Update on antifungal resistance

Preclinical Pharmacokinetic/Pharmacodynamic Studies and Clinical Trials in the Drug Development Process of EMA-Approved Antifungal Agents: A Review

Antifungal drug development is essential as invasive fungal disease is still associated with a very high mortality rate and the emergence of resistant species in the last decade. In Europe, the European Medical Agency (EMA) approves antifungals and publishes the European Public Assessment Report (EPAR) including the information leading up to the authorisation. We looked at EMA-approved antifungals and their reports within the last 23 years. We focused primarily on the role of pharmacokinetic/pharmacodynamic indices in antifungal development and the level of information depicted in their corresponding report. Furthermore, we investigated guidelines applicable to the development process at the time and compared the content with a focus on pharmacokinetic/pharmacodynamic studies and preclinical requirements. Since 2000, six new antifungal substances have been authorised. Most were authorised for treatment of Candida infections or Aspergillus infections but also included rarer pathogens. Pharmacokinetic/pharmacodynamic indices were scarcely investigated and/or mentioned in the report. Current antifungal EMA guidelines started emphasising investigating pharmacokinetic/pharmacodynamic indices in 2010 and then again in 2016. It remains to be seen how this translates into the authorisation process for new antifungals.

Exogenous melatonin enhances cell wall response to salt stress in common bean (Phaseolus vulgaris) and the development of the associated predictive molecular markers

Common bean (Phaseolus vulgaris) is an important food crop; however, its production is affected by salt stress. Salt stress can inhibit seed germination, promote senescence, and modify cell wall biosynthesis, assembly, and architecture. Melatonin, an indole heterocycle, has been demonstrated to greatly impact cell wall structure, composition, and regulation in plants under stress. However, the molecular basis for such assumptions is still unclear. In this study, a common bean variety, "Naihua" was treated with water (W), 70 mmol/L NaCl solution (S), and 100 μmol/L melatonin supplemented with salt solution (M+S) to determine the response of common bean to exogenous melatonin and explore regulatory mechanism of melatonin against salt stress. The results showed that exogenous melatonin treatment alleviated salt stress-induced growth inhibition of the common bean by increasing the length, surface area, volume, and diameter of common bean sprouts. Moreover, RNA sequencing (RNA-seq) and real-time quantitative PCR (qRT-PCR) indicated that the cell wall regulation pathway was involved in the salt stress tolerance of the common bean enhanced by melatonin. Screening of 120 germplasm resources revealed that melatonin treatment improved the salt tolerance of more than 65% of the common bean germplasm materials. Melatonin also up-regulated cell wall pathway genes by at least 46%. Furthermore, we analyzed the response of the common bean germplasm materials to melatonin treatment under salt stress using the key genes associated with the synthesis of the common bean cell wall as the molecular markers. The results showed that two pairs of markers were significantly associated with melatonin, and these could be used as candidate markers to predict whether common bean respond to exogenous melatonin and then enhance salt tolerance at the sprouting stage. This study shows that cell wall can respond to exogenous melatonin and enhance the salt tolerance of common bean. The makers identified in this study can be used to select common bean varieties that can respond to melatonin under stress. Overall, the study found that cell wall could response melatonin and enhance the salt tolerance and developed the makers for predicting varieties fit for melatonin under stress in common bean, which may be applied in the selection or development of common bean varieties with abiotic stress tolerance.

Efficacy and Safety of Terbinafine 500 mg Once Daily in Patients with Dermatophytosis

Introduction:

Dermatophytosis are the most common fungal infections globally. Terbinafine is considered to have good potency against dermatophytes, but resistance to terbinafine is on the rise.

Objective:

The objective of this study was to evaluate the efficacy and safety of terbinafine 500 mg given once daily in treatment of patients with superficial dermatophytosis.

Materials and Methods:

It was a retrospective questionnaire-based survey. Each doctor was given survey questionnaire booklet containing survey forms. Clinical response was graded according to the improvement in the affected lesion. Mycological cure was defined as negative microscopy under potassium hydroxide examination and a negative culture in Sabouraud's dextrose agar. Patients were divided into three groups depending on the duration of therapy, Group A – terbinafine 500 mg for 2 weeks, Group B – terbinafine 500 mg for 4 weeks, and Group C – terbinafine 500 mg for 6 weeks.

Results:

Total 50 doctors completed the survey involving 440 patients. In Group A, out of 194 patients, 87% (n = 169) patients showed very good response. In Group B, out of 211 patients, 92% (n = 194) of the patients showed very good response with >75% improvement in their lesion. In Group C, out of 35 patients, 80% (n = 30) patients showed very good response. Adverse drug reactions of mild to moderate intensity related to terbinafine were seen in 57 patients.

Conclusion:

Our survey indicates that terbinafine in a dose of 500 mg given once daily was efficacious and safe in the treatment of patients with dermatophytosis.

In vitro antifungal activities of Actinomyces species isolated from soil samples against Trichophyton mentagrophytes

Background and Purpose:

Cutaneous infections arise from a homogeneous group of keratinophilic fungi, known as dermatophytes. Since these pathogenic dermatophytes are eukaryotes in nature, use of chemical antifungal agents for treatment may affect the host tissue cells. In this study, we aimed to evaluate the antifungal activity of Actinomyces species against Trichophyton mentagrophytes (abbreviated as T. mentagrophytes). The isolates were obtained from soil samples and identified by polymerase chain reaction (PCR) technique.

Material and Methods:

In total, 100 strains of Actinomyces species were isolated from soil samples in order to determine their antagonistic activities against T. mentagrophytes in Kerman, Iran. The electron microscopic study of these isolates was performed, based on the physiological properties of these antagonists (e.g., lipase, amylase, protease and chitinase), using relevant protocols. The isolates were identified using gene 16S rDNA via PCR technique.

Results:

Streptomyces flavogriseus, Streptomyces zaomyceticus strain xsd08149 and Streptomyces rochei were isolated and exhibited the most significant antagonistic activities against T. mentagrophytes. Images were obtained by an electron microscope and some spores, mycelia and morphology of spore chains were identified. Molecular, morphological and biochemical characteristics of these isolates were studied, using the internal 16S rDNA gene. Active isolates of Streptomyces sequence were compared to GenBank sequences. According to nucleotide analysis, isolate D5 had maximum similarity to Streptomyces flavogriseus (99%).

Conclusion:

The findings of this study showed that Streptomyces isolates from soil samples could exert antifungal effects on T. mentagrophytes.

In Vitro Evaluation of Enzymatic and Antifungal Activities of Soil-Actinomycetes Isolates and Their Molecular Identification by PCR

Background:

Human cutaneous infection caused by a homogeneous group of keratinophilic fungi called dermatophytes. These fungi are the most common infectious agents in humans that are free of any population and geographic area. Microsporum canis is a cause of dermatophytosis (Tinea) in recent years in Iran and atypical strain has been isolated in Iran. Its cases occur sporadically due to M. canis transmission from puppies and cats to humans. Since this pathogenic dermatophyte is eukaryotes, chemical treatment with antifungal drugs may also affect host tissue cells.

Objectives:

The aim of the current study was to find a new antifungal agent of soil-Actinomycetes from Kerman province against M. canis and Actinomycete isolates were identified by PCR.

Materials and Methods:

A number of hundred Actinomycete isolated strains were evaluated from soil of Kerman province, for their antagonistic activity against the M. canis. M. canis of the Persian Type Culture Collection (PTCC) was obtained from the Iranian Research Organization for Science and Technology (IROST). Electron microscope studies of these isolates were performed based on the physiological properties of these antagonists including lipase, amylase, protease and chitinase activities according to the relevant protocols and were identified using gene 16SrDNA.

Results:

In this study the most antagonist of Actinomycete isolates with antifungal activity against M. canis isolates of L1, D5, Ks1m, Km2, Kn1, Ks8 and Ks1 were shown in vitro. Electron microscopic studies showed that some fungal strains form spores, mycelia and spore chain. Nucleotide analysis showed that Ks8 had maximum homology (98%) to Streptomyceszaomyceticus strain xsd08149 and L1 displayed 100% homology to Streptomyces sp. HVG6 using 16SrDNA studies.

Conclusions:

Our findings showed that Streptomyces has antifungal effects against M. canis.

Mechanisms of antifungal drug resistance in Candida dubliniensis

Candida dubliniensis was first described in 1995 and is the most closely related species to the predominant human fungal pathogen Candida albicans. C. dubliniensis is significantly less prevalent and less pathogenic than C. albicans and is primarily associated with infections in HIV-infected individuals and other immunocompromised cohorts. The population structure of C. dubliniensis consists of three well-defined major clades and is significantly less diverse than C. albicans. The majority of C. dubliniensis isolates are susceptible to antifungal drugs commonly used to treat Candida infections. To date only two major patterns of antifungal drug resistance have been identified and the molecular mechanisms of these are very similar to the resistance mechanisms that have been described previously in C. albicans. However, significant differences are evident in the predominant antifungal drug mechanisms employed by C. dubliniensis, differences that reflect its more clonal nature, its lower prevalence and characteristics of its genome, the complete sequence of which has only recently been determined.

FTR1335 is a novel synthetic inhibitor of Candida albicans N-myristoyltransferase with fungicidal activity

Inhibitors of the fungal enzyme N-myristoyltransferase (Nmt) reduce fungal growth, as this enzyme is essential for viability. We found that a newly synthesized benzothiazole derivative, (1R,3S)-N-{2-[(cyclopeanthylcarbonyl) amino]-benzothiazol-6-yl}-3-[(2-naphthylmethyl) amino] cyclohexanecarboxamide (FTR1335), preferentially inhibited Candida albicans Nmt (CaNmt) in a dose-dependent manner. The 50% inhibitory concentration (IC(50)) for CaNmt was 0.49 nM, which was much lower than the 5400 nM IC(50) for human Nmt (HsNmt1). The mode of CaNmt inhibition was competitive with the substrate peptide and non-competitive with myristoyl-CoA. Moreover, FTR1335 showed strong antifungal activity in vitro, and the minimum fungicidal concentration for C. albicans was 0.78 microM. These results indicate that FTR1335 might represent a novel family of Nmt inhibitors with fungicidal activity.

Importance of antifungal drug-resistance: clinical significance and need for novel therapy

The incidence of fungal infections has increased dramatically over the past few decades due to the increase in the members of the population susceptible to such infections. This population includes individuals undergoing chemotherapy for cancer, those enduring long-term treatment with antibacterial agents, those receiving immunosuppressive drugs following transplantations, or those immunosuppressed due to diseases, such as AIDS, or malignancies. Newer antifungal agents, namely the triazoles, have aided in both the treatment of fungal infections and in the prevention of disease in susceptible individuals. However, resistance to the azoles, as well as to the polyenes, has resulted in clinical failures. Only a few potential antifungal targets have been exploited to date and there is a critical need for the discovery and development of novel antifungal agents that will result in improved therapy in this ever-expanding patient population. An increased intensity in the study of fungal pathogens at the molecular level holds the key to such advances.

Synthesis, antimicrobial activity and chemotherapeutic potential of inorganic derivatives of 2-(4′-thiazolyl)benzimidazole{thiabendazole}: X-ray crystal structures of [Cu(TBZH)2Cl]Cl·H2O·EtOH and TBZH2NO3 (TBZH=thiabendazole)

Thiabendazole (TBZH) reacts with iron(III) nitrate causing protonation of the ligand to yield the nitrate salt [TBZH(2)NO(3)] (1). Reaction of TBZH with copper(II) acetate results in the deprotonation of the ligand yielding [Cu(TBZ)2.(H2O)2] (2). Reactions of TBZH with the chloride, nitrate and butanedioate salts of copper(II) yields [Cu(TBZH)2Cl]Cl.H2O.EtOH (3), [Cu(TBZH)(2)(NO(3))(2)] (4) and [Cu(TBZH)(O(2)C-CH(2)CH(2)-CO(2))] (5), respectively. The TBZH acts as a neutral chelating ligand in 3-5. Molecular structures of 1 and 3 were determined crystallographically. In 1, the asymmetric unit contains one TBZH(2)(+) cation and one NO(3)(-) anion. The structure of 3 comprises a five coordinate copper centre with the metal bound to two chelating TBZH ligands and one chloride. The geometry is best described as trigonal bipyramidal. Hydrogen bonding connects the complex cation with the uncoordinated chloride anion and the water and ethanol solvate molecules. Compound 1 and the copper complexes 2-5, the metal free ligands and a number of simple copper(II) salts were each tested for their ability to inhibit the growth of Candida albicans. The metal free TBZH and its nitrate salt (1) exhibited very poor activity. Complex 2, in which the TBZH is present as an anionic ligand (TBZ(-)), exhibits moderate activity towards the pathogen. Chelation of the neutral TBZH to copper centres (complexes 3-5) results in potent anti-candida activity. The dimethyl sulphoxide (DMSO) soluble complexes 3 and 4, along with metal free TBZH were assessed for their cancer chemotherapeutic potential towards two human epithelial-derived cancer model cell lines. Complexes 3 and 4 displayed similar dose-dependent cytotoxicity in both cell lines with IC(50) values of approximately 50 microM, which were found to be significantly lower than that for metal free TBZH.

Efficacy of chlorhexidine gluconate rinse for treatment and prevention of oral candidiasis in HIV-infected children: a pilot study

PURPOSE

We evaluated the effect of chlorhexidine (CHX) 0.12% rinses on the clinical and microbiologic manifestations of oral candidiasis in HIV-infected children.

STUDY DESIGN

This was a cross-sectional, clinical intervention study of 38 HIV-positive children. Inclusion in the study was based on oral examination and positive oral culture for Candida. At baseline, subjects with no clinical lesions but who were culture-positive for Candida (N = 9) were placed on preventive therapy of CHX q.d. for 90 days. Subjects with clinical oral candidiasis (N = 9) were placed on therapeutic CHX b.i.d. All 38 subjects received oral exams at monthly intervals. At 90 days oral mucosal samples were again taken for Candida. Colony-forming units (CFU) were determined before and after CHX treatment.

RESULTS

Of 18 culture-positive subjects, 12 were included in the CFU analyses. After 3 months of CHX oral rinse therapy, Candida was undetectable in 3 children; another 8 showed an average 2-fold reduction in CFU. In 1 child the number of CFU increased modestly. Overall, the average pre- and posttreatment mean CFU was 6.18 +/- 2.19 and 2.73 +/- 3.15, respectively (P = .009). Five patients with clinical oral candidiasis at baseline, including all 3 who had pseudomembranous candidiasis, were free of signs of disease at the end of the study.

CONCLUSIONS

This study suggests that the topical disinfectant CHX may be a promising agent for treating and preventing oral candidiasis in HIV-infected children.

Detection of human P-glycoprotein-like molecule in azole-resistant Candida albicans from HIV+ patients

Azole resistance in Candida albicans may be due to several mechanisms. It has been demonstrated that C. albicans possesses sequences with a high degree of homology with the human MDR-1 gene coding for P-glycoprotein (P-gp), belonging to the ATP-binding cassette transporter (ABC) superfamily and responsible for the multidrug resistance (MDR) in tumor cells. On this basis, the expression and intracellular localization of human P-gp-like molecule in C. albicans strains showing different sensitivity to fluconazole were investigated by flow cytometry and immunoelectron microscopy. Post-embedding immunolabeling revealed that monoclonal antibody (mAb) MM4.17, which recognizes an external epitope of human P-gp, reacted with both fluconazole-sensitive (3153 and CO 23-1) and fluconazole-resistant (AIDS 68 and CO 23-2, isolated from AIDS patient and in vitro drug-selected, respectively) strains of C. albicans. However, the resistant strains displayed a number of MM4.17-reactive epitopes much higher than the drug-sensitive ones. The C. krusei ATCC 6458 strain, whose resistance is not mediated by the presence of ABC transporters, was not reactive at all with mAb MM4.17. The specificity of the immunolabeling was confirmed by a competitive inhibition assay performed by using phage clone particles capable of mimicking the MM4.17-reactive epitope. The flow cytometric analysis confirmed a higher level of intracytoplasmic P-gp expression in azole-resistant strains of C. albicans. Both cyclosporin A and verapamil, which are well-known MDR inhibitors, strongly reduced the MICs for fluconazole and itraconazole of the tested azole-resistant AIDS 68 strain, while they did not influence the MICs of either the sensitive 3153 strain of C. albicans or the ATCC 6458 strain of C. krusei. Overall, our data suggest the existence of a P-gp-like drug efflux pump in C. albicans that may participate in the mechanisms of azole-resistance of this fungus.

Discovery, SAR, synthesis, pharmacokinetic and biochemical characterization of A-192411: a novel fungicidal lipopeptide-(I)

The echinocandin class of cyclic lipopeptides has been simplified to discover potent antifungal compounds. Namely A-192411 shows good in vitro activity against common pathogenic yeasts and has an acceptable safety window in vivo. Discovery, limited SAR, synthesis, biochemical and pharmaco-dynamic profiles of A-192411 are presented.

In vivo characterization of A-192411: a novel fungicidal lipopeptide (II)

The ability of the novel antifungal cyclic hexalipopetide A-192411 to treat fungal infections in rodents is presented. Efficacy was demonstrated against Candida albicans as both prolonged survival of systemically infected mice and clearance of viable yeasts from kidneys. The efficacy of A-192411, administered intraperitoneally, was equivalent to amphotercin B at a 4-fold lower dose by weight in the systemic candidiasis models in mice, while the efficacy of A-192441 administered intravenously was equivalent to amphotercin B by weight in the Candida pyelonephritis model in rats. A-192411 also slightly prolonged the survival of immunocompromised mice infected systemically with Aspergillus fumigatus.

Antifungal agents of use in animal health--chemical, biochemical and pharmacological aspects

A limited number of antifungal agents is licensed for use in animals, however, many of those available for the treatment of mycoses in humans are used by veterinary practitioners. This review includes chemical aspects, spectra of activity, mechanisms of action and resistance, adverse reactions and drug interactions of the antifungals in current use.

Effects of carbohydrate polymers applicable in saliva substitutes on the anti-Candida activity of a histatin-derived peptide

The effects of polymers applicable in saliva substitutes on the anti-Candida activity of the cationic antimicrobial peptide dhvar1 were investigated. Dhvar1 is a derivative of the 14 C-terminal amino acids of histatin 5. The effects of the following polymers were tested: uncharged hydroxyethylcellulose (HEC), negatively charged xanthan (XG) and three types of negatively charged carboxymethylcellulose (CMC) of identical mass but different degrees of carboxylic acid-group substitution (DS). The effects were tested at pH 4.0, 7.0 and 8.5 in a killing assay. HEC had no effect at any pH tested; XG and the three types of CMC caused a decrease in activity at increasing concentrations. Within the CMC group, inhibition increased slightly with increasing DS. These results suggest that the reduction in activity associated with these polymers is the result of electrostatic interaction between the positively charged peptides and the negatively charged polymers. In the absence of polymers, no effect of pH was found on the activity of dhvar1. In the presence of the charged polymers XG and CMC, lowering the pH from 7.0 to 4.0 resulted in a decrease of dhvar1 activity. It was concluded that, with respect to the retention of activity, HEC is the most appropriate polymer for use in combination with dhvar1. However, for use in saliva substitutes XG seems more suitable because of its rheological properties. If XG or CMC are to be used, their reductive effect on the anti-Candida activity of dhvar1 should be compensated for by increasing the peptide dose.

Oral candidal infections and antimycotics

The advent of the human immunodeficiency virus infection and the increasing prevalence of compromised individuals in the community due to modern therapeutic advances have resulted in a resurgence of opportunistic infections, including oral candidoses. One form of the latter presents classically as a white lesion of "thrush" and is usually easily diagnosed and cured. Nonetheless, a minority of these lesions appears in new guises such as erythematous candidosis, thereby confounding the unwary clinician and complicating its management. Despite the availability of several effective antimycotics for the treatment of oral candidoses, failure of therapy is not uncommon due to the unique environment of the oral cavity, where the flushing effect of saliva and the cleansing action of the oral musculature tend to reduce the drug concentration to sub-therapeutic levels. This problem has been partly circumvented by the introduction of the triazole agents, which initially appeared to be highly effective. However, an alarming increase of organisms resistant to the triazoles has been reported recently. In this review, an overview of clinical manifestations of oral candidoses and recent advances in antimycotic therapy is given, together with newer concepts, such as the post-antifungal effect (PAFE) and its possible therapeutic implications.

Molecular heterogeneity of fluconazole-resistant and -susceptible oral Candida albicans isolates within a single geographic locale

The emergence of drug-resistant Candida albicans in immunocompromised patients is common. A disconcerting aspect of this phenomenon is the rapid emergence of C. albicans strains that are resistant to a widely used azole drug, fluconazole (FLZ). To understand the origin of FLZ-resistant yeast isolates, we investigated molecular profiles of 20 geographically related oral C. albicans isolates using three genotyping methods: randomly amplified polymorphic DNA-PCR, with six different primers (OBU1, OBU2, OBU3 RSD6, RSD11 and RSD12); electrophoretic karyotyping by pulsed-field gel electrophoresis; and HinfI restriction fragment analysis. Of the 20 isolates studied, 10 were FLZ- resistant and originated from patients with oral candidosis with a history of FLZ therapy, and the remainder were FLZ susceptible from individuals with oral candidosis, but without a history of FLZ therapy. A composite genotype was generated for each strain by combining molecular types derived from the three independent molecular methods. The composite profiles indicated genetic diversity amongst both the FLZ-resistant as well as -sensitive isolates, and no specific features emerged distinguishing the drug-resistant and -sensitive groups. These observations cast doubt on the theory of a clonal origin of FLZ-resistant C. albicans isolates.

Prevalence of fluconazole-resistant strains of Candida albicans in otherwise healthy outpatients

BACKGROUND

In contrast to the immunosuppressed patient population, the prevalence of fluconazole-resistant strains of Candida albicans among healthy individuals has not been extensively studied.

METHODS

Candida species were cultured form 50 healthy outpatients with clinical signs of oral candidiasis. Following one week of the recommended fluconazole regimen, post-treatment cultures were obtained. Both pre- and post-treatment yeasts were identified and in vitro susceptibility testing was performed using the NCCLS M-27A method. Strains were further differentiated using established cDNA probes.

RESULTS

Forty-four patients (88%) had positive C.albicans cultures prior to treatment. Antifungal susceptibility testing of these strains demonstrated no in vitro resistance to fluconazole. At post-treatment evaluation, eight patients (18%) had persistent signs of infection and 10 patients (23%) had positive Candida sp. cultures despite no clinical signs of infection. DNA analysis confirmed that the same C. albicans strain was present both in the pre-treatment and the post-treatment cultures.

CONCLUSIONS

Our results showed that the presence of fluconazole-resistant strains of C.albicans does not appear to be prevalent among healthy outpatients furthermore, in vitro antifungal susceptibility testing does not always predict successful therapy in these patients.

Infectious morbidity in critically ill patients with cancer

Infection frequently complicates the course of cancer treatment and often adversely affects the outcome. Patients have a greater tendency for acquiring infections caused by opportunistic microorganisms. Agents with low virulence potential may lead to invasive and often life-threatening infections because of altered host immune function. The immune dysfunction may be caused by the underlying malignancy, by antineoplastic chemotherapy, or by invasive procedures during supportive care.

HWY-289, a novel semi-synthetic protoberberine derivative with multiple target sites in Candida albicans

The antifungal properties of 515 synthetic and semi-synthetic protoberberines were investigated. HWY-289 was chosen for further study because it exhibited the most significant anti-Candida activity (MICs were 1.56 mg/L for Candida albicans and Candida krusei; 6.25 mg/L for Candida guilliermondii) but did not demonstrate toxicity in rats. HWY-289 inhibited the incorporation of L-[methyl-(14)C]methionine into the C-24 of ergosterol in whole cells of C. albicans (IC(50) 20 microM). However, HWY-289 (100 microM) had no effect on mammalian cholesterol biosynthesis in rat microsomes while miconazole (100 microM) was a potent inhibitor of cholesterol biosynthesis under identical assay conditions. A second major target site for HWY-289 was identified that involves cell wall biosynthesis in C. albicans. HWY-289 was a potent inhibitor of the chitin synthase isozymes CaCHS1 and CaCHS2, with IC(50) values of 22 microM for each enzyme. The effect was highly specific in that HWY-289 had no significant effect on C. albicans CaCHS3 (IC(50) > 200 microM). Thus, HWY-289 compared favourably with well-established antifungal agents as an inhibitor of the growth of Candida species in vitro, and may have considerable potential as a new class of antifungal agent that lacks toxic side effects in the human host.

Cross-Resistance of clinical isolates of Candida albicans and Candida glabrata to over-the-counter azoles used in the treatment of vaginitis

Antifungal drug resistance in Candida spp. continues to increase in response to the widespread application of triazole therapeutics among immunosuppressed patients. Azole-based over-the-counter (OTC) antifungal agents used to treat vaginitis have the potential to exacerbate this problem by contributing to the selection of highly resistant strains of Candida in otherwise healthy women. In this study, we show that fluconazole-resistant (MIC > 64 microg/mL) blood stream isolates of Candida albicans and Candida glabrata obtained from cancer patients were cross-resistant to the root drugs miconazole, clotrimazole, and tioconazole (found in several over-the-counter products), but remained susceptible to butoconazole. We also provide evidence that spontaneous mutants of Candida glabrata selected for resistance to clotrimazole were cross-resistant to other azolebased drugs, including fluconazole. Our findings demonstrate cross-resistance of Candida strains to fluconazole and OTC azole antifungals, and support the notion that OTC drugs can promote azole resistance in Candida spp.

Dynamic and heterogeneous mutations to fluconazole resistance in Cryptococcus neoformans

Infections with the human pathogenic basidiomycetous yeast Cryptococcus neoformans are often treated with fluconazole. Resistance to this antifungal agent has been reported. This study investigated the patterns of mutation to fluconazole resistance in C. neoformans in vitro. The MIC of fluconazole was measured for 21 strains of C. neoformans. The MICs for these 21 strains differed (0.25 to 4.0 microg/ml), but the strains were selected for this study because they exhibited no growth on plates of yeast morphology agar (YMA) containing 8 microg of fluconazole per ml. To determine their mutation rates, six independent cultures from a single original colony were established for each of the 21 strains. Each culture was then spread densely on a YMA plate with 8 microg of fluconazole per ml. A random set of putative mutants was subcultured, and the MIC of fluconazole was determined for each mutant. The 21 strains evinced significant heterogeneity in their mutation rates. The MICs of the putative mutants ranged widely, from their original MIC to 64 microg of fluconazole per ml. However, for this set of 21 strains, there was no significant correlation between the original MIC for a strain and the mutation rate of that strain; the MIC for the mutant could not be predicted from the original MIC. These results suggest that dynamic and heterogeneous mutational processes are involved in generating fluconazole resistance in C. neoformans.

Antifungal rapamycin analogues with reduced immunosuppressive activity

Several 1,2,3,4-tetrahydro- and 7-N-hydroxycarbamate derivatives of the natural product rapamycin were prepared and assayed for their immunosuppressive and antifungal profiles. Substitutions at the 7-position indicate the possibility of a differentiated immunosuppressive to antifungal profile, whereas 40-position variants of the tetrahydro-analogues did not show similar differentiated activity.

Applications of flow cytometry to clinical microbiology

Classical microbiology techniques are relatively slow in comparison to other analytical techniques, in many cases due to the need to culture the microorganisms. Furthermore, classical approaches are difficult with unculturable microorganisms. More recently, the emergence of molecular biology techniques, particularly those on antibodies and nucleic acid probes combined with amplification techniques, has provided speediness and specificity to microbiological diagnosis. Flow cytometry (FCM) allows single- or multiple-microbe detection in clinical samples in an easy, reliable, and fast way. Microbes can be identified on the basis of their peculiar cytometric parameters or by means of certain fluorochromes that can be used either independently or bound to specific antibodies or oligonucleotides. FCM has permitted the development of quantitative procedures to assess antimicrobial susceptibility and drug cytotoxicity in a rapid, accurate, and highly reproducible way. Furthermore, this technique allows the monitoring of in vitro antimicrobial activity and of antimicrobial treatments ex vivo. The most outstanding contribution of FCM is the possibility of detecting the presence of heterogeneous populations with different responses to antimicrobial treatments. Despite these advantages, the application of FCM in clinical microbiology is not yet widespread, probably due to the lack of access to flow cytometers or the lack of knowledge about the potential of this technique. One of the goals of this review is to attempt to mitigate this latter circumstance. We are convinced that in the near future, the availability of commercial kits should increase the use of this technique in the clinical microbiology laboratory.

Applications of flow cytometry to clinical microbiology

Classical microbiology techniques are relatively slow in comparison to other analytical techniques, in many cases due to the need to culture the microorganisms. Furthermore, classical approaches are difficult with unculturable microorganisms. More recently, the emergence of molecular biology techniques, particularly those on antibodies and nucleic acid probes combined with amplification techniques, has provided speediness and specificity to microbiological diagnosis. Flow cytometry (FCM) allows single- or multiple-microbe detection in clinical samples in an easy, reliable, and fast way. Microbes can be identified on the basis of their peculiar cytometric parameters or by means of certain fluorochromes that can be used either independently or bound to specific antibodies or oligonucleotides. FCM has permitted the development of quantitative procedures to assess antimicrobial susceptibility and drug cytotoxicity in a rapid, accurate, and highly reproducible way. Furthermore, this technique allows the monitoring of in vitro antimicrobial activity and of antimicrobial treatments ex vivo. The most outstanding contribution of FCM is the possibility of detecting the presence of heterogeneous populations with different responses to antimicrobial treatments. Despite these advantages, the application of FCM in clinical microbiology is not yet widespread, probably due to the lack of access to flow cytometers or the lack of knowledge about the potential of this technique. One of the goals of this review is to attempt to mitigate this latter circumstance. We are convinced that in the near future, the availability of commercial kits should increase the use of this technique in the clinical microbiology laboratory.

Clonal and spontaneous origins of fluconazole resistance in Candida albicans

The genotypes and susceptibilities to fluconazole of 78 strains of the human pathogenic yeast Candida albicans were compared. The strains comprised two sets of samples from Durham, N.C.: one from patients infected with the human immunodeficiency virus (HIV) and the other from healthy volunteers. For each strain, the MIC of fluconazole was determined by the standard National Committee for Clinical Laboratory Standards protocol. Genotypes were determined by PCR fingerprinting with five separate primers. The analysis revealed little evidence for genotypic clustering according to HIV status or body site. However, a small group of fluconazole-resistant strains isolated from patients infected with HIV formed a distinct cluster. In addition, two fluconazole-resistant strains were isolated from individuals who never took fluconazole, one from a patient infected with HIV and the other from a healthy person. The results suggest both clonal and spontaneous origins of fluconazole resistance in C. albicans.

Candida albicans pathogenicity: a proteomic perspective

Candida albicans is an opportunistic fungus which causes both superficial infections and life-threatening systemic candidiasis in immunocompromised hosts such as AIDS patients, people with cancer, or other immunosuppressed individuals. Virulence factors for this fungus include the ability to adhere to host tissues, production of tissue damaging secreted enzymes, and changes in morphological form that may enhance tissue penetration and avoidance of immune surveillance. Treatment of candidiasis patients is hampered by a limited choice of antifungal agents and the appearance of clinical isolates resistant to azole drugs. Proteome analysis involves the separation and isolation of proteins by two-dimensional gel electrophoresis and their identification and characterization by mass spectrometry. The systematic application of this methodology to C. albicans is in its infancy, but is progressing rapidly. Comparing protein profiles between avirulent and virulent C. albicans strains, between drug-sensitive and -resistant strains, or between different morphological forms, could identify key control and effector proteins. There are difficulties, however, associated with the display of low abundance and cell envelope-associated proteins and the choice of conditions for obtaining suitable C. albicans cells. This article describes the potential of applying proteome analysis to C. albicans in order to better understand pathogenicity and identify new antifungal targets.

Cloning of a centromere binding factor 3d (CBF3D) gene from Candida glabrata

The gene encoding centromere binding factor 3d (CBF3D) of the human pathogenic yeast Candida glabrata has been isolated by hybridization of Saccharomyces cerevisiae CBF3D (ScCBF3D) DNA to a C. glabrata partial genomic library. Sequence analysis revealed a 540 bp open reading frame encoding a protein of 179 amino acids with a calculated molecular mass of 20.9 kDa. The amino acid sequence is highly homologous (78.6% identity) to ScCbf3d and 48.3% identical to the human homologue p19 (SKP1). Southern blot analysis indicates that CgCbf3d is encoded by an unique nuclear gene. The cloned CgCBF3D gene can functionally substitute the S. cerevisiae homologue in a S. cerevisiae CBF3D-deletion mutant. The GenBank Accession No. for this gene is AF 072472.

The in vitro post-antifungal effect of nystatin on Candida species of oral origin

The post-antifungal effect (PAFE) is defined as the suppression of growth that persists following limited exposure of yeasts to antimycotics and subsequent removal of the drug. Although limited data are available on the PAFE of nystatin on oral isolates of C albicans, there is no information on non-albicans Candida species. As nystatin is the commonest antifungal agent prescribed in dentistry, the main aim of this investigation was to measure the PAFE of oral isolates of Candida belonging to six different species (five isolates each of C. albicans, C. tropicalis, C. krusei, C. parapsilosis, C. glabrata and C. guilliermondii) following limited exposure (1 h) to nystatin. The yeasts were examined for the presence of the PAFE after 1 h exposure to the minimum inhibitory concentration (MIC) of nystatin. The PAFE was determined as the difference in time (h) required for the growth of the drug-free control and the drug-exposed test cultures to increase to the 0.05 absorbance level following removal of the antifungal agent. The mean duration of nystatin-elicited PAFE was lowest for C. albicans (6.85 h) and greatest for C. parapsilosis (15.17 h), while C. krusei (11.58 h), C. tropicalis (12.73 h), C. glabrata (8.51 h), and C. guilliermondii (8.68 h) elicited intermediate values. These findings clarify another intriguing possibility for the persistent, chronic recurrence of oral C. albicans infections despite apparently adequate antifungal drug regimens. The significant variations in nystatin-induced PAFE amongst non-albicans species may also have clinical implications, in terms of nystatin regimens used in the management of these fungal infections.

Adhesion of oral Candida albicans isolates to denture acrylic following limited exposure to antifungal agents

Candidal adherence to denture acrylic surfaces is implicated as the first step in the pathogenesis of Candida-associated denture stomatitis, the most prevalent form of oral candidosis in the West. This condition is treated by topically administered antifungal agents, mainly belonging to the polyenes and azoles. As the intraoral concentrations of antifungals fluctuate considerably due to the dynamics of the oral environment, the effect of short exposure to sublethal concentrations of antifungals on the adhesion of Candida albicans to denture acrylic surfaces was investigated. Seven oral C. albicans isolates were exposed to four-eight times minimum inhibitory concentrations (MIC) of five antifungal drugs, nystatin, amphotericin B, 5-fluorocytosine, ketoconazole and fluconazole, for 1 h. After removing the drug (by repeated washing) the adhesion of these isolates to acrylic strips was assessed by an in vitro adhesion assay. Exposure to antifungal agents significantly reduced the adherence of all seven C. albicans isolates to denture acrylic. The mean percentage reductions of adhesion after limited exposure to nystatin, amphotericin B, 5-fluorocytosine, ketoconazole and fluconazole were 86.48, 90.85, 66.72, 65.88 and 47.42%, respectively. These findings indicate that subtherapeutic doses of antifungals may modulate oral candidal colonization. Further, these results may have an important bearing on dosage regimens currently employed in treating oral candidosis.

The postantifungal effect (PAFE) of antimycotics on oral C. albicans isolates and its impact on candidal adhesion

OBJECTIVE

Postantifungal effect (PAFE) is defined as the suppression of growth that persists following limited exposure of yeasts to antimycotics and subsequent removal of the drug. As there are no data on the PAFE of oral C. albicans isolates the main aim of this investigation was to measure the PAFE of 10 oral isolates of C. albicans following limited exposure (1 h) to five antifungal drugs, including nystatin which has not been previously used in PAFE assays. A secondary aim of the study was to evaluate the biological significance of PAFE, using a nystatin pre-exposed isolate of C. albicans and observing its adherence to denture acrylic surfaces, during the PAFE period.

DESIGN

A total of 10 oral isolates of C. albicans were examined for the presence of the PAFE after 1 h exposure to five antifungal drugs, nystatin, amphotericin B, 5-fluorocytosine, ketoconazole and fluconazole. PAFE was automatically assessed with the help of a Spectramax machine which utilizes the principle of periodic turbidometric assessment of growth rates at a given temperature over a given period. The data thus collected are automatically processed in a graphic format as a computer printout. The PAFE was determined as the difference in time (h) required for growth of the drug-free control and the drug-exposed test cultures to increase to 0.05 absorbance level following removal of the antifungal agent (by repeated washing). The adhesion of the single isolate to denture acrylic following limited exposure to nystatin was assessed by a previously described in vitro adhesion assay.

RESULTS

Significant PAFE were observed for nystatin, amphotericin-B and 5-fluorocytosine. A marginal PAFE was observed for ketoconazole and little or none for fluconazole. The mean duration of the PAFE of nystatin, amphotericin-B, 5-fluorocytosine, ketoconazole and fluconazole were 2.89 (+/- 0.27) h, 2.83 (+/- 0.23) h, 3.18 (+/- 0.31) h, 0.65 (+/- 0.11) h and 0.16 (+/- 0.06) h, respectively. The mean percentage reduction of adhesion of oral C. albicans BU47204 to denture acrylic during the PAFE period following exposure to nystatin for 10, 30, 50, 70 and 90 min was 9.12%, 61.73%, 65.99%, 82.16% and 83.14%, respectively.

CONCLUSIONS

These in vitro findings imply that even a short period of exposure to antifungals may result in modulation of the growth and the virulent attributes of C. albicans, which however is largely dictated by the antimycotic agent in question. Whether such mechanisms operate in vivo needs to be clarified by further studies.

The effect of limited exposure to antimycotics on the relative cell-surface hydrophobicity and the adhesion of oral Candida albicans to buccal epithelial cells

Candida albicans is the major aetiological agent of oral candidosis. Adhesion to oral mucosal surfaces is considered a prerequisite for its successful colonization and subsequent infection, and its relative cell-surface hydrophobicity (CSH) is a contributory physical force. Thus, the main aim here was to determine the CSH of 10 isolates of oral C. albicans after a short exposure to sublethal concentrations of four antifungal agents and to correlate these findings with their adhesion to human buccal epithelial cells (BEC). The yeasts were exposed to sublethal concentrations of nystatin [x 6 minimal inhibitory concentration (MIC)], 5-fluorocytosine (x 8 MIC), ketoconazole (x 4 MIC) and fluconazole (x 4 MIC) for 1 h. The drug was then removed, and the CSH and BEC adhesion assessed by a biphasic aqueous-hydrocarbon assay and a microscopic method, respectively. The mean percentage reductions of CSH after exposure to nystatin, 5-fluorocytosine, ketoconazole and fluconazole were 27.14% (p = 0.01), 9.46% (p = 0.43), 19.47% (p = 0.04) and 6.16% (p = 0.59). Similarly, exposure to all the drugs except 5-fluorocytosine resulted in a significant inhibition of yeast adhesion to BEC, with nystatin eliciting the highest and fluconazole the least inhibition. Further, on regression analysis a strong positive correlation was observed between CSH and adhesion to BEC after limited exposure to 5-fluorocytosine (r = 0.48, p < 0.0001), ketoconazole (r = 0.48, p < 0.0001), fluconazole (r = 0.55, p < 0.0001) as well as in the unexposed controls (r = 0.41, p = 0.001), although nystatin was an exception (r = 0.09, p = 0.44). Taken together, these data elucidate further mechanisms by which antimycotics may operate in vivo to suppress candidal pathogenicity.

Adhesion of oral C. albicans to human buccal epithelial cells following limited exposure to antifungal agents

The major aetiologic agent of oral candidosis is C. albicans, and adhesion to oral mucosal surfaces is considered a vital prerequisite for successful colonisation and subsequent infection by this agent. Although many antimycotics are available for the treatment of oral candidosis, the diluent effect of saliva and the cleansing action of the oral musculature often tend to reduce the availability of the agents below that of the effective therapeutic concentration. Therefore, the yeasts undergo only a limited exposure to the antifungals during therapy. Hence, the main aim of the present study was to determine the in vitro adhesion of ten isolates of oral C. albicans to buccal epithelial cells (BEC) following a short exposure to sublethal concentrations of four antifungal agents. The yeasts were exposed to sublethal concentrations of nystatin (x6 MIC), 5-fluorocytosine (x8 MIC), ketoconazole (x4 MIC) and fluconazole (x4 MIC) for a period of 1 h. Following subsequent removal of the drug, the adhesion of these isolates to BEC was assessed by a previously described adhesion assay. The mean percentage reductions of candidal adhesion to BEC following exposure to sublethal concentrations of nystatin, 5-fluorocytosine, ketoconazole and fluconazole were 72.88%, 16.52%, 40.16% and 24.36%, respectively. Ultrastructural studies revealed that short exposure to nystatin and the azoles (but not 5-fluorocytosine) resulted in aberrant cellular features. These findings indicate that subtherapeutic levels of antifungals may modulate candidal colonisation of the oral mucosa and thereby suppress the invasive potential of the pathogen.

Identification and expression of multidrug transporters responsible for fluconazole resistance in Candida dubliniensis

Candida dubliniensis is a recently described Candida species associated with oral candidosis in human immunodeficiency virus (HIV)-infected and AIDS patients, from whom fluconazole-resistant clinical isolates have been previously recovered. Furthermore, derivatives exhibiting a stable fluconazole-resistant phenotype have been readily generated in vitro from fluconazole-susceptible isolates following exposure to the drug. In this study, fluconazole-resistant isolates accumulated up to 80% less [3H] fluconazole than susceptible isolates and also exhibited reduced susceptibility to the metabolic inhibitors 4-nitroquinoline-N-oxide and methotrexate. These findings suggested that C. dubliniensis may encode multidrug transporters similar to those encoded by the C. albicans MDR1, CDR1, and CDR2 genes (CaMDR1, CaCDR1, and CaCDR2, respectively). A C. dubliniensis homolog of CaMDR1, termed CdMDR1, was cloned; its nucleotide sequence was found to be 92% identical to the corresponding CaMDR1 sequence, while the predicted CdMDR1 protein was found to be 96% identical to the corresponding CaMDR1 protein. By PCR, C. dubliniensis was also found to encode homologs of CDR1 and CDR2, termed CdCDR1 and CdCDR2, respectively. Expression of CdMDR1 in a fluconazole-susceptible delta pdr5 null mutant of Saccharomyces cerevisiae conferred a fluconazole-resistant phenotype and resulted in a 75% decrease in accumulation of [3H]fluconazole. Northern analysis of fluconazole-susceptible and -resistant isolates of C. dubliniensis revealed that fluconazole resistance was associated with increased expression of CdMDR1 mRNA. In contrast, most studies showed that overexpression of CaCDR1 was associated with fluconazole resistance in C. albicans. Increased levels of the CdMdr1p protein were also detected in fluconazole-resistant isolates. Similar results were obtained with fluconazole-resistant derivatives of C. dubliniensis generated in vitro, some of which also exhibited increased levels of CdCDR1 mRNA and CdCdr1p protein. These results demonstrate that C. dubliniensis encodes multidrug transporters which mediate fluconazole resistance in clinical isolates and which can be rapidly mobilized, at least in vitro, on exposure to fluconazole.