In vitro susceptibility of fluconazole-susceptible and -resistant isolates of Malassezia pachydermatis against azoles

Antifungal activity of azoles, allylamines, and 8-hidroxiquinolines, alone and in combination, against Malassezia pachydermatis in vitro and in vivo

Malassezia pachydermatis is often reported as the causative agent of dermatitis in dogs. This study aims to evaluate the in vitro and in vivo antifungal activity of azoles and terbinafine (TRB), alone and in combination with the 8-hydroxyquinoline derivatives (8-HQs) clioquinol (CQL), 8-hydroxyquinoline-5-(n-4-chlorophenyl)sulfonamide (PH151), and 8-hydroxyquinoline-5-(n-4-methoxyphenyl)sulfonamide (PH153), against 16 M. pachydermatis isolates. Susceptibility to the drugs was evaluated by in vitro broth microdilution and time-kill assays. The Toll-deficient Drosophila melanogaster fly model was used to assess the efficacy of drugs in vivo. In vitro tests showed that ketoconazole (KTZ) was the most active drug, followed by TRB and CQL. The combinations itraconazole (ITZ)+CQL and ITZ+PH151 resulted in the highest percentages of synergism and none of the combinations resulted in antagonism. TRB showed the highest survival rates after seven days of treatment of the flies, followed by CQL and ITZ, whereas the evaluation of fungal burden of dead flies showed a greater fungicidal effect of azoles when compared to the other drugs. Here we showed for the first time that CQL is effective against M. pachydermatis and potentially interesting for the treatment of malasseziosis.

ERG11 Gene Variability and Azole Susceptibility in Malassezia pachydermatis

Malassezia pachydermatis is part of the normal skin microbiota of various animal species but under certain circumstances becomes an opportunistic pathogen producing otitis and dermatitis. Commonly these Malassezia diseases are effectively treated using azoles. However, some cases of treatment failure have been reported. Alterations in the ERG11 gene have been associated with in vitro azole resistance in M. pachydermatis. In the present study, in vitro antifungal susceptibility of 89 different strains of M. pachydermatis isolated from different animal species and health status was studied. The susceptibility to fluconazole (FLZ), itraconazole (ITZ), ketoconazole and amphotericin B was tested by a disk diffusion method and 17 strains were also subjected to an ITZ E-test. Mueller-Hinton supplemented with 2% glucose and methylene blue was used as culture medium in both susceptibility assays. Multilocus sequence typing was performed in 30 selected strains using D1D2, ITS, CHS2 and β-tubulin genes. Also, ERG11 gene was sequenced. The four antifungals tested were highly effective against most of the strains. Only two strains showed no inhibition zone to antifungals and a strain showed an increased MIC to ITZ. The study of the ERG11 sequences revealed a high diversity of DNA sequences and a total of 23 amino acid substitutions, from which only two have been previously described. Also, three deleterious substitutions (A302T, G459D and G461D) previously associated with azole resistance in this yeast were recovered. A correlation between certain genotypes and ERG11 mutations was observed. Some of the ERG11 mutations recovered were correlated with a reduced susceptibility to azoles.

In Vitro Assessment of Azole and Amphotericin B Susceptibilities of Malassezia spp. Isolated from Healthy and Lesioned Skin

Malassezia yeasts have recently gained medical importance as emerging pathogens associated with a wide range of dermatological and systemic infections. Since standardized methods for in vitro antifungal susceptibility testing have not yet been established for Malassezia spp., related diseases are always treated empirically. As a result, a high rate of recurrence and decreased antifungal susceptibility have appeared. Thus, the aims of the study were to assess and analyze the in vitro susceptibility of Malassezia isolated from pityriasis versicolor (PV) lesions and healthy controls. A total of 58 Malassezia strains isolated from PV patients and healthy controls were tested. In vitro antifungal susceptibility testing was conducted using the CLSI broth microdilution with some modifications. Candida spp. criteria established in accordance with CLSI guidelines were used for data interpretation. Ketoconazole and posaconazole seemed to be the most effective molecules against Malassezia species. However, considerable percentages of itraconazole, fluconazole, and amphotericin B ‘‘resistant’’ strains (27.6%, 29.3%, and 43.1%, respectively) were revealed in this study. Malassezia furfur, M. sympodialis, and M. globosa showed different susceptibility profiles to the drugs tested. These results emphasize the importance of accurately identifying and evaluating the antifungal susceptibility of Malassezia species in order to guide a specific and effective treatment regimen.

Pharmacokinetics of fluconazole after oral administration to healthy beagle dogs

BACKGROUND

Fluconazole can be effective in the treatment of superficial mycoses in dogs. However, the pharmacokinetics of fluconazole have not yet been evaluated to determine its optimal dosing regimen.

OBJECTIVES

This study aimed to determine the plasma concentration of fluconazole after single and multiple administrations at two different dosages in dogs.

METHODS AND MATERIALS

Eight healthy beagle dogs were divided into two groups, and each group received either 5 or 10 mg/kg of fluconazole per os. The pharmacokinetics of fluconazole was determined following single and multiple administrations p.o. Single- and multiple-dose treatment periods were separated by a washout period of seven days. Plasma concentrations of fluconazole were determined by established high-performance liquid chromatography coupled with tandem mass spectrometry system.

RESULTS

In the 5 mg/kg group, the mean maximum concentrations (C_max ) and the area under the plasma concentrations (AUC_0-24h ) were 4.84 μg/mL and 85.56 μg*h/mL, respectively, after single administration and 6.58 μg/mL and 119.52 μg*h/mL, respectively, after multiple administrations. In the 10 mg/kg group, the C_max and AUC_0-24h were 5.67 μg/mL and 109.19 μg*h/mL, respectively, after single administration and 15.10 μg/mL and 291.51 μg*h/mL, respectively, after multiple administrations. The C_max (p < 0.001) and AUC_0-24h (p < 0.001) were significantly lower in the 5 mg/kg group than those in the 10 mg/kg group at multiple administrations.

CONCLUSIONS AND CLINICAL RELEVANCE

Fluconazole accumulates in plasma and exhibits dose-proportional pharmacokinetics after multiple doses, and was safe and well tolerated at these doses for short-term administration.

Virulence factors of Malassezia strains isolated from pityriasis versicolor patients and healthy individuals

Over the last decade, Malassezia species have emerged as increasingly important pathogens associated with a wide range of dermatological disorders and bloodstream infections. The pathogenesis of Malassezia yeasts is not completely clear but it seems to be strictly related to Malassezia strains and hosts and need to be better investigated. This study aimed to assess the enzymatic activities, biofilm formation and in vitro antifungal profiles of Malassezia spp. from Pityriasis versicolor and heathy patients. The potential relationship between virulence attributes, the antifungal profiles and the origin of strains were also assessed. A total of 44 Malassezia strains isolated from patients with (n = 31) and without (n = 13) Pityriasis versicolor (PV) were employed to evaluate phospholipase (Pz), lipase (Lz), hemolytic (Hz) activities and biofilm formation. In addition, in vitro antifungal susceptibility testing was conducted using the CLSI broth microdilution with some modifications. A high percentage of strains produced phospholipase, lipase, hemolysins and biofilm regardless of their clinical origin. The highest number of strains producing high enzymatic activities came from PV patients. A correlation between the intensity of hydrolytic activities (lipase and phospholipase activities) and the hemolytic activity was detected. Positive associations between Lz and the low fluconazole susceptibility and Hz and biofilm formation were observed. These results suggest that enzyme patterns and biofilm formation together with antifungal profiles play a role in the pathogenicity of Malassezia spp. and might explain the implication of some Malassezia spp. in invasive fungal infections and in the development of inflammation.

Malassezia: Zoonotic Implications, Parallels and Differences in Colonization and Disease in Humans and Animals

Malassezia spp. are commensals of the skin, oral/sinonasal cavity, lower respiratory and gastrointestinal tract. Eighteen species have been recovered from humans, other mammals and birds. They can also be isolated from diverse environments, suggesting an evolutionary trajectory of adaption from an ecological niche in plants and soil to the mucocutaneous ecosystem of warm-blooded vertebrates. In humans, dogs and cats, Malassezia-associated dermatological conditions share some commonalities. Otomycosis is common in companion animals but is rare in humans. Systemic infections, which are increasingly reported in humans, have yet to be recognized in animals. Malassezia species have also been identified as pathogenetic contributors to some chronic human diseases. While Malassezia species are host-adapted, some species are zoophilic and can cause fungemia, with outbreaks in neonatal intensive care wards associated with temporary colonization of healthcare worker’s hands from contact with their pets. Although standardization is lacking, susceptibility testing is usually performed using a modified broth microdilution method. Antifungal susceptibility can vary depending on Malassezia species, body location, infection type, disease duration, presence of co-morbidities and immunosuppression. Antifungal resistance mechanisms include biofilm formation, mutations or overexpression of ERG11, overexpression of efflux pumps and gene rearrangements or overexpression in chromosome 4.

Conventional therapy and new antifungal drugs against Malassezia infections

Malassezia yeasts are commensal microorganisms occurring on the skin of humans and animals causing dermatological disorders or systemic infections in severely immunocompromised hosts. Despite attempts to control such yeast infections with topical and systemic antifungals, recurrence of clinical signs of skin infections as well as treatment failure in preventing or treating Malassezia furfur fungemia have been reported most likely due to wrong management of these infections (e.g., due to early termination of treatment) or due to the occurrence of resistant phenomena. Standardized methods for in vitro antifungal susceptibility tests of these yeasts are still lacking, thus resulting in variable susceptibility profiles to azoles among Malassezia spp. and a lack of clinical breakpoints. The inherent limitations to the current pharmacological treatments for Malassezia infections both in humans and animals, stimulated the interest of the scientific community to discover new, effective antifungal drugs or substances to treat these infections. In this review, data about the in vivo and in vitro antifungal activity of the most commonly employed drugs (i.e., azoles, polyenes, allylamines, and echinocandins) against Malassezia yeasts, with a focus on human bloodstream infections, are summarized and their clinical implications are discussed. In addition, the usefulness of alternative compounds is discussed.

A case of anti- pityriasis versicolor therapy that preserves healthy mycobiome

Background

The impact of Malassezia yeasts on skin mycobiome and health has received considerable attention recently. Pityriasis versicolor (PV), a common dermatosis caused by Malassezia genus worldwide, is a manifestation of dysbiosis. PV can be associated with hyper- and/or hypopigmented skin lesions. This disease entity is characterized by high percentage of relapses, which demands a proper antifungal therapy that is based on unambiguous species identification and drug susceptibility testing.

Case presentation

Comprehensive analysis of PV case in man presenting simultaneously hyper- and hypopigmented skin lesions was performed. Conventional and molecular diagnostic procedures revealed Malassezia furfur and Malassezia sympodialis, respectively as etiological agents of skin lesions observed. Susceptibility tests showed significantly lowered sensitivity of M. furfur cells to fluconazole. Based on susceptibility profiles local antifungal therapy with drugs characterized by entirely different mechanism of action was included.

Conclusions

Our study indicates that cases of PV represented by two types of skin lesions in one patient may be associated with distinct Malassezia species. Moreover, as observed in this case, each of the isolated etiological agents of PV may differ significantly in susceptibility to antifungals. This can significantly complicate the treatment of dermatosis, which by definition is associated with a significant percentage of relapses. In the presented case localized topical treatment was sufficient and successful while allowing maintaining the physiological mycobiome.

Biology, diagnosis and treatment of Malassezia dermatitis in dogs and cats Clinical Consensus Guidelines of the World Association for Veterinary Dermatology

BACKGROUND

The genus Malassezia is comprised of a group of lipophilic yeasts that have evolved as skin commensals and opportunistic cutaneous pathogens of a variety of mammals and birds.

OBJECTIVES

The objective of this document is to provide the veterinary community and other interested parties with current information on the ecology, pathophysiology, diagnosis, treatment and prevention of skin diseases associated with Malassezia yeasts in dogs and cats.

METHODS AND MATERIAL

The authors served as a Guideline Panel (GP) and reviewed the literature available prior to October 2018. The GP prepared a detailed literature review and made recommendations on selected topics. The World Association of Veterinary Dermatology (WAVD) Clinical Consensus Guideline committee provided guidance and oversight for this process. The document was presented at two international meetings of veterinary dermatology societies and one international mycology workshop; it was made available for comment on the WAVD website for a period of six months. Comments were shared with the GP electronically and responses incorporated into the final document.

CONCLUSIONS AND CLINICAL IMPORTANCE

There has been a remarkable expansion of knowledge on Malassezia yeasts and their role in animal disease, particularly since the early 1990's. Malassezia dermatitis in dogs and cats has evolved from a disease of obscurity and controversy on its existence, to now being a routine diagnosis in general veterinary practice. Clinical signs are well recognised and diagnostic approaches are well developed. A range of topical and systemic therapies is known to be effective, especially when predisposing factors are identified and corrected.

Antifungal Resistance Regarding Malassezia pachydermatis: Where Are We Now?

Malassezia pachydermatis is a yeast inhabiting the skin and ear canals in healthy dogs. In the presence of various predisposing conditions it can cause otitis and dermatitis, which are treated with multiple antifungal agents, mainly azole derivatives. This manuscript aims to review the available evidence regarding the occurrence of resistance phenomena in this organism. Various findings support the capacity of M. pachydermatis for developing resistance. These include some reports of treatment failure in dogs, the reduced antifungal activity found against yeast isolates sampled from dogs with exposure to antifungal drugs and strains exposed to antifungal agents in vitro, and the description of resistance mechanisms. At the same time, the data reviewed may suggest that the development of resistance is a rare eventuality in canine practice. For example, only three publications describe confirmed cases of treatment failure due to antifungal resistance, and most claims of resistance made by past studies are based on interpretive breakpoints that lack sound support from the clinical perspective. However, it is possible that resistant cases are underreported in literature, perhaps due to the difficulty of obtaining a laboratory confirmation given that a standard procedure for susceptibility testing of M. pachydermatis is still unavailable. These considerations highlight the need for maintaining surveillance for the possible emergence of clinically relevant resistance, hopefully through a shared strategy put in place by the scientific community.

Systemic Infection Caused by Malassezia pachydermatis in Infants: Case Series and Review of the Literature

BACKGROUND

Malassezia pachydermatis is a rare cause of systemic infection in infants.

METHODS

A total of 4 cases of M. pachydermatis fungemia that occurred in our neonatal intensive care unit over a 21-month period were reviewed, as well as 27 cases reported in the literature since 1988.

RESULTS

The patients were preterm with multiple complications and had birth weights ranging from 490 to 810 g and gestational age between 23 and 26 weeks. All patients had received prophylactic fluconazole, broad-spectrum antibiotics and parenteral lipid supplements before fungemia onset, which occurred between the age of 7 and 28 days. Symptoms were nonspecific and thrombocytopenia was the primary laboratory finding. All patients received intravenous antifungal treatment and recovered from their infection. The 27 cases from review of the literature also indicated that the infected infants were extremely low birth weight (77.8%), with multiple underlying diseases (94.7%), receiving lipid-supplementation (100%) from a central vascular catheter. Most infants received antifungal treatment (73.1%) and catheter removal (73.1%) as the management.

CONCLUSIONS

M. pachydermatis is a pathogenic agent that causes late onset sepsis in critically ill low birth weight infants with generally good outcomes. Targeted antifungal treatment as well as catheter removal appear to be key factors for infection management.

Genomic Multiplication and Drug Efflux Influence Ketoconazole Resistance in Malassezia restricta

Malassezia restricta is an opportunistic fungal pathogen on human skin; it is associated with various skin diseases, including seborrheic dermatitis and dandruff, which are usually treated using ketoconazole. In this study, we clinically isolated ketoconazole-resistant M. restricta strains (KCTC 27529 and KCTC 27550) from patients with dandruff. To understand the mechanisms of ketoconazole resistance in the isolates, their genomes were sequenced and compared with the susceptible reference strain M. restricta KCTC 27527. Using comparative genome analysis, we identified tandem multiplications of the genomic loci containing ATM1 and ERG11 homologs in M. restricta KCTC 27529 and KCTC 27550, respectively. Additionally, we found that the copy number increase of ATM1 and ERG11 is reflected in the increased expression of these genes; moreover, we observed that overexpression of these homologs caused ketoconazole resistance in a genetically tractable fungal pathogen, Cryptococcus neoformans. In addition to tandem multiplications of the genomic region containing the ATM1 homolog, the PDR5 homolog, which encodes the drug efflux pump protein was upregulated in M. restricta KCTC 27529 compared to the reference strain. Biochemical analysis confirmed that drug efflux was highly activated in M. restricta KCTC 27529, implying that upregulation of the PDR5 homolog may also contribute to ketoconazole resistance in the strain. Overall, our results suggest that multiplication of the genomic loci encoding genes involved in ergosterol synthesis, mitochondrial iron metabolism, and oxidative stress response and overexpression of the drug efflux pumps are the mechanisms underlying ketoconazole resistance in M. restricta.

New Therapeutic Candidates for the Treatment of Malassezia pachydermatis -Associated Infections

The opportunistic pathogen Malassezia pachydermatis causes bloodstream infections in preterm infants or individuals with immunodeficiency disorders and has been associated with a broad spectrum of diseases in animals such as seborrheic dermatitis, external otitis and fungemia. The current approaches to treat these infections are failing as a consequence of their adverse effects, changes in susceptibility and antifungal resistance. Thus, the identification of novel therapeutic targets against M. pachydermatis infections are highly relevant. Here, Gene Essentiality Analysis and Flux Variability Analysis was applied to a previously reported M. pachydermatis metabolic network to identify enzymes that, when absent, negatively affect biomass production. Three novel therapeutic targets (i.e., homoserine dehydrogenase (MpHSD), homocitrate synthase (MpHCS) and saccharopine dehydrogenase (MpSDH)) were identified that are absent in humans. Notably, L-lysine was shown to be an inhibitor of the enzymatic activity of MpHCS and MpSDH at concentrations of 1 mM and 75 mM, respectively, while L-threonine (1 mM) inhibited MpHSD. Interestingly, L- lysine was also shown to inhibit M. pachydermatis growth during in vitro assays with reference strains and canine isolates, while it had a negligible cytotoxic activity on HEKa cells. Together, our findings form the bases for the development of novel treatments against M. pachydermatis infections.

Malassezia Yeasts in Veterinary Dermatology: An Updated Overview

Lipophilic yeasts of the genus Malassezia are important skin commensals and opportunistic skin pathogens in a variety of animals. The species M. pachydermatis was first isolated from the skin of a captive Indian rhinoceros with an exfoliative dermatitis in 1925, recognized as an important otic pathogen of dogs in the 1950's, and finally accepted, after several years of controversy, as a common cause of canine dermatitis in the 1990's. Since then, there has been considerable research into the biology of Malassezia yeasts and their interaction with their animal hosts. In dogs and cats, M. pachydermatis is associated with ceruminous otitis externa and a "seborrhoeic" dermatitis, wherein pruritic, erythematous skin lesions, often with brown/black greasy, malodourous material matting hairs, preferentially develop in intertriginous areas. Skin disease is favored by folds, underlying hypersensitivity disorders, endocrinopathies, defects of cornification, and in cats, various visceral paraneoplastic syndromes. Diagnosis is based on detecting the yeast in compatible skin lesions, usually by cytology, and observing a clinical and mycological response to therapy. Treatment normally comprises topical or systemic azole therapy, often with miconazole-chlorhexidine shampoos or oral itraconazole or ketoconazole. Management of concurrent diseases is important to minimize relapses. Historically, wild-type Malassezia isolates from dogs and cats were typically susceptible to azoles, with the exception of fluconazole, but emerging azole resistance in field strains has recently been associated with either mutations or quadruplication of the ERG11 gene. These observations have prompted increased interest in alternative topical antifungal drugs, such as chlorhexidine, and various essential oils. Further clinical trials are awaited with interest.

Susceptibility of Malassezia pachydermatis Clinical Isolates to Allopathic Antifungals and Brazilian Red, Green, and Brown Propolis Extracts

Clinical mycoses treatment is associated with issues such as negative side effects, high cost, prolonged treatment, and resistant strain selection. Malassezia pachydermatis is the most frequently isolated yeast in cases of canine otitis and dermatitis. The number of fungal strains exhibiting primary resistance to several drugs in vitro is increasing. Propolis has a diverse chemical composition and well-known therapeutic properties against mycoses. An alternative method for producing propolis extracts using supercritical fluid has higher selectivity, yielding extracts with fewer pollutant residues. This study therefore aimed to evaluate the in vitro susceptibility profile of M. pachydermatis clinical isolates to precharacterized supercritical and ethanolic extracts. Three types of Brazilian propolis extracts (green, red, and brown) and commercial allopathic antifungals were used in this investigation. We used the microdilution broth technique to evaluate the susceptibility profile of the yeasts. The minimum inhibitory concentration (MIC) of the brown propolis ethanolic extract was ≥16 μg/mL for all isolates. The MICs of fluconazole, ketoconazole, itraconazole, and amphotericin B ranged from 8 to >64 μg/mL, 0.032–4 μg/mL, 0.0313–16 μg/mL, and 1–2 μg/mL, respectively. The MICs of ethanolic red propolis extracts were lower than those of supercritical red propolis extracts. However, the green propolis ethanolic extract had more pronounced fungicidal activity. Isolates with lower susceptibility to commercial fungicides were inhibited by red and green propolis extracts. These results indicate that propolis can potentially be used in in vivo experiments as a promising therapeutic agent against M. pachydermatis infections.

Antifungal in vitro Activity of Essential Oils against Clinical Isolates of Malassezia pachydermatis from Canine Ears: A Report from a Practice Laboratory

BACKGROUND

The yeast Malassezia pachydermatis is a commensal but also the most isolated pathogenic yeast in canine otitis externa. Essential oils (EOs) exhibit antimicrobial activity and thus could be an alternative for treatment of otitis.

OBJECTIVE

The aim of this study was to analyse the in vitro efficacy of EOs against M. pachydermatis isolates from canine ears.

MATERIALS AND METHODS

Twenty-two EOs were tested for their in vitro activity against 15 M. pachydermatis isolates by agar disc diffusion. In addition, diluted EOs were tested and volatile antifungal activity was analysed by vapour assay.

RESULTS

Most EOs showed in vitro efficacy against M. pachydermatis. A different susceptibility pattern of tested isolates was found. Overall, the most potential EO was lemon grass. Also, cinnamon leaf, clove, manuka, Indian melissa, oregano, palmarosa, and winter savory oil exhibited a strong antifungal activity. Volatile activity was proven by the inhibiting effect in vapour assay.

CONCLUSION

EOs show in vitro activity against M. pachydermatis. This study gives scientific background for the use of EOs in veterinary medicine. Diverse susceptibility patterns of different M. pachydermatis strains emphasise the helpfulness of an aromatogram as one lead for the best choice of an EO for therapy.

In vitro activity of carvacrol, cinnamaldehyde and thymol combined with antifungals against Malassezia pachydermatis

Malassezia pachydermatis is an important opportunistic agent of dermatitis and otitis in dogs. M. pachydermatis is generally treated with topical therapies using combinations of antifungal, antimicrobial and anti-inflammatory agents. We investigated the in vitro activities of carvacrol (CRV), cinnamaldehyde (CIN) and thymol (THY) alone and in combination with antifungal agents (fluconazole, itraconazole, ketoconazole, clotrimazole, miconazole, terbinafine and nystatin) against M. pachydermatis. The assays were performed according to the Clinical and Laboratory Standards Institute (CLSI), using Sabouraud dextrose broth and checkerboard microdilution. The mean fractional inhibitory concentration index (FICI) showed primary synergies for the combinations carvacrol+nystatin, thymol+nystatin, and carvacrol+miconazole (80%). In conclusion, the results obtained indicate that the phytochemicals tested showed relevant in vitro anti-M. pachydermatis activity. Future in vivo experiments are needed to elucidate the safety and therapeutic potential of these combinations.

Antifungal Susceptibility of Malassezia pachydermatis Isolates from Dogs

The genus Malassezia belongs to Basidiomycota and includes 16 species, from which M. pachydermatis is the most common in dogs. M. pachydermatis is a member of the normal mycobiota of the skin and mucosal sites of dogs. Under certain conditions, these yeasts can be opportunistic pathogens and involved skin and ear canal infections of these animals. Topical and oral antifungal agents are used for the therapy of Malassezia dermatitis and otitis. With the expanding use of antifungal agents, resistant strains of Malassezia are increasingly detected. In this study, the susceptibility of 40 M. pachydermatis isolates to fluconazole, itraconazole, ketoconazole, clotrimazole and nystatin were evaluated in vitro based on the modified standard disk diffusion method M44-2A.

Azole resistance of Malassezia pachydermatis causing treatment failure in a dog

A 5-year-old neutered female toy Poodle chronically treated with systemic and topical azoles to control recurrent Malassezia dermatitis/otitis was presented because of the loss of treatment efficacy. Minimum Inhibitory Concentrations (MICs) obtained in vitro for various azoles (especially itraconazole and ketoconazole) against Malassezia strains isolated from the dog were increased by several-fold compared with MICs obtained for control isolates. These results reinforced the assumption based on clinical observation, i.e. the development of azole resistance

Treatment of Selected Canine Dermatological Conditions in Portugal - A Research Survey

INTRODUCTION

Staphylococcus pseudintermedius and Malassezia pachydermatis often cause skin diseases in dogs.

MATERIAL AND METHODS

An online survey was e-mailed to veterinary practices nationwide covering demographics, diagnosis methods, and oral and topical treatment options. Of the 740 surveys sent, 100 complete replies were obtained.

RESULTS

The majority of clinicians were unaware of the existence of the International Society for Companion Animal Infectious Diseases guidelines or did not follow them (53%). Oral antibiotics were used universally for superficial bacterial folliculitis treatment, particularly amoxicillin-clavulanic acid (100%), cephalexin (94%), enrofloxacin (67%), or marbofloxacin (60%). For fold dermatitis (FD) and otitis externa (OE), oral antibiotics were also given as treatment in 88% and 82% of cases, respectively. Oral antifungals were often prescribed for generalised Malassezia dermatitis (85%), FD (70%), and OE (59%). S. pseudintermedius and M. pachydermatis were frequently treated topically, particularly with antibacterials or antifungals only, or a combination of antibacterials, antifungals, and glucocorticoids. Alternative options such as honey-based products were not frequently used.

CONCLUSION

Our survey suggests that oral antibiotics are overused by Portuguese clinicians despite the spread of antibiotic resistant S. pseudintermedius. Oral antibiotics and antifungals are commonly prescribed for skin conditions manageable with topical treatments.

A Ketoconazole Susceptibility Test for Malassezia pachydermatis Using Modified Leeming⁻Notman Agar

The aim of this study was to establish a ketoconazole susceptibility test for Malassezia pachydermatis using modified Leeming–Notman agar (mLNA). The susceptibilities of 33 M. pachydermatis isolates obtained by modified CLSI M27-A3 method were compared with the results by disk diffusion method, which used different concentrations of ketoconazole on 6 mm diameter paper disks. Results showed that 93.9% (31/33) of the minimum inhibitory concentration (MIC) values obtained from both methods were similar (consistent with two methods within 2 dilutions). M. pachydermatis BCRC 21676 and Candida parapsilosis ATCC 22019 were used to verify the results obtained from the disk diffusion and modified CLSI M27-A3 tests, and they were found to be consistent. Therefore, the current study concludes that this new novel test—using different concentrations of reagents on cartridge disks to detect MIC values against ketoconazole—can be a cost-effective, time-efficient, and less technically demanding alternative to existing methods.

Methodological Issues in Antifungal Susceptibility Testing of Malassezia pachydermatis

Reference methods for antifungal susceptibility testing of yeasts have been developed by the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antibiotic Susceptibility Testing (EUCAST). These methods are intended to test the main pathogenic yeasts that cause invasive infections, namely Candida spp. and Cryptococcusneoformans, while testing other yeast species introduces several additional problems in standardization not addressed by these reference procedures. As a consequence, a number of procedures have been employed in the literature to test the antifungal susceptibility of Malassezia pachydermatis. This has resulted in conflicting results. The aim of the present study is to review the procedures and the technical parameters (growth media, inoculum preparation, temperature and length of incubation, method of reading) employed for susceptibility testing of M. pachydermatis, and when possible, to propose recommendations for or against their use. Such information may be useful for the future development of a reference assay.

Assessment of in vitro inhibitory activity of hydrogen peroxide on the growth of Malassezia pachydermatis and to compare its efficacy with commercial ear cleaners

Otitis caused by Malassezia pachydermatis is generally a common and recurrent disease in canine clinical pathology. The increased incidence of fungal resistant to antifungal in both humans and pets is a cause for concern and is associated with the indiscriminate use of antifungals. Finding the most effective disinfectants and antifungals has become essential. To evaluate the in vitro inhibitory activity of hydrogen peroxide on the growth of M. pachydermatis and compare its efficacy with commercial ear cleaners. The test for sensitivity to antimicrobials was carried out following the indications of the CLSI document M44-A2. The comparative results demonstrated that hydrogen peroxide 1.5% showed excellent results for growth inhibition of M. pachydermatis, followed by Epiotic^® and MalAcetic^® , the lowest result was for Otoclean^® .

Exploration of anti-Malassezia potential of Nyctanthes arbor-tristis L. and their application to combat the infection caused by Mala s1 a novel allergen

Background

Malassezia commensal yeasts along with multitude of antigens have been found to be associated with various skin disorders including Pityriasis versicolor (PV). Amongst them Mala s1, a 37 kDa protein has been proved to be a major allergen reacting with a large panel of sera. However, there exists no therapeutic alternative to combat such problems in form of plant based natural compounds. The purpose of this study is in the first place, to determine the anti-Malassezia activity of Nyctanthes arbor-tristis L. (NAT) ethanolic leaf extract through turbidimetric growth curves, disruption of plasma membrane and secondly, it aims to present in silico validation of its active constituents over Mala s1a novel allergen.

Methods

The antifungal susceptibility 50 % ethanolic extract of NAT was determined by broth microdilution method according to CLSI guidelines. Further MICs and IC₅₀ were determined spectrophotometrically using the software SoftMax® Pro-5 (Molecular Devices, USA). Active constituents mediated disruption of plasma membrane was studied through flowcytometry by permeabilization of fluorescent dye Propidium Iodide (PI). Antioxidant activity of the extract was determined using the DPPH stable radical. Molecular validation of fungal DNA from the extract was observed using PCR amplification. In silico analysis of its active constituents over Mala s1 was performed using HEX software and visualized through Pymol.

Results

The anti-Malassezia potential of NAT leaf extracts reflected moderate MIC 1.05 μg/μl against M. globosa, while least effective against M. restricta with MIC 1.47 μg/μl. A linear correlation coefficient R² = 0.866 was obtained in case of M. globosa while minimum was observed in M. restricta with R² = 0.732. The flow cytometric data reveal ~ 75 % cell death when treated with active constituents β-Sitosterol and Calceolarioside A. The docking confirmations and the interaction energies between Mala s1 and the active constituents (β-Sitosterol and Calceolarioside A) from extracts showed an effective binding which suggests Mala s1 as efficient allergen for site specific targeting.

Conclusions

This study revealed that Nyctanthes arbor-tristis L. (NAT) extracts possess high anti-Malassezia potential which is driven mainly by disruption of plasma membrane. Also in silico validation and molecular modeling studies establishes Mala s1 as a novel allergen that could be a potential target in disease treatment. Our results would also provide a foundation for the development of new therapeutic approach using NAT extract as lead compound with high antioxidant property as an added trait for skin care.

Changing of bloodstream infections in a medical center neonatal intensive care unit

BACKGROUND/PURPOSE

Bloodstream infections (BSIs) are associated with high mortality and morbidity in neonatal intensive care units (NICUs). The epidemiology of these infections may change after the application of new infection control policies. The aims of this study are to reveal the changing epidemiology of BSIs in our NICU and inspect the effects of infection control efforts.

METHODS

We reviewed and analyzed the clinical characteristics of culture-proven BSIs in our NICU from 2008 to 2013 and compared them with our two previously reported data (1992-2001 and 2002-2007).

RESULTS

The mortality rate decreased from 16.3% in 1992-2001 to 5.6% in 2008-2013. In the recent study period, Gram-positive infections became predominant (58.0%). Coagulase-negative staphylococci remained the most commonly isolated organisms (26.0%). Group B Streptococcus (GBS) BSIs had the highest mortality rate (30.0%). Most GBS-infected infants' mother did not perform prenatal GBS screening. There was a decrease in the total fungal infection rate after fluconazole prophylaxis for very-low-birth-weight (VLBW) neonates, but the infections of fluconazole-resistant Malassezia pachydermatis increased. The incidence of central line-associated BSI increased to 10.6% in 2011. After restricting the catheter duration to <21 days, the incidence decreased to 4.2% in 2013.

CONCLUSION

Through the years, the overall mortality rate of BSIs in our NICU decreased. Maternal GBS screening is an important issue for avoiding early onset GBS mortality. Fungal infection rate decreased after antifungal prophylaxis policy for VLBW infants, but we should be aware of resistant strains. Restriction of the catheter duration may decrease the incidence of catheter-related BSI.

Agar Diffusion Procedures for Susceptibility Testing of Malassezia pachydermatis: Evaluation of Mueller-Hinton Agar Plus 2 % Glucose and 0.5 µg/ml Methylene Blue as the Test Medium

Aim of this study was to verify whether Mueller-Hinton agar supplemented with 2 % glucose and methylene blue (MH-GM), which is used for disk diffusion susceptibility testing of Candida species by the Clinical and Laboratory Standards Institute, is suitable for testing Malassezia pachydermatis. A variant of the disk diffusion procedure utilizing a 9-mm tablet was used to test 31 isolates against clotrimazole and miconazole using MH-GM as test medium. The MH-GM agar optimally supported the growth of all M. pachydermatis isolates, provided that the yeast inoculum was prepared with a lipid source (Tween 40 and 80). Zone edges were frequently definite and clear, facilitating the measurement of zone size and minimizing subjectivity. The inhibition zones correlated with MIC values obtained in a broth dilution assay. The agar diffusion method with MH-GM as the test medium appears as a suitable procedure for testing the susceptibility of M. pachydermatis to CTZ and MCZ in clinical laboratories. This test format may allow processing a large number of isolates in epidemiological studies. This may in turn facilitate clarifying to what extent the problem "drug resistance" accounts for cases of treatment failure in dogs with Malassezia otitis and dermatitis.

Biofilm formation in Malassezia pachydermatis strains isolated from dogs decreases susceptibility to ketoconazole and itraconazole

Malassezia pachydermatis is a commonly isolated yeast in veterinary dermatology that can produce biofilms in vitro and in vivo, lowering its susceptibility to antimicrobial drugs. The aim of this study was to determine and compare the in vitro susceptibility of planktonic cells and biofilms of M. pachydermatis isolates to ketoconazole and itraconazole. The presence of biofilm formation was confirmed by crystal violet staining and absorbance measurement at 595 nm wavelength, and by a scanning electron microscopy method. Cell viability was determined by the Celltiter 96 Aqueous One solution assay containing a water-soluble tetrazolium compound (MTS) with absorbance measurement at 490 nm. Planktonic cell minimum inhibitory concentrations (MICs) and minimum fungicidal concentrations (MFCs) of ketoconazole and itraconazole were very low: MIC90 and MFC90 were 0.032 and 0.125 μg/ml for ketoconazole, while 0.063 and 0.25 μg/ml for itraconazole, respectively. Also, the half maximal effective concentrations (EC50) of itraconazole were higher for planktonic cells and biofilms compared to ketoconazole. The EC50 values of ketoconazole were 18-169 times higher and those of itraconazole 13-124 times higher for biofilms than for planktonic cells. Biofilm EC50 levels exceeded MICs 103-2060 times for ketoconazole and 84-1400 times for itraconazole. No significant difference was found between these values of the two substances. In conclusion, biofilms of all examined M. pachydermatis strains were much less susceptible to ketoconazole and itraconazole than their planktonic forms.

In vitro antifungal susceptibility of Malassezia furfur from bloodstream infections

Fungaemia caused by Malassezia spp. in hospitalized patients requires prompt and appropriate therapy, but standard methods for the definition of the in vitro antifungal susceptibility have not been established yet. In this study, the in vitro susceptibility of Malassezia furfur from bloodstream infections (BSIs) to amphotericin B (AMB), fluconazole (FLC), itraconazole (ITC), posaconazole (POS) and voriconazole (VRC) was assessed using the broth microdilution (BMD) method of the Clinical and Laboratory Standards Institute (CLSI) with different media such as modified Sabouraud dextrose broth (SDB), RPMI and Christensen’s urea broth (CUB). Optimal broth media that allow sufficient growth of M. furfur, and produce reliable and reproducible MICs using the CLSI BMD protocol were assessed. Thirty-six M. furfur isolates collected from BSIs of patients before and during AMB therapy, and receiving FLC prophylaxis, were tested. A good growth of M. furfur was observed in RPMI, CUB and SDB at 32 °C for 48 and 72 h. No statistically significant differences were detected between the MIC values registered after 48 and 72 h incubation. ITC, POS and VRC displayed lower MICs than FLC and AMB. These last two antifungal drugs showed higher and lower MICs, respectively, when the isolates were tested in SDB. SDB is the only medium in which it is possible to detect isolates with high FLC MICs in patients receiving FLC prophylaxis. A large number of isolates showed high AMB MIC values regardless of the media used. In conclusion, SDB might be suitable to determine triazole susceptibility. However, the media, the drug formulation or the breakpoints herein applied might not be useful for assessing the AMB susceptibility of M. furfur from BSIs.

Malassezia pachydermatis fungemia in a preterm neonate resistant to fluconazole and flucytosine

A case of Malassezia pachydermatis fungemia in a preterm neonate is described. The isolate was identified by rDNA sequencing and was resistant to fluconazole and flucytosine. Since M. pachydermatis does not require lipid supplementation for growth, it can be misidentified as a Candida species. The report highlights M. pachydermatis as a cause of late onset sepsis in preterm neonates and emphasizes the need for prior antifungal susceptibility testing.

In vitro amphotericin B susceptibility of Malassezia pachydermatis determined by the CLSI broth microdilution method and Etest using lipid-enriched media

We determined the in vitro amphotericin B susceptibility of 60 Malassezia pachydermatis isolates by the CLSI broth microdilution method and the Etest using lipid-enriched media. All isolates were susceptible at MICs of ≤ 1 μg/ml, confirming the high activity of amphotericin B against this yeast species. Overall, the essential agreement between the tested methods was high (80% and 96.7% after 48 h and 72 h, respectively), and all discrepancies were regarded as nonsubstantial.

Atividade antifúngica do óleo essencial de Origanum vulgare frente a Malassezia pachydermatis

Objetivou-se com este estudo avaliar a atividade antifúngica in vitro do óleo essencial de Origanum vulgare frente a isolados clínicos de Malassezia pachydermatis. As folhas secas de O. vulgare foram adquiridas de distribuidor comercial com certificado de qualidade e origem e encaminhadas para extração do óleo essencial e cromatografia. Para realização do teste in vitro, foi utilizada a técnica de microdiluição em caldo (CLSI M27A3) com modificações para fitofármacos e M. pachydermatis. O óleo essencial de orégano foi testado nas concentrações de 28 a 0,87mg/mL diluído em caldo Sabouraud com 1% de tween 80. Todos os isolados foram testados em duplicata. Na análise cromatográfica do óleo essencial, foram identificados 12 compostos, sendo timol, a-terpineno e 4-terpineol os compostos majoritários. A CIM e a CFM dos 42 isolados de M. pachydermatis variaram de <0,87 a 7mg/mL, com valores de CIM50 e CIM90 de 1,18 e 3,28mg/mL, respectivamente. Com este estudo foi possível concluir que M. pachydermatis é sensível ao óleo essencial de orégano mesmo em concentrações baixas. Dessa maneira, o óleo essencial de orégano apresenta-se como promissor na bioprospecção de novos fármacos para o tratamento das otites e dermatites na clínica de pequenos animais.

Antifungal agent susceptibilities and interpretation of Malassezia pachydermatis and Candida parapsilosis isolated from dogs with and without seborrheic dermatitis skin

Malassezia pachydermatis and Candida parapsilosis are recognized as commensal yeasts on the skin of healthy dogs but also causative agents of eborrheic dermatitis, especially in atopic dogs. We determined and compared the susceptibility levels of yeasts isolated from dogs with and without seborrheic dermatitis (SD) using the disk diffusion method (DD) for itraconazole (ITZ), ketoconazole (KTZ), nystatin (NYS), terbinafine (TERB) and 5-fluorocytosine (5-FC) and the broth microdilution method (BMD) for ITZ and KTZ. The reliability between the methods was assessed using an agreement analysis and linear regression. Forty-five M. pachydermatis and 28 C. parapsilosis isolates were identified based on physiological characteristics and an approved molecular analysis. By DD, all tested M. pachydermatis isolates were susceptible to ITZ, KTZ, NYS and TERB but resistant to 5-FC. Only 46 - 60% of the tested C. parapsilosis isolates were susceptible to KTZ, TERB and 5-FC, but ITZ and NYS were effective against all. By BMD, over 95% of M. pachydermatis isolates were susceptible to KTZ and ITZ with an MIC90 < 0.03 and 0.12 μg/ml, respectively. The frequency of KTZ- and ITZ-resistant C. parapsilosis was 29% and 7%, and the MIC90 values were 1 μg/ml and 0.5-1 μg/ml, respectively. Regarding the agreement analysis, 2.2% of minor errors were observed in M. pachydermatis and 0.2-1% of very major errors occurred among C. parapsilosis. There were no significant differences in the yeast resistance rates between dogs with and without SD. KTZ and ITZ were still efficacious for M. pachydermatis but a high rate of KTZ resistant was reported in C. parapsilosis.

Susceptibility variation of Malassezia pachydermatis to antifungal agents according to isolate source

Malassezia pachydermatis is associated with dermatomycoses and otomycosis in dogs and cats. This study compared the susceptibility of M. pachydermatis isolates from sick (G1) and healthy (G2) animals to azole and polyene antifungals using the M27-A3 protocol. Isolates from G1 animals were less sensitive to amphotericin B, nystatin, fluconazole, clotrimazole and miconazole.

Assessment of the antifungal susceptibility of Malassezia pachydermatis in various media using a CLSI protocol

The microdilution antifungal method (CLSI BMD, M27-A3) was used for testing the antifungal susceptibility of Malassezia species. However, optimal broth media that allow sufficient growth of M. pachydermatitis and produce reliable and reproducible MICs using the CLSI BMD protocol are yet to be established. In this study, the susceptibility of M. pachydermatis isolates to ketoconazole (KTZ), itraconazole (ITZ) and fluconazole (FLZ) was evaluated in vitro by the CLSI BMD test using Christensen's urea broth (CUB) and mRPMI 1640 containing lipid supplementation, Sabouraud dextrose broth with 1% tween 80 (SDB), and Dixon broth (DXB). A FLZ-resistant M. pachydermatis was generated in vitro and tested under the same conditions. A good growth of M. pachydermatis incubated for 48 and 72 h, respectively, was observed in CUB, SDB and DXB and not in mRPMI 1640 (p<0.001). No statistically significant differences were detected between the MIC values registered after 48 h and 72 h incubation. ITZ displayed lower MIC values than KTZ and FLZ regardless of the media employed. A large number of FLZ-resistant Malassezia strains (86.6%) was observed using DXB. A MIC>64 mg/L was observed only when the FLZ-resistant M. pachydermatis isolate was tested in SDB. Based on the results obtained herein, culture in SDB, stock inoculum suspensions of 1-5 × 10(6)CFU/ml, and an incubation time of 48 h are proposed as optimal conditions for the evaluation of the in vitro antifungal susceptibility of M. pachydermatis using a modified CLSI BMD protocol.

Proton-pumping-ATPase-targeted antifungal activity of cinnamaldehyde based sulfonyl tetrazoles

Azoles are generally fungistatic, and resistance to fluconazole is emerging in several fungal pathogens. We designed a series of cinnamaldehyde based sulfonyl tetrazole derivatives. To further explore the antifungal activity, in vitro studies were conducted against 60 clinical isolates and 6 standard laboratory strains of Candida. The rapid irreversible action of these compounds on fungal cells suggested a membrane-located target for their action. Results obtained indicate plasma membrane H(+)-ATPase as site of action of the synthesized compounds. Inhibition of H(+)-ATPase leads to intracellular acidification and cell death. Presence of chloro and nitro groups on the sulfonyl pendant has been demonstrated to be a key structural element of antifungal potency. SEM micrographs of treated Candida cells showed severe cell breakage and alterations in morphology.