Antifungal drug resistance of oral fungi

Cell-free supernatants of probiotic consortia impede hyphal formation and disperse biofilms of vulvovaginal candidiasis causing Candida in an ex-vivo model

Vulvovaginal candidiasis is the second most common vaginal infection caused by drug-resistant Candida species that affects about 70-75% of reproductive age group women across the globe. As current-day antifungal drugs are ineffective against the biofilms formed by the drug-resistant Candida strains, several natural compounds and antagonistic microbes are being explored as alternative antifungal agents. In the present study, we investigated the anti-biofilm activity of Cell-Free Supernatant (CFS) extracted from the commercially available probiotics VSL-3 against the biofilms of Candida species and also evaluated their efficacy in curbing the yeast-to-hyphal transition. Various methodologies like crystal violet staining and scanning electron microscopy were used to study the effect of CFS against the biofilms formed by the species. The ability of CFS to interfere with yeast to hyphal transition in Candida was studied by colony morphology assay and visually confirmed with phase contrast microscopy. The potential of the CFS of the probiotics was also evaluated using goat buccal tissue, a novel ex-vivo model that mimics the vaginal environment. Moreover, the supernatant extracted from VSL-3 had the ability to down-regulate the expression of virulence genes of Candida from the biofilm formed over the ex-vivo model. These results emphasize the anti-fungal and anti-infective properties of the CFS of VSL-3 against drug-resistant Candida strains causing vulvovaginal candidiasis.

Discovery of phosphorylated lantibiotics with proimmune activity that regulate the oral microbiome

Lantibiotics are ribosomally synthesized and posttranslationally modified peptides (RiPPs) that are produced by bacteria. Interest in this group of natural products is increasing rapidly as alternatives to conventional antibiotics. Some human microbiome-derived commensals produce lantibiotics to impair pathogens' colonization and promote healthy microbiomes. Streptococcus salivarius is one of the first commensal microbes to colonize the human oral cavity and gastrointestinal tract, and its biosynthesis of RiPPs, called salivaricins, has been shown to inhibit the growth of oral pathogens. Herein, we report on a phosphorylated class of three related RiPPs, collectively referred to as salivaricin 10, that exhibit proimmune activity and targeted antimicrobial properties against known oral pathogens and multispecies biofilms. Strikingly, the immunomodulatory activities observed include upregulation of neutrophil-mediated phagocytosis, promotion of antiinflammatory M2 macrophage polarization, and stimulation of neutrophil chemotaxis-these activities have been attributed to the phosphorylation site identified on the N-terminal region of the peptides. Salivaricin 10 peptides were determined to be produced by S. salivarius strains found in healthy human subjects, and their dual bactericidal/antibiofilm and immunoregulatory activity may provide new means to effectively target infectious pathogens while maintaining important oral microbiota.

Identification and susceptibility testing of oral candidiasis in advanced cancer patients

BACKGROUND

Patients with advanced cancer are prone to develop different opportunistic oral infection due to anti-cancer treatment or the malignancies themselves. Studies of oral fungal samples show an increased prevalence of non-Candida albicans species in mixed oral infections with Candida albicans. Non-C. albicans and C. albicans are associated with varying degrees of resistance to azoles, which may have implications for treatment. This study aimed to assess the diversity and antifungal susceptibility of Candida species detected in the oral cavity.

METHODS

An observational study with microbiological analysis was conducted. Clinical fungal isolates were collected from patients in a hospice unit in 2014-2016. Isolates were re-grown on chromID® Candida plates in 2020. Single colony of each species was re-cultivated and prepared for biochemical identification with a VITEK2® system and verified by gene sequencing. Etest was performed on RPMI agar, and the antifungals fluconazole, amphotericin B, anidulafungin and nystatin were applied.

RESULTS

Fifty-six isolates from 45 patients were identified. Seven different Candida species and one Saccharomyces species were detected. The results of biochemical identification were confirmed with sequencing analysis. Thirty-six patients had mono infection, and nine out of 45 patients had 2-3 different species detected. Of C. albicans strains, 39 out of 40 were susceptible to fluconazole. Two non-C. albicans species were resistant to fluconazole, one to amphotericin B and three to anidulafungin.

CONCLUSION

C. albicans was the predominant species, with a high susceptibility to antifungal agents. Different Candida species occur in both mono and mixed infections. Identification and susceptibility testing may therefore lead to more effective treatment and may prevent the development of resistance among patients with advanced cancer.

TRAIL REGISTRATION

The study Oral Health in Advanced Cancer was registered at ClinicalTrials.gov (#NCT02067572) in 20/02/2014.

Potential Inhibitory Effect of Miltefosine against Terbinafine-Resistant Trichophyton indotineae

Several prolonged and significant outbreaks of dermatophytosis caused by Trichophyton indotineae, a new emerging terbinafine-resistant species, have been ongoing in India in recent years, and have since spread to various countries outside Asia. Miltefosine, an alkylphosphocholine, is the most recently approved drug for the treatment of both visceral and cutaneous leishmaniasis. Miltefosine in vitro activity against terbinafine-resistant and susceptible T. mentagrophytes/T. interdigitale species complex, including T. indotineae, is limited. The current study aimed to assess miltefosine's in vitro activity against dermatophyte isolates, which are the most common causes of dermatophytosis. Miltefosine, terbinafine, butenafine, tolnaftate, and itraconazole susceptibility testing was performed using Clinical and Laboratory Standards Institute broth microdilution methods (CLSI M38-A3) against 40 terbinafine-resistant T. indotineae isolates and 40 terbinafine-susceptible T. mentagrophytes/T. interdigitale species complex isolates. Miltefosine had MIC ranges of 0.063-0.5 µg/mL and 0.125-0.25 µg/mL against both terbinafine-resistant and susceptible isolates. In terbinafine-resistant isolates, the MIC₅₀ and MIC₉₀ were 0.125 µg/mL and 0.25 µg/mL, respectively, and 0.25 µg/mL in susceptible isolates. Miltefosine had statistically significant differences in MIC results when compared to other antifungal agents (p-value 0.05) in terbinafine-resistant strains. Accordingly, the findings suggest that miltefosine has a potential activity for treating infections caused by terbinafine-resistant T. indotineae. However, further studies are needed to determine how well this in vitro activity translates into in vivo efficacy.

Culturing the Human Oral Microbiota, Updating Methodologies and Cultivation Techniques

Recent years have been marked by a paradigm shift in the study of the human microbiota, with a re-emergence of culture-dependent approaches. Numerous studies have been devoted to the human microbiota, while studies on the oral microbiota still remain limited. Indeed, various techniques described in the literature may enable an exhaustive study of the microbial composition of a complex ecosystem. In this article, we report different methodologies and culture media described in the literature that can be applied to study the oral microbiota by culture. We report on specific methodologies for targeted culture and specific culture techniques and selection methodologies for cultivating members of the three kingdoms of life commonly found in the human oral cavity, namely, eukaryota, bacteria and archaea. This bibliographic review aims to bring together the various techniques described in the literature, enabling a comprehensive study of the oral microbiota in order to demonstrate its involvement in oral health and diseases.

High-throughput assay for effect screening of amphotericin B and bioactive components on filamentous Candida albicans

AIMS

The aim of this study was to develop a high-throughput robotic microtiter plate-based screening assay for Candida albicans, optimizing growth conditions to replicate the filamentous biofilm growth found in vivo, and subsequently, to demonstrate the assay by evaluating the effect of nutritional drinks alone and in combination with the antifungal amphotericin B (AmB).

METHODS AND RESULTS

Candida albicans cultured in a defined growth medium showed filamentous growth in microcolonies, mimicking the morphology of oral mucosal disease (oral candidiasis). Addition of nutrient drinks containing fruit juices, fish oil and whey protein to the medium resulted in changed morphology and promoted growth as free yeast cells and with weak biofilm structures. Minimum inhibitory concentration of AmB on the biofilms was 0.25 μg ml^-1 , and this was eightfold reduced (0.0038 μg ml^-1 ) in the presence of the nutritional drinks.

CONCLUSIONS

The established assay demonstrated applicability for screening of antifungal and anti-biofilm effects of bioactive substances on C. albicans biofilm with clinically relevant morphology.

SIGNIFICANCE AND IMPACT OF THE STUDY

Candida albicans is the causative agent of the majority of fungal infections globally. The filamentous morphology of C. albicans and the ability to form biofilm are traits known to increase virulence and resistance towards antifungals. This study describes the development of a plate-based in vitro screening method mimicking the filamentous morphology of C. albicans found in vivo. The assay established can thus facilitate efficient antifungal drug discovery and development.

Efficacy of oral nystatin treatment for patients with oral mucosal dysesthesia but without objective oral mucosal manifestations and necessity of Candida culture test before oral nystatin treatment

Background/purpose

Materials and methods

Results

Conclusion

The antifungal and antibiofilm activity of Cymbopogon nardus essential oil and citronellal on clinical strains of Candida albicans

OBJECTIVE

This study investigated the antifungal and antibiofilm activity of Cymbopogon nardus essential oil (EO) and its major compound, citronellal, in association with miconazole and chlorhexidine on clinical strains of Candida albicans. The likely mechanism(s) of action of C. nardus EO and citronellal was further determined.

MATERIALS AND METHODS

The EO was chemically characterized by gas chromatography coupled with mass spectrometry (GC-MS). The antifungal activity (MIC/MFC) and antibiofilm effects of C. nardus EO and citronellal were determined by the microdilution method, and their likely mechanism(s) of action was determined by the sorbitol and ergosterol assays. Then, the samples were tested for a potential association with standard drugs through the checkerboard technique. Miconazole and chlorhexidine were used as positive controls and the assays were performed in triplicate.

RESULTS

The GC-MS analysis tentatively identified citronellal as the major compound in C. nardus EO. Both samples showed antifungal activity, with MIC of 256 µg/mL, as compared to 128 µg/mL and 8 µg/mL of miconazole and chlorhexidine, respectively. C. nardus EO and citronellal effectively inhibited biofilm formation (p < 0.05) and disrupted preformed biofilms (p < 0.0001). They most likely interact with the cell membrane, but not the cell wall, and did not present any synergistic activity when associated with standard drugs.

CONCLUSION

C. nardus EO and citronellal showed strong in vitro antifungal and antibiofilm activity on C. albicans.

CLINICAL RELEVANCE

Natural products have been historically bioprospected for novel solutions to control fungal biofilms. Our data provide relevant insights into the potential of C. nardus EO and citronellal for further clinical testing. However, additional bioavailability and toxicity studies must be carried out before these products can be used for the chemical control of oral biofilms.

Phylogeny, Antifungal Susceptibility, and Point Mutations of SQLE Gene in Major Pathogenic Dermatophytes Isolated From Clinical Dermatophytosis

Drug resistance is one of the major challenges to skin fungal infections, especially in tropical and subtropical infections caused by dermatophytes. This study aimed to determine the antifungal susceptibility of clinically dermatophytes and evaluate point mutations in terbinafine-resistant isolates. A total number of 123 clinical dermatophyte isolates in eight species were evaluated in terms of sensitivity to seven major antifungals. Furthermore, the point mutation in squalene epoxidase (SQLE) gene responsible for terbinafine resistance was studied. The dermatophytes species were identified by morphological characteristics and confirmed by the ITS sequencing. Also, the phylogenetic tree was drawn using the RAxML analyses for 123 dermatophytes isolates. A new XXIX genotype was also found in 4 Trichophyton mentagrophytes isolates. Based on the results obtained, terbinafine was the most effective antifungal drug followed by itraconazole and voriconazole. Trichophyton rubrum and Trichophyton tonsurans were the most susceptible species (MIC₅₀ = 0.01, 0.09 μg/ml), and T. mentagrophytes was the most resistant species (MIC₅₀ = 0.125 μg/ml) to terbinafine. Of the 123 dermatophytes isolates, six isolates showed reduced susceptibility to terbinafine, and only Trichophyton indotineae had a mutation in SQLE gene as a Phe397Leu substitution. Overall, the antifungal susceptibility test is necessary for managing dermatophytosis. These results help physicians to control the course of the disease and provide further insights to select effective drugs for patients with dermatophytosis, especially in tropical and subtropical regions of the world, where dermatophytosis is still a public health problem.

Antifungal Activity of Beluntas "Indian Camphorweed" (Pluchea indica) Ethanol Extract on Candida albicans In Vitro Using Different Solvent Concentrations

Objective  Oral candidiasis is an infection caused by pathogenic fungi Candida albicans , with a considerably high prevalence of 20 to 72%. Indian camphorweed ( Pluchea indica ) also known as “beluntas” as the local name has been known as a traditional medicine in Indonesia. The objective of this study is to research the minimum inhibitory concentration (MIC) and the minimum fungicidal concentration (MFC) of beluntas ethanolic extract against the growth of C. albicans .

Materials and Methods  The MIC and MFC were measured by microdilution assay and total plate count respectively with a variation of solvents (DMSO 1%, 10%, and 4%) and beluntas extract with concentrations between 0.3125 and 200 mg/mL. Amphotericin and nystatin were used as a comparison.

Statistical Analysis  One-way analysis of variance and posthoc Tukey test were used to determine the significant difference between treatments.

Results  It was found that the MIC ranged from 50 to 200 mg/mL in the test with DMSO 10% solvent and MFC was found to be at a concentration of 200 mg/mL. However, there is a significant inhibitory effect and killing effect from DMSO 10% against C. albicans ( p  = 0.000). MIC was also found within concentrations of 100 mg/mL of beluntas extract in DMSO 4%. In this study, the DMSO 4% concentration neither showed significant inhibitory effects nor killing effects; therefore, the result was acceptable ( p  = 0.357).

Conclusion  Ethanol extract of beluntas ( P. Indica ) has the potential of being an antifungal agent with inhibitory activity in concentrations ≥100 mg/mL, which is similar to nystatin ( p  = 0.278). The MFC for the extract was above 100 mg/mL, which cannot be measured with this method as a higher concentration of DMSO is needed, which had a toxic effect on the tested fungi.

Volatile phenolics: A comprehensive review of the anti-infective properties of an important class of essential oil constituents

Historically, essential oils and their lead molecules have been extensively recognised for their anti-infective properties. In this context, certain volatile phenolics (VPs) have emerged as important antimicrobial compounds with excellent inhibitory activity against pathogenic bacteria and fungi, which further extends to drug-resistant and biofilm-forming micro-organisms. In this review, we aim to collate and discuss a number of published papers on the anti-infective activities of naturally occurring VPs with special emphasis on eugenol, isoeugenol, thymol and carvacrol, using Scopus Web of Science and PubMed databases. The biosynthesis and extraction of these VPs are discussed, while particular attention is given to their broad-spectrum antimicrobial activity and the mechanisms of action. We highlight combinational studies of the VPs with other phytocompounds and with commercially available drugs, which may be a promising and a rewarding future approach to combat antimicrobial resistance. These VPs alone, or concomitantly with other compounds or drugs, have the potential to be incorporated into different formulations for biomedical applications. An in-depth assessment of 2310 articles retrieved from the Scopus database spanning a 35-year period indicated 23.1% increase in global publication growth in VPs anti-infective research, with authors from Italy, Portugal and Austria dominating the research landscape. The dominant areas of investigations are identified as antimicrobial activity, antibacterial mechanism of action, antifungal mechanism of action, extraction methods and phytochemistry, use in the food industry, and for oral and dental anti-infective activity. Specific research areas, which require future attention include; antituberculosis research, nanoparticle formulation of antimicrobial active VP molecules, preclinical and clinical trials. The antimicrobial testing of isoeugenol was found to be the least studied of the VPs and this requires further attention.

Identification of Promising Antifungal Drugs against Scedosporium and Lomentospora Species after Screening of Pathogen Box Library

Fungal infections have been increasing during the last decades. Scedosporium and Lomentospora species are filamentous fungi most associated to those infections, especially in immunocompromised patients. Considering the limited options of treatment and the emergence of resistant isolates, an increasing concern motivates the development of new therapeutic alternatives. In this context, the present study screened the Pathogen Box library to identify compounds with antifungal activity against Scedosporium and Lomentospora. Using antifungal susceptibility tests, biofilm analysis, scanning electron microscopy (SEM), and synergism assay, auranofin and iodoquinol were found to present promising repurposing applications. Both compounds were active against different Scedosporium and Lomentospora, including planktonic cells and biofilm. SEM revealed morphological alterations and synergism analysis showed that both drugs present positive interactions with voriconazole, fluconazole, and caspofungin. These data suggest that auranofin and iodoquinol are promising compounds to be studied as repurposing approaches against scedosporiosis and lomentosporiosis.

Solid and Semisolid Innovative Formulations Containing Miconazole-Loaded Solid Lipid Microparticles to Promote Drug Entrapment into the Buccal Mucosa

The currently available antifungal therapy for oral candidiasis (OC) has various limitations restricting its clinical use, such as short retention time, suboptimal drug concentration and low patients compliance. These issues could be overcome using micro or nanotechnology. In particular, solid lipid microparticles (SLMs) resulted as a particularly promising penetration enhancer carrier for lipophilic drugs, such as the antifungal miconazole (MCZ). Based on these considerations, cetyl decanoate (here synthesized without the use of metal catalysis) was employed together with 1-hexadecanol to prepare MCZ-loaded SLMs. These resulted in a powder composed of 45–300 µm diameter solid spherical particles, able to load a high amount of MCZ in the amorphous form and characterized by a melting temperature range perfectly compatible with oromucosal administration (35–37 °C). Moreover, when compared to Daktarin^® 2% oral gel in ex vivo experiments, SLMs were able to increase up to three-fold MCZ accumulation into the porcine buccal mucosa. The prepared SLMs were then loaded into a buccal gel or a microcomposite mucoadhesive buccal film and evaluated in terms of MCZ permeation and/or accumulation into porcine buccal mucosa by using lower doses than the conventional dosage form. The promising results obtained highlighted an enhancement in terms of MCZ accumulation even at low doses. Furthermore, the prepared buccal film was eligible as stable, reproducible and also highly mucoadhesive. Therefore, the formulated SLMs represent a penetration enhancer vehicle suitable to reduce the dose of lipophilic drugs to be administered to achieve the desired therapeutic effects, as well as being able to be effectively embedded into easily administrable solid or semisolid dosage forms.

Histatin 5 Metallopeptides and Their Potential against Candida albicans Pathogenicity and Drug Resistance

Usually caused by Candida albicans, buccal candidiasis begins with the morphological transition between yeast and hyphal cells. Over time and without the correct treatment, it can be disseminated through the bloodstream becoming a systemic infection with high mortality rates. C. albicans already shows resistance against antifungals commonly used in treatments. Therefore, the search for new drugs capable of overcoming antifungal resistance is essential. Histatin 5 (Hst5) is an antimicrobial peptide of the Histatin family, that can be found naturally in human saliva. This peptide presents high antifungal activity against C. albicans. However, Hst5 action can be decreased for interaction with enzymes and metal ions present in the oral cavity. The current work aims to bring a brief review of relevant aspects of the pathogenesis and resistance mechanisms already reported for C. albicans. In addition, are also reported here the main immune responses of the human body and the most common antifungal drugs. Finally, the most important aspects regarding Histatin 5 and the benefits of its interaction with metals are highlighted. The intention of this review is to show the promising use of Hst5 metallopeptides in the development of effective drugs.

Biofilm formation in clinically relevant filamentous fungi: a therapeutic challenge

Biofilms are highly-organized microbial communities attached to a biotic or an abiotic surface, surrounded by an extracellular matrix secreted by the biofilm-forming cells. The majority of fungal pathogens contribute to biofilm formation within tissues or biomedical devices, leading to serious and persistent infections. The clinical significance of biofilms relies on the increased resistance to conventional antifungal therapies and suppression of the host immune system, which leads to invasive and recurrent fungal infections. While different features of yeast biofilms are well-described in the literature, the structural and molecular basis of biofilm formation of clinically related filamentous fungi has not been fully addressed. This review aimed to address biofilm formation in clinically relevant filamentous fungi.

Oral candidiasis in HIV-uninfected pediatric population in areas with limited fungal diagnosis: A case study from a tertiary hospital, Tanzania

Background

Oral candidiasis (OC) is an indirect indicator of cell-mediated immunodeficiency with a high predictive value of disseminated candidiasis. Here, we report the prevalence and factors associated with laboratory-confirmed OC in human immunodeficiency virus (HIV)-uninfected children with clinical OC attending the outpatient clinic or admitted in pediatric wards of the Bugando Medical Center (BMC).

Methods

A cross-sectional study was conducted between January and June 2017. Social demographic and clinical data were collected using a pre-tested data collection tool. Oral swabs were collected using a sterile cotton swab and mycological culture was done to detect Candida spp. followed by susceptibility testing as per European Committee on Antimicrobial Testing (EUCAST) guidelines. Data were analyzed using STATA version 13 following study objectives.

Results

A total of 325 non-repetitive oral swabs from HIV-uninfected children aged between 2 and 156 months were collected. Candida spp. were detected in 123 (37.8%) children. One (1.8%) C. albicans isolate was resistant to fluconazole, voriconazole, and posaconazole with minimum inhibitory concentrations (MIC) of 256 μg/ml, 32 μg/ml, and 0.31 μg/ml, respectively. Upon multivariate logistic regression analysis, being a male child (OR 2, 95% CI 1.2-3.2, p = 0.008) and having a history of antibiotic use (OR 1.8, 95% CI 1.1-2.8, p = 0.017) independently predicted laboratory-confirmed OC among HIV-uninfected children.

Conclusion

Only a third of children with clinical OC were laboratory confirmed, and this was more likely in male children with a history of antibiotic use. Most of the isolates were highly susceptible to commonly used antifungal agents like fluconazole. Treatment of children at risk should be prioritized to reduce associated morbidity.

In Vitro Antifungal Activity and Mechanism of Ag3PW12O40 Composites against Candida Species

Fungal infections pose a serious threat to human health. Polyoxometalates (POMs) are metal–oxygen clusters with potential application in the control of microbial infections. Herein, the Ag₃PW₁₂O₄₀ composites have been synthesized and verified by Fourier transform infrared (FT-IR) spectrum, transmission electron microscopy (TEM), scanning electron microscope (SEM), elemental analysis, and X-ray diffraction (XRD). The antifungal activities of Ag₃PW₁₂O₄₀ were screened in 19 Candida species strains through the determination of minimum inhibitory concentration (MIC) by the microdilution checkerboard technique. The minimum inhibitory concentration (MIC₅₀) values of Ag₃PW₁₂O₄₀ are 2~32 μg/mL to the Candida species. The MIC₈₀ value of Ag₃PW₁₂O₄₀ to resistant clinical isolates C. albicans HL963 is 8 μg/mL, which is lower than the positive control, fluconazole (FLC). The mechanism against C. albicans HL963 results show that Ag₃PW₁₂O₄₀ can decrease the ergosterol content. The expressions of ERG1, ERG7, and ERG11, which impact on the synthesis of ergosterol, are all prominently upregulated by Ag₃PW₁₂O₄₀. It indicates that Ag₃PW₁₂O₄₀ is a candidate in the development of new antifungal agents.

Antagonistic effect of isolated and commercially available probiotics on the growth of Candida albicans on acrylic resin denture surfaces

STATEMENT OF PROBLEM

Biofilms can be retained on dental prostheses leading to the development of infections. The indiscriminate use of antifungal drugs can result in the development of microorganisms that are resistant to these antimicrobial agents. Whether probiotics are a suitable alternative for reducing the prevalence of oral candidiasis is unclear.

PURPOSE

The purpose of this in vitro study was to evaluate the influence of 6 different live strains of probiotics and 2 commercially available probiotic supplements used for inhibiting the growth of Candida albicans biofilm in heat-polymerized acrylic resin denture base material and to determine whether biofilm byproducts modify the surface of specimens.

MATERIAL AND METHODS

Biofilms of C. albicans were formed on acrylic resin specimens in the presence of probiotics and quantified by colony-forming units (CFUs), and the surface roughness (Ra) of the specimens was assessed before and after the formation of biofilms. The CFU and roughness data were analyzed by analysis of variance and the Tukey HSD test (α=.05).

RESULTS

A significant decrease in the number (CFU/mL) of C. albicans cells was found when they were cultured with 4 probiotics: B. lactis (P=.045), B. longum (P<.001), L. casei (P<.001), and L. helveticus (P<.001) and with the commercially available probiotic Prolive (P=.05). The Ra of specimens decreased after exposure to different microbial biofilms (P≤.05) except in 3 experimental groups.

CONCLUSIONS

In general, the tested probiotics had an antagonistic effect on the growth of C. albicans, and the surface of acrylic resin was altered after exposure to biofilm byproducts.

DNA microsatellite genotyping of potentially pathogenic Candida albicans and C. dubliniensis isolated from the oral cavity and dental prostheses

This study investigated the incidence, genetic diversity, antifungal sensitivity, and virulence of Candida albicans and C. dubliniensis isolated from subjects using dental prostheses and subjects clinically indicated for the first prosthetic rehabilitation. Subjects were divided into four groups and samples were collected twice: at first rehabilitation by removable partial (A) and total (C) dental prostheses, and replacement of the removable partial (B) and total (D) prostheses. Yeasts were genotyped using DNA microsatellite markers. Microbiological methods were used to screen for azole antifungal resistance and exoenzyme production. In the initial sampling, oral colonization by Candida was observed in 31 (53.4%) subjects in groups A (33.3%), B (68.2%), and D (65%); 20 (47.6%) subjects displayed colonization of prostheses: groups B (50%) and D (45%). The second sampling (±30 days) revealed Candida in 2 (3.4%: oral cavity) and 4 (6.9%: prosthetic) subjects from group B. C. albicans and C. dubliniensis displayed both polyclonal and monoclonal patterns of infection. Azole-resistant C. albicans and SAPs⁺ strains were prevalent. Related strains were found in one or several oral sites (mucosa and prosthesis), as well as intra- and inter-subject, -gender, -group, and -time of sampling. However, the patterns of clonality can be altered under dental care.

The effectiveness of microwave disinfection in treating Candida-associated denture stomatitis: a systematic review and metaanalysis

OBJECTIVE

To evaluate the effectiveness of microwave disinfection in treating Candida-associated denture stomatitis (CADS).

MATERIALS AND METHODS

The PubMed/MEDLINE, Embase, and Scopus databases were searched for reports on randomized clinical trials (RCTs) published in English until May 2020 (PROSPERO CRD42020192062) that evaluated the treatment of CADS by using microwave disinfection. The main outcomes were the improvement of clinical signs and/or the decrease in the residual yeast present on the dentures and palatal mucosa. The mean differences, standard deviations, risk ratio, and 95% confidence interval were calculated by using the random-effects model. Heterogeneity was assessed by using Cochran's Q test and I² values. The level of significance was set at α = 0.05.

RESULTS

Five RCTs with 245 participants were included. The descriptive investigations demonstrated that microwave disinfection was as effective (p > 0.05) as 0.2% chlorhexidine, 0.02% sodium hypochlorite, and topical nystatin (100.000 IU/mL), and was superior to topical miconazole in treating CADS. The metaanalysis did not show a statistical difference between microwave disinfection and nystatin (100.000 IU/mL) treatment in terms of mycological counts, cure, and recurrence rates (p > 0.05).

CONCLUSION

Microwave disinfection showed comparable results with those of conventional therapies for treating CADS. In addition, treatment with 650 W for 3 min once a week for 14 days had better cost-effect results, indicating both the prevention and treatment of CADS.

CLINICAL RELEVANCE

Our findings provide evidence regarding the treatment of CADS using microwave disinfection, and also indicating the best cost-effective option for this treatment modality.

Comparative inhibitory effects of 4-allylpyrocatechol isolated from Piper betle on Streptococcus intermedius, Streptococcus mutans, and Candida albicans

Streptococcus intermedius, Streptococcus mutans, and Candida albicans are harmful oral pathogens and prone to resist chemical antimicrobial agents. Active ingredients from plants are of increasing interest as an alternative. This study aims to compare antimicrobial effects of 4-allylpyrocatechol (APC) extracted from Piper betle on these oral pathogens. Minimum concentration of APC against the tested pathogens was determined using a broth microdilution assay. Killing kinetic study of APC was carried out within 24 h. Morphology of the pathogenic cells was assessed using scanning electron microscopy (SEM). Anti-biofilm was investigated using crystal violet assay and confocal laser scanning microscopy (CLSM). The results showed that the mechanism of inhibition of APC was bactericidal and fungicidal effects. APC at minimum concentration of 400 μg/mL could completely kill Streptococcus and Candida spp., however, the killing rate on S. intermedius and C. albicans was significantly faster than on S. mutans. APC inhibited biofilm formation of C. albicans more efficiently than that of the bacterial cells. Cell morphology from SEM indicated that APC caused bacterial cell membrane destruction and inhibited fungal budding or tubing formation. CLSM images confirmed the killing potential of APC and suggested that bacterial dead cells could be easier washed out than the fungal dead cells. It is concluded that APC potentially inhibits growth and biofilms of oral Streptococcus and Candida spp. in different mechanism of action and killing rate. APC can be considered as a promising agent for preventing and treating dental disorders caused by S. intermedius, S. mutans, and C. albicans.

Effect of Antibacterial Silver-Releasing Filler on the Physicochemical Properties of Poly(Methyl Methacrylate) Denture Base Material

Colonization of polymeric dental prosthetic materials by yeast-like fungi and the association of these microorganisms with complications occurring during prosthetic treatment are important clinical problems. In previously presented research, submicron inorganic particles of silver sodium hydrogen zirconium phosphate (S-P) were introduced into poly(methyl methacrylate) (PMMA) denture base material which allowed for obtaining the antimicrobial effect during a 90 day experiment. The aim of the present study was to investigate the flexural strength, impact strength, hardness, wear resistance, sorption, and solubility during three months of storage in distilled water. With increasing S-P concentration after 2 days of conditioning in distilled water, reduced values of flexural strength (107-72 MPa), impact strength (18.4-5.5 MPa) as well as enhanced solubility (0.95-1.49 µg/mm3) were registered, but they were at acceptable levels, and the sorption was stable. Favorable changes included increased hardness (198-238 MPa), flexural modulus (2.9-3.3 GPa), and decreased volume loss during wear test (2.9-0.2 mm3). The percentage changes of the analyzed properties during the 90 days of storage in distilled water were similar for all materials.

The Role of Biofilms and Material Surface Characteristics in Microbial Adhesion to Maxillary Obturator Materials: A Literature Review

BACKGROUND

Maxillofacial prosthetics includes restoration of maxillary defects resulting from resection of palate and nasosinus neoplasms with obturator prostheses which may be colonized by microorganisms and function as a reservoir of infection. Patients with neoplasms commonly also require radiotherapy that can result in changes in saliva quality and quantity and changes in the oral microbial flora. The altered flora, in individuals immunocompromised from cancer therapy, increases their risk of prosthesis-related infections.

OBJECTIVES

In this review article, we explore microbial biofilms, their main components, mechanisms of microbial adhesion, and stages of biofilm development. We also discuss the different materials that are used for manufacturing maxillary obturators, their characteristic features, and how these can affect microbial adhesion. Furthermore, we shed some light on the factors that affect microbial adhesion to the surface of maxillary obturators including tissue proteins, protein adsorption, and the acquired enamel pellicle.

CONCLUSIONS

The conclusions drawn from this literature review are that it is imperative to minimize the risk of local and systemic infections in immunocompromised patients with cancer having maxillary defects. It is also important to determine the role of saliva in microbial adhesion to obturator materials as well as develop materials that have a longer life span with surface characteristics that promote less microbial adhesion than current materials.

The Dysbiosis and Inter-Kingdom Synergy Model in Oropharyngeal Candidiasis, a New Perspective in Pathogenesis

As more information emerges on oral microbiota using advanced sequencing methodologies, it is imperative to examine how organisms modulate the capacity of each other to colonize or trigger infection. Most mouse models of oral C. albicans infection have focused on interactions with single bacterial species. Thus, little is known about the microbiome-mediated interactions that control the switch of C. albicans from commensalism to infection. Evidence is accumulating that in immunosuppression where mucosal candidiasis is more prevalent, there is an altered oral bacterial microbiome with reduced diversity, but not an altered mycobiome. Oropharyngeal candidiasis in immunosuppressed humans and mice is associated with a further reduction in oral bacterial diversity and a dysbiotic shift with significant enrichment of streptococcal and enterococcal species. Our recent studies in a cancer chemotherapy mouse model supported the combined profound effect of immunosuppression and C. albicans in reducing oral bacterial diversity and provided the first direct evidence that these changes contribute to pathogenesis, representing dysbiosis. There is still a gap in understanding the relationship between Candida and the oral bacterial microbiome. We propose that certain oral commensal bacteria contribute to fungal pathogenesis and we identify gaps in our understanding of the mechanisms involved in this cooperative virulence.

Structural design of microbicidal cationic oligomers and their synergistic interaction with azoles against Candida albicans

Membrane-disrupting synthetic antimicrobial polymers have been well developed as antimicrobial peptide (AMP) mimics to mitigate antimicrobial resistance (AMR). However, synthetic polymers possess inherent drawbacks, being a mixture of different chain lengths, which restricts their clinical applications. In fact, synthetic oligomers with defined chain length and molecular structure could be better representatives of AMPs. Herein, a series of novel imidazolium-ammonium oligomers developed in this work exhibit excellent broad spectrum antimicrobial activity, specifically the salient structure dependent high efficiency against C. albicans. Moreover, synergistic effect emerged when the combined azoles and synthetic oligomers were applied against C. albicans. The detail structural coupling between azoles and oligomers was scrutinized through molecular dynamics simulations to unravel the interaction details with the atomistic resolution. The labile interaction between oligomer and azoles facilitated the transfer of drug into fungal cells, which can be a synergistic solution to prevent the development of resistance on C. albicans.

Anti-biofilm Action of Chenopodium ambrosioides Extract, Cytotoxic Potential and Effects on Acrylic Denture Surface

Considering the challenge to control Candida-associated denture stomatitis, the search for antifungal substances derived from natural sources has become a trend in the literature. In this study the following effects of Chenopodium ambrosioides extract (CAE) were investigated: action against biofilms of Candida albicans, its cytotoxic potential, and changes caused in acrylic resin. The CAE was characterized by High Performance Liquid Chromatography (HPLC). The susceptibility of C. albicans to CAE was investigated by Minimum Inhibitory Concentration and Minimum Fungicidal Concentration (MIC and MFC) tests. Acrylic resin disks were fabricated, and C. albicans biofilms were developed on these for 48 h. Afterward the disks were immersed for 10 min in: PBS (Negative Control); 1% Sodium Hypochlorite (1% SH, Positive Control) or CAE at MIC or 5xMIC. The biofilms were investigated relative to counts and metabolic activity. The cytotoxic potential in keratinocytes and fibroblasts was verified by MTT test. Change in color and roughness of the acrylic resin was analyzed after 28 days of immersion in CAE. The data were analyzed by the ANOVA considering a 5% level of significance. The main compounds detected by HPLC were kaempferol and quercetin. Both MIC and MFC obtained the value of 0.25 mg/mL. The MIC was sufficient to significantly reduce the counts and activity of the biofilm cells (p < 0.0001), while 5xMIC resulted in almost complete eradication, similar to 1% SH. Keratinocytes and fibroblasts exposed to the MIC and 5xMIC presented cell viability similar to that of the Control Group (p > 0.05). No important changes in acrylic resin color and roughness were detected, even after 28 days. It could be concluded that the immersion of acrylic resin in C. ambrosioides extract in its minimum inhibitory concentration was effective for the reduction of C. albicans biofilms without any evidence of cytotoxic effects or changes in roughness and color of this substrate.

Effects of Streptococcus salivarius K12 with nystatin on oral candidiasis-RCT

OBJECTIVE

To evaluate the efficacy and safety of Streptococcus salivarius K12 as an adjuvant in treating oral candidiasis.

METHODS

A total of 56 patients were participated in the randomized, double-blinded, placebo-controlled clinical trial. The S. salivarius K12 or placebo lozenges plus nystatin tablets were given for up to 4 weeks at 1-week interval and then followed up for 1 week thereafter. We collected and analyzed the mycological and clinical data, treatment course, and safety data.

RESULTS

At the end of the treatment, significant differences were found in the mycological cure rates between K12 group and control group (90.48% and 55.56%, respectively, p = 0.008). Survival analysis demonstrated no statistical difference in overall cure rates comprehensively considering mycological cure, clinical improvement, and recurrence (p = 0.078), while statistical difference was found in mycological cure (p = 0.013) between the two groups. The median treatment courses of K12 group and control group were 3 weeks and 4 weeks, respectively. No severe events were reported during the study.

CONCLUSION

Streptococcus salivarius K12 exhibited potential efficacy and safety as an adjuvant in treating oral candidiasis by enhancing mycological cure and shortening the treatment course of conventional antifungal therapy in this randomized, double-blinded, placebo-controlled clinical trial. Further large-scale clinical studies are desired to accumulate more evidence for its clinical applications.

In vivo effectiveness and safety of probiotics on prophylaxis and treatment of oral candidiasis: a systematic review and meta-analysis

Background

To systematically review and assess the in vivo effectiveness and safety of probiotics for prophylaxis and treating oral candidiasis.

Methods

A literature search for studies published in English until August 1, 2018 was conducted in the following databases: PubMed, EMBASE, Cochrane Library, and Web of Science. Randomized controlled clinical trials and experimental mouse animal model studies comparing probiotics (at any dosage and in any form) with control groups (placebo, blank control or other agents) and reporting outcomes of the prophylactic and therapeutic effects were considered for inclusion. A descriptive study and, potentially, a meta-analysis were planned.

Results

Six randomized controlled clinical trials and 5 controlled experiments of mouse animal models were included in the systematic review. Four randomized controlled clinical trials comparing a probiotics group with a placebo/blank control group in 480 elderly and denture wearers were included in the meta-analysis. The overall combined odds ratio of the (random effects) meta-analysis was 0.24 (95% CI =0.09–0.63, P < 0.01). The overall combined odds ratio of the (fixed effects) sensitivity analysis was 0.39 (95% CI =0.25–0.60, P < 0.01) by excluding a study with the smallest sample size. These analyses showed that there was a statistically significant difference in the effect of probiotics compared with the control groups in elderly and denture wearers. The remaining 2 studies compared probiotics with other agents in a population aged 18–75 years and children aged 6–14 years respectively, and were analyzed descriptively. Meta-analysis and descriptive analyses indicated that probiotics were potentially effective in reducing morbidity, improving clinical symptoms and reducing oral Candida counts in oral candidiasis. The biases of the included studies were low or uncertain. The relatively common complaints reported were gastrointestinal discomfort and unpleasant taste, and no severe adverse events were reported.

Conclusions

Probiotics were superior to the placebo and blank control in preventing and treating oral candidiasis in the elderly and denture wearers. Although probiotics showed a favorable effect in treating oral candidiasis, more evidence is required to warrant their effectiveness when compared with conventional antifungal treatments. Moreover, data on the safety of probiotics are still insufficient, and further research is needed.

Effect of Terminalia catappa Linn. on Biofilms of Candida albicans and Candida glabrata and on Changes in Color and Roughness of Acrylic Resin

This study aimed to investigate the effect of the n-butanol fraction of Terminalia catappa Linn., (FBuTC) on biofilm of Candida albicans and Candida glabrata, as well as changes in color and roughness of polymethyl methacrylate resin (PMMA). The susceptibility of C. albicans and C. glabrata to FBuTC was evaluated by means of the Minimum Inhibitory and Minimum Fungicidal Concentration (MIC and MFC). PMMA acrylic resin discs (N= 108) were fabricated. For the susceptibility tests, biofilms of C. albicans and C. glabrata were developed on discs for 48 h and immersed in phosphate-saline buffer solution (PBS), 1% sodium hypochlorite (SH 1%), or FBuTC at MIC, 5xMIC, or 10xMIC. For the color and roughness change tests, the discs were immersed in distilled water, SH 1%, or FBuTC in the concentrations of 0.25 mg/mL, 2.5 mg/mL, or 25.0 mg/mL. After 28 days of incubation, color change was evaluated by spectrophotometry and roughness, by using a profilometer. The biofilms were investigated by one-way ANOVA and, the color and roughness changes (two-way ANOVA and the Tukey test; α=0.05). For both MIC and MFC the value of 0.25 mg/mL of FBuTC was observed for the planktonic cells of C. albicans and C. glabrata. Exposure to FBuTC at 10xMIC had a significant effect on the biofilm of C. albicans, showing a reduction in cell counts when compared with PBS, (p=0.001). For the biofilm of C. glabrata, the MIC was sufficient for significantly reducing the cell count (p<0.001). No important changes in color and roughness of the acrylic resin were observed, even after 28 days, irrespective of the concentration of FBuTC used (p >0.05). It could be concluded that the immersion of acrylic resin for dental prosthesis in FBuTC was effective in reducing the biofilms of C. albicans and C. glabrata without evidence of change in roughness and color of this substrate.

Efficacy of removing Candida albicans from orthodontic acrylic bases: an in vitro study

Background

This study evaluated the efficacy of four methods in removing Candida albicans from the acrylic base material used to fabricate removable orthodontic appliances.

Methods

Heat-processed bars of orthodontic acrylic were incubated in a suspension of C. albicans for 2 h at 37 °C. Samples were allocated into five groups (five bars per group) according to the cleaning method: (1) manual brushing using a toothbrush; (2) soaking in a commercial denture cleaning solution; (3) soaking in a commercial mouthwash solution; (4) using an ultrasonic cleaner; and (5) soaking in distilled water as a negative control. Yeast remaining attached to the bars after cleaning were removed by vortexing in growth medium and plated on Sabouraud dextrose agar. The reduction in yeast colony count after cleaning was calculated and expressed as the number of colony forming units per acrylic bar (CFU/bar). The experiment was carried out three times.

Results

All four cleaning methods resulted in a significant decrease in viable yeast cells associated with the acrylic bars compared to the control group. The mean percentage reduction in viable yeast cells affected by the cleaning methods was: brushing 89.9%; chlorhexidine 95.8%; ultrasonic cleaning 99.9%; and denture tablet 100%.

Conclusions

All four methods evaluated in this study were effective, to some extent, in removing C. albicans from orthodontic acrylic samples. The most effective, and readily available, cleaning method was the use of commercial denture sterilizing tablets.

Antifungal activities against Candida albicans, of cell-free supernatants obtained from probiotic Pediococcus acidilactici HW01

OBJECTIVE

The aim of this study was to investigate the antifungal activities of cell-free supernatants of a probiotic strain, Pediococcus acidilactici HW01, against Candida albicans.

DESIGN

C. albicans was cultured in the presence of different concentration of cell-free supernatants obtained from P. acidilactici HW01 (HW01 CFS) and the growth of C. albicans was determined. C. albicans was incubated with HW01 CFS for 24 h and the biofilm formation of C. albicans was determined by staining crystal violet and by using a scanning electron microscope. Biofilm quantification was determined by 2, 3-Bis (2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide (XTT) assay.

RESULTS

HW01 CFS inhibitedC. albicans growth, whereas bacteriocin, which is a well-known antimicrobial peptide of lactic acid bacteria, failed to inhibit C. albicans growth. Pre-treatment and simultaneous treatment with HW01 CFS exhibited a significant inhibition of C. albicans biofilm. Although post-treatment with HW01 CFS did not disrupt the established biofilm of C. albicans at 3 h-incubation, significant reduced C. albicans biofilm was observed after 6 h-incubation in the presence of HW01 CFS.

CONCLUSION

These results suggested that the CFS fromP. acidilactici HW01 was revealed as an effective antifungal agent against C. albicans by reducing the growth and biofilm formation.

Prevalence and antifungal susceptibility profiles of Candida glabrata, Candida parapsilosis and their close-related species in oral candidiasis

OBJECTIVE

To evaluate the importance of Candida glabrata, Candida parapsilosis and their close-related species, Candida bracarensis, Candida nivariensis, Candida metapsilosis and Candida orthopsilosis in patients with oral candidiasis and, to determine the in vitro activities of antifungal drugs currently used for the treatment.

METHODS

One hundred fourteen isolates of C. glabrata and 97 of C. parapsilosis, previously identified by conventional mycological methods, were analysed by molecular techniques. In vitro antifungal susceptibility to fluconazole, itraconazole, miconazole, and nystatin was evaluated by CLSI M44-A2 disk diffusion test, and by CLSI M27-A3 microdilution for fluconazole.

RESULTS

All C. glabrata isolates were identified as C. glabrata sensu stricto, 93 out of 97 C. parapsilosis isolates as C. parapsilosis sensu stricto, three as C. orthopsilosis and one as C. metapsilosis. Candida glabrata was mainly isolated in mixed cultures but C. parapsilosis complex was more frequent in pure culture. Candida metapsilosis and C. orthopsilosis were isolated as pure culture and both species were susceptible to all antifungal agents tested. Most C. glabrata isolates were susceptible to miconazole and nystatin, but resistant to fluconazole and itraconazole. Azole cross resistance was also observed. Candida parapsilosis isolates were susceptible to fluconazole although azole cross resistance to miconazole and itraconazole was observed.

CONCLUSION

This study highlights the importance of accurate identification and antifungal susceptibility testing of oral Candida isolates in order to have an in-depth understanding of the role of C. glabrata and C. parapsilosis in oral candidiasis.

In Vitro Antifungal Susceptibility of Candida Species Isolated from Iranian Patients with Denture Stomatitis

Background

Candida-associated denture stomatitis (CADS) is a common fungal infection in people who wear dentures. The main objective of this study was to make molecular identification of causative agents of CADS and in vitro antifungal susceptibility testing (AFST) in the Iranian patients with denture stomatitis.

Methods

A total of 134 Candida spp. were obtained from patients with denture stomatitis. The Candida spp. were identified using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) involving the universal internal transcribed spacer (ITS1 and ITS4) primers, which were subjected to digestion with MspI and BlnI restriction enzymes. The in vitro antifungal susceptibility of Candida spp. to fluconazole (FLC), terbinafine (TRB), itraconazole (ITC), voriconazole (VRC), posaconazole (POS), ketoconazole (KET), amphotericin B (AMB), and caspofungin (CAS) was evaluated using the Clinical and Laboratory Standards Institute M27-A3 and M27-S4 guidelines.

Results

Overall, C. albicans was the most commonly isolated species (n = 84; 62.6%), followed by C. glabrata (n = 23; 17.2%), C. tropicalis (n = 16; 12%), and C. parapsilosis (n = 11; 8.2%). Posaconazole had the lowest geometric mean minimum inhibitory concentration (MIC) (0.03 μg/ml), followed by AMB (0.05 μg/ml), ITC (0.08 μg/ml), VRC (0.11 μg/ml), CAS (0.12 μg/ml), KET (0.15 μg/ml), and FLC (0.26 μg/ml).

Discussion

Our study showed that C. albicans was most prevalent in Iranian patients with CADS and was susceptible to both azoles and amphotericin B. In addition, POS could be an appropriate alternative to the current antifungal agents used for the treatment of CADS, as well as in the treatment of recurrent candidiasis.

Synthesis and Anticandidal Activity of New Imidazole-Chalcones

In the present work, 15 new 1-(4-(1H-imidazol-1-yl)phenyl)-3-(4-substituedphenyl)prop-2-en-1-one derivatives (3a–3o) were synthesized to evaluate their antifungal activity. Structures of newly synthesized imidazole derivatives (3a–3o) were characterized by IR, ¹H-NMR, ¹³C-NMR, and LCMSMS spectroscopic methods. The anticandidal activity of compounds (3a–3o) against C. albicans (ATCC 24433), C. krusei (ATCC 6258), C. parapsilosis (ATCC 22019), and C. glabrata (ATCC 90030) was elucidated according to the EUCAST definitive (EDef 7.1) method. Consistent with the activity studies, 3a–3d were found to be more potent derivatives with their MIC₅₀ values (0.78 µg/mL–3.125 µg/mL) against Candida strains. Compound 3c indicated similar antifungal activity to ketoconazole against all Candida species and was evaluated as the most active derivative in the series. Effects of the most potent derivatives 3a–3d on ergosterol biosynthesis were observed by LC-MS-MS method, which is based on quantification of the ergosterol level in C. krusei. Moreover, these compounds were subjected to a cytotoxicity test for the preliminary toxicological profiles and were found as non-cytotoxic. Furthermore, docking studies for the most active derivative 3c were performed to evaluate its binding modes on lanosterol 14-α-demethylase. In addition to in vitro tests, docking studies also revealed that Compound 3c is a potential ergosterol biosynthesis inhibitor.

Recent advances in delivery of antifungal agents for therapeutic management of candidiasis

Candidiasis is a fungal infection caused by yeasts that belong to the genus Candida. There are over twenty species of Candida yeasts that can cause infection in humans, the most common of which is Candida albicans. Candida yeasts normally reside in the intestinal tract and can be found on mucous membranes and skin without causing infection; however, overgrowth of these organisms can cause symptoms to develop. Presence of other diseases that compromises the patient's immunity makes it more difficult to treat. Candidiasis is majorly divided into superficial infections (oral or vaginal) and systemic infections, also known as invasive candidiasis. The conventional therapeutic modalities used to treat candidiasis are associated with several side effects that limits the dose and dosing frequency. Development of novel drug delivery systems for reduction in dose and alleviation of side effects is an important strategy to improve the clinical efficacy and patient acceptability. This review gives a bird's eye view of the classification and current therapeutic regime of candidiasis. It presents the varied types of drug delivery systems that have been exploited for delivery of antifungal agents with measurable benefits. It also touches upon echinocandins a relatively new class of drugs that are amenable for translation into novel dosage forms with application against biofilm producing and fluconazole resistant strains contributing to a better therapeutic management of candidiasis.

Probiotic Bacteria Alter Pattern-Recognition Receptor Expression and Cytokine Profile in a Human Macrophage Model Challenged with Candida albicans and Lipopolysaccharide

Probiotics are live microorganisms that confer benefits to the host health. The infection rate of potentially pathogenic organisms such as Candida albicans, the most common agent associated with mucosal candidiasis, can be reduced by probiotics. However, the mechanisms by which the probiotics interfere with the immune system are largely unknown. We evaluated the effect of probiotic bacteria on C. albicans challenged human macrophages. Macrophages were pretreated with lactobacilli alone (Lactobacillus rhamnosus LR32, Lactobacillus casei L324m, or Lactobacillus acidophilus NCFM) or associated with Escherichia coli lipopolysaccharide (LPS), followed by the challenge with C. albicans or LPS in a co-culture assay. The expression of pattern-recognition receptors genes (CLE7A, TLR2, and TLR4) was determined by RT-qPCR, and dectin-1 reduced levels were confirmed by flow cytometry. The cytokine profile was determined by ELISA using the macrophage cell supernatant. Overall probiotic lactobacilli down-regulated the transcription of CLEC7A (p < 0.05), resulting in the decreased expression of dectin-1 on probiotic pretreated macrophages. The tested Lactobacillus species down-regulated TLR4, and increased TLR2 mRNA levels in macrophages challenged with C. albicans. The cytokines profile of macrophages challenged with C. albicans or LPS were altered by the probiotics, which generally led to increased levels of IL-10 and IL-1β, and reduction of IL-12 production by macrophages (p < 0.05). Our data suggest that probiotic lactobacilli impair the recognition of PAMPs by macrophages, and alter the production of pro/anti-inflammatory cytokines, thus modulating inflammation.

Potent In Vitro Synergism of Fluconazole and Osthole against Fluconazole-Resistant Candida albicans

Osthole is a natural coumarin that exhibits wide biological and pharmacological activities such as neuroprotective, osteogenic, immunomodulation, antitumor, and anti-inflammatory effects. In this study, we investigated the antifungal effects of osthole in vitro A checkerboard microdilution assay showed that osthole has significant synergistic effect with fluconazole against fluconazole-resistant Candida albicans Similar results were obtained from a growth curve assay. Meanwhile, XTT reduction assay demonstrated the synergism of fluconazole and osthole against C. albicans biofilm formation. Microarray results showed that the expression of genes involved in the oxidation-reduction process, energy metabolism, and transportation changed significantly after the combined treatment with fluconazole and osthole, and further results showed that endogenous reactive oxygen species (ROS) was significantly increased in the combination group. In conclusion, these results demonstrate the synergism of fluconazole and osthole against fluconazole-resistant C. albicans and indicate that endogenous ROS augmentation might contribute to the synergism of fluconazole and osthole.

Oral candidiasis among African human immunodeficiency virus-infected individuals: 10 years of systematic review and meta-analysis from sub-Saharan Africa

Oral candidiasis (OC) is the most common opportunistic fungal infection among immunocompromised individuals. This systematic review and meta-analysis reports on the contribution of non-albicans Candida species in causing OC among human immunodeficiency virus (HIV)-infected individuals in sub-Saharan Africa between 2005 and 2015. Thirteen original research articles on oral Candida infection/colonization among HIV-infected African populations were reviewed. The prevalence of OC ranged from 7.6% to 75.3%. Pseudomembranous candidiasis was found to range from 12.1% to 66.7%. The prevalence of non-albicans Candida species causing OC was 33.5% [95% confidence interval (CI) 30.9–36.39%]. Of 458 non-albicans Candida species detected, C. glabrata (23.8%; 109/458) was the most common, followed by C. tropicalis (22%; 101/458) and C. krusei (10.7%; 49/458). The overall fluconazole resistance was 39.3% (95% CI 34.4–44.1%). Candida albicans was significantly more resistant than non-albicans Candida species to fluconazole (44.7% vs 21.9%; p < 0.001). One-quarter of the cases of OC among HIV-infected individuals in sub-Saharan Africa were due to non-albicans Candida species. Candida albicans isolates were more resistant than the non-albicans Candida species to fluconazole and voriconazole. Strengthening the capacity for fungal diagnosis and antifungal susceptibility testing in sub-Saharan Africa is mandatory in order to track the azole resistance trend.

Preclinical study of a cost-effective photodynamic therapy protocol for treating oral candidoses

Photodynamic therapy (PDT) is a promising treatment for oral candidoses. Its use as an alternative to antifungals prevents several adverse effects, including microbial resistance. However, most PDT protocols do not employ devices and consumables commonly available in dental practice, thus influencing treatment affordability. This study aimed to determine the efficacy of a PDT method based on light curing units' blue LEDs combined to a plaque-disclosing composition (5% erythrosine) against C. albicans in culture and in a murine model of oral candidosis. Standard and resistant fungal strains were tested in vitro in planktonic and biofilm forms. PDT (pre-irradiation time periods: 30 and 60 s; irradiation time: 3 min) was compared to control conditions without light and/or erythrosine. Mice with induced oral candidosis (n = 40) randomly received PDT or similar control conditions with subsequent C. albicans count. These mice underwent histological analysis, as well as 12 healthy mice submitted to experimental treatments. PDT completely inactivated C. albicans planktonic cells and biofilm. Control conditions presented minor differences (ANOVA, p < 0.05), with mean values ranging from 5.2 to 6.8 log10 (UFC/mL). Infected mice presented no significant difference in C. albicans counts consequent to treatments (ANOVA, p = 0.721), although the PDT protocol was able to enhance the inflammatory infiltrate in healthy mice. It can be concluded that the tested PDT protocol can inactivate C. albicans but still needs further investigation in order to achieve efficacy and safety.

Fungal Biofilms and Polymicrobial Diseases

Biofilm formation is an important virulence factor for pathogenic fungi. Both yeasts and filamentous fungi can adhere to biotic and abiotic surfaces, developing into highly organized communities that are resistant to antimicrobials and environmental conditions. In recent years, new genera of fungi have been correlated with biofilm formation. However, Candida biofilms remain the most widely studied from the morphological and molecular perspectives. Biofilms formed by yeast and filamentous fungi present differences, and studies of polymicrobial communities have become increasingly important. A key feature of resistance is the extracellular matrix, which covers and protects biofilm cells from the surrounding environment. Furthermore, to achieve cell–cell communication, microorganisms secrete quorum-sensing molecules that control their biological activities and behaviors and play a role in fungal resistance and pathogenicity. Several in vitro techniques have been developed to study fungal biofilms, from colorimetric methods to omics approaches that aim to identify new therapeutic strategies by developing new compounds to combat these microbial communities as well as new diagnostic tools to identify these complex formations in vivo. In this review, recent advances related to pathogenic fungal biofilms are addressed.

Antifungal Activity of the Ethanol Extract from Flos Rosae Chinensis with Activity against Fluconazole-Resistant Clinical Candida

This study was designed to investigate the antifungal activity of a hydroalcoholic extract from Flos Rosae Chinensis (FRC) combined with fluconazole (FCZ) against clinical isolates of Candida albicans resistant to FCZ. The minimum inhibitory concentration (MIC) of FRC was determined using a checkerboard microdilution assay. The synergistic effects of the combination of FRC and FCZ against clinical isolates of C. albicans resistant to FCZ were further confirmed by constructing time-growth curves and performing an agar diffusion test. FRC alone exerted efficient antifungal activities against C. albicans within a MIC₈₀ ranging from 20 μg/ml to 40 μg/ml. FRC failed to enhance the effects of FCZ against sensitive C. albicans strains, although it rendered FCZ-resistant C. albicans more sensitive. These results were further confirmed by the result of in vivo study. Our study is the first to discover that FRC can inhibit the growth of C. albicans to a certain degree. An FRC antifungal mechanism study showed that FRC strengthens FCZ to inhibit the action of ergosterol biosynthesis by promoting the transformation of lanosterol to eburicol, suggesting that the antifungal mechanism of FRC involves the inhibition of ergosterol biosynthesis.

In Vitro Antifungal Susceptibility of Oral Candida Isolates from Patients Suffering from Caries and Chronic Periodontitis

Caries and chronic periodontitis are common oral diseases where a higher Candida colonization is reported. Antifungal agents could be adjuvant drugs for the therapy of both clinical conditions. The aim of the current study has been to evaluate the in vitro activities of conventional and new antifungal drugs against oral Candida isolates from patients suffering from caries and/or chronic periodontitis. In vitro activities of amphotericin B, fluconazole, itraconazole, miconazole, nystatin, posaconazole and voriconazole against 126 oral Candida isolates (75 Candida albicans, 18 Candida parapsilosis, 11 Candida dubliniensis, six Candida guilliermondii, five Candida lipolytica, five Candida glabrata, four Candida tropicalis and two Candida krusei) from 61 patients were tested by the CLSI M27-A3 method. Most antifungal drugs were highly active, and resistance was observed in less than 5% of tested isolates. Miconazole was the most active antifungal drug, being more than 98% of isolates susceptible. Fluconazole, itraconazole, and the new triazoles, posaconazole and voriconazole, were also very active. Miconazole, fluconazole and voriconazole have excellent in vitro activities against all Candida isolates and could represent suitable treatment for a hypothetically adjunctive therapy of caries and chronic periodontitis.