Inhibitory effects of chlorpromazine on Candida species

Drug repurposing strategies in the development of potential antifungal agents

Abstract

The morbidity and mortality caused by invasive fungal infections are increasing across the globe due to developments in transplant surgery, the use of immunosuppressive agents, and the emergence of drug-resistant fungal strains, which has led to a challenge in terms of treatment due to the limitations of three classes of drugs. Hence, it is imperative to establish effective strategies to identify and design new antifungal drugs. Drug repurposing is a potential way of expanding the application of existing drugs. Recently, various existing drugs have been shown to be useful in the prevention and treatment of invasive fungi. In this review, we summarize the currently used antifungal agents. In addition, the most up-to-date information on the effectiveness of existing drugs with antifungal activity is discussed. Moreover, the antifungal mechanisms of existing drugs are highlighted. These data will provide valuable knowledge to stimulate further investigation and clinical application in this field.

Key points

• Conventional antifungal agents have limitations due to the occurrence of drug-resistant strains.

• Non-antifungal drugs act as antifungal agents in various ways toward different targets.

• Non-antifungal drugs with antifungal activity are demonstrated as effective antifungal strategies.

Alternative treatment of fungal infections: Synergy with non-antifungal agents

Fungal infections are responsible for high mortality rates in immunocompromised and high-risk surgical patients. Therapy failures during the last decades due to increasing multidrug resistance demand innovative strategies for novel and effective antifungal drugs. Synergistic combinations of antifungals with non-antifungal agents highlight a pragmatic strategy to reduce the development of drug resistance and potentially repurpose known compounds with other functions to bypass costly and time-consuming novel drug development.

Synergistic anticandidal activity of etomidate and azoles against clinical fluconazole-resistant Candida isolates

Aim: The purpose of this study was to evaluate the effect of etomidate alone and in combination with azoles on resistant strains of Candida spp. in both planktonic cells and biofilms. Materials & methods: The antifungal activity of etomidate was assessed by the broth microdilution test; flow cytometric procedures to measure fungal viability, mitochondrial transmembrane potential, free radical generation and cell death; as well detection of DNA damage using the comet assay. The interaction between etomidate and antifungal drugs (itraconazole and fluconazole) was evaluated by the checkerboard assay. Results: Etomidate showed antifungal activity against resistant strains of Candida spp. in planktonic cells and biofilms. Etomidate also presented synergism with fluconazole and itraconazole in planktonic cells and biofilms. Conclusion: Etomidate showed antifungal activity against Candida spp., indicating that it is a possible therapeutic alternative.

In vitro antifungal activity of antipsychotic drugs and their combinations with conventional antifungals against Scedosporium and Pseudallescheria isolates

In the present study, in vitro antifungal activities of five antipsychotic drugs (i.e., chlorpromazine hydrochloride, CPZ; trifluoperazine hydrochloride, TPZ; amantadine hydrochloride; R-(-)-deprenyl hydrochloride, and valproic acid sodium salt) and five conventional antifungal drugs (i.e., amphotericin B, AMB; caspofungin, CSP; itraconazole; terbinafine, TRB and voriconazole, VRC) were investigated in broth microdilution tests against four clinical and five environmental Scedosporium and Pseudallescheria isolates. When used alone, phenothiazines CPZ and TPZ exerted remarkable antifungal effects. Thus, their in vitro combinations with AMB, CSP, VRC, and TRB were also examined against the clinical isolates. In combination with antifungal agents, CPZ was able to act synergistically with AMB and TRB in cases of one and two isolates, respectively. In all other cases, indifferent interactions were revealed. Antagonism was not observed between the tested agents. These combinations may establish a more effective and less toxic therapy after further in vitro and in vivo studies for Scedosporium and Pseudallescheria infections.

In vitro antifungal activity of phenothiazines and their combination with amphotericin B against different Candida species

Candidiosis is a mycosis that is currently increasingly affecting the population in consequence of its frequency and the severity of its complications, especially among immunocompromised hosts. In this work, the in vitro anticandidal activities of two phenothiazines (PTZs), chlorpromazine (CPZ) and trifluoperazine (TFP), and their combinations with amphotericin B (AMB) were tested against 12 different Candida strains representing 12 species (Candida albicans, Candida glabrata, Candida guillermondii, Candida inconspicua, Candida krusei, Candida lusitaniae, Candida lypolitica, Candida norvegica, Candida parapsilosis, Candida pulcherrima, Candida tropicalis and Candida zeylanoides). When used alone, both tested PTZs exerted antifungal effects against these strains. In their combinations, these PTZs and AMB mainly acted antagonistically at higher concentrations, but additively and synergistically at lower concentrations as concerns the clinically most important species (C. albicans and C. parapsilosis). For C. albicans, only synergistic interactions were revealed between CPZ and AMB. Synergistic, additive or no interactions were demonstrated between the investigated compounds for the most PTZ-susceptible (C. glabrata to TFP and C. krusei to CPZ) and insusceptible strains (C. glabrata to CPZ and C. lypolitica to TFP).

In vitro activity of phenothiazines and their combinations with amphotericin B against Zygomycetes causing rhinocerebral zygomycosis

The in vitro antifungal activities of two phenothiazine (PTZ) compounds, trifluoperazine (TFP) and chlorpromazine (CPZ) separately and in combination with amphotericin B (AMB) were tested against eight fungal isolates known to be possible agents of rhinocerebral zygomycosis. While both PTZs individually had antifungal effects against these filamentous fungi, only the antifungal activity of TFP increased in presence of AMB. TFP and AMB acted synergistically and caused full inhibition of all strains tested except for Absidia glauca. In contrast, CPZ was found to act antagonistically with AMB with all of studied isolates.

Activity and post antifungal effect of chlorpromazine and trifluopherazine against Aspergillus, Scedosporium and zygomycetes

The phenothiazine compounds chlorpromazine and trifluopherazine are antipsychotic agents that exhibit antimicrobial activity against bacteria, some protozoa and yeasts. Data of activity against filamentous fungi are lacking. The in vitro activity and postantifungal effect (PAFE) of chlorpromazine and trifluopherazine was determined against Aspergillus species, zygomycetes and Scedosporium species. In vitro susceptibility testing was performed with CLSI M38A and the PAFE was determined with previously established methods. Both drugs inhibited the growth of all fungi tested at concentrations of 16 to 64 microg ml(-1). For Aspergillus species the mean PAFE was 3.7 and 4.7 h; for zygomycetes, 3.1 and 3.4 h; for Scedosporium, 4.3 and 5.3 h for chlorpromazine and trifluoroperazine respectively. These are the first drugs shown to induce PAFE against Scedosporium. We show that phenothiazine compounds have in vitro antifungal activity and exhibit PAFE against a broad range of filamentous fungal pathogens. Although the exact mechanism of action is unknown, further studies are needed to explore the clinical usefulness of phenothiazine compounds.

A Novel Spectrophotometric Determination of Some Phenothiazines Involving Iodine monochloride from Chloramine-T with Iodine

A novel, simple, sensitive spectrophotometric method is proposed for the determination of five phenothiazines. Chloramine-T with iodine in acetic acid produces iodine monochloride which oxidizes phenothiazines to absorbing cations. Those would associate later with unreacted ICl to form an ion pair, [Ph+] [ICl-(2)] in hydrochloric acid medium. These appear to provide exceptional color stability to the systems. A probable mechanism along with experimental stoichiometry and stability constants of such ion pairs is indicated. The method is not only successful in stabilizing the color of the systems, but also in making a unique observation of two regions of concentration of phenothiazines adhering separately to Beer's law. The results obtained from the analyses of pure samples and their drug formulations in both regions of concentration are comparable with those obtained either with a reported titrimetric method or with a British Pharmacopoeia (B.P.) UV-spectrophotometric method. The conditions required for the quantitative determination of phenothiazines are described and related analytical parameters are also calculated.

Biochemical characterization of Ca2+/calmodulin dependent protein kinase from Candida albicans

A multifunctional Ca2+/calmodulin dependent protein kinase was purified approximately 650 fold from cytosolic extract of Candida albicans. The purified preparation gave a single band of 69 kDa on sodium dodecyl sulfate polyacrylamide gel electrophoresis with its native molecular mass of 71 kDa suggesting that the enzyme is monomeric. Its activity was dependent on calcium, calmodulin and ATP when measured at saturating histone IIs concentration. The purified Ca2+/CaMPK was found to be autophosphorylated at serine residue(s) in the presence of Ca2+/calmodulin and enzyme stimulation was strongly inhibited by W-7 (CaM antagonist) and KN-62 (Ca2+/CaM dependent PK inhibitor). These results confirm that the purified enzyme is Ca2+/CaM dependent protein kinase of Candida albicans. The enzyme phosphorylated a number of exogenous and endogenous substrates in a Ca2+/calmodulin dependent manner suggesting that the enzyme is a multifunctional Ca2+/calmodulin-dependent protein kinase of Candida albicans.

Antifungal activity of nonantifungal drugs

The antifungal activity of synthetic, nonchemotherapeutic compounds, antineoplastic agents and antibacterial drugs, such as sulphonamides, has been known since the early 20th century (1932). In this context, the term "nonantifungal" is taken to include a variety of compounds that are employed in the management of pathological conditions of nonfungal infectious etiology but have been shown to exhibit broad-spectrum antifungal activity. In this review, the antifungal properties of compounds such as chlorpromazine, proton pump inhibitors, antiarrhythmic agents, cholesterol-lowering agents, antineoplastic and immunosuppressive agents, antiparasitic drugs and antibiotics are described. Since fungi are eukaryotic cells, they share many pathways with human cells, thus increasing the probability of antifungal activity of "nonfungal drugs". The potential of these drugs for treatment of fungal infections has been investigated sporadically using the drugs alone or in combination with "classic" antifungal agents. A review of the literature, supplemented with a number of more recent investigations, suggests that some of these compounds enhance the activity of conventional antifungal agents, eliminate natural resistance to specific antifungal drugs (reversal of resistance) or exhibit strong activity against certain fungal strains in vitro and in animal models. The role of these agents in the epidemiology and in the clinical manifestations of fungal infections and the potential of certain drugs for treatment of invasive fungal infections require further investigation.

Inhibition of HIV replication by neuroleptic agents and their potential use in HIV infected patients with AIDS related dementia

A series of neuroleptic agents and their structural isomers have been tested as inhibitors of HIV-replication. At non-toxic concentrations, cis (Z)- and trans (E)-flupentixol and several derivatives of the 5HT-uptake-inhibitors paroxetine and femoxetine, inhibit HIV-1 replication. The findings indicated that these compounds could be used in combination with other anti-retroviral therapy in HIV-1 infected patients with AIDS-related dementia.

Antifungal activity of local anesthetics against Candida species

OBJECTIVE

To evaluate the activity of benzydamine, lidocaine, and bupivacaine, three drugs with local anesthetic activity, against Candida albicans and non-albicans strains and to clarify their mechanism of activity.

METHODS

The minimal inhibitory concentration (MIC) was determined for 20 Candida strains (18 clinical isolates and two American Type Culture Collection strains). The fungistatic activity was studied with the fluorescent probe FUN-1 and observation under epifluorescence microscopy and flow cytometry. The fungicidal activity of the three drugs was assayed by viability counts. Membrane alterations induced in the yeast cells were evaluated by staining with propidium iodide, by quantitation of intracellular K+ leakage and by transmission electron microscopy of intact yeast cells and prepared spheroplasts.

RESULTS

The MIC ranged from 12.5-50.0 microg/mL, 5.0-40.0 mg/mL, and 2.5-10.0 mg/mL for benzydamine, lidocaine, and bupivacaine, respectively. The inhibitory activity of these concentrations could be detected with the fluorescent probe FUN-1 after incubation for 60 minutes. A very fast fungicidal activity was shown by 0.2, 50, and 30 mg/mL of benzydamine, lidocaine, and bupivacaine, respectively.

CONCLUSIONS

At lower concentrations, the tested drugs have a fungistatic activity, due to yeast metabolic impairment, while at higher concentrations they are fungicidal, due to direct damage to the cytoplasmic membrane.

Current trends in Candida albicans research

Candida albicans is an opportunistic pathogen of human beings and other mammals. Two other features, besides its pathogenicity, have made it a popular organism of study. It exists in different cellular forms and can change from one form to another, depending on growth conditions. Thus, it is being used as a model system to study cellular differentiation. It can also heritably and reversibly switch its cellular and colony morphologies. The yeast is diploid and lacks a sexual cycle. Thus, it has not been possible to apply the powerful methods of genetic analysis to understand morphogenesis or pathogenesis. Few clinical isolates are haploid, but they do not form hyphae and are not yet well characterized. Recombinant DNA techniques are increasingly being applied to C. albicans to solve many of the unanswered questions of morphogenesis and pathogenesis. Genetic transformation and gene-disruption techniques were recently developed for the yeast. Thus it is possible to study the role of any cloned gene through directed mutagenesis. However, the difficulty is to clone the putative genes involved in morphogenesis or pathogenesis. Candida albicans exists in four different cellular forms, namely blastospores, pseudohyphae, hyphae and chlamydospores. Blastospore-to-hypha conversion is well studied. A variety of conditions can induce this transition. It is not clear how cells sense such varied conditions and respond appropriately. In other systems where differentiation is well understood, regulatory genes which control differentiation have been uncovered. These genes cause differential expression of other genes, and ultimately differentiated phenotypes. Thus, it is likely that differential gene expression is involved in the bud-to-hypha transition in C. albicans. Certain proteins are expressed exclusively on the cell surface of hyphae. It should be possible to clone genes coding for these proteins. A study of the expression of these genes might allow us to identify the regulatory gene which determines differentiation. Another approach to understanding morphogenesis is to study how the difference in the shape of buds and hyphae is generated. This difference appears to be due to the differential activity of apical and general growth zones, which determine growth of the cell wall. Activity of these growth zones is apparently determined by actin localization. It remains a possibility that conditions which induce hyphae formation may directly affect actin localization or cell-wall growth zones and cause differences in cell shape. Candida albicans can also heritably switch its cellular phenotype. This has come to light from a study of colony-morphology switching. Some strains can switch their colony morphology, both heritably and reversibly.(ABSTRACT TRUNCATED AT 400 WORDS)

Interaction between Candida agglutinins and antifungal agents

Antifungal agents alter the function and morphology of Candida cell membranes and cell walls. We observed that brief (30 minute) exposure to either amphotericin B or clotrimazole inhibited the agglutination of Candida blastoconidia by murine bronchoalveolar lavage fluid. This inhibition required continuous drug presence. Neither amphotericin nor clotrimazole inhibited Candida agglutination by concanavalin A or pooled human serum. These results demonstrate that antifungal drugs can produce rapid changes in the surface characteristics of some fungi.

Comparative antibacterial activity of Vancocin and generic vancomycin

The in vitro antibacterial activity of generic vancomycin was compared with that of Vancocin (vancomycin hydrochloride; Eli Lilly & Co.) using macrotube dilution testing and subculture. There were no significant differences in MICs or MBCs of the two drugs when tested against a variety of recently isolated hospital pathogens.

Effect of Candida morphology on amphotericin B susceptibility

We showed that brief exposures to amphotericin B (AmB) inhibited the induction of new Candida germ tubes and the lengthening of partially induced germ tubes. Blastoconidia with germ tubes were more susceptible to AmB killing, and this varied directly with the induction period and the AmB exposure period. AmB did not preferentially affect germ tube adherence to fibrin matrices.

Chlorpromazine as permeabilizer and reagent for detection of microbial peroxidase and peroxidaselike activities

Chlorpromazine was used to perform a test for the detection of microbial peroxidase activities. The compound acts as both a cell permeabilizer and a reagent in the procedure developed which allows the detection of peroxidase and peroxidase like reactions both semiquantitatively in whole cell determinations and quantitatively in cell-free supernatants.

Effect of calmodulin inhibitors on viability and mitochondrial potential of Plasmodium falciparum in culture

Calmodulin inhibitors are toxic for a variety of protozoa. Chlorpromazine, calmidazolium, and trifluoperazine inhibited the incorporation of [3H]hypoxanthine and [3H]phenylalanine into Plasmodium falciparum organisms in cultures with 50% inhibitory concentrations varying from 5.1 microM (with calmidazolium) to 48 microM (with chlorpromazine), the former being more sensitive than the latter. However, these concentrations also immediately dissipated rhodamine 123 from the parasite mitochondrion. Similar concentrations inhibit other protozoa, as well as mammalian cells, and the possibility that mitochondrial function rather than that of calmodulin is the target of these drugs should be considered.