Will resistance in fungi emerge on a scale similar to that seen in bacteria?

Dendrimers against fungi - A state of the art review

Fungal based diseases currently affect nearly a quarter of the population around the world, which diseases are usually limited to superficial infections. Perversely, along with the development of modern medicine, cases of life-threatening systemic fungi are more and more often encountered. Compared to antibacterial drugs, significantly fewer fungicides are tested and introduced to clinical practice. At the same time, the drug resistance of pathological fungi is constantly growing. In addition to obtaining new derivatives of already-established classes of drugs, such as azoles, there is a growing interest in new compounds with potentially new mechanisms and application possibilities. Polymers are included in the flow of these studies, and among them - dendrimers. Dendrimers are a special type of polymers with a strictly defined structure and a plethora of functionalization possibilities. This allows them to not only be used as effective antifungal drug carriers but also enables them to exhibit antifungal activity per se. In this review, we have introduced to the epidemiology of fungal infections and summarized the aspects related to their control and therapy. Various polymers and dendrimers with antifungal activity were presented. In the subsequent sections antifungal acting dendrimers were discussed within three subchapters, based on their chemical structure: (i) amino acid-based dendrimers, (ii) amino based dendrimers, and (iii) other, which do not share similarities in structure. We have gathered and summarized the reports regarding the direct action of dendrimers on infectious fungi, as well as their effect when used as solubilizers, carriers or adjuvants with currently used antifungals. Use of dendrimers for the sensing of fungi or their metabolites are also considered. Special attention was also paid to the applications of dendrimers together with photosensitizers in antimicrobial photodynamic therapy.

Mitigation of human-pathogenic fungi that exhibit resistance to medical agents: can clinical antifungal stewardship help?

Reducing indiscriminate antimicrobial usage to combat the expansion of multidrug-resistant human-pathogenic bacteria is fundamental to clinical antibiotic stewardship. In contrast to bacteria, fungal resistance traits are not understood to be propagated via mobile genetic elements, and it has been proposed that a global explosion of resistance to medical antifungals is therefore unlikely. Clinical antifungal stewardship has focused instead on reducing the drug toxicity and high costs associated with medical agents. Mitigating the problem of human-pathogenic fungi that exhibit resistance to antimicrobials is an emergent issue. This article addresses the extent to which clinical antifungal stewardship could influence the scale and epidemiology of resistance to medical antifungals both now and in the future. The importance of uncharted selection pressure exerted by agents outside the clinical setting (agricultural pesticides, industrial xenobiotics, biocides, pharmaceutical waste and others) on environmentally ubiquitous spore-forming molds that are lesserstudied but increasingly responsible for drug-refractory infections is considered.

Isolation, structure, and biological activity of Phaeofungin, a cyclic lipodepsipeptide from a Phaeosphaeria sp. Using the Genome-Wide Candida albicans Fitness Test

Phaeofungin (1), a new cyclic depsipeptide isolated from Phaeosphaeria sp., was discovered by application of reverse genetics technology, using the Candida albicans fitness test (CaFT). Phaeofungin is comprised of seven amino acids and a β,γ-dihydroxy-γ-methylhexadecanoic acid arranged in a 25-membered cyclic depsipeptide. Five of the amino acids were assigned with d-configurations. The structure was elucidated by 2D-NMR and HRMS-MS analysis of the natural product and its hydrolyzed linear peptide. The absolute configuration of the amino acids was determined by Marfey's method by complete and partial hydrolysis of 1. The CaFT profile of the phaeofungin-containing extract overlapped with that of phomafungin (3), another structurally different cyclic lipodepsipeptide isolated from a Phoma sp. using the same approach. Comparative biological characterization further demonstrated that these two fungal lipodepsipeptides are functionally distinct. While phomafungin was potentiated by cyclosporin A (an inhibitor of the calcineurin pathway), phaeofungin was synergized with aureobasidin A (2) (an inhibitor of the sphingolipid biosynthesis) and to some extent caspofungin (an inhibitor of glucan synthase). Furthermore, phaeofungin caused ATP release in wild-type C. albicans strains but phomafungin did not. It showed modest antifungal activity against C. albicans (MIC 16-32 μg/mL) and better activity against Aspergillus fumigatus (MIC 8-16 μg/mL) and Trichophyton mentagrophytes (MIC 4 μg/mL). The linear peptide was inactive, suggesting that the macrocyclic depsipeptide ring is essential for target engagement and antifungal activity.

Structure-activity relationship of cytochrome bc1 reductase inhibitor broad spectrum antifungal ilicicolin H

Ilicicolin H is a broad spectrum antifungal agent showing sub micro g/mL MICs against Candida spp., Aspergillus fumigatus and Cryptococcus spp. It is a potent inhibitor (C50 2-3ng/mL) of the mitochondrial cytochrome bc1 reductase with over 1000-fold selectivity against rat liver cytochrome bc1 reductase. Structure-activity relationship of semisynthetic derivatives by chemical modification of ilicicolin H and its 19-hydroxy derivative produced by biotransformation have been described. Basic 4'-esters and moderately polar N- and O-alkyl derivatives retained antifungal and the cytochrome bc1 reductase activities. 4',19-Diacetate and 19-cyclopropyl acetate retained antifungal and enzyme activity and selectivity with over 20-fold improvement of plasma protein binding.

Antifungal spectrum, in vivo efficacy, and structure-activity relationship of ilicicolin h

Ilicicolin H is a polyketide-nonribosomal peptide synthase (NRPS)-natural product isolated from Gliocadium roseum, which exhibits potent and broad spectrum antifungal activity, with sub-μg/mL MICs against Candida spp., Aspergillus fumigatus, and Cryptococcus spp. It showed a novel mode of action, potent inhibition (IC50 = 2-3 ng/mL) of the mitochondrial cytochrome bc1 reductase, and over 1000-fold selectivity relative to rat liver cytochrome bc1 reductase. Ilicicolin H exhibited in vivo efficacy in murine models of Candida albicans and Cryptococcus neoformans infections, but efficacy may have been limited by high plasma protein binding. Systematic structural modification of ilicicolin H was undertaken to understand the structural requirement for the antifungal activity. The details of the biological activity of ilicicolin H and structural modification of some of the key parts of the molecule and resulting activity of the derivatives are discussed. These data suggest that the β-keto group is critical for the antifungal activity.

Azole resistance by loss of function of the sterol Δ⁵,⁶-desaturase gene (ERG3) in Candida albicans does not necessarily decrease virulence

The inactivation of ERG3, a gene encoding sterol Δ⁵,⁶-desaturase (essential for ergosterol biosynthesis), is a known mechanism of in vitro resistance to azole antifungal drugs in the human pathogen Candida albicans. ERG3 inactivation typically results in loss of filamentation and attenuated virulence in animal models of disseminated candidiasis. In this work, we identified a C. albicans clinical isolate (VSY2) with high-level resistance to azole drugs in vitro and an absence of ergosterol but normal filamentation. Sequencing of ERG3 in VSY2 revealed a double base deletion leading to a premature stop codon and thus a nonfunctional enzyme. The reversion of the double base deletion in the mutant allele (erg3-1) restored ergosterol biosynthesis and full fluconazole susceptibility in VSY2, confirming that ERG3 inactivation was the mechanism of azole resistance. Additionally, the replacement of both ERG3 alleles by erg3-1 in the wild-type strain SC5314 led to the absence of ergosterol and to fluconazole resistance without affecting filamentation. In a mouse model of disseminated candidiasis, the clinical ERG3 mutant VSY2 produced kidney fungal burdens and mouse survival comparable to those obtained with the wild-type control. Interestingly, while VSY2 was resistant to fluconazole both in vitro and in vivo, the ERG3-derived mutant of SC5314 was resistant only in vitro and was less virulent than the wild type. This suggests that VSY2 compensated for the in vivo fitness defect of ERG3 inactivation by a still unknown mechanism(s). Taken together, our results provide evidence that contrary to previous reports inactivation of ERG3 does not necessarily affect filamentation and virulence.

Evaluation of "Candida score" in critically ill patients: a prospective, multicenter, observational, cohort study

Introduction

Although prompt initiation of appropriate antifungal therapy is essential for the control of invasive Candida infections and an improvement of prognosis, early diagnosis of invasive candidiasis remains a challenge and criteria for starting empirical antifungal therapy in ICU patients are poorly defined. Some scoring systems, such as the "Candida score" could help physicians to differentiate patients who could benefit from early antifungal treatment from those for whom invasive candidiasis is highly improbable. This study evaluated the performance of this score in a cohort of critically ill patients.

Methods

A prospective, observational, multicenter, cohort study was conducted from January 2010 to March 2011 in five intensive care units in Nord-Pas de Calais, an area from North of France. All patients exhibiting, on ICU admission or during their ICU stay, a hospital-acquired severe sepsis or septic shock could be included in this study. The data collected included patient characteristics on ICU admission and at the onset of severe sepsis or septic shock. The "Candida score" was calculated at the onset of sepsis or shock. The incidence of invasive candidiasis was determined and its relationship with the value of the "Candida score" was studied.

Results

Ninety-four patients were studied. When severe sepsis or shock occurred, 44 patients had a score = 2, 29 patients had a score = 3, 17 patients had a score = 4, and 4 patients had a score = 5. Invasive candidiasis was observed in five (5.3%) patients. One patient had candidemia, three patients had peritonitis, and one patient had pleural infection. The rates of invasive candidiasis was 0% in patients with score = 2 or 3, 17.6% in patients with score = 4, and 50% in patients with score = 5 (p < 0.0001).

Conclusions

Our results confirm that the "Candida score" is an interesting tool to differentiate among ICU patients who exhibit hospital-acquired severe sepsis or septic shock those would benefit from early antifungal treatment (score > 3) from those for whom invasive candidiasis is highly improbable (score ≤ 3).

Azole resistance in Aspergillus fumigatus: a new challenge in the management of invasive aspergillosis?

Azole resistance is emerging in Aspergillus fumigatus isolates. The exact mechanism of evolution of azole resistance has not been fully elucidated yet but increasing evidence indicates a role for azole fungicide used in agriculture. Patients confronted with an invasive fungal infection from an azole-resistant A. fumigatus isolate will fail azole treatment. Azole resistance in A. fumigatus isolates impacts the management of invasive aspergillosis (IA) since the azoles are the primary agents used for prophylaxis and treatment. Because A. fumigatus will always be present in our environment and also in the close vicinity of patients at risk for IA, there is an urgent need to understand the evolution of the increasing azole resistance in A. fumigatus. Thereby, induction of azole resistance or its spread can possibly be prevented to allow future treatment of A. fumigatus IA.

Activity of MGCD290, a Hos2 histone deacetylase inhibitor, in combination with azole antifungals against opportunistic fungal pathogens

We report on the in vitro activity of the Hos2 fungal histone deacetylase (HDAC) inhibitor MGCD290 (MethylGene, Inc.) in combination with azoles against azole-resistant yeasts and molds. Susceptibility testing was performed by the CLSI M27-A3 and M38-A2 broth microdilution methods. Testing of the combinations (MGCD290 in combination with fluconazole, posaconazole, or voriconazole) was performed by the checkerboard method. The fractional inhibitory concentrations were determined and were defined as <0.5 for synergy, >or=0.5 but <4 for indifference, and >or=4 for antagonism. Ninety-one isolates were tested, as follows: 30 Candida isolates, 10 Aspergillus isolates, 15 isolates of the Zygomycetes order, 10 Cryptococcus neoformans isolates, 8 Rhodotorula isolates, 8 Fusarium isolates, 5 Trichosporon isolates, and 5 Scedosporium isolates. MGCD290 showed modest activity when it was used alone (MICs, 1 to 8 microg/ml) and was mostly active against azole-resistant yeasts, but the MICs against molds were high (16 to >32 microg/ml). MGCD290 was synergistic with fluconazole against 55 (60%) of the 91 isolates, with posaconazole against 46 (51%) of the 91 isolates, and with voriconazole against 48 (53%) of the 91 isolates. Synergy between fluconazole and MGCD290 was observed against 26/30 (87%) Candida isolates. All 23 of the 91 Candida isolates that were not fluconazole susceptible demonstrated a reduced fluconazole MIC that crossed an interpretive breakpoint (e.g., resistant [MIC, >or=64 microg/ml] to susceptible [MIC, <or=8 microg/ml]) when fluconazole was combined with MGCD290 at 0.12 to 4 microg/ml. The activity of fluconazole plus MGCD290 was also synergistic against 6/10 Aspergillus isolates. Posaconazole plus MGCD290 demonstrated synergy against 14/15 Zygomycetes (9 Rhizopus isolates and 5 Mucor isolates). Voriconazole plus MGCD290 demonstrated synergy against six of eight Fusarium isolates. Thus, MGCD290 demonstrated in vitro synergy with azoles against the majority of clinical isolates tested, including many azole-resistant isolates and genera inherently resistant to azoles (e.g., Mucor and Fusarium). Further evaluation of fungal HDAC inhibitor-azole combinations is indicated.

Usefulness of the "Candida score" for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: a prospective multicenter study

OBJECTIVE

To assess the usefulness of the "Candida score" (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point.

DESIGN

Prospective, cohort, observational study.

SETTING

Thirty-six medical-surgical intensive care units of Spain, Argentina, and France.

PATIENTS

A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007.

MEASUREMENTS AND MAIN RESULTS

Clinical data, surveillance cultures for fungal growth, and serum levels of (1-3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition x1, plus surgery x1, plus multifocal Candida colonization x1, plus severe sepsis x2. A CS >or=3 accurately selected patients at high risk for IC. The colonization index was registered if >or=0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06-3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p <or= 0.001). The area under the receiver operating characteristic curve for CS was 0.774 (95% CI 0.715-0.832) compared with 0.633 (95% CI 0.557-0.709) for CI. (1-3)-Beta-d-glucan was also an independent predictor of IC (odds ratio 1.004, 95% CI 1.0-1.007). The relative risk for developing IC in colonized patients without antifungal treatment was 6.83 (95% CI 3.81-12.45).

CONCLUSIONS

In this cohort of colonized patients staying >7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.

Isolation, structure elucidation, and biological activity of virgineone from Lachnum Wirgineum using the genome-wide Candida albicans fitness test

A glycosylated tetramic acid, virgineone (1), was isolated from saprotrophic Lachnum virgineum. The antifungal activity of the fermentation extract of L. virgineum was characterized in the Candida albicans fitness test as distinguishable from other natural products tested. Bioassay-guided fractionation yielded 1, a tyrosine-derived tetramic acid with a C-22 oxygenated chain and a beta-mannose. It displayed broad-spectrum antifungal activity against Candida spp. and Aspergillus fumigatus with a MIC of 4 and 16 microg/mL, respectively. Virgineone was also identified in a number of Lachnum strains collected from diverse geographies and habitats.

Isolation, structure and biological activity of phomafungin, a cyclic lipodepsipeptide from a widespread tropical Phoma sp

We isolated a cyclic lipodepsipeptide, phomafungin, from a Phoma sp. The distinct antifungal activity of phomafungin in the crude extract was initially discovered by mechanistic profiling in the Candida albicans fitness test. The purified compound contains a 28 member ring consisting of eight amino acids and a beta-hydroxy-gamma-methyl-hexadecanoic acid, and displays a broad spectrum of antifungal activity against Candida spp., Aspergillus fumigatus and Trichophyton mentagrophytes with MIC of 2-8 microg/ml, and toxicity to mice at 25 mg/kg. The linear peptide derived from opening of the lactone ring was devoid of antifungal activity as well as toxicity. Phomafungin has been identified in a number of Phoma spp. collected from Africa and the Indian and Pacific Ocean islands.