of
the formulations on disease outcome are summarized in Fig.
1, which shows that only topical
administration of AmB complexed with cholesteryl sulfate in 10%
ethanol caused a marked reduction in lesion size. The effect was
statistically significant from week 3 onward (P < 0.003 at week 3 and P < 0.0001 at weeks 4 and 5).
The 5% glucose group had statistically smaller lesions than the
controls at only one time point (week 4), and little or no effect was
found for the other groups. No relapse was observed after the
discontinuation of therapy (in any of the experiments performed).
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FIG. 1.
Effect of Amphocil in various solvents on the course of
disease. Dispersions of Amphocil were prepared in various solvents and
topically applied to the base of the tail during the first 3 weeks of
an L. major infection. The effect on lesion size was
determined weekly. Each group included eight mice.  , untreated;  ,
glycerol;  , polypropylene glycol;  , 10% ethanol;  , glucose.
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|
Additional experiments showed that dispersions of AmB and cholesteryl
sulfate in 5, 10, and 25% ethanol had approximately
equivalent effects
on lesion size. Aqueous ethanol alone, applied
at 5, 10, and 25% to
three experimental groups, did not affect
lesion size (Fig.
2), nor did a suspension of AmB and
cholesteryl
sulfate in water (Fig.
3). An
ethanolic formulation containing
Fungizone (AmB-sodium deoxycholate)
was much less effective topically
than those formulations described
above (Fig.
3).
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FIG. 2.
Effect of Amphocil dissolved in different ethanol
concentrations on the course of disease. Amphocil in 5, 10, and 25%
ethanol in aqueous solution or ethanol without Amphocil was topically
applied to the base of the tail during the first 3 weeks of an L. major infection. The effect on lesion size was determined weekly.
Each group included eight mice.  , AmB and 5% ethanol; , AmB and
10% ethanol;  , AmB and 25% ethanol; , 5% ethanol; , 10%
ethanol;
 , 25%
ethanol,  , untreated.
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FIG. 3.
Comparison of the effect of the addition of 5% ethanol
to Amphocil and to Fungizone. The effect of Amphocil in the presence of
5% ethanol was compared to the effect of Fungizone in the presence of
5% ethanol and to the effect of Amphocil without ethanol when the
formulations were topically applied during the first 3 weeks of an
L. major infection. The effect on lesion size was determined
weekly. Each experiment included eight mice. , untreated; , AmB
in ethanol; , AmB in DDW; , Fungizone in ethanol.
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|
AmB was also tested in a form of AmB-phospholipid
(DMPC:DMPG, 7:3) complex (ABPLC). A topical formulation of
ABPLC in 0.9%
NaCl-5% ethanol was found to be as effective as the
AmB-cholesteryl
sulfate formulations in reducing lesion size, despite
the large
particle size (approximately 2.75 µm) in this formulation
(data
not shown). Therefore, it seems that no apparent correlation
exists
between particle size and the therapeutic efficacy of a given
dispersion.
Effects of AmB formulations on L. major promastigotes
in vitro.
The effects of Amphocil formulations in aqueous ethanol
or DDW on the viability of L. major promastigotes were
determined. The results from two independent experiments, summarized in
Table 2,, indicate that Fungizone, although
highly effective in killing parasites in vitro, was ineffective in
vivo, even when it was applied topically in 5% ethanol (Fig. 3). The
results further show that ethanol is not required for the effectiveness
of AmB in vitro since identical parasite killing was obtained with
AmB-cholesteryl sulfate prepared in DDW or in aqueous ethanolic
solutions, whereas Fungizone, in the presence or absence of ethanol,
was the most efficacious in vitro but lacked therapeutic efficacy in
vivo.
Comparison of organ biodistribution of AmB formulations after
topical and systemic administration.
The levels of AmB in body
tissues after topical administration of various levels of Amphocil in
10% ethanol were determined and were compared to those obtained after
i.v. administration. The level of AmB in the kidneys, liver, and spleen
after the application of a topical total dose of 0.9 mg of AmB was
below the detection limit. After the application of a total dose of 8.1 mg, 2 to 5.5 µg/g of tissue was detected in the internal organs. In
comparison, after i.v. administration of 0.1 mg, 0.5, 14, and 50 µg/g
of tissue were detected in the kidneys, spleen, and liver,
respectively. In a similar experiment with topical ethanolic aqueous
ABPLC, 3.5 to 4.5 µg/g of tissue was detected in the internal organs after the application of a total topical dose of 0.9 mg of AmB.
The data indicate that even for much smaller cumulative doses (40 to
400 µg versus 1 to several milligrams for topical application),
comparable or sometimes greater levels of drug were detected in
the
internal organs. For Amphocil, in particular, large amounts
of the drug
were found in the liver and the
spleen.
| |
DISCUSSION |
Cutaneous leishmaniasis is a potentially disfiguring disease that
occurs in more than 60 countries, with approximately 200 million people
at risk and 300,000 cases occurring annually (2). Three
lipid formulations of AmB are now marketed for clinical use in many
countries worldwide (see reference 14 and the
references listed therein). These formulations are successful
treatments for visceral leishmaniasis both in mice (12, 21)
and in humans (8) because the drug is administered i.v. and
thus is easily delivered to the affected organs. However, studies with
these formulations for the treatment of CL have shown that they have little or no effect against experimental CL (20) or clinical mucocutaneous leishmaniasis (17). A more recent study has
shown that one formulation, AmBisome, when injected i.v., is effective against experimental CL, albeit at doses approximately five times higher than those required for the treatment of visceral disease (24). These results support the notion that a lack of
effective treatment for CL is due to a lack of proper delivery rather
than a lack of drug efficacy. The efficacious in vitro killing of
L. major promastigotes by Fungizone, Amphocil, and Ambisome
(24; this study) support this notion.
The results obtained in this study suggest that the therapeutic
efficacies of AmB-lipid formulations in ethanolic aqueous carriers are
related to the presence of low concentrations of ethanol in the
carrier. The addition of ethanol does not affect the parasites directly
(Table 2) and does not improve the efficacy of AmB against the
parasite in vitro. The effect of ethanol at the percent used (5 to
25%) should therefore be related to the effects on the skin or on
skin-carrier interactions. Several factors may be involved in the
ethanol-induced topical therapeutic effects of Amphocil and ABPLC: (i)
reduction of skin-water surface tension and/or reduction of viscosity
of the drug dispersion. However, because the presence of ethanol did
not improve the performance of the AmB-deoxycholate mixed micelles
(Fungizone), the effect of ethanol on surface tension and viscosity is
either not important or not sufficient, and ethanol at 5 to 25% is not
an effective enhancer of skin permeability. (ii) We must therefore
assume that the effects of ethanol on the physical properties of
Amphocil and ABPLC are the dominant factors. In this respect sodium
deoxycholate-AmB mixed micelles are very different from Amphocil and
ABPLC. Although the last two formulations differ from each other, they
share a much higher association constant of AmB to their lipids
(3, 7). Also, in Amphocil discoids (16) and in
ABPLC large particles, the curvature is much smaller than that in
Fungizone. The increase in the size of the Amphocil particles with
increasing ethanol concentration from 120 nm without ethanol to 167 nm
in 5% (0.8 M) ethanol to 259 nm in 25% (~4 M) ethanol (Table 1)
supports our hypothesis that the ethanol which partitions into the
Amphocil particles affects its properties. This size increase resembles an earlier observation for dipalmitoylphosphatidylcholine (DPPC) large unilamellar vesicles (LUV; 100 nm) (23). As in the
case of DPPC LUV, the Amphocil particles remain intact in the range of
0.8 to 4 M ethanol used in the present study. The similarities in the
effects of ethanol on particle size increases for Amphocil and DPPC LUV
suggest that the partition of Amphocil into the interface region of the
discoid particles increases the lateral as well as the transverse
repulsion between the lipid molecules, which leads to increases in the
area per molecule and head group solvation. The increase in the ratio
of the polar region cross section/hydrophobic region cross section
induces interdigitation, thereby causing the less flexible AmB to
protrude from the assembly and become more available to the skin. For
ABPLC we assume that the effect of ethanol will be similar, although it
is technically not feasible to measure size changes, because the size
distribution is very heterogeneous and most particles are in the micron
size range.
As demonstrated by the biodistribution studies, the doses of the
ethanolic formulations of AmB applied topically result in much lower
levels of the drug in internal organs than those obtained with lower
doses administered systemically (especially for Amphocil). Accordingly,
higher doses may be used topically with greatly reduced toxic side effects.
The profile of the organ biodistribution of AmB delivered topically as
Amphocil or ABPLC is very different from the biodistribution when these
formulations are given i.v. When given topically, the skin (site of
application) is the major tissue of accumulation. For both Amphocil and
ABPLC the order of tissue concentration is skin > kidney > spleen > liver, while after i.v. delivery the liver is by far the
major organ of accumulation, especially for Amphocil (liver > spleen > kidney) (3, 14). This suggests that, when
applied topically, AmB is dissociated from the lipid carrier molecule
and there is no transdermal delivery of the intact AmB-lipid assembly.
| |
ACKNOWLEDGMENTS |
This work was supported by the Leslie Nicholas Fund, Hadasit
Medical Research Services and Development, the Horowitz Foundation, and
the Chief Scientist's Office, Ministry of Health, Israel.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Department of
Dermatology, Hadassah Medical Organization, POB 12 000, Jerusalem, 91 120, Israel. Phone: 9722 677 8442. Fax: 9722 643 4434. E-mail: franks{at}cc.huji.ac.il.
| |
REFERENCES |
| 1.
|
Aerdts, S. J.,
R. van-Dalen,
H. A. Clasener,
J. Festen,
H. J. van-Lier, and E. J. Vollaard.
1991.
Antibiotic prophylaxis of respiratory tract infection in mechanically ventilated patients. A prospective, blinded, randomized trial of the effect of a novel regimen.
Chest
100:783-791[Abstract/Free Full Text].
|
| 2.
|
Ashford, R. W.,
P. Desjeux, and P. deRaadt.
1992.
Estimation of population at risk of infection and number of cases of leishmaniasis.
Parasitol. Today
8:104-105.
[Medline] |
| 3.
|
Barenholz, Y., and R. Cohen.
1995.
Rational design of amphiphile-based drug carriers and sterically stabilized carriers.
J. Liposome Res.
5:905-932.
|
| 4.
|
Bensalah, A.,
H. Zakraoui,
A. Zaatour,
A. Ftaiti,
B. Zaafouri,
A. Garraoui,
P. L. Olliaro,
K. Dellagi, and R. Benismail.
1995.
A randomized, placebo-controlled trial in Tunisia treating cutaneous leishmaniasis with paromomycin ointment.
Am. J. Trop. Med. Hyg.
53:162-166.
|
| 5.
|
Bent, J. P., III, and F. A. Kuhn.
1996.
Antifungal activity against allergic fungal sinusitis organisms.
Laryngoscope
106:1331-1334[Medline].
|
| 6.
|
Brajtburg, J., and J. Bolard.
1996.
Carrier effects on biological activity of amphotericin B.
J. Clin. Microbiol. Rev.
9:512-531[Abstract].
|
| 7.
|
Cohen, R.,
I. Polacheck,
S. Benita,
M. Levi, and Y. Barenholz.
1996.
Comparative evaluation of five types of amphiphile-based assemblies containing amphotericin B.
In
Program and abstracts of the Conference on Liposome Advances; Progress in Drug Delivery and Vaccine Delivery. Centre for Drug Delivery Research, School of Pharmacy, University of London, London, United Kingdom.
|
| 8.
|
Dimartino, L.,
R. N. Davidson,
R. Giacchino,
S. Scotti,
F. Raimondi,
E. Casstagnola,
L. Tasso,
A. Cascio,
L. Gradoni,
M. Gramiccia,
M. Pettoellomantovani, and A. D. M. Bryceson.
1997.
Treatment of visceral leishmaniasis in children with liposomal amphotericin B.
J. Pediatr.
131:271-277[Medline].
|
| 9.
|
El-On, J.,
J. P. Geoffrey,
E. Witztum, and C. L. Greenblatt.
1984.
Development of topical treatment for cutaneous leishmaniasis caused by Leishmania major in experimental animals.
Antimicrob. Agents Chemother.
26:745-751[Abstract/Free Full Text].
|
| 10.
|
El-On, J.,
L. Weinrauch,
R. Livshin,
Z. Even Paz, and G. P. Jacobs.
1985.
Topical treatment of recurrent cutaneous leishmaniasis with ointment containing paromomycin and methyl-benzethonium chloride.
Br. Med. J.
291:704.
|
| 11.
|
Engelhard, D.,
A. Eldor,
I. Polacheck,
I. Hardan,
D. Ben-Yehuda,
S. Amselem,
I. F. Salkin,
G. Lopez-Berestein,
T. Sacks,
E. A. Rachmilewitz, and Y. Barenholz.
1993.
Disseminated fusariosis treated with amphotericin B-phospholipid complex.
Leuk. Lymphoma
9:385-392[Medline].
|
| 12.
|
Gangneux, J. P.,
A. Sulahian,
Y. J. F. Garin, and F. Derouin.
1996.
Lipid formulations of amphotericin B in the treatment of experimental visceral leishmaniasis due to Leishmania infantum.
Trans. R. Soc. Trop. Med. Hyg.
90:574-577[Medline].
|
| 13.
|
Giri, O. P.
1993.
Amphotericin B therapy in kala-azar J.
Indian Med. Assoc.
91:91-93.
|
| 14.
|
Hiemenz, J. W., and T. J. Walsh.
1996.
Lipid formulations of amphotericin B: recent progress and future directions.
Clin. Infect. Dis.
2:S133-S144.
|
| 15.
|
Klaus, S.,
O. Axelrod,
F. Jonas, and S. Frankenburg.
1994.
Changing patterns of cutaneous leishmaniasis in Israel.
Trans. R. Soc. Trop. Med. Hyg.
88:649-650[Medline].
|
| 16.
|
Lasic, D. D.
1992.
Mixed micelles in drug delivery.
Nature
355:279-280[Medline].
|
| 17.
| Llanos-Cuentas, A., J. Echevarria, J. Chang, P. Campos, J. Cieza, D. Lentnek, D. Gonzalez, M. Robbins, and R. Williams. 1991. Randomized trial of amphotericin B complex (ABLC)
versus Fungizone in patients with mucocutaneous leishmaniasis. Mem.
Inst. Oswaldo Cruz 86(Suppl.):238.
|
| 18.
|
Lotery, A. J.,
J. R. Kerr, and B. A. Page.
1994.
Fungal keratitis caused by Scopulariopsis brevicaulis: successful treatment with topical amphotericin B and chloramphenicol without the need for surgical debridement.
Br. J. Ophthalmol.
78:730[Free Full Text].
|
| 19.
|
Neva, F. A.,
C. Ponce,
E. Ponce,
R. Kreutzer,
F. Modabber, and P. Olliaro.
1997.
Non ulcerative cutaneous leishmaniasis in Honduras fails to respond to topical paromomycin.
Trans. R. Soc. Trop. Med. Hyg.
91:473-475[Medline].
|
| 20.
|
Panosian, C. B.,
M. Barza,
F. Szoka, and D. J. Wyler.
1984.
Treatment of experimental cutaneous leishmaniasis with liposome-intercalated amphotericin B.
Antimicrob. Agents Chemother.
25:655-656[Abstract/Free Full Text].
|
| 21.
|
Paul, M.,
R. Durand,
H. Fessi,
D. Rivollet,
R. Houin,
A. Astier, and M. Deniau.
1997.
Activity of a new liposomal formulation of amphotericin B against two strains of leishmania infantum in a murine model.
Antimicrob. Agents Chemother.
41:1731-1734[Abstract].
|
| 22.
|
Pleyer, U.,
A. Legmann,
B. J. Mondino, and D. A. Lee.
1992.
Use of collagen shields containing amphotericin B in the treatment of experimental Candida albicans-induced keratomycosis in rabbits.
Am. J. Ophthalmol.
113:303-308[Medline].
|
| 23.
|
Vierl, U.,
L. Lobbecke,
N. Nagel, and G. Cevc.
1994.
Solute effects on the colloidal and phase behavior of lipid bilayer membranes: ethanol-dipalmitoylphosphatidylcholine mixtures.
Biophys. J.
67:1067-1079[Medline].
|
| 24.
|
Yardley, V., and S. Croft.
1997.
Activity of liposomal amphotericin B against experimental cutaneous leishmaniasis.
Antimicrob. Agents Chemother.
41:752-756[Abstract].
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Antimicrobial Agents and Chemotherapy, December 1998, p. 3092-3096, Vol. 42, No. 12
0066-4804/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
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Abstract
Introduction
