Combination antifungal therapy

Activity of antifungal agents alone and in combination against echinocandin-susceptible and -resistant Candida parapsilosis strains

BACKGROUND

Candida parapsilosis may acquire resistance to echinocandins, a fact that prompts the search for new therapeutic options.

AIMS

The present study aimed to evaluate the in vitro activity of antifungal agents, alone and in combination, against four groups of C. parapsilosis strains: (1) echinocandin-susceptible (ES) clinical isolates (MIC ≤ 2μg/ml), (2) anidulafungin-resistant strains (MIC ≥ 8μg/ml), (3) caspofungin-resistant strains (MIC ≥ 8μg/ml), and (4) micafungin-resistant strains (MIC ≥ 8μg/ml).

METHODS

Antifungal interactions were evaluated by a checkerboard micro-dilution method. The determination of the MIC to each drug for every isolate according to the Clinical and Laboratory Standards Institute documents M27 (2017) and M60 (2017) was also done.

RESULTS

The echinocandins-resistant (ER) strains showed higher MICs to the tested antifungals than the ES strains, except for amphotericin B, for which the ER groups remained susceptible.

CONCLUSIONS

Most combinations showed indifferent interactions. The use of monotherapy still seems to be the best option. As resistance to echinocandins is an emergent phenomenon, further studies are required to provide clearer information on the susceptibility differences between strains to these antifungal agents.

Vacuolar proton-translocating ATPase is required for antifungal resistance and virulence of Candida glabrata

Vacuolar proton-translocating ATPase (V-ATPase) is located in fungal vacuolar membranes. It is involved in multiple cellular processes, including the maintenance of intracellular ion homeostasis by maintaining acidic pH within the cell. The importance of V-ATPase in virulence has been demonstrated in several pathogenic fungi, including Candida albicans. However, it remains to be determined in the clinically important fungal pathogen Candida glabrata. Increasing multidrug resistance of C. glabrata is becoming a critical issue in the clinical setting. In the current study, we demonstrated that the plecomacrolide V-ATPase inhibitor bafilomycin B₁ exerts a synergistic effect with azole antifungal agents, including fluconazole and voriconazole, against a C. glabrata wild-type strain. Furthermore, the deletion of the VPH2 gene encoding an assembly factor of V-ATPase was sufficient to interfere with V-ATPase function in C. glabrata, resulting in impaired pH homeostasis in the vacuole and increased sensitivity to a variety of environmental stresses, such as alkaline conditions (pH 7.4), ion stress (Na⁺, Ca²⁺, Mn²⁺, and Zn²⁺ stress), exposure to the calcineurin inhibitor FK506 and antifungal agents (azoles and amphotericin B), and iron limitation. In addition, virulence of C. glabrata Δvph2 mutant in a mouse model of disseminated candidiasis was reduced in comparison with that of the wild-type and VPH2-reconstituted strains. These findings support the notion that V-ATPase is a potential attractive target for the development of effective antifungal strategies.

New 4-methoxy-naphthalene derivatives as promisor antifungal agents for paracoccidioidomycosis treatment

AIM

Novel 4-methoxy-naphthalene derivatives were synthesized based on hits structures in order to evaluate the antifungal activity against Paracoccidioides spp.

METHODS

Antifungal activity of compounds was evaluated against P. brasiliensis and most promising compounds 2 and 3 were tested against eight clinically important fungal species.

RESULTS

Compound 3 was the more active compound with MIC 8 to 32 μg.ml^-1 for Paracoccidioides spp without toxicity monkey kidney and murine macrophagecells. Carbohydrazide 3 showed good synergistic antifungal activity with amphotericin B against P. brasiliensis specie. Titration assay of carbohydrazide 3 with PbHSD enzyme demonstrates the binding ligand-protein. Molecular dynamics simulations show that ligand 3 let the PbHSD protein more stable.

CONCLUSION

New carbohydrazide 3 is an attractive lead for drug development to treat paracoccidioidomycoses.

In vitro interactions of azoles and echinocandins against clinical strains of Aspergillus flavus

Combinations of an azole (itraconazole, voriconazole, or posaconazole) with an echinocandin (caspofungin, micafungin, or anidulafungin) were tested against 20 clinical isolates of Aspergillus flavus according to EUCAST guidelines. The interactions were determined using two endpoints-minimal effective concentration (MEC) and minimal inhibitory concentration (MIC)-via calculation of the fractional inhibitory concentration (FIC) index. A higher prevalence of synergistic interactions was observed for MIC, whereas indifference was the most frequent outcome according to MEC among the 20 strains. Combined treatment of A. flavus with these two important classes of antifungals should be explored further in in vivo studies.

Sophorolipid exhibits antifungal activity by ROS mediated endoplasmic reticulum stress and mitochondrial dysfunction pathways in Candida albicans

In the present study, we investigated the mechanism of cell death in C. albicans due to treatment with sophorolipid (SL). SL is an extracellular glycolipid biosurfactant produced by various species of non-pathogenic yeasts and is known to inhibit the growth and biofilm formation of C. albicans. This study revealed that treatment of C. albicans cells with SL increases the ROS production and expression of oxidative stress-related genes significantly (SOD1, CAT1). Increased ROS level within the cells causes ER stress and release of Ca²⁺ in the cytoplasm and alteration of the mitochondrial membrane potential (MMP). Quantitative real time-polymerase chain reaction (qRT-PCR) data showed that SL also upregulates the Endoplasmic Reticulum (ER) stress marker HAC1. Flow cytometric analysis (AnnexinV/PI) indicated that the cell death may have occurred due to necrosis which was further confirmed by LDH release assay and transmission electron microscopy (TEM). Further experiments with the null mutant Δ hog1 strain of C. albicans SC5314 indicated the activation of the osmotic stress response pathway (HOG-MAPK) and SAP9. This study gave an insight into the mechanism of cell death initiation by glycolipids and indicated that further modification of these molecules can lead to the development of new therapeutic agent against C. albicans.

Sophorolipid induces ROS generation in C. albicans leading to mitochondrial dysfunction and ER stress followed by the release of Ca²⁺ ions (from the ER lumen) that enter mitochondria and further magnify ROS generation leading to cell death.

Synergistic Interaction of Fluconazole/Amphotericin B on Inhibition of Enzymes Contributes to the Pathogenesis of Candida Tropicalis

Background: Candidiasis has gained much attention in recent decades due to its increasing prevalence in immunocompromised patients. Usually, antifungals such as fluconazole and amphotricin B are used for treatment of candidiasis, but one of the major clinical problems is the emergence of antifungal resistance. Combination antifungal therapy is one of the most commonly used methods to alleviate the problem of antifungal resistance. Methods: The effect of fluconazole alone and in combination with amphotericin B on C. tropicalis isolates were performed using the Clinical and Laboratory Standards Institute (CLSI) reference method. Eventually hypha formation, time kill study, proteinase and phospholipase activity and expression of PLB and SAP2 genes were carried out to investigate the enzymes inhibitory properties of antifungal tested against C. tropicalis. Results: Results showed the significant synergic effect of fluconazole in combination with amphotericin B in inhibiting the growth of C. tropicalis isolates, with fractional inhibitory concentration indices ranging from 0.06 to 0.5. The combination of fluconazole with amphotericin B reduced the number of yeast form and inhibited the yeast to hyphae transition in C. tropicalis. The antifungals tested were able to show the effect of down regulating expression of the selected genes significantly in fluconazole/amphotericin B ranging from 1.42- to 2.27-fold. Conclusion: Our results demonstrated that the synergistic interaction of fluconazole/amphotericin B would be worth exploring for the management of candidiasis. In addition, PLB and SAP2 genes could be probable molecular targets in the synergistic interaction of fluconazole/amphotericin B in C. tropicalis.

Phytochemical Analysis and Antimicrobial Efficacy of Macleaya cordata against Extensively Drug-Resistant Staphylococcus aureus

The antibiotic resistant threat is continuing to grow, due in part to the overuse of antibiotics in livestock feed. Many nations in Europe have banned the use of antibiotics in feed, leading to higher rates of infection in livestock animals and reduced productivity for the food market. Increasingly, researchers are looking into the efficacy of phytopreparations to replace antibiotics in feed, allowing for increased animal health without the development of resistance. Macleaya cordata, or Chinese plume poppy, shows promise as a food additive. To evaluate the antimicrobial efficacy of this plant, we tested in vitro activity of M. cordata extract, as well as pure compounds sanguinarine and chelerythrine against wild-type, methicillin-resistant, and multiply-resistant strains of Staphylococcus aureus (SA1199, AH1263, and IA116, respectively). Combination tests to evaluate synergy, additivity, and antagonism within the extract were also completed for the first time. Sanguinarine and chelerythrine showed complete growth inhibition of all strains of S. aureus at concentrations ranging from 3-10 µg/mL, and were equal in activity or were more potent than the reference compound chloramphenicol. Combination studies of pure sanguinarine and chelerythrine with M. cordata extract revealed additivity or indifference of mixture components with these compounds. Because sanguinarine and chelerythrine represent the major active constituents of M. cordata, the pooled amounts of these two compounds may be useful for establishing potency for quality control purposes. This is the first report of activity of chelerythrine and sanguinarine against methicillin-resistant S. aureus AH1263 and multiply-resistant S. aureus IA116, and illustrates the promise of M. cordata extract as an alternative to antibiotics in feed additives.

Novel Combinations of Agents Targeting Translation That Synergistically Inhibit Fungal Pathogens

A range of fungicides or antifungals are currently deployed to control fungi in agriculture or medicine, but resistance to current agents is growing so new approaches and molecular targets are urgently needed. Recently, different aminoglycoside antibiotics combined with particular transport inhibitors were found to produce strong, synergistic growth-inhibition of fungi, by synergistically increasing the error rate of mRNA translation. Here, focusing on translation fidelity as a novel target for combinatorial antifungal treatment, we tested the hypothesis that alternative combinations of agents known to affect the availability of functional amino acids would synergistically inhibit growth of major fungal pathogens. We screened 172 novel combinations against three phytopathogens (Rhizoctonia solani, Zymoseptoria tritici, and Botrytis cinerea) and three human pathogens (Cryptococcus neoformans, Candida albicans, and Aspergillus fumigatus), showing that 48 combinations inhibited strongly the growth of the pathogens; the growth inhibition effect was significantly greater with the agents combined than by a simple product of their individual effects at the same doses. Of these, 23 combinations were effective against more than one pathogen, including combinations comprising food-and-drug approved compounds, e.g., quinine with bicarbonate, and quinine with hygromycin. These combinations [fractional inhibitory combination (FIC) index ≤0.5] gave up to 100% reduction of fungal growth yield at concentrations of agents which, individually, had negligible effect. No synergy was evident against bacterial, plant or mammalian cells, indicating specificity for fungi. Mode-of-action analyses for quinine + hygromycin indicated that synergistic mistranslation was the antifungal mechanism. That mechanism was not universal as bicarbonate exacerbated quinine action by increasing drug uptake. The study unveils chemical combinations and a target process with potential for control of diverse fungal pathogens, and suggests repurposing possibilities for several current therapeutics.

Significantly Improved Pharmacokinetics Enhances In Vivo Efficacy of APX001 against Echinocandin- and Multidrug-Resistant Candida Isolates in a Mouse Model of Invasive Candidiasis

APX001 is a first-in-class, intravenous and orally available, broad-spectrum antifungal agent in clinical development for the treatment of life-threatening invasive fungal infections. The half-life of APX001A, the active moiety of APX001, is significantly shorter in mice than in humans (1.4 to 2.75 h in mice versus 2 to 2.5 days in humans), making the exploration of efficacy in mouse models difficult.

APX001 is a first-in-class, intravenous and orally available, broad-spectrum antifungal agent in clinical development for the treatment of life-threatening invasive fungal infections. The half-life of APX001A, the active moiety of APX001, is significantly shorter in mice than in humans (1.4 to 2.75 h in mice versus 2 to 2.5 days in humans), making the exploration of efficacy in mouse models difficult. After pretreatment with 1-aminobenzotriazole (ABT), a nonspecific cytochrome P450 inhibitor, greatly increased plasma APX001A exposure was observed in mice of different strains and of both genders. As a consequence, 26 mg/kg APX001 plus ABT sterilized kidneys in mice infected with Candida albicans, while APX001 alone at the same dose resulted in a modest burden reduction of only 0.2 log₁₀ CFU/g, relative to the vehicle control. In the presence of ABT, 2 days of once-daily dosing with APX001 at 26 mg/kg also demonstrated significant in vivo efficacy in the treatment of Candida glabrata infections in mice. Potent kidney burden reduction was achieved in mice infected with susceptible, echinocandin-resistant, or multidrug-resistant strains. In contrast, the standard of care (micafungin) was ineffective in treating infections caused by the resistant C. glabrata isolates.

Antibacterial hop extracts encapsulated in nanochitosan matrices

Hops and the components extracted from them are well known antibacterial agents used in beers and as food preservatives, in formulations for topical applications on their own or together with other antimicrobial agents, in hormone replacement therapy, as antioxidants, tumor development antagonists, and angiogenesis inhibitors. Their shortcomings: very low bioavailability, bitter taste, and susceptibility to oxidative decomposition have limited their applications. We propose nanosized chitosan, an inexpensive, readily available biopolymer with a broad spectrum of antibacterial activity, as carrier for lupulone (L) and xanthohumol (X), two components of hops. Chitosan nanoparticles (CNP) and chitosan-based nanocomposites encapsulating lupulone (CNL) and xanthohumol (CNX) were prepared by ionotropic gelation using sodium tripolyphosphate (TPP) as crosslinker. Different preparative ratios and conditions were investigated and the nanoparticles obtained were characterized by FTIR, colloidal titration, size, zeta potential, and antimicrobial activity. The kinetics of the release of L/X from composites was studied in vitro. All the nanoparticles were active against several Gram-positive, Gram-negative, and Candida strains. Synergistic interactions were observed in all cases, although hops are known mainly for their activity against Gram-positive bacteria. All nanoparticles showed good stability over several months.

In vitro activity of antifungal combinations against planktonic and sessile cells of Candida albicans isolated from medical devices in an intensive care department

BACKGROUND

Invasive fungal infections are an emerging health problem worldwide. They are responsible for a significant rate of morbidity and mortality. Infections caused by Candida albicans involve proliferation of biofilms on biotic or abiotic surface. These adherent communities exhibit characteristics distinct from planktonic cells such as the ability to tolerate high concentrations of antifungal.

OBJECTIVE

The object of our study was focused on the determination of the susceptibility to amphotericin B, caspofungin, voriconazole and two antifungal combinations (amphotericin B/caspofungin and amphotericin B/voriconazole) of both planktonic and sessile cells of C. albicans, which were isolated from catheters.

MATERIAL AND METHODS

The susceptibility of C. albicans to antifungals was determined using the broth microdilution method according to Clinical Laboratory Standards Institute CLSI (2008). A Checkerboard assay was employed to evaluate the efficacy of drugs combinations. Biofilm susceptibility was determined using a metabolic [2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide] (XTT) reduction assay.

RESULTS

The minimal inhibitory concentrations of individual antifungal drugs determined against C. albicans biofilms (SMICs) were significantly higher (P<0.05) than planktonic ones (MICs). They went from 2 to 64μg/mL for amphotericin B, from 1 to 64μg/mL for caspofungin and from 2 to 128μg/mL for voriconazole. The combination of amphotericin B to caspofungin or to voriconazole decreased significantly the MIC values for planctonic (P<0.0001) and sessile cells (P=0.0016). Based on Fractional Inhibitory Concentration Index (FICI), no antagonistic interaction was observed.

CONCLUSION

The obtained results showed that the combination of amphotericin B with either caspofungin or voriconazole can be used as a new strategy for management of systemic mycoses associated to medical devices.

Antifungal mechanism of action of Schinus lentiscifolius Marchand essential oil and its synergistic effect in vitro with terbinafine and ciclopirox against dermatophytes

OBJECTIVES

The aim of this study was to evaluate the antifungal, antichemotactic and antioxidant activities of Schinus lentiscifolius essential oil, as well as its combined effect with terbinafine and ciclopirox, against dermatophytes.

METHODS

Essential oil was analysed by GC-MS. The antifungal activity and the mechanism of action were determined by broth microdilution, sorbitol and ergosterol assays, as well as scanning electron microscopy. The checkerboard method was used for evaluating the interactions with commercial antifungal agents. The antioxidant and antichemotactic activities were measured using the DPPH and the modified Boyden chamber methods, respectively.

KEY FINDINGS

Chemical analysis revealed the presence of 33 compounds, the primary ones being γ-eudesmol (12.8%) and elemol (10.5%). The oil exhibited 97.4% of antichemotactic activity and 37.9% of antioxidant activity. Antifungal screening showed effect against dermatophytes with minimum inhibitory concentration values of 125 and 250 μg/ml. Regarding the mechanisms of action, the assays showed that the oil can act on the fungal cell wall and membrane. Synergistic interactions were observed using the combination with antifungals, primarily terbinafine.

CONCLUSIONS

Schinus lentiscifolius essential oil acted as a chemosensitizer of the fungal cell to the drug, resulting in an improvement in the antifungal effect. Therefore, this combination can be considered as an alternative for the topical treatment of dermatophytosis.

Circadian Rhythm, and Antimicrobial and Anticholinesterase Activities of Essential Oils from Vitex gardneriana

Vitex gardneriana, popularly known as “jaramataia”, is a shrub commonly found in the caatinga biome located in northeast Brazil. In folk medicine, its leaves have been used as analgesic and anti-inflammatory agents. Here we describe, for the first time, the chemical composition of the leaf essential oils extracted at 8.00, 12.00 and 17.00 h from V. gardneriana and report on their circadian rhythm, and antimicrobial and anticholinesterase activities. The essential oils’ antifungal activity was evaluated by a broth microdilution method using strains of dermatophytes, fungi and yeasts. The modulatory activity assays were performed by the checkerboard technique using ketoconazole as a standard drug, and acetylcholinesterase inhibitory activity was performed using Ellman's colorimetric method and compared with a reference acetycholinesterase inhibitor (physostigmine). The essential oils extracted from the leaves were analyzed by GC/MS and GC/FID. Twenty-five constituents (94.7%) were identified in the 8 o'clock oil, these being 2 monoterpenes (0.4%) and 23 sesquiterpenes (94.3%). For the essential oil extracted at 12 o'clock, 26 constituents (91.8%) were identified, of which 2 were monoterpenes (0.3%) and 24 sesquiterpenes (91.5%). For the essential oil extracted at 17.00 h, 32 constituents (91.4%) were identified, of which 5 were monoterpenes (3.4%) and 27 sesquiterpenes (88%). The main constituents of the 8.00, 12.00 and 17.00 h essential oils were the sesquiterpenes cis-calamenene (27.9, 24.5 and 25.8%), 6,9-guaiadiene (21.8, 11.2 and 18.4%) and caryophyllene oxide (16.7, 26.3 and 13.8%), respectively. The essential oils showed activity against strains of Trichophyton rubrum.

Verapamil Targets Membrane Energetics in Mycobacterium tuberculosis

Mycobacterium tuberculosis kills more people than any other bacterial pathogen and is becoming increasingly untreatable due to the emergence of resistance. Verapamil, an FDA-approved calcium channel blocker, potentiates the effect of several antituberculosis (anti-TB) drugs in vitro and in vivo. This potentiation is widely attributed to inhibition of the efflux pumps of M. tuberculosis, resulting in intrabacterial drug accumulation. Here, we confirmed and quantified verapamil's synergy with several anti-TB drugs, including bedaquiline (BDQ) and clofazimine (CFZ), but found that the effect is not due to increased intrabacterial drug accumulation. We show that, consistent with its in vitro potentiating effects on anti-TB drugs that target or require oxidative phosphorylation, the cationic amphiphile verapamil disrupts membrane function and induces a membrane stress response similar to those seen with other membrane-active agents. We recapitulated these activities in vitro using inverted mycobacterial membrane vesicles, indicating a direct effect of verapamil on membrane energetics. We observed bactericidal activity against nonreplicating “persister” M. tuberculosis that was consistent with such a mechanism of action. In addition, we demonstrated a pharmacokinetic interaction whereby human-equivalent doses of verapamil caused a boost of rifampin exposure in mice, providing a potential explanation for the observed treatment-shortening effect of verapamil in mice receiving first-line drugs. Our findings thus elucidate the mechanistic basis for verapamil's potentiation of anti-TB drugs in vitro and in vivo and highlight a previously unrecognized role for the membrane of M. tuberculosis as a pharmacologic target.

Potential effect of 2-isopropyl-5-methylphenol (thymol) alone and in combination with fluconazole against clinical isolates of Candida albicans, C. glabrata and C. krusei

Limitations of antifungals used in the treatment of candidiasis, as the development of resistant strains, are known by the scientific community. In this context, the aim of this study was to investigate the activity of 2-isopropyl-5-methylphenol (thymol) in combination with fluconazole (FLZ) against clinical Candida strains. The antifungal activity of thymol along with FLZ was evaluated by the Clinical Laboratory Standards Institute (CLSI) M27-A2 broth microdilution method. In addition, synergism was observed for clinical strains of Candida spp. with combination of thymol-FLZ evaluated by the chequerboard microdilution method. The mean of minimum inhibitory concentration (MIC) values of thymol and FLZ were 49.37 and 0.475μg/ml for C. albicans, 51.25 and 18.80μg/ml for C. glabrata and 70 and 179.20μg/ml for C. krusei strains, respectively. Thymol in combination with FLZ exhibited the synergistic effects against all species of Candida tested. FICI values for thymol plus FLZ ranged from 0.366 to 0.607 for C. albicans strains, 0.367 to 0.482 for C. glabrata strains, and 0.375 to 0.563 for C. krusei strains. No antagonistic activity was seen in the strains tested. Thymol was found to have a fungicidal effect on Candida species and a synergistic effect when combined with FLZ.

In vitro combination of voriconazole with micafungin against azole-resistant clinical isolates of Aspergillus fumigatus from different geographical regions

In vitro interaction of voriconazole with micafungin was evaluated against 33 clinical Aspergillus fumigatus isolates, including azole-resistant (n=31) and -susceptible (n=2) isolates. Interaction was synergistic for only 1 resistant isolate carrying the TR₃₄/L98H mutation. No antagonistic effects were observed for 96.8% of azole-resistant isolates.

Anti-Candidal Activity and Functional Mapping of Recombinant and Synthetic Neosartorya fischeri Antifungal Protein 2 (NFAP2)

The increasing number of life-threatening Candida infections caused by antifungal drug-resistant strains urges the development of new therapeutic strategies. The small, cysteine-rich, and cationic Neosartorya fischeri antifungal protein 2 (NFAP2) effectively inhibits the growth of Candida spp. Limiting factors of its future application, are the low-yield production by the native producer, unavailable information about potential clinical application, and the unsolved relationship between the structure and function. In the present study we adopted a Penicillium chrysogenum-based expression system for bulk production of recombinant NFAP2. Furthermore, solid-phase peptide synthesis and native chemical ligation were applied to produce synthetic NFAP2. The average yield of recombinant and synthetic NFAP2 was 40- and 16-times higher than in the native producer, respectively. Both proteins were correctly processed, folded, and proved to be heat-stable. They showed the same minimal inhibitory concentrations as the native NFAP2 against clinically relevant Candida spp. Minimal inhibitory concentrations were higher in RPMI 1640 mimicking the human inner fluid than in a low ionic strength medium. The recombinant NFAP2 interacted synergistically with fluconazole, the first-line Candida therapeutic agent and significantly decreased its effective in vitro concentrations in RPMI 1640. Functional mapping with synthetic peptide fragments of NFAP2 revealed that not the evolutionary conserved antimicrobial γ-core motif, but the mid-N-terminal part of the protein influences the antifungal activity that does not depend on the primary structure of this region. Preliminary nucleic magnetic resonance measurements signed that the produced recombinant NFAP2 is suitable for further structural investigations.

Cinnamomum zeylanicum bark essential oil induces cell wall remodelling and spindle defects in Candida albicans

Background

Cinnamon (Cinnamomum zeylanicum) bark extract exhibits potent inhibitory activity against Candida albicans but the antifungal mechanisms of this essential oil remain largely unexplored.

Results

We analyzed the impact of cinnamon bark oil on C. albicans RSY150, and clinical strains isolated from patients with candidemia and candidiasis. The viability of RSY150 was significantly compromised in a dose dependent manner when exposed to cinnamon bark oil, with extensive cell surface remodelling at sub inhibitory levels (62.5 μg/mL). Atomic force microscopy revealed cell surface exfoliation, altered ultrastructure and reduced cell wall integrity for both RSY150 and clinical isolates exposed to cinnamon bark oil. Cell wall damage induced by cinnamon bark oil was confirmed by exposure to stressors and the sensitivity of cell wall mutants involved in cell wall organization, biogenesis, and morphogenesis. The essential oil triggered cell cycle arrest by disrupting beta tubulin distribution, which led to mitotic spindle defects, ultimately compromising the cell membrane and allowing leakage of cellular components. The multiple targets of cinnamon bark oil can be attributed to its components, including cinnamaldehyde (74%), and minor components (< 6%) such as linalool (3.9%), cinamyl acetate (3.8%), α-caryophyllene (5.3%) and limonene (2%). Complete inhibition of the mitotic spindle assembly was observed in C. albicans treated with cinnamaldehyde at MIC (112 μg/mL).

Conclusions

Since cinnamaldehyde disrupts both the cell wall and tubulin polymerization, it may serve as an effective antifungal, either by chemical modification to improve its specificity and efficacy or in combination with other antifungal drugs.

Electronic supplementary material

The online version of this article (10.1186/s40694-018-0046-5) contains supplementary material, which is available to authorized users.

An in Vitro Study on the Effect of Combined Treatment with Photodynamic and Chemical Therapies on Candida albicans

Candida albicans is the most commonly encountered human fungal pathogen, and it is traditionally treated with antimicrobial chemical agents. The antimicrobial effect of these agents is largely weakened by drug resistance and biofilm-associated virulence. Enhancement of the antimicrobial activity of existing agents is needed for effective candidiasis treatment. Our aim was to develop a therapy that combined biofilm disruption with existing antimicrobial agents. Photodynamic therapy (PDT) utilizing curcumin and blue light was tested as an independent therapy and in combination with fluconazole treatment. Viability assays and morphology analysis were used to assess the effectiveness of C. albicans treatment. Results showed that fluconazole treatment decreased the viability of planktonic C. albicans, but the decrease was not as pronounced in adherent C. albicans because its biofilm form was markedly more resistant to the antimicrobiotic. PDT effectively eradicated C. albicans biofilms, and when combined with fluconazole, PDT significantly inhibited C. albicans to a greater extent. This study suggests that the addition of PDT to fluconazole to treat C. albicans infection enhances its effectiveness and can potentially be used clinically.

A general pharmacodynamic interaction model identifies perpetrators and victims in drug interactions

Assessment of pharmacodynamic (PD) drug interactions is a cornerstone of the development of combination drug therapies. To guide this venture, we derive a general pharmacodynamic interaction (GPDI) model for ≥2 interacting drugs that is compatible with common additivity criteria. We propose a PD interaction to be quantifiable as multidirectional shifts in drug efficacy or potency and explicate the drugs’ role as victim, perpetrator or even both at the same time. We evaluate the GPDI model against conventional approaches in a data set of 200 combination experiments in Saccharomyces cerevisiae: 22% interact additively, a minority of the interactions (11%) are bidirectional antagonistic or synergistic, whereas the majority (67%) are monodirectional, i.e., asymmetric with distinct perpetrators and victims, which is not classifiable by conventional methods. The GPDI model excellently reflects the observed interaction data, and hence represents an attractive approach for quantitative assessment of novel combination therapies along the drug development process.

Assessment of pharmacodynamic interactions is at the heart of combination therapy development. Here the authors introduce a general drug interaction scoring model that enables quantification of synergistic and antagonistic interactions and determination of the directionality of the interactions.

Synergistic Response of Rifampicin with Hydroperoxides on Mycobacterium: A Mechanistic Study

Prolonged chemotherapy as well as rapid development of antimicrobial resistance are two of the major concerns for treatment of mycobacterial infections. To enhance the effectiveness of current drug regimens, search for compounds having synergistic interaction with anti-mycobacterial drugs has become indispensable. Here, we have investigated the intervention by oxidative stress, a major factor in mycobacterial pathogenesis, in combination with rifampicin (RIF), a first-line drug used against Mycobacterium tuberculosis. We have observed that a sub-inhibitory concentration of cumene hydroperoxide (CHP), a hydrophobic oxidant, synergistically reduced the minimum inhibitory concentration of RIF by fourfold, with a Fractional Inhibitory Concentration Index (FICI) of 0.45. Also, this interaction was found to be robust and synergistic against different strains of M. smegmatis as well as on M. bovis BCG, with FICI ranging from 0.3 to 0.6. Various physiological, biochemical and molecular parameters were explored to understand the mechanism of synergy. It was observed that increased membrane permeability owing to the presence of the oxidant, led to higher uptake of the drug. Moreover, downregulation of the hydroperoxide reductases by RIF, a transcriptional inhibitor, prevented quenching of the reactive oxygen species produced in the presence of CHP. The lipid soluble reactive species triggered autocatalytic lipid peroxidation (LPO), observed here as extensive membrane damage eventually leading to growth inhibition. Furthermore, it was seen that in combination with hydrogen peroxide (H2O2), the effect was only additive, establishing LPO as a key aspect leading toward synergism. To conclude, this work suggests that targeting the bacterial membrane by a radical species can have a significant impact on the treatment of tuberculosis.

Effects of Echinocandins in Combination with Nikkomycin Z against Invasive Candida albicans Bloodstream Isolates and the fks Mutants

We evaluated the in vitro and in vivo effects of nikkomycin Z combined with an echinocandin (anidulafungin or micafungin) against two Candida albicans isolates and their lab-derived echinocandin-resistant fks mutants with FKS1 S645Y and FKS1 S645P. Synergistic effects were observed in all tested strains (fractional inhibitory concentration index, <0.5). Enhanced survival was observed in an immunocompromised murine model (log-rank test, P < 0.02). Our study demonstrated the therapeutic potential of nikkomycin Z-echinocandin combinations in managing echinocandin resistance.

Targeting the Homoserine Dehydrogenase of Paracoccidioides Species for Treatment of Systemic Fungal Infections

This work evaluated new potential inhibitors of the enzyme homoserine dehydrogenase (HSD) of Paracoccidioides brasiliensis, one of the etiological agents of paracoccidioidomycosis. The tertiary structure of the protein bonded to the analogue NAD, and l-homoserine was modeled by homology. The model with the best output was subjected to gradient minimization, redocking, and molecular dynamics simulation. Virtual screening simulations with 187,841 molecules purchasable from the Zinc database were performed. After the screenings, 14 molecules were selected and analyzed by the use of absorption, distribution, metabolism, excretion, and toxicity criteria, resulting in four compounds for in vitro assays. The molecules HS1 and HS2 were promising, exhibiting MICs of 64 and 32 μg · ml^-1, respectively, for the Pb18 isolate of P. brasilensis, 64 μg · ml^-1 for two isolates of P. lutzii, and also synergy with itraconazole. The application of these molecules to human-pathogenic fungi confirmed that the HSD enzyme may be used as a target for the development of drugs with specific action against paracoccidioidomycosis; moreover, these compounds may serve as leads in the design of new antifungals.

Unexpected effects of azole transporter inhibitors on antifungal susceptibility in Candida glabrata and other pathogenic Candida species

The pathogenic fungus Candida glabrata is often resistant to azole antifungal agents. Drug efflux through azole transporters, such as Cdr1 and Cdr2, is a key mechanism of azole resistance and these genes are under the control of the transcription factor Pdr1. Recently, the monoamine oxidase A (MAO-A) inhibitor clorgyline was shown to inhibit the azole efflux pumps, leading to increased azole susceptibility in C. glabrata. In the present study, we have evaluated the effects of clorgyline on susceptibility of C. glabrata to not only azoles, but also to micafungin and amphotericin B, using wild-type and several mutant strains. The addition of clorgyline to the culture media increased fluconazole susceptibility of a C. glabrata wild-type strain, whereas micafungin and amphotericin B susceptibilities were markedly decreased. These phenomena were also observed in other medically important Candida species, including Candida albicans, Candida parapsilosis, Candida tropicalis, and Candida krusei. Expression levels of CDR1, CDR2 and PDR1 mRNAs and an amount of Cdr1 protein in the C. glabrata wild-type strain were highly increased in response to the treatment with clorgyline. However, loss of Cdr1, Cdr2, Pdr1, and a putative clorgyline target (Fms1), which is an ortholog of human MAO-A, or overexpression of CDR1 did not affect the decreased susceptibility to micafungin and amphotericin B in the presence of clorgyline. The presence of other azole efflux pump inhibitors including milbemycin A4 oxime and carbonyl cyanide 3-chlorophenylhydrazone also decreased micafungin susceptibility in C. glabrata wild-type, Δcdr1, Δcdr2, and Δpdr1 strains. These findings suggest that azole efflux pump inhibitors increase azole susceptibility but concurrently induce decreased susceptibility to other classes of antifungals independent of azole transporter functions.

High-dose fluconazole in combination with amphotericin B is more efficient than monotherapy in murine model of cryptococcosis

Cryptococcus spp., the causative agents of cryptococcosis, are responsible for deaths of hundreds of thousands of people every year worldwide. The drawbacks of available therapeutic options are aggravated by the increased resistance of yeast to the drugs, resulting in inefficient therapy. Also, the antifungal 5FC is not available in many countries. Therefore, a combination of antifungal drugs may be an interesting option, but in vitro and theoretical data point to the possible antagonism between the main antifungals used to treat cryptococcosis, i.e., fluconazole (FLC), and amphotericin B (AMB). Therefore, in vivo studies are necessary to test the above hypothesis. In this study, the efficacy of FLC and AMB at controlling C. gattii infection was evaluated in a murine model of cryptococcosis caused by C. gattii. The infected mice were treated with FLC + AMB combinations and showed a significant improvement in survival as well as reduced morbidity, reduced lung fungal burden, and the absence of yeast in the brain when FLC was used at higher doses, according to the Tukey test and principal component analysis. Altogether, these results indicate that combinatorial optimization of antifungal therapy can be an option for effective control of cryptococcosis.

Onychomycosis in the 21st Century: An Update on Diagnosis, Epidemiology, and Treatment

Onychomycosis accounts for 50% of all nail disease cases and is commonly caused by dermatophytes. Diabetes, human immunodeficiency virus, immunosuppression, obesity, smoking, and advancing age are predisposing factors of this fungal infection. Potassium hydroxide and culture are considered the current standard for diagnosing onychomycosis, revealing both fungal viability and species identification. Other diagnostic tests currently available include periodic acid-Schiff staining, polymerase chain reaction techniques, and fluorescent staining. Across 6 recently published epidemiology studies, the global prevalence of onychomycosis was estimated to be 5.5%, falling within the range of previously reported estimates (2%-8%). Newly approved onychomycosis treatments include efinaconazole, tavaborole, and laser therapy with lasers only approved to temporarily increase the amount of clear nail. Additional onychomycosis treatments being investigated include iontophoresis and photodynamic therapy with small open-label studies reported thus far. Preventative strategies, to help decrease recurrence and reinfection rates, include sanitisation of footwear and prophylactic topical antifungal agents.

Activity of Combined Antifungal Agents Against Multidrug-Resistant Candida glabrata Strains

In this study, we evaluated the in vitro activity of echinocandins, azoles, and amphotericin B alone and in combination against echinocandin/azole-sensitive and echinocandin/azole-resistant Candida glabrata isolates. Susceptibility tests were performed using the broth microdilution method in accordance with the Clinical and Laboratory Standards Institute document M27-A3. The checkerboard method was used to evaluate the fractional inhibitory concentration index of the interactions. Cross-resistance was observed among echinocandins; 15% of the isolates resistant to caspofungin were also resistant to anidulafungin and micafungin. Synergistic activity was observed in 70% of resistant C. glabrata when anidulafungin was combined with voriconazole or posaconazole. Higher (85%) synergism was found in the combination of caspofungin and voriconazole. The combinations of caspofungin with fluconazole, posaconazole and amphotericin B, micafungin with fluconazole, posaconazole and voriconazole, and anidulafungin with amphotericin B showed indifferent activities for the majority of the isolates. Anidulafungin combined with fluconazole showed the same percentage of synergism and indifference (45%). Antagonism was detected in 50% of isolates when micafungin was combined with amphotericin B. Combinations of echinocandins and antifungal azoles have great potential for in vivo assays which are required to evaluate the efficacy of these combinations against multidrug-resistant C. glabrata strains.

Combination therapy for the treatment of pulmonary mold infections

INTRODUCTION

Pulmonary mold infections are caused by ubiquitous organisms found in soil, water, and decaying vegetation, including Aspergillus spp., the Mucormycetes, hyaline molds, and dematiaceous (black) molds. Areas covered: These infections are often a challenge to diagnose and even more difficult to treat. Recently, antifungal combination therapy has emerged as a promising strategy to treat some forms of invasive mycoses, including pulmonary mold infections. Historically, this approach has been limited due to non-uniform interpretation criteria, variations in pharmacodynamic/pharmacokinetic properties of antifungals used in combination, and an inability to predict clinical success based on in vitro data and animal models. However, recent advances have helped mitigate some of these challenges. Expert commentary: In this paper, we explore what is known about the antifungal combination therapy in the treatment of pulmonary mold infections and explore how it may impact clinical practice. We pay particular attention to novel combinations and the challenges associated with the development of new antifungal agents.

Combination Antifungal Therapy: A Review of Current Data

The incidence of invasive fungal infections has been on the rise, particularly in transplant recipients and in patients with hematological malignancies and other forms of immunosuppression. There is a mismatch between the rate of antifungal resistance and the development of new antifungal agents. Based on this, the idea of combining antifungals in the treatment of invasive fungal infections appears tempting for many clinicians, particularly after many in vitro studies showed synergism between many antifungal agents. Several randomized controlled trials have been published regarding the efficacy and safety of combination of antifungals, but the high cost, the limited number of cases and the multitude of confounding factors lead in some instances to weak and sometimes contradictory results. The lack of consensus in many clinical scenarios raises the importance of the need for more studies about combination antifungal therapies and should incite infectious disease societies to develop specific recommendations for the clinicians to follow while approaching patients with invasive fungal infections.

Epedimiologic, clinical profile and factors affecting the outcome in febrile neutropenia

BACKGROUND

Febrile neutropenia (FN) is common in cancer patients particularly hematologic malignancies due to intensive cytotoxic chemotherapy. It is an important cause of morbidity, mortality and treatment delays. The risk is greater in patients with ANC < 500/ mm3 and increases dramatically in those with ANC < 100/ mm3 and duration of neutropenia more than 1 week.

AIMS AND OBJECTIVES

The purpose of this study was to evaluate the incidence, demographic characteristics, clinical profile, mortality, outcome and factors affecting the outcome in patients with febrile neutropenia (FN) admitted at our Center between January 2011 and November 2012.

MATERIALS AND METHODS

All cases of FN admitted in our Institute between January 2011 and November 2012 were analyzed. Data was analyzed using IBM statistic SPSS version 19.

RESULTS

A total of 333 episodes of FN were reviewed. Hematologic malignancies accounted for 299 (89.7%) episodes and 88% of all the episodes had grade 4 neutropenia. There was a significant association noted between high serum bilirubin, creatinine and outcome. Isolation of an organism from blood culture, positive findings on chest X-ray and fungal infection was associated with higher mortality. Association between transfusion requirements and outcome was analyzed and it was observed that patients who had multiple component transfusions vs single component ones were at a significantly higher risk of death. There were only 7 deaths noted among the patient population.

CONCLUSION

Leukemias are the leading cause of FN at our Institute. Higher bilirubin, creatinine, chest imaging favoring pneumonia, positive isolates and multiple transfusions had significant association with mortality. Large scale prospective studies are needed to determine the association of preemptive therapy with higher mortality. The outcome of high risk FN in this study is favorable.

Preparations based on minerals extracts of Calicotome villosa roots and bovine butyrate matter: Evaluation in vitro of their antifungal activity

OBJECTIVE

The use of preparations based on minerals extracts of Calicotome villosa and butter is born from the misuse of drugs without specific microbiological analyzes. Seventeen different preparations were performed. The antibacterial and antifungal activities were determined on five bacteria and two fungi strains respectively.

MATERIAL AND METHODS

C. villosa ashes are obtained by incineration of roots plant at 498°C for 4hours. They are analyzed to determine the shape of the particles and the mineral constituents by scanning electronic microscopy (SEM) and energy dispersive X-ray spectroscopy (EDX) techniques respectively. The effectiveness of preparations or tablets is measured in solid medium. It allows to measure the diameter of the inhibition zone for the antibacterial activity as well as the diameter of mycelia growth and the critical values (MIC, MFC, IC₅₀ and IC₉₀) for the antifungal activity. Finally, the results are compared to the activity of a commercial positive control aiming to give value of the observed activity.

RESULTS

SEM observations reveal the presence of nanoparticles agglomerated with size of about 50nm. The EDX analyzes indicate the presence of Fe, Na, Al, Mg, Si, K, Ca, O₂ and C. Among all the results, the preparation (B_s+A) or (B_sd+A) can completely inhibit the growth of two fungal pathogens. The activity of the preparation is faced with the activity of the synthetic fungicide nystatin.

CONCLUSION

The efficacy of the preparation (B_s+A) or (B_sd+A) is higher than that of nystatin against Aspergillus sp. and Fusarium sp. The preparation could serve as natural antifungal for the pharmaceutical industry.

Cephem Potentiation by Inactivation of Nonessential Genes Involved in Cell Wall Biogenesis of β-Lactamase-Producing Escherichia coli

Reversal of antimicrobial resistance is an appealing and largely unexplored strategy in drug discovery. The objective of this study was to identify potential targets for "helper" drugs reversing cephem resistance in Escherichia coli strains producing β-lactamases. A CMY-2-encoding plasmid was transferred by conjugation to seven isogenic deletion mutants exhibiting cephem hypersusceptibility. The effect of each mutation was evaluated by comparing the MICs in the wild type and the mutant harboring the same plasmid. Mutation of two genes encoding proteins involved in cell wall biosynthesis, dapF and mrcB, restored susceptibility to cefoxitin (FOX) and reduced the MICs of cefotaxime and ceftazidime, respectively, from the resistant to the intermediate category according to clinical breakpoints. The same mutants harboring a CTX-M-1-encoding plasmid fell into the intermediate or susceptible category for all three drugs. Individual deletion of dapF and mrcB in a clinical isolate of CTX-M-15-producing E. coli sequence type 131 (ST131) resulted in partial reversal of ceftazidime and cefepime resistance but did not reduce MICs below susceptibility breakpoints. Growth curve analysis indicated no fitness cost in a ΔmrcB mutant, whereas a ΔdapF mutant had a 3-fold longer lag phase than the wild type, suggesting that drugs targeting DapF may display antimicrobial activity, in addition to synergizing with selected cephems. DapF appeared to be a potential FOX helper drug target candidate, since dapF inactivation resulted in synergistic potentiation of FOX in the genetic backgrounds tested. The study showed that individual inactivation of two nonessential genes involved in cell wall biogenesis potentiates cephem activity according to drug- and strain-specific patterns.

Potent Antifungal Synergy of Phthalazinone and Isoquinolones with Azoles Against Candida albicans

Four phthalazinones (CIDs 22334057, 22333974, 22334032, 22334012) and one isoquinolone (CID 5224943) were previously shown to be potent enhancers of antifungal activity of fluconazole against Candida albicans. Several even more potent analogues of these compounds were identified, some with EC₅₀ as low as 1 nM, against C. albicans. The compounds exhibited pharmacological synergy (FIC < 0.5) with fluconazole. The compounds were also shown to enhance the antifungal activity of isavuconazole, a recently FDA approved azole antifungal. Isoquinolone 15 and phthalazinone 24 were shown to be active against several resistant clinical isolates of C. albicans.

Antifungal Therapy: New Advances in the Understanding and Treatment of Mycosis

The high rates of morbidity and mortality caused by fungal infections are associated with the current limited antifungal arsenal and the high toxicity of the compounds. Additionally, identifying novel drug targets is challenging because there are many similarities between fungal and human cells. The most common antifungal targets include fungal RNA synthesis and cell wall and membrane components, though new antifungal targets are being investigated. Nonetheless, fungi have developed resistance mechanisms, such as overexpression of efflux pump proteins and biofilm formation, emphasizing the importance of understanding these mechanisms. To address these problems, different approaches to preventing and treating fungal diseases are described in this review, with a focus on the resistance mechanisms of fungi, with the goal of developing efficient strategies to overcoming and preventing resistance as well as new advances in antifungal therapy. Due to the limited antifungal arsenal, researchers have sought to improve treatment via different approaches, and the synergistic effect obtained by the combination of antifungals contributes to reducing toxicity and could be an alternative for treatment. Another important issue is the development of new formulations for antifungal agents, and interest in nanoparticles as new types of carriers of antifungal drugs has increased. In addition, modifications to the chemical structures of traditional antifungals have improved their activity and pharmacokinetic parameters. Moreover, a different approach to preventing and treating fungal diseases is immunotherapy, which involves different mechanisms, such as vaccines, activation of the immune response and inducing the production of host antimicrobial molecules. Finally, the use of a mini-host has been encouraging for in vivo testing because these animal models demonstrate a good correlation with the mammalian model; they also increase the speediness of as well as facilitate the preliminary testing of new antifungal agents. In general, many years are required from discovery of a new antifungal to clinical use. However, the development of new antifungal strategies will reduce the therapeutic time and/or increase the quality of life of patients.

Anti-fungal activity of Ctn[15-34], the C-terminal peptide fragment of crotalicidin, a rattlesnake venom gland cathelicidin

Crotalicidin (Ctn), a 34-residue cathelicidin from a South American rattlesnake, and its fragment (Ctn[15-34]) have shown anti-infective and cytotoxic activities against Gram-negative bacteria and certain tumor lines, respectively. The extent of such effects has been related to physicochemical characteristics such as helicity and hydrophobicity. We now report the anti-fungal activity of Ctn and its fragments (Ctn[1-14]) and (Ctn[15-34]). MIC determination and luminescent cell viability assays were used to evaluate the anti-infective activity of Ctn and its fragments (Ctn[1-14]) and (Ctn[15-34]) as anti-fungal agents against opportunistic yeast and dermatophytes. Cytotoxicity towards healthy eukaryotic cells was assessed in vitro with healthy human kidney-2 (HK-2) cells and erythrocytes. The checkerboard technique was performed to estimate the effects of combining either one of the peptides with amphotericin B. Ctn was the most active peptide against dermatophytes and also the most toxic to healthy eukaryotic cells. Fragments Ctn[1-14] and Ctn[15-35] lost activity against dermatophytes, but became more active against pathogenic yeasts, including several Candida species, both clinical isolates and standard strains, with MICs as low as 5 μm. Interestingly, the two peptide fragments were less cytotoxic to healthy HK-2 cells and less hemolytic to human erythrocytes than the standard-of-care amphotericin B. Also noteworthy was the synergy between Ctn peptides and amphotericin B, with consequent reduction in MICs of both drug and peptides. Altogether, Ctn and its fragments, particularly Ctn[15-34], are promising leads, either alone or in combined regimen with amphotericin B, for the treatment of fungal diseases.

Antifungal activity of Rubus chingii extract combined with fluconazole against fluconazole-resistant Candida albicans

This study aimed to investigate the antifungal activity of Rubus chingii extract in combination with fluconazole (FLC) against FLC-resistant Candida albicans 100 in vitro. A R. chingii extract and FLC-resistant C. albicans fungus suspension were prepared. The minimum inhibitory concentration and fractional inhibitory concentration index of R. chingii extract combined with FLC against C. albicans were determined, after which growth curves for C. albicans treated with R. chingii extract, FLC alone and a combination of these preparations were constructed. Additionally, the mechanisms of drug combination against C. albicans were explored by flow cytometry, gas chromatographic mass spectrometry and drug efflux pump function detection. R. chingii extract combined with FLC showed significant synergy. Flow cytometry suggested that C. albicans cells mainly arrest in G1 and S phases when they have been treated with the drug combination. The drug combination resulted in a marked decrease in the ergosterol content of the cell membrane. Additionally, efflux of Rhodamine 6G decreased with increasing concentrations of R. chingii extract. R. chingii extract combined with FLC has antifungal activity against FLC-resistant C. albicans.

Reversal of fluconazole resistance induced by a synergistic effect with Acca sellowiana in Candida glabrata strains

CONTEXT

The increased incidence of non-albicans Candida (NAC) resistant to fluconazole (FLZ) makes it necessary to use new therapeutic alternatives. Acca sellowiana (O.berg) Burret (Myrtaceae) is a guava with several proven biological activities. The interaction with fluconazole can be a feasible alternative to overcome this resistance.

OBJECTIVE

This study evaluates the in vitro antifungal activity of fractions obtained from the lyophilized aqueous extract of the leaves of A. sellowiana against resistant strains of NAC.

MATERIALS AND METHODS

The antifungal activity of the fractions was evaluated at 500 μg/mL by microdilution method. Checkerboard assay was performed to determine the effect of the combination of the F2 fraction and antifungal at concentrations: MIC/4, MIC/2, MIC, MIC × 2 and MIC × 4.

RESULTS

Candida glabrata showed the lowest MIC values (500-3.90 μg/mL) and the F2 active fraction was the most effective. The association of F2 with FLZ showed a strong synergistic effect (FICI ≤ 0.5) against 100% of C. glabrata resistant isolates. Moreover, the F2 active fraction has demonstrated that probably acts in the cell wall of these yeasts. There was no observed acute dermal toxicity of lyophilized aqueous extract of leaves of A. sellowiana on pig ear skin cells.

DISCUSSION AND CONCLUSION

The interaction between substances present in the F2 active fraction is possibly responsible for the antifungal activity presented by this fraction. This study is unprecedented and suggests that the combination of F2 active fraction and FLZ might be used as an alternative treatment for mucocutaneus infections caused by C. glabrata resistant.