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Klimt M, Stadler M, Binder U, Krauss J. Synthesis of novel benzylamine antimycotics and evaluation of their antimycotic potency. Arch Pharm (Weinheim) 2024; 357:e2300381. [PMID: 38345272 DOI: 10.1002/ardp.202300381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 05/08/2024]
Abstract
A series of 23 novel benzylamines was synthesized by reductive amination from halogen-substituted 3- and 4-benzyloxybenzaldehyde derivatives and 6-methylhept-2-yl amine or n-octylamine. The antimycotic activity of the resulting amines was evaluated in a microdilution assay against the apathogenic yeast Yarrowia lipolytica as test microorganism. Promising compounds were also tested against human pathogenic Candida species. The influence of halogen substituents at the benzyl ether side chain was studied in this screening, as well as the influence of the branched side chain of (±)-6-methylhept-2-yl amine in comparison with the n-octyl side chain.
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Affiliation(s)
- Monika Klimt
- Department of Pharmacy-Center for Drug Research, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martina Stadler
- Department of Pharmacy-Center for Drug Research, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ulrike Binder
- Department of Hygiene, Microbiology and Public Health, Institute of Hygiene and Medical Microbiology, Medical University Innsbruck, Innsbruck, Austria
| | - Jürgen Krauss
- Department of Pharmacy-Center for Drug Research, Ludwig-Maximilians-University Munich, Munich, Germany
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2
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Coelho RA, Almeida-Silva F, Figueiredo-Carvalho MHG, Rabello VBDS, de Souza GR, Lourenço MCDS, Rodrigues ML, Almeida-Paes R. Comparison of the antifungal activity of the pyrimidine analogs flucytosine and carmofur against human-pathogenic dematiaceous fungi. Med Mycol 2024; 62:myae029. [PMID: 38533658 PMCID: PMC11008743 DOI: 10.1093/mmy/myae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/07/2024] [Accepted: 03/25/2024] [Indexed: 03/28/2024] Open
Abstract
Chromoblastomycosis (CBM) and pheohyphomycosis (PHM) are the most common implantation mycoses caused by dematiaceous fungi. In the past, flucytosine (5-FC) has been used to treat CBM, but development of resistance is common. Carmofur belongs to the same class as 5-FC and has in vitro inhibitory activity against the main agents of CBM and PHM. The aim of this study was to compare the action of these two pyrimidine analog drugs against CBM and PHM agents. The minimum inhibitory concentration (MIC) and the selectivity index based on cytotoxicity tests of these two drugs against some agents of these mycoses were determined, with carmofur presenting a higher selectivity index than 5-FC. Carmofur demonstrated here synergistic interactions with itraconazole and amphotericin B against Exophiala heteromorpha, Fonsecaea pedrosoi, Fonsecaea monophora, and Fonsecaea nubica strains. Additionally, carmofur plus itraconazole demonstrated here synergism against a Phialophora verrucosa strain. To evaluate the development of carmofur resistance, passages in culture medium containing subinhibitory concentrations of this pyrimidine analog were carried out, followed by in vitro susceptibility tests. Exophiala dermatitidis quickly developed resistance, whereas F. pedrosoi took seven passages in carmofur-supplemented medium to develop resistance. Moreover, resistance was permanent in E. dermatitidis but transient in F. pedrosoi. Hence, carmofur has exhibited certain advantages, albeit accompanied by limitations such as the development of resistance, which was expected as with 5-FC. This underscores its therapeutic potential in combination with other drugs, emphasizing the need for a meticulous evaluation of its application in the fight against dematiaceous fungi.
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Affiliation(s)
- Rowena Alves Coelho
- Mycology Laboratory, National Institute of Infectious Diseases Evandro Chagas, INI/Fiocruz, Rio de Janeiro, Brazil
| | - Fernando Almeida-Silva
- Mycology Laboratory, National Institute of Infectious Diseases Evandro Chagas, INI/Fiocruz, Rio de Janeiro, Brazil
| | | | | | - Gabriela Rodrigues de Souza
- RPT 11B Bioassay Platform, National Institute of Infectious Diseases Evandro Chagas, INI/Fiocruz, Rio de Janeiro, Brazil
| | | | - Marcio L Rodrigues
- Carlos Chagas Institute, Fiocruz, Paraná, Brazil
- Institute of Microbiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Rodrigo Almeida-Paes
- Mycology Laboratory, National Institute of Infectious Diseases Evandro Chagas, INI/Fiocruz, Rio de Janeiro, Brazil
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Coelho RA, Figueiredo-Carvalho MHG, Almeida-Silva F, de Souza Rabello VB, de Souza GR, Sangenito LS, Joffe LS, Santos ALSD, da Silva Lourenço MC, Rodrigues ML, Almeida-Paes R. Repurposing Benzimidazoles against Causative Agents of Chromoblastomycosis: Albendazole Has Superior In Vitro Activity Than Mebendazole and Thiabendazole. J Fungi (Basel) 2023; 9:753. [PMID: 37504741 PMCID: PMC10381309 DOI: 10.3390/jof9070753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
Chromoblastomycosis (CBM) is a neglected human implantation mycosis caused by several dematiaceous fungal species. Currently available therapy is usually associated with physical methods, especially surgery, and with high refractoriness. Therefore, drug discovery for CBM is essential. Drug repositioning is a strategy used to facilitate the discovery of new treatments for several diseases. The aim of this study was to discover substances with antifungal activity against CBM agents from a collection of drugs previously approved for use in human diseases. A screening was performed with the NIH Clinical Collection against Fonsecaea pedrosoi. Ten substances, with clinical applicability in CBM, inhibited fungal growth by at least 60%. The minimum inhibitory concentration (MIC) of these substances was determined against other CBM agents, and the benzimidazoles albendazole, mebendazole and thiabendazole presented the lowest MIC values. The selectivity index, based on MIC and cytotoxicity of these substances, revealed albendazole to be more selective. To investigate a possible synergism of this benzimidazole with itraconazole and terbinafine, the chequerboard method was used. All interactions were classified as indifferent. Our current results suggest that benzimidazoles have repositioning potential against CBM agents. Albendazole seems to be the most promising, since it presented the highest selectivity against all dematiaceous fungi tested.
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Affiliation(s)
- Rowena Alves Coelho
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, INI/Fiocruz, Rio de Janeiro 21040-900, RJ, Brazil
| | | | - Fernando Almeida-Silva
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, INI/Fiocruz, Rio de Janeiro 21040-900, RJ, Brazil
| | - Vanessa Brito de Souza Rabello
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, INI/Fiocruz, Rio de Janeiro 21040-900, RJ, Brazil
| | - Gabriela Rodrigues de Souza
- Plataforma de Bioensaios RPT 11B, Instituto Nacional de Infectologia Evandro Chagas, INI/Fiocruz, Rio de Janeiro 21040-900, RJ, Brazil
| | - Leandro Stefano Sangenito
- Laboratório de Estudos Avançados de Microrganismos Emergentes e Resistentes, Departamento de Microbiologia Geral, Instituto de Microbiologia Paulo de Goés, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, RJ, Brazil
- Instituto Federal de Educação, Ciência e Tecnologia do Rio de Janeiro, Nilópolis 26530-060, RJ, Brazil
| | - Luna Sobrino Joffe
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY 11792, USA
| | - André Luis Souza Dos Santos
- Laboratório de Estudos Avançados de Microrganismos Emergentes e Resistentes, Departamento de Microbiologia Geral, Instituto de Microbiologia Paulo de Goés, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, RJ, Brazil
- Rede Micologia RJ, Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Rio de Janeiro 21941-901, RJ, Brazil
| | - Maria Cristina da Silva Lourenço
- Plataforma de Bioensaios RPT 11B, Instituto Nacional de Infectologia Evandro Chagas, INI/Fiocruz, Rio de Janeiro 21040-900, RJ, Brazil
| | - Marcio L Rodrigues
- Instituto Carlos Chagas, Fundação Oswaldo Cruz, Curitiba 81350-010, PR, Brazil
- Instituto de Microbiologia, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro 21941-902, RJ, Brazil
| | - Rodrigo Almeida-Paes
- Laboratório de Micologia, Instituto Nacional de Infectologia Evandro Chagas, INI/Fiocruz, Rio de Janeiro 21040-900, RJ, Brazil
- Rede Micologia RJ, Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Rio de Janeiro 21941-901, RJ, Brazil
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Hanzlicek AS, KuKanich KS, Cook AK, Hodges S, Thomason JM, DeSilva R, Ramachandran A, Durkin MM. Clinical utility of fungal culture and antifungal susceptibility in cats and dogs with histoplasmosis. J Vet Intern Med 2023; 37:998-1006. [PMID: 37092675 DOI: 10.1111/jvim.16725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/08/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Culture can be used for diagnosis and antifungal susceptibility testing in animals with fungal infections. Limited information is available regarding the diagnostic performance of culture and the susceptibility patterns of Histoplasma spp. isolates. HYPOTHESIS/OBJECTIVES Describe the clinical utility of culture and the susceptibility patterns of Histoplasma spp. isolates causing histoplasmosis in cats and dogs. ANIMALS Seventy-one client-owned animals, including 33 cats and 19 dogs with proven or probable histoplasmosis. METHODS Culture was attempted from tissue or fluid samples. Diagnostic performance of culture, cytopathology, and antigen detection were compared with final diagnosis. Susceptibility to antifungal agents was determined for a subset (11 from dogs, 9 from cats) of culture isolates. RESULTS Culture had a diagnostic sensitivity of 17/33 (52%; 95% confidence interval [CI], 34%-69%) and 15/19 (79%; 95% CI, 61%-97%) and specificity of 6/6 (100%; 95% CI, 54%-100%) and 10/10 (100%; 95% CI, 69%-100%) in cats and dogs, respectively. Culture was not positive in any animal in which cytopathology and antigen testing were negative. Target drug exposure (area under the concentration curve [AUC]/minimum inhibitory concentration [MIC] >25) should be easily achieved for all isolates for itraconazole, voriconazole, or posaconazole. Five of 20 (25%) isolates had fluconazole MIC ≥32 μg/mL and achieving target drug exposure is unlikely. CONCLUSIONS AND CLINICAL IMPORTANCE Fungal culture did not improve diagnostic sensitivity when used with cytopathology and antigen detection. Susceptibility testing might help identify isolates for which fluconazole is less likely to be effective.
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Affiliation(s)
- Andrew S Hanzlicek
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, Oklahoma, USA
- MiraVista Diagnostics, Indianapolis, Indiana, USA
| | - Kate S KuKanich
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas, USA
| | - Audrey K Cook
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Steven Hodges
- Oklahoma Veterinary Specialists, Tulsa, Oklahoma, USA
| | - John M Thomason
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA
| | - Rupika DeSilva
- Oklahoma Animal Disease Diagnostic Laboratory, Department of Veterinary Pathobiology, College of Veterinary Medicine, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Akhilesh Ramachandran
- Oklahoma Animal Disease Diagnostic Laboratory, Department of Veterinary Pathobiology, College of Veterinary Medicine, Oklahoma State University, Stillwater, Oklahoma, USA
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Kane A, Carter DA. Augmenting Azoles with Drug Synergy to Expand the Antifungal Toolbox. Pharmaceuticals (Basel) 2022; 15:482. [PMID: 35455479 PMCID: PMC9027798 DOI: 10.3390/ph15040482] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 03/25/2022] [Accepted: 03/26/2022] [Indexed: 12/23/2022] Open
Abstract
Fungal infections impact the lives of at least 12 million people every year, killing over 1.5 million. Wide-spread use of fungicides and prophylactic antifungal therapy have driven resistance in many serious fungal pathogens, and there is an urgent need to expand the current antifungal arsenal. Recent research has focused on improving azoles, our most successful class of antifungals, by looking for synergistic interactions with secondary compounds. Synergists can co-operate with azoles by targeting steps in related pathways, or they may act on mechanisms related to resistance such as active efflux or on totally disparate pathways or processes. A variety of sources of potential synergists have been explored, including pre-existing antimicrobials, pharmaceuticals approved for other uses, bioactive natural compounds and phytochemicals, and novel synthetic compounds. Synergy can successfully widen the antifungal spectrum, decrease inhibitory dosages, reduce toxicity, and prevent the development of resistance. This review highlights the diversity of mechanisms that have been exploited for the purposes of azole synergy and demonstrates that synergy remains a promising approach for meeting the urgent need for novel antifungal strategies.
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Affiliation(s)
| | - Dee A. Carter
- School of Life and Environmental Sciences and Sydney ID, University of Sydney, Camperdown, NSW 2006, Australia;
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Lu H, Shrivastava M, Whiteway M, Jiang Y. Candida albicans targets that potentially synergize with fluconazole. Crit Rev Microbiol 2021; 47:323-337. [PMID: 33587857 DOI: 10.1080/1040841x.2021.1884641] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Fluconazole has characteristics that make it widely used in the clinical treatment of C. albicans infections. However, fluconazole has only a fungistatic activity in C. albicans, therefore, in the long-term treatment of C. albicans infection with fluconazole, C. albicans has the potential to acquire fluconazole resistance. A promising approach to increase fluconazole's efficacy is identifying potential targets of drugs that can enhance the antifungal effect of fluconazole, or even make the drug fungicidal. In this review, we systematically provide a global overview of potential targets of drugs synergistic with fluconazole in C. albicans, identify new avenues for research on fluconazole potentiation, and highlight the promise of combinatorial strategies with fluconazole in combatting C. albicans infections.
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Affiliation(s)
- Hui Lu
- Department of Pharmacology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | | | - Malcolm Whiteway
- Department of Biology, Concordia University, Montreal, QC, Canada
| | - Yuanying Jiang
- Department of Pharmacology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
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Tits J, Cammue BPA, Thevissen K. Combination Therapy to Treat Fungal Biofilm-Based Infections. Int J Mol Sci 2020; 21:ijms21228873. [PMID: 33238622 PMCID: PMC7700406 DOI: 10.3390/ijms21228873] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022] Open
Abstract
An increasing number of people is affected by fungal biofilm-based infections, which are resistant to the majority of currently-used antifungal drugs. Such infections are often caused by species from the genera Candida, Aspergillus or Cryptococcus. Only a few antifungal drugs, including echinocandins and liposomal formulations of amphotericin B, are available to treat such biofilm-based fungal infections. This review discusses combination therapy as a novel antibiofilm strategy. More specifically, in vitro methods to discover new antibiofilm combinations will be discussed. Furthermore, an overview of the main modes of action of promising antibiofilm combination treatments will be provided as this knowledge may facilitate the optimization of existing antibiofilm combinations or the development of new ones with a similar mode of action.
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8
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Sharma P, Bhalla M, Thami GP. Antifungal combination therapy in dermatophytosis: a clinical insight. J DERMATOL TREAT 2020; 31:41-42. [DOI: 10.1080/09546634.2019.1675853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Priyanka Sharma
- Department of Dermatology, Government Medical College and Hospital, Chandigarh, India
| | - Mala Bhalla
- Department of Dermatology, Government Medical College and Hospital, Chandigarh, India
| | - Gurvinder P. Thami
- Department of Dermatology, Government Medical College and Hospital, Chandigarh, India
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9
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Structural design of microbicidal cationic oligomers and their synergistic interaction with azoles against Candida albicans. Sci Rep 2019; 9:11885. [PMID: 31417167 PMCID: PMC6695401 DOI: 10.1038/s41598-019-48322-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/01/2019] [Indexed: 12/13/2022] Open
Abstract
Membrane-disrupting synthetic antimicrobial polymers have been well developed as antimicrobial peptide (AMP) mimics to mitigate antimicrobial resistance (AMR). However, synthetic polymers possess inherent drawbacks, being a mixture of different chain lengths, which restricts their clinical applications. In fact, synthetic oligomers with defined chain length and molecular structure could be better representatives of AMPs. Herein, a series of novel imidazolium-ammonium oligomers developed in this work exhibit excellent broad spectrum antimicrobial activity, specifically the salient structure dependent high efficiency against C. albicans. Moreover, synergistic effect emerged when the combined azoles and synthetic oligomers were applied against C. albicans. The detail structural coupling between azoles and oligomers was scrutinized through molecular dynamics simulations to unravel the interaction details with the atomistic resolution. The labile interaction between oligomer and azoles facilitated the transfer of drug into fungal cells, which can be a synergistic solution to prevent the development of resistance on C. albicans.
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de Oliveira Santos GC, Vasconcelos CC, Lopes AJO, de Sousa Cartágenes MDS, Filho AKDB, do Nascimento FRF, Ramos RM, Pires ERRB, de Andrade MS, Rocha FMG, de Andrade Monteiro C. Candida Infections and Therapeutic Strategies: Mechanisms of Action for Traditional and Alternative Agents. Front Microbiol 2018; 9:1351. [PMID: 30018595 PMCID: PMC6038711 DOI: 10.3389/fmicb.2018.01351] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 06/05/2018] [Indexed: 12/14/2022] Open
Abstract
The Candida genus comprises opportunistic fungi that can become pathogenic when the immune system of the host fails. Candida albicans is the most important and prevalent species. Polyenes, fluoropyrimidines, echinocandins, and azoles are used as commercial antifungal agents to treat candidiasis. However, the presence of intrinsic and developed resistance against azole antifungals has been extensively documented among several Candida species. The advent of original and re-emergence of classical fungal diseases have occurred as a consequence of the development of the antifungal resistance phenomenon. In this way, the development of new satisfactory therapy for fungal diseases persists as a major challenge of present-day medicine. The design of original drugs from traditional medicines provides new promises in the modern clinic. The urgent need includes the development of alternative drugs that are more efficient and tolerant than those traditional already in use. The identification of new substances with potential antifungal effect at low concentrations or in combination is also a possibility. The present review briefly examines the infections caused by Candida species and focuses on the mechanisms of action associated with the traditional agents used to treat those infections, as well as the current understanding of the molecular basis of resistance development in these fungal species. In addition, this review describes some of the promising alternative molecules and/or substances that could be used as anticandidal agents, their mechanisms of action, and their use in combination with traditional drugs.
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Affiliation(s)
- Giselle C. de Oliveira Santos
- Programa de Doutorado em Biotecnologia da Rede Nordeste de Biotecnologia (RENORBIO), Universidade Federal do Maranhão, São Luís, Brazil
| | - Cleydlenne C. Vasconcelos
- Programa de Doutorado em Biotecnologia da Rede Nordeste de Biotecnologia (RENORBIO), Universidade Federal do Maranhão, São Luís, Brazil
| | - Alberto J. O. Lopes
- Postgraduate Program in Health Sciences, Universidade Federal do Maranhão, São Luís, Brazil
| | | | - Allan K. D. B. Filho
- Departamento de Engenharia Elétrica, Programa de Doutorado em Biotecnologia da Rede Nordeste de Biotecnologia (RENORBIO), Universidade Federal do Maranhão, São Luís, Brazil
| | | | - Ricardo M. Ramos
- Department of Information, Environment, Health and Food Production, Laboratory of Information Systems, Federal Institute of Piauí, Teresina, Brazil
| | | | - Marcelo S. de Andrade
- Postgraduate Program in Health Sciences, Universidade Federal do Maranhão, São Luís, Brazil
| | - Flaviane M. G. Rocha
- Laboratório de Micologia Médica, Programa de Mestrado em Biologia Parasitária, Universidade Ceuma, São Luís, Brazil
| | - Cristina de Andrade Monteiro
- Laboratório de Micologia Médica, Programa de Mestrado em Biologia Parasitária, Universidade Ceuma, São Luís, Brazil
- Departmento de Biologia, Instituto Federal do Maranhão, São Luís, Brazil
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da Rocha Curvelo JA, Reis de Sá LF, Moraes DC, Soares RM, Ferreira-Pereira A. Histatin-5 induces the reversal of Pdr5p mediated fluconazole resistance in Saccharomyces cerevisae. J Mycol Med 2017; 28:137-142. [PMID: 29217144 DOI: 10.1016/j.mycmed.2017.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/23/2017] [Accepted: 11/04/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Candidiasis is a major opportunistic fungal infection in humans. The low number of antifungal drugs available to treat Candida infections and the increasing incidence of multidrug resistant (MDR) strains point to an urgent need of identifying new therapeutic options. The role of salivary components can provide insights for the development of new methodologies of control. OBJECTIVE The aim of this study was to evaluate the ability of histatin-5, a constitutive immunological peptide present in saliva, in reversing fungal MDR phenotype, using a resistant Saccharomyces cerevisiae strain as model of study. RESULTS A total of 2.5μg and 5μg of histatin-5 revealed to be able to chemosensitize (to revert antifungal resistance) a MDR strain to fluconazole impairing its intrinsic resistance. The presence of histatin-5 decreased the strain growth when associated to fluconazole, and also assisted in the retention of rhodamine 6G within cell cytoplasm. The ATPase activity of Pdr5p, an ABC efflux transporter, was significantly reduced up to 65% within physiological concentration of the peptide. CONCLUSION Results revealed that histatin-5 is able to revert MDR phenotype and may be considered a potential alternative MDR inhibitor. Since Pdr5p is homologous to Candida albicans CaCdr1p and CaCdr2p, data obtained might be extrapolated to these transporters, inferring that associating fluconazole and histatin-5 may be a useful tool to circumvent failure treatments of infections caused by Candida MDR strains.
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Affiliation(s)
- J A da Rocha Curvelo
- Laboratório de Bioquímica Microbiana, Instituto de Microbiologia Paulo de Góes, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Bloco I-44, Cidade Universitária, 21941-590 Rio de Janeiro, RJ, Brazil
| | - L F Reis de Sá
- Laboratório de Bioquímica Microbiana, Instituto de Microbiologia Paulo de Góes, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Bloco I-44, Cidade Universitária, 21941-590 Rio de Janeiro, RJ, Brazil
| | - D C Moraes
- Laboratório de Bioquímica Microbiana, Instituto de Microbiologia Paulo de Góes, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Bloco I-44, Cidade Universitária, 21941-590 Rio de Janeiro, RJ, Brazil
| | - R M Soares
- Laboratório de Bioquímica Microbiana, Instituto de Microbiologia Paulo de Góes, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Bloco I-44, Cidade Universitária, 21941-590 Rio de Janeiro, RJ, Brazil
| | - A Ferreira-Pereira
- Laboratório de Bioquímica Microbiana, Instituto de Microbiologia Paulo de Góes, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Bloco I-44, Cidade Universitária, 21941-590 Rio de Janeiro, RJ, Brazil.
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12
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Campitelli M, Zeineddine N, Samaha G, Maslak S. Combination Antifungal Therapy: A Review of Current Data. J Clin Med Res 2017; 9:451-456. [PMID: 28496543 PMCID: PMC5412516 DOI: 10.14740/jocmr2992w] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 12/27/2022] Open
Abstract
The incidence of invasive fungal infections has been on the rise, particularly in transplant recipients and in patients with hematological malignancies and other forms of immunosuppression. There is a mismatch between the rate of antifungal resistance and the development of new antifungal agents. Based on this, the idea of combining antifungals in the treatment of invasive fungal infections appears tempting for many clinicians, particularly after many in vitro studies showed synergism between many antifungal agents. Several randomized controlled trials have been published regarding the efficacy and safety of combination of antifungals, but the high cost, the limited number of cases and the multitude of confounding factors lead in some instances to weak and sometimes contradictory results. The lack of consensus in many clinical scenarios raises the importance of the need for more studies about combination antifungal therapies and should incite infectious disease societies to develop specific recommendations for the clinicians to follow while approaching patients with invasive fungal infections.
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Affiliation(s)
- Marco Campitelli
- Northwell Health at Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA
| | - Nabil Zeineddine
- Northwell Health at Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA
| | - Ghassan Samaha
- Northwell Health at Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA
| | - Stephen Maslak
- Northwell Health at Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA
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13
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Resistance to antifungal therapies. Essays Biochem 2017; 61:157-166. [DOI: 10.1042/ebc20160067] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/02/2017] [Accepted: 01/05/2017] [Indexed: 11/17/2022]
Abstract
The evolution of antifungal resistance among fungal pathogens has rendered the limited arsenal of antifungal drugs futile. Considering the recent rise in the number of nosocomial fungal infections in immunocompromised patients, the emerging clinical multidrug resistance (MDR) has become a matter of grave concern for medical professionals. Despite advances in therapeutic interventions, it has not yet been possible to devise convincing strategies to combat antifungal resistance. Comprehensive understanding of the molecular mechanisms of antifungal resistance is essential for identification of novel targets that do not promote or delay emergence of drug resistance. The present study discusses features and limitations of the currently available antifungals, mechanisms of antifungal resistance and highlights the emerging therapeutic strategies that could be deployed to combat MDR.
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Synthetic Organotellurium Compounds Sensitize Drug-Resistant Candida albicans Clinical Isolates to Fluconazole. Antimicrob Agents Chemother 2016; 61:AAC.01231-16. [PMID: 27821447 DOI: 10.1128/aac.01231-16] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/20/2016] [Indexed: 02/07/2023] Open
Abstract
Invasive Candida albicans infections are a serious health threat for immunocompromised individuals. Fluconazole is most commonly used to treat these infections, but resistance due to the overexpression of multidrug efflux pumps is of grave concern. This study evaluated the ability of five synthetic organotellurium compounds to reverse the fluconazole resistance of C. albicans clinical isolates. Compounds 1 to 4, at <10 μg/ml, ameliorated the fluconazole resistance of Saccharomyces cerevisiae strains overexpressing the major C. albicans multidrug efflux pumps Cdr1p and Mdr1p, whereas compound 5 only sensitized Mdr1p-overexpressing strains to fluconazole. Compounds 1 to 4 also inhibited efflux of the fluorescent substrate rhodamine 6G and the ATPase activity of Cdr1p, whereas all five of compounds 1 to 5 inhibited Nile red efflux by Mdr1p. Interestingly, all five compounds demonstrated synergy with fluconazole against efflux pump-overexpressing fluconazole-resistant C. albicans clinical isolates, isolate 95-142 overexpressing CDR1 and CDR2, isolate 96-25 overexpressing MDR1 and ERG11, and isolate 12-99 overexpressing CDR1, CDR2, MDR1, and ERG11 Overall, organotellurium compounds 1 and 2 were the most promising fluconazole chemosensitizers of fluconazole-resistant C. albicans isolates. Our data suggest that these novel organotellurium compounds inhibit pump efflux by two very important and distinct families of fungal multidrug efflux pumps: the ATP-binding cassette transporter Cdr1p and the major facilitator superfamily transporter Mdr1p.
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Han B, Chen J, Yu YQ, Cao YB, Jiang YY. Antifungal activity of Rubus chingii extract combined with fluconazole against fluconazole-resistant Candida albicans. Microbiol Immunol 2016; 60:82-92. [PMID: 26891940 DOI: 10.1111/1348-0421.12357] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 12/16/2015] [Accepted: 01/06/2016] [Indexed: 10/22/2022]
Abstract
This study aimed to investigate the antifungal activity of Rubus chingii extract in combination with fluconazole (FLC) against FLC-resistant Candida albicans 100 in vitro. A R. chingii extract and FLC-resistant C. albicans fungus suspension were prepared. The minimum inhibitory concentration and fractional inhibitory concentration index of R. chingii extract combined with FLC against C. albicans were determined, after which growth curves for C. albicans treated with R. chingii extract, FLC alone and a combination of these preparations were constructed. Additionally, the mechanisms of drug combination against C. albicans were explored by flow cytometry, gas chromatographic mass spectrometry and drug efflux pump function detection. R. chingii extract combined with FLC showed significant synergy. Flow cytometry suggested that C. albicans cells mainly arrest in G1 and S phases when they have been treated with the drug combination. The drug combination resulted in a marked decrease in the ergosterol content of the cell membrane. Additionally, efflux of Rhodamine 6G decreased with increasing concentrations of R. chingii extract. R. chingii extract combined with FLC has antifungal activity against FLC-resistant C. albicans.
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Affiliation(s)
- Bing Han
- Department of Pharmacy, Minhang Hospital, Fudan University, 201199
| | - Jia Chen
- Department of Pharmacy, Minhang Hospital, Fudan University, 201199
| | - Yi-qun Yu
- Department of Pharmacy, Minhang Hospital, Fudan University, 201199
| | - Yong-bing Cao
- Research and Development Center for New Drugs, School of Pharmacy, Second Military Medical University, Shanghai, 200433, China
| | - Yuan-ying Jiang
- Research and Development Center for New Drugs, School of Pharmacy, Second Military Medical University, Shanghai, 200433, China
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16
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Premachandra IDUA, Scott KA, Shen C, Wang F, Lane S, Liu H, Van Vranken DL. Potent Synergy between Spirocyclic Pyrrolidinoindolinones and Fluconazole against Candida albicans. ChemMedChem 2015; 10:1672-86. [PMID: 26263912 PMCID: PMC4682886 DOI: 10.1002/cmdc.201500271] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Indexed: 11/12/2022]
Abstract
A spiroindolinone, (1S,3R,3aR,6aS)-1-benzyl-6'-chloro-5-(4-fluorophenyl)-7'-methylspiro[1,2,3a,6a-tetrahydropyrrolo[3,4-c]pyrrole-3,3'-1H-indole]-2',4,6-trione, was previously reported to enhance the antifungal effect of fluconazole against Candida albicans. A diastereomer of this compound was synthesized, along with various analogues. Many of the compounds were shown to enhance the antifungal effect of fluconazole against C. albicans, some with exquisite potency. One spirocyclic piperazine derivative, which we have named synazo-1, was found to enhance the effect of fluconazole with an EC50 value of 300 pM against a susceptible strain of C. albicans and going as low as 2 nM against some resistant strains. Synazo-1 exhibits true synergy with fluconazole, with an FIC index below 0.5 in the strains tested. Synazo-1 exhibited low toxicity in mammalian cells relative to the concentrations required for antifungal synergy.
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Affiliation(s)
| | - Kevin A Scott
- Department of Chemistry, University of California, Irvine, 1102 Natural Sciences 2, Irvine, CA 92697-2025 (USA)
| | - Chengtian Shen
- Department of Chemistry, University of California, Irvine, 1102 Natural Sciences 2, Irvine, CA 92697-2025 (USA)
| | - Fuqiang Wang
- Department of Biological Chemistry, University of California, Irvine, 825 Health Sciences Road, Medical Sciences I, Irvine, CA 92697-1700 (USA)
| | - Shelley Lane
- Department of Biological Chemistry, University of California, Irvine, 825 Health Sciences Road, Medical Sciences I, Irvine, CA 92697-1700 (USA)
| | - Haoping Liu
- Department of Biological Chemistry, University of California, Irvine, 825 Health Sciences Road, Medical Sciences I, Irvine, CA 92697-1700 (USA)
| | - David L Van Vranken
- Department of Chemistry, University of California, Irvine, 1102 Natural Sciences 2, Irvine, CA 92697-2025 (USA).
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Sun LM, Liao K, Liang S, Yu PH, Wang DY. Synergistic activity of magnolol with azoles and its possible antifungal mechanism against Candida albicans. J Appl Microbiol 2015; 118:826-38. [DOI: 10.1111/jam.12737] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 12/09/2014] [Accepted: 12/22/2014] [Indexed: 11/30/2022]
Affiliation(s)
- L.-M. Sun
- Department of Pharmacology; Medical School of Southeast University; Nanjing China
| | - K. Liao
- Department of Pathology and Pathophysiology; Medical School; Southeast University; Nanjing China
| | - S. Liang
- Department of Pharmacology; Medical School of Southeast University; Nanjing China
| | - P.-H. Yu
- Department of Pharmacology; Medical School of Southeast University; Nanjing China
| | - D.-Y. Wang
- Key Laboratory of Developmental Genes and Human Disease in Ministry of Education; Medical School of Southeast University; Nanjing China
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Comparative evaluation of a new commercial colorimetric microdilution assay (SensiQuattro Candida EU) with MIC test strip and EUCAST broth microdilution methods for susceptibility testing of invasive Candida isolates. J Clin Microbiol 2014; 53:255-61. [PMID: 25392352 DOI: 10.1128/jcm.02830-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Candidemia is an important cause of morbidity and mortality in immunosuppressed patients. Candida isolates must be cultivated, identified, and tested for susceptibility. We compared the performance of a new colorimetric broth microdilution panel (SensiQuattro Candida EU) for antifungal susceptibility testing to that of Liofilchem's MIC test strip and the EUCAST reference broth microdilution protocol. We tested 187 blood culture isolates of 5 Candida spp. (120 C. albicans, 38 C. glabrata, 10 C. parapsilosis, 12 C. tropicalis, and 7 C. krusei) against seven antifungal agents (amphotericin B, fluconazole, voriconazole, posaconazole, caspofungin, anidulafungin, and micafungin) and interpreted the MICs according to the EUCAST recommendations. If applicable, the overall essential agreement (EA) of the SensiQuattro panel with the reference broth microdilution was slightly higher for C. albicans (87%) than for other species (85.8%). We found that SensiQuattro performed best in testing amphotericin B (EA, 100%), voriconazole (EA, 93.7%), and posaconazole (EA, 94.8%) against C. albicans, but its error rate for this species was high (29.6%) because of mainly major errors (26.7%) in testing anidulafungin and micafungin. Compared to the SensiQuattro panel, the MIC test strip exhibited a higher level of agreement for most isolates. SensiQuattro assays are easy to perform, but they are currently not suitable for testing echinocandins against Candida spp.
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Terbinafine in combination with other antifungal agents for treatment of resistant or refractory mycoses: investigating optimal dosing regimens using a physiologically based pharmacokinetic model. Antimicrob Agents Chemother 2013; 58:48-54. [PMID: 24126579 DOI: 10.1128/aac.02006-13] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Terbinafine is increasingly used in combination with other antifungal agents to treat resistant or refractory mycoses due to synergistic in vitro antifungal activity; high doses are commonly used, but limited data are available on systemic exposure, and no assessment of pharmacodynamic target attainment has been made. Using a physiologically based pharmacokinetic (PBPK) model for terbinafine, this study aimed to predict total and unbound terbinafine concentrations in plasma with a range of high-dose regimens and also calculate predicted pharmacodynamic parameters for terbinafine. Predicted terbinafine concentrations accumulated significantly during the first 28 days of treatment; the area under the concentration-time curve (AUC)/MIC ratios and AUC for the free, unbound fraction (fAUC)/MIC ratios increased by 54 to 62% on day 7 of treatment and by 80 to 92% on day 28 compared to day 1, depending on the dose regimen. Of the high-dose regimens investigated, 500 mg of terbinafine taken every 12 h provided the highest systemic exposure; on day 7 of treatment, the predicted AUC, maximum concentration (Cmax), and minimum concentration (Cmin) were approximately 4-fold, 1.9-fold, and 4.4-fold higher than with a standard-dose regimen of 250 mg once daily. Close agreement was seen between the concentrations predicted by the PBPK model and the observed concentrations, indicating good predictive performance. This study provides the first report of predicted terbinafine exposure in plasma with a range of high-dose regimens.
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Lafleur MD, Sun L, Lister I, Keating J, Nantel A, Long L, Ghannoum M, North J, Lee RE, Coleman K, Dahl T, Lewis K. Potentiation of azole antifungals by 2-adamantanamine. Antimicrob Agents Chemother 2013; 57:3585-92. [PMID: 23689724 PMCID: PMC3719723 DOI: 10.1128/aac.00294-13] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 05/07/2013] [Indexed: 11/20/2022] Open
Abstract
Azoles are among the most successful classes of antifungals. They act by inhibiting α-14 lanosterol demethylase in the ergosterol biosynthesis pathway. Oropharyngeal candidiasis (OPC) occurs in about 90% of HIV-infected individuals, and 4 to 5% are refractory to current therapies, including azoles, due to the formation of resistant biofilms produced in the course of OPC. We reasoned that compounds affecting a different target may potentiate azoles to produce increased killing and an antibiofilm therapeutic. 2-Adamantanamine (AC17) was identified in a screen for compounds potentiating the action of miconazole against biofilms of Candida albicans. AC17, a close structural analog to the antiviral amantadine, did not affect the viability of C. albicans but caused the normally fungistatic azoles to become fungicidal. Transcriptome analysis of cells treated with AC17 revealed that the ergosterol and filamentation pathways were affected. Indeed, cells exposed to AC17 had decreased ergosterol contents and were unable to invade agar. In vivo, the combination of AC17 and fluconazole produced a significant reduction in fungal tissue burden in a guinea pig model of cutaneous candidiasis, while each treatment alone did not have a significant effect. The combination of fluconazole and AC17 also showed improved efficacy (P value of 0.018) compared to fluconazole alone when fungal lesions were evaluated. AC17 is a promising lead in the search for more effective antifungal therapeutics.
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Amino acid-derived 1,2-benzisothiazolinone derivatives as novel small-molecule antifungal inhibitors: identification of potential genetic targets. Antimicrob Agents Chemother 2012; 56:4630-9. [PMID: 22687516 DOI: 10.1128/aac.00477-12] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
We have identified four synthetic compounds (DFD-VI-15, BD-I-186, DFD-V-49, and DFD-V-66) from an amino acid-derived 1,2-benzisothiazolinone (BZT) scaffold that have reasonable MIC(50) values against a panel of fungal pathogens. These compounds have no structural similarity to existing antifungal drugs. Three of the four compounds have fungicidal activity against Candida spp., Cryptococcus neoformans, and several dermatophytes, while one is fungicidal to Aspergillus fumigatus. The kill rates of our compounds are equal to those in clinical usage. The BZT compounds remain active against azole-, polyene-, and micafungin-resistant strains of Candida spp. A genetics-based approach, along with phenotype analysis, was used to begin mode of action (MOA) studies of one of these compounds, DFD-VI-15. The genetics-based screen utilized a homozygous deletion collection of approximately 4,700 Saccharomyces cerevisiae mutants. We identified mutants that are both hypersensitive and resistant. Using FunSpec, the hypersensitive mutants and a resistant ace2 mutant clustered within a category of genes related directly or indirectly to mitochondrial functions. In Candida albicans, the functions of the Ace2p transcription factor include the regulation of glycolysis. Our model is that DFD-VI-15 targets a respiratory pathway that limits energy production. Supporting this hypothesis are phenotypic data indicating that DFD-VI-15 causes increased cell-reactive oxidants (ROS) and a decrease in mitochondrial membrane potential. Also, the same compound has activity when cells are grown in a medium containing glycerol (mitochondrial substrate) but is much less active when cells are grown anaerobically.
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Zhu SL, Jiang ZH, Gao PH, Qiu Y, Wang L, Jiang YY, Zhang DZ. A novel polyamide SL-A92 as a potential fungal resistance blocker: synthesis and bioactivities in Candida albicans. Acta Pharmacol Sin 2010; 31:855-60. [PMID: 20562904 DOI: 10.1038/aps.2010.59] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
AIM To synthesize a novel polyamide SL-A92 and evaluate its bioactivity against drug resistance in Candida albicans. METHODS SL-A92 was synthesized using N-hydroxybenzotriazole (HOBT)/N,N'-dicyclohexylcarbodiimide (DCC) in solution phase. Its antifungal activities and effects on strain growth were tested using the micro-broth dilution method and growth curves, respectively. Induced drug resistance in the C. albicans collection strain SC5314 was obtained by incubation with fluconazole (12 microg/mL) for 21 passages. Meanwhile, incubations with SL-A92 plus fluconazole were also carried out in SC5314 strains, and the MIC(80)s were used to evaluate the inhibitory effects of SL-A92 on drug resistance during the induction process. Real time RT-PCR was performed to investigate the CDR1 and CDR2 mRNA levels in induced SC5314 strains. RESULTS SC5314 strain induced by the combination of fluconazole and SL-A92 (200 microg/mL) did not develop drug resistance. On day 24, the CDR1 and CDR2 mRNA levels in SC5314 strain co-treated with fluconazole and SL-A92 relative to fluconazole alone were 26% and 24%, respectively, and on day 30 the CDR1 and CDR2 mRNA levels were 43% and 31%, respectively. CONCLUSION SL-A92 can block the development of drug resistance during the fluconazole induction process, which partially results from the down-regulation of CDR1 and CDR2.
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23
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Krishnan-Natesan S. Terbinafine: a pharmacological and clinical review. Expert Opin Pharmacother 2009; 10:2723-33. [DOI: 10.1517/14656560903307462] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Odds FC. In Candida albicans, resistance to flucytosine and terbinafine is linked to MAT locus homozygosity and multilocus sequence typing clade 1. FEMS Yeast Res 2009; 9:1091-101. [PMID: 19799637 DOI: 10.1111/j.1567-1364.2009.00577.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A panel of 637 isolates of Candida albicans that had been typed by multilocus sequence typing (MLST) and tested for susceptibility to amphotericin B, caspofungin, fluconazole, flucytosine, itraconazole, ketoconazole, miconazole, terbinafine and voriconazole was the material for a statistical analysis of possible associations between antifungal susceptibility and other properties. For terbinafine and flucytosine, the greatest proportion of low-susceptibility isolates, judged by two resistance breakpoints, was found in MLST clade 1 and among isolates homozygous at the MAT locus, although only three isolates showed cross-resistance to the two agents. Most instances of low susceptibility to azoles, flucytosine and terbinafine were among oropharyngeal isolates from HIV-positive individuals. Statistically significant correlations were found between terbinafine and azole minimal inhibitory concentrations (MICs), while correlations between flucytosine MICs and azole MICs were less strong. It is concluded that a common regulatory mechanism may operate to generate resistance to the two classes of agent that inhibit ergosterol biosynthesis, terbinafine and the azoles, but that flucytosine resistance, although still commonly associated with MAT homozygosity, is differently regulated.
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Affiliation(s)
- Frank C Odds
- Aberdeen Fungal Group, School of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK.
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25
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Zhang J, Xi L, Lu C, Li X, Xie T, Zhang H, Xie Z, De Hoog S. Successful treatment for chromoblastomycosis caused by Fonsecaea monophora: a report of three cases in Guangdong, China. Mycoses 2008; 52:176-81. [PMID: 18627476 DOI: 10.1111/j.1439-0507.2008.01547.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Fonsecaea pedrosoi is the most prevalent aetiological agent of chromoblastomycosis. Fonsecaea monophora is a new species segregated from Fonsecaea pedrosoi. Herein, we report on three cases of chromoblastomycosis caused by F. monophora that were successfully treated with terbinafine and/or itraconazole. Clinical characteristics and mycological parameters are described. Two of the three patients underwent combination therapy with itraconazole and terbinafine during early stages of treatment and were completely healed in a relatively short course of treatment.
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Affiliation(s)
- Junmin Zhang
- Department of Dermatology, Second Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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Abstract
The past decade has seen a significant increase in the incidence of invasive fungal infections. The antifungal armamentarium for the treatment of serious fungal infections remains limited. A possible approach to overcoming antifungal drug resistance and high mortality rates seen in severe fungal infections is to combine two or three classes of antifungals, especially if the drugs have different mechanisms of action. Combinations of new agents along with more traditional antifungals have now been shown to possess some synergistic or at least additive activity against many fungi in in vitro and animal studies. On the other hand, caution is still needed since some antifungal combinations have also demonstrated antagonistic activity. Well-controlled clinical trials are still required to define the most efficacious antifungal regimen. Furthermore, these trials should also evaluate the side-effect potential of combination regimens and the pharmacoeconomic impact these regimens may have.
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Affiliation(s)
- Jose A Vazquez
- Henry Ford Hospital, Division of Infectious Diseases, Detroit, MI 48202, USA.
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27
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Zhang L, Yan K, Zhang Y, Huang R, Bian J, Zheng C, Sun H, Chen Z, Sun N, An R, Min F, Zhao W, Zhuo Y, You J, Song Y, Yu Z, Liu Z, Yang K, Gao H, Dai H, Zhang X, Wang J, Fu C, Pei G, Liu J, Zhang S, Goodfellow M, Jiang Y, Kuai J, Zhou G, Chen X. High-throughput synergy screening identifies microbial metabolites as combination agents for the treatment of fungal infections. Proc Natl Acad Sci U S A 2007; 104:4606-11. [PMID: 17360571 PMCID: PMC1838648 DOI: 10.1073/pnas.0609370104] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Indexed: 11/18/2022] Open
Abstract
The high mortality rate of immunocompromised patients with fungal infections and the limited availability of highly efficacious and safe agents demand the development of new antifungal therapeutics. To rapidly discover such agents, we developed a high-throughput synergy screening (HTSS) strategy for novel microbial natural products. Specifically, a microbial natural product library was screened for hits that synergize the effect of a low dosage of ketoconazole (KTC) that alone shows little detectable fungicidal activity. Through screening of approximately 20,000 microbial extracts, 12 hits were identified with broad-spectrum antifungal activity. Seven of them showed little cytotoxicity against human hepatoma cells. Fractionation of the active extracts revealed beauvericin (BEA) as the most potent component, because it dramatically synergized KTC activity against diverse fungal pathogens by a checkerboard assay. Significantly, in our immunocompromised mouse model, combinations of BEA (0.5 mg/kg) and KTC (0.5 mg/kg) prolonged survival of the host infected with Candida parapsilosis and reduced fungal colony counts in animal organs including kidneys, lungs, and brains. Such an effect was not achieved even with the high dose of 50 mg/kg KTC. These data support synergism between BEA and KTC and thereby a prospective strategy for antifungal therapy.
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Affiliation(s)
- Lixin Zhang
- Institute of Microbiology, Chinese Academy of Sciences, Beijing 100080, China.
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Garg S, Naidu J, Singh S, Nawange S, Jharia N, Saxena M. In vitro activity of terbinafine against Indian clinical isolates of Candida albicans and non- albicans using a macrodilution method. J Mycol Med 2006. [DOI: 10.1016/j.mycmed.2006.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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29
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Ferahbas A, Koc AN, Uksal U, Aygen E, Mistik S, Yildiz S. Terbinafine Versus Itraconazole and Fluconazole in the Treatment of Vulvovaginal Candidiasis. Am J Ther 2006; 13:332-6. [PMID: 16858169 DOI: 10.1097/00045391-200607000-00010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Vulvovaginal candidiasis is one of the most frequent infections of the female genital tract with a high incidence. Although numerous antimycotical agents are available for treatment of yeast vaginitis, there are few comparative data on the in vivo and in vitro activity of these drugs. The aim of this open, randomized, and comparative study was to determine in vivo and in vitro effectiveness of the 3 systemic antifungal agents: terbinafine and 2 azoles (itraconazole and fluconazole) in the treatment of patients with Vulvovaginal candidiasis. A total of 44 patients who had signs and symptoms of Vulvovaginal candidiasis were recruited for the study. Patients were randomly assigned to 3 groups: terbinafine 500 mg/d orally was used for 7 days, itraconazole 200 mg/d orally was used for 7 days, and fluconazole 150 mg orally was used as a single dose. Both clinical and mycologic examinations were performed for posttreatment assessment at week 4. This study revealed a clinical cure rate 33.3% for terbinafine, 60% for itraconazole, and 66.6% for fluconazole (P>0.05). Mycologic cure rates were 33.3%, 10%, and 66.6% respectively (P<0.05). Overall cure rates were 33.3%, 10%, and 53.3% (P>0.05). Terbinafine could be an alternative treatment option in Vulvovaginal candidiasis because there were no significant differences in the clinical and overall cure rates among 3 antifungal agents. However, terbinafine could not be suggested as a first-line treatment in Vulvovaginal candidiasis. Systemic use of terbinafine in larger numbers of cases may give more information about the effectiveness of this drug in the treatment of patients with vulvovaginal candidiasis.
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Affiliation(s)
- Ayten Ferahbas
- Department of Dermatology, Erciyes University, Medical Faculty, Kayseri, Turkey.
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30
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Quan H, Cao YY, Xu Z, Zhao JX, Gao PH, Qin XF, Jiang YY. Potent in vitro synergism of fluconazole and berberine chloride against clinical isolates of Candida albicans resistant to fluconazole. Antimicrob Agents Chemother 2006; 50:1096-9. [PMID: 16495278 PMCID: PMC1426442 DOI: 10.1128/aac.50.3.1096-1099.2006] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In vitro interaction of fluconazole and berberine chloride was investigated against 40 fluconazole-resistant clinical isolates of Candida albicans. Synergism in fungistatic activity was found with the checkerboard microdilution assay. The findings of agar diffusion tests and time-kill curves confirmed the synergistic interaction, but no antagonistic action was observed.
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Affiliation(s)
- Hua Quan
- Department of Pharmacology, School of Pharmacy, Second Military Medical University, Shanghai, People's Republic of China
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31
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Abstract
Combination antifungal therapy has been an area of research and clinical interest since systemic antifungals became available decades ago. In vitro and clinical data were generated for some of the more common invasive fungal infections, especially candidiasis, but until very recently few clinical studies were performed. The first invasive fungal infection to be examined in clinical trials with adequate statistical power was cryptococcal meningitis and several of these trials stand out as classical studies in the clinical evaluation of combination antifungal therapy. More recently, since the availability of the newer antifungal agents, including the echinocandins and extended-spectrum triazoles, there has been a growing interest in examining combination antifungal therapy for invasive fungal disease, especially invasive aspergillosis. This is by no means a comprehensive review of all existing experimental data. Instead, the focus is on the clinical data that have been generated to date and on providing insights into potential future clinical directions. For instance, recent clinical data for cryptococcosis confirm that amphotericin B plus flucytosine is the most active combination for patients with cryptococcal meningitis. A recently completed clinical trial in candidaemia suggests a trend towards improved outcomes among patients receiving amphotericin B plus fluconazole versus fluconazole alone. In aspergillosis, several experimental models suggest benefit of a variety of antifungal combinations, but have not been confirmed in prospective clinical trials. Ultimately, the goal is to provide the reader with a comprehensive but useful review to this complicated and often confusing therapeutic dilemma.
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Affiliation(s)
- John W Baddley
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, and Birmingham Veteran's Administration Medical Center, Birmingham, Alabama 35294-0006, USA
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Meletiadis J, Verweij PE, TeDorsthorst DTA, Meis JFGM, Mouton JW. Assessing in vitro combinations of antifungal drugs against yeasts and filamentous fungi: comparison of different drug interaction models. Med Mycol 2005; 43:133-52. [PMID: 15832557 DOI: 10.1080/13693780410001731547] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Non-parametric and parametric approaches of two competing zero-interaction theories--the Loewe additivity and the Bliss independence - were evaluated for analyzing the in vitro interactions of various antifungal drugs. Fifty-one data sets, derived from three drug combinations, tested in triplicate against 17 clinical yeast and mold isolates with a two-dimensional checkerboard microdilution technique, were selected to span from strong synergy to strong antagonism. These were analyzed with the standard FIC index model and modern concentration-effect response surface models: the fully parametric model developed by Greco et al. and the 3-D analysis developed by Prichard et al. The FIC index model is subjective, sensitive to experimental errors and resulted in approximated results and variable conclusions depending on the MIC endpoints determined and interpretation endpoints used. By using the MIC-2 endpoint (lowest drug concentration showing 50% of growth) for calculating the FIC indices, problems due to trailing phenomena were reduced and weak interactions could be detected; higher levels of reproducibility and agreement with the other models were achieved using the MIC-0 and MIC-1 (lowest drug concentration showing 10 and 25% of growth, respectively). High reproducibility was achieved in interpreting the FIC indices when the cutoffs of 0.25 and 4 (for single experiments) and the cutoff of 1 (for replicates) were used for defining the limits of additivity/indifference. Although the fully parametric Greco model did not describe precisely the entire response surface of all antifungal drug interactions, it was able to differentiate synergistic from non-synergistic interactions with a non-unit, reproducible, concentration-independent interaction parameter, including its uncertainty, without requiring replication. The Bliss independence based models resulted in mosaics of synergistic and antagonistic combinations, raising questions about the concentration-dependent nature of antifungal drug interaction. The sum of all statistically significant interactions were used as a summary interaction parameter for the entire response surface, concluding synergy or antagonism when it was positive or negative, respectively. The cutoffs of 100% and 200% were used to distinguish weak and moderate interactions, respectively in 12-16 x 8-12 checkerboard formats. Semi-parametric approaches need particular care as experimental errors are not eliminated from the entire response surface.
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Affiliation(s)
- Joseph Meletiadis
- Department of Medical Microbiology, Nijmegen University Center for Infectious Diseases, Nijmegen, The Netherlands
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Cantón E, Pemán J, Gobernado M, Viudes A, Espinel-Ingroff A. Synergistic activities of fluconazole and voriconazole with terbinafine against four Candida species determined by checkerboard, time-kill, and Etest methods. Antimicrob Agents Chemother 2005; 49:1593-6. [PMID: 15793148 PMCID: PMC1068629 DOI: 10.1128/aac.49.4.1593-1596.2005] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The in vitro activities of fluconazole or voriconazole plus terbinafine were evaluated against 20 Candida isolates by the checkerboard, time-kill, and Etest methods. Synergism (C. albicans, C. glabrata, and C. tropicalis) and indifference (C. krusei) were observed. Correlation among methods was good. The Etest is a suitable method to determine drug interactions.
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Affiliation(s)
- Emilia Cantón
- Unidad de Microbiología Experimental, Centro de Investigación, Hospital Universitario La Fe, Avenida Campanar 21, 46009 Valencia, Spain.
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Barchiesi F, Spreghini E, Maracci M, Fothergill AW, Baldassarri I, Rinaldi MG, Scalise G. In vitro activities of voriconazole in combination with three other antifungal agents against Candida glabrata. Antimicrob Agents Chemother 2004; 48:3317-22. [PMID: 15328091 PMCID: PMC514763 DOI: 10.1128/aac.48.9.3317-3322.2004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Candida glabrata has recently emerged as a significant pathogen involved in both superficial and deep-seated infections. In the present study, a checkerboard broth microdilution method was performed to investigate the in vitro activities of voriconazole (VOR) in combination with terbinafine (TRB), amphotericin B (AMB), and flucytosine (5FC) against 20 clinical isolates of C. glabrata. Synergy, defined as a fractional inhibitory concentration (FIC) index of < or = 0.50, was observed in 75% of VOR-TRB, 10% of VOR-AMB, and 5% of VOR-5FC interactions. None of these combinations yielded antagonistic interactions (FIC index > 4). When synergy was not achieved, there was still a decrease in the MIC of one or both drugs used in the combination. In particular, the MICs were reduced to < or = 1.0 microg/ml as a result of the combination for all isolates for which the AMB MIC at the baseline was > or = 2.0 microg/ml. By a disk diffusion assay, the halo diameters produced by antifungal agents in combination were greater that those produced by each drug alone. Finally, killing curves showed that VOR-AMB exhibited synergistic interactions, while VOR-5FC sustained fungicidal activities against C. glabrata. These studies demonstrate that the in vitro activity of VOR against this important yeast pathogen can be enhanced upon combination with other drugs that have different modes of action or that target a different step in the ergosterol pathway. Further studies are warranted to elucidate the potential beneficial effects of such combination regimens in vivo.
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Affiliation(s)
- Francesco Barchiesi
- Istituo di Malattie Infettive e Medicina Pubblica, Università Politecnica delle Marche, Azienda Ospedaliera Umberto I degrees, Via Conca, 60020 Torrette di Ancona, Ancona, Italy
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35
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Cuenca-Estrella M. Combinations of antifungal agents in therapy--what value are they? J Antimicrob Chemother 2004; 54:854-69. [PMID: 15375111 DOI: 10.1093/jac/dkh434] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Concurrent or sequential antifungal treatment for invasive mycoses has been typically considered as an option to improve results of monotherapy. However, data on the efficacy of combination therapy are sparse and consist largely of results from studies in vitro and experimental animal models. These studies have yielded controversial results depending on the criteria used to evaluate the antifungal interaction. Several combinations that showed synergy in vitro failed to do so in animal models. Overall, apart from cryptococcal infections, combined antifungal therapy is not significantly better than monotherapy in terms of clinical efficacy. It is questionable whether combination therapy should be used in most cases as there is a lack of evidence from well-designed clinical trials. However, combination therapy could be an alternative to monotherapy for patients with invasive infections that are difficult to treat, such as those due to multi-resistant species and for those who fail to respond to standard treatment.
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Affiliation(s)
- Manuel Cuenca-Estrella
- Servicio de Micología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Ctra Majadahonda-Pozuelo Km 2, 28220 Majadahonda, Madrid, Spain.
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Johnson MD, MacDougall C, Ostrosky-Zeichner L, Perfect JR, Rex JH. Combination antifungal therapy. Antimicrob Agents Chemother 2004; 48:693-715. [PMID: 14982754 PMCID: PMC353116 DOI: 10.1128/aac.48.3.693-715.2004] [Citation(s) in RCA: 400] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Melissa D Johnson
- Departments of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Abstract
UNLABELLED Terbinafine, an orally and topically active antimycotic agent, inhibits the biosynthesis of the principal sterol in fungi, ergosterol, at the level of squalene epoxidase. Squalene epoxidase inhibition results in ergosterol-depleted fungal cell membranes (fungistatic effect) and the toxic accumulation of intracellular squalene (fungicidal effect). Terbinafine has demonstrated excellent fungicidal activity against the dermatophytes and variable activity against yeasts and non-dermatophyte molds in vitro. Following oral administration, terbinafine is rapidly absorbed and widely distributed to body tissues including the poorly perfused nail matrix. Nail terbinafine concentrations are detected within 1 week after starting therapy and persist for at least 30 weeks after the completion of treatment. Randomized, double-blind trials showed oral terbinafine 250 mg/day for 12 or 16 weeks was more efficacious than itraconazole, fluconazole and griseofulvin in dermatophyte onychomycosis of the toenails. In particular, at 72 weeks' follow-up, the multicenter, multinational, L.I.ON. (Lamisil vs Itraconazole in ONychomycosis) study found that mycologic cure rates (76 vs 38% of patients after 12 weeks' treatment; 81 vs 49% of recipients after 16 weeks' therapy) and complete cure rates were approximately twice as high after terbinafine treatment than after itraconazole (3 or 4 cycles of 400 mg/day for 1 week repeated every 4 weeks) in patients with toenail mycosis. Furthermore, the L.I.ON. Icelandic Extension study demonstrated that terbinafine was more clinically effective than intermittent itraconazole to a statistically significant extent at 5-year follow-up. Terbinafine produced a superior complete cure rate (35 vs 14%), mycologic cure rate (46 vs 13%) and clinical cure rate (42 vs 18%) to that of itraconazole. The mycologic and clinical relapse rates were 23% and 21% in the terbinafine group, respectively, compared with 53% and 48% in the itraconazole group. In comparative clinical trials, oral terbinafine had a better tolerability profile than griseofulvin and a comparable profile to that of itraconazole or fluconazole. Post marketing surveillance confirmed terbinafine's good tolerability profile. Adverse events were experienced by 10.5% of terbinafine recipients, with gastrointestinal complaints being the most common. Unlike the azoles, terbinafine has a low potential for drug-drug interactions. Most pharmacoeconomic evaluations have shown that the greater clinical effectiveness of oral terbinafine in dermatophyte onychomycosis translates into a cost-effectiveness ratio superior to that of itraconazole, fluconazole and griseofulvin. CONCLUSION Oral terbinafine has demonstrated greater effectiveness than itraconazole, fluconazole and griseofulvin in randomized trials involving patients with onychomycosis caused by dermatophytes. The drug is generally well tolerated and has a low potential for drug interactions. Therefore, terbinafine is the treatment of choice for dermatophyte onychomycosis.
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Gómez-López A, Cuenca-Estrella M, Mellado E, Rodríguez-Tudela JL. In vitro evaluation of combination of terbinafine with itraconazole or amphotericin B against Zygomycota. Diagn Microbiol Infect Dis 2003; 45:199-202. [PMID: 12663161 DOI: 10.1016/s0732-8893(02)00509-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The combined activity in vitro of amphotericin B/terbinafine and itraconazole/terbinafine was assessed against 17 clinical isolates of Zygomycota using a checkerboard technique. Itraconazole/terbinafine combination exhibited a potent synergistic effect against the most of strains. Amphotericin B/terbinafine combination showed an indifferent interaction for Rhizopus oryzae, and an additive effect for the other species.
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Affiliation(s)
- Alicia Gómez-López
- Servicio de Micología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, 28220 Majadahonda, Madrid, Spain
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39
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Vazquez JA. Combination antifungal therapy againstCandidaspecies: the new frontier-are we there yet? Med Mycol 2003; 41:355-68. [PMID: 14653512 DOI: 10.1080/13693780310001616528] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
In the past decade, we have seen a significant increase in the incidence of invasive fungal infections. In addition, opportunistic fungal infections resistant to antifungal agents have become increasingly common and their frequency will more than likely continue to increase. The antifungal armamentarium for the treatment of serious fungal infections remains limited. A possible approach to overcoming antifungal drug resistance and high mortality rates seen in severe fungal infections is to combine two or three classes of antifungals, especially if the drugs have different mechanisms of action. The unique properties of newer antifungals now provide us with the opportunity to investigate antifungal combinations that may become the standard of care for serious fungal infections. Combinations of new agents along with more traditional antifungals have now been shown to possess some synergistic or at least additive activity against Candida in clinical trials. On the other hand, caution is still needed since other antifungal combinations have demonstrated antagonistic activity in vitro. Well-controlled clinical trials are needed to define the most efficacious antifungal regimen. Furthermore, these trials should also evaluate the side effect potential of combination regimens and the pharmacoeconomic impact these regimens may have. Thus, while much optimism exists for combination therapy, there is much yet to be done.
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Affiliation(s)
- J A Vazquez
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan, USA.
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40
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Gupta AK, Taborda PR, Sanzovo AD. Alternate week and combination itraconazole and terbinafine therapy for chromoblastomycosis caused by Fonsecaea pedrosoi in Brazil. Med Mycol 2002; 40:529-34. [PMID: 12462534 DOI: 10.1080/mmy.40.5.529.534] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Patients with long-standing chromoblastomycosis may respond poorly to standard treatments such as amphotericin B, oral antifungals, surgical measures or thermotherapy. The objective of this study was to determine the potential of alternate week and combination therapy with itraconazole and terbinafine in the treatment of poorly responsive, or non-responsive, chromoblastomycosis. Four patients with longstanding chromoblastomycosis (8-23 years) caused by Fonsecaea pedrosoi had responded poorly to standard therapies including monotherapy with the oral antifungal agents. In order to try and improve the response to oral itraconazole and terbinafine, alternate week or combination therapy with itraconazole and terbinafine was initiated. Bloodwork including complete blood count and liver function tests were performed every 3-8 weeks to ensure patient safety. Reduction or resolution of lesions of chromoblastomycosis was noted with alternate week or combination treatment using oral itraconazole and terbinafine. Three of four patients experienced no clinical side-effects; the third reported mild, transient gastric discomfort which responded to antacids. Bloodwork generally remained within normal limits throughout the entire course of treatment with no clinically significant changes. The combination therapy was considered effective in treating the poorly responsive chromoblastomycosis of all four patients. Some success with alternative week therapy was also noted in one patient. The favorable response and lack of significant adverse effects suggests that these regimens may be an option for some patients with chromoblastomycosis.
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Affiliation(s)
- A K Gupta
- Division of Dermatology, Sunnybrook and Women's College Health Science Center, University of Toronto, Toronto, Ontario, Canada.
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41
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Dannaoui E, Afeltra J, Meis JFGM, Verweij PE. In vitro susceptibilities of zygomycetes to combinations of antimicrobial agents. Antimicrob Agents Chemother 2002; 46:2708-11. [PMID: 12121963 PMCID: PMC127328 DOI: 10.1128/aac.46.8.2708-2711.2002] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2002] [Accepted: 04/30/2002] [Indexed: 11/20/2022] Open
Abstract
Combinations of antimicrobial agents were tested against 35 strains of zygomycetes. The interaction between amphotericin B and rifampin was synergistic or additive. Flucytosine alone was inactive and, upon combination with amphotericin B, synergy was not achieved. The combination of amphotericin B with terbinafine was synergistic for 20% of strains, and the interaction between terbinafine and voriconazole was synergistic for 44% of strains. Antagonism was not observed.
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Affiliation(s)
- Eric Dannaoui
- Department of Medical Microbiology, University Medical Center St. Radboud, 6500 HB Nijmegen, The Netherlands
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42
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Perea S, Gonzalez G, Fothergill AW, Sutton DA, Rinaldi MG. In vitro activities of terbinafine in combination with fluconazole, itraconazole, voriconazole, and posaconazole against clinical isolates of Candida glabrata with decreased susceptibility to azoles. J Clin Microbiol 2002; 40:1831-3. [PMID: 11980970 PMCID: PMC130943 DOI: 10.1128/jcm.40.5.1831-1833.2002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2001] [Revised: 12/12/2001] [Accepted: 02/26/2002] [Indexed: 11/20/2022] Open
Abstract
A checkerboard microdilution method, performed according to the recommendations of the National Committee for Clinical Laboratory Standards, was used to study the in vitro interaction of terbinafine (TRB) with fluconazole (FLU), itraconazole (ITRA), voriconazole (VRC), and posaconazole (PSZ) in 24 isolates of Candida glabrata with decreased susceptibility to azoles isolated from the oral cavities of human immunodeficiency virus patients. Synergy, defined as a fractional inhibitory concentration index of < or =0.5, was observed in 17% of TRB-FLU interactions, 21% of TRB-ITRA interactions, 33% of TRB-VRC interactions, and 12% of TRB-PSZ interactions. Where synergy was not achieved, there was still a decrease in the MIC of one or both drugs when used in combination. Antagonism was not observed in any drug combination. Clinical studies are warranted to elucidate the potential utility of these combination therapies.
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Affiliation(s)
- Sofia Perea
- Department of Medicine, Division of Infectious Diseases, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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43
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Hossain MA, Ghannoum MA. New developments in chemotherapy for non-invasive fungal infections. Expert Opin Investig Drugs 2001; 10:1501-11. [PMID: 11772265 DOI: 10.1517/13543784.10.8.1501] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dermatomycosis and subcutaneous mycosis comprise the non-invasive fungal infections commonly encountered in clinical practice around the world. The limited activity of early topical antifungal agents prompted the development of more effective systemic agents. While griseofulvin has been used for more than four decades, the use of early azoles, such as ketoconazole have resulted in better patient compliance and thus greater success. However, poor response and recurrence in dermatomycosis, as well as toxicity associated with ketoconazole therapy, has led to the search for newer antifungal agents and more effective treatment strategies. Terbinafine, itraconazole and fluconazole have the advantage of non-toxicity and a broad spectrum of activity. An overview of non-invasive fungal infections, antifungal agents in clinical use and recent developments in antifungal therapy is reviewed in this article.
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Affiliation(s)
- M A Hossain
- Center for Medical Mycology, Department of Dermatology, Case Western Reserve University and University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio 44106-5028, USA
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44
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Abstract
The relentless increase of invasive fungal infections and poor outcomes associated with available antifungal agents prompted the search for better therapeutic strategies. Combining antifungal drugs was recommended as a means to enhance efficacy in a variety of invasive infections including cryptococcosis, candidiasis, and aspergillosis. With the exception of cryptococcal meningitis, data from controlled clinical trials supporting such combinations are sparse. Moreover, little consensus exists regarding which combinations are synergistic or antagonistic in vitro and in vivo. Based on available data, several principles underlie these combinations.
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Affiliation(s)
- R E Lewis
- Department of Clinical Sciences and Administration, University of Houston College of Pharmacy Texas Medical Center, 77030-4095, USA
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45
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Weig M, Müller FM. Synergism of voriconazole and terbinafine against Candida albicans isolates from human immunodeficiency virus-infected patients with oropharyngeal candidiasis. Antimicrob Agents Chemother 2001; 45:966-8. [PMID: 11181393 PMCID: PMC90406 DOI: 10.1128/aac.45.3.966-968.2001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The synergism of voriconazole (VRC) and terbinafine was studied by using 39 genotypically defined clinical Candida albicans isolates that were cross-resistant to fluconazole and VRC and serial isolates that gradually developed azole resistance. Synergy was noticed in 100% (eight of eight) of the strains that were resistant to VRC. Antagonism was not observed.
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Affiliation(s)
- M Weig
- Department of Bacteriology, University of Göttingen, Göttingen, Germany.
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46
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Ryder NS, Leitner I. Synergistic interaction of terbinafine with triazoles or amphotericin B against Aspergillus species. Med Mycol 2001; 39:91-5. [PMID: 11270414 DOI: 10.1080/mmy.39.1.91.95] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The in vitro activity of terbinafine alone and in combination with other antifungal agents was tested against isolates of Aspergillus fumigatus, A. flavus and A. niger. Testing was performed in a modified National Committee for Clinical Laboratory Standards (NCCLS) macrodilution broth assay, and interactions were examined using a checkerboard design. Terbinafine was highly active against Aspergillus isolates (minimum inhibitory concentration [MIC] 0.01 to 2 microg ml(-1)) with a primary fungicidal action (minimum fungicidal concentration [MFC] 0.02 to 4 microg ml(-1)). Amphotericin B was also highly active and cidal as expected (MIC 1 microg ml(-1), MFC 1 to 4 microg ml(-1)). The triazoles itraconazole and voriconazole were highly active but showed a variable degree of cidal activity against the different strains, voriconazole having the more potent cidal activity. Fluconazole had no significant activity (MIC > 128 microg ml(-1)). Drug combinations were tested in the A. fumigatus and A. niger strains. Terbinafine and amphotericin showed an additive to synergistic interaction depending on the isolate. Combinations of terbinafine with itraconazole or voriconazole displayed a potent synergistic interaction and fungicidal activity against all isolates. Surprisingly, fluconazole also potentiated the activity of terbinafine in an additive to synergistic fashion, despite its lack of activity alone. The results suggest potential clinical application of terbinafine in aspergillosis, either alone or in combination with amphotericin or triazoles.
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Affiliation(s)
- N S Ryder
- Novartis Research Institute, Vienna, Austria.
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47
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Graybill JR. The role of murine models in the development of antifungal therapy for systemic mycoses. Drug Resist Updat 2000; 3:364-383. [PMID: 11498404 DOI: 10.1054/drup.2000.0171] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Animal testing is crucial to the development of new antifungal compounds. This review describes the role that murine and other animal models have played in the development of three classes of antifungal agents: the polyenes, the triazoles and the echinocandins and the ways in which these models have been either the positive link in the path from in vitro studies to the patient, or have foreclosed later clinical evaluation. Efficacy studies in particular mycoses are discussed, as well as studies designed to determine whether combinations of antifungal drugs may have value over single agents. Copyright 2000 Harcourt Publishers Ltd.
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48
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Meletiadis J, Mouton JW, Meis JF, Verweij PE. Combination chemotherapy for the treatment of invasive infections by Scedosporium prolificans. Clin Microbiol Infect 2000; 6:336-7. [PMID: 11168146 DOI: 10.1046/j.1469-0691.2000.00089.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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49
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Meletiadis J, Mouton JW, Rodriguez-Tudela JL, Meis JF, Verweij PE. In vitro interaction of terbinafine with itraconazole against clinical isolates of Scedosporium prolificans. Antimicrob Agents Chemother 2000; 44:470-2. [PMID: 10639389 PMCID: PMC89710 DOI: 10.1128/aac.44.2.470-472.2000] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In order to develop new approaches for the chemotherapy of invasive infections caused by Scedosporium prolificans, the in vitro interaction between itraconazole and terbinafine against 20 clinical isolates was studied using a checkerboard microdilution method. Itraconazole and terbinafine alone were inactive against most isolates, but the combination was synergistic against 95 and 85% of isolates after 48 and 72 h of incubation, respectively. Antagonism was not observed. The MICs obtained with the terbinafine-itraconazole combination were within levels that can be achieved in plasma.
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Affiliation(s)
- J Meletiadis
- Department of Medical Microbiology, University Hospital Nijmegen, Nijmegen, The Netherlands
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50
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Abstract
The in vitro activity of six polycationic peptides, buforin II, cecropin P1, indolicidin, magainin II, nisin, and ranalexin, were evaluated against several clinical isolates of gram-positive and gram-negative aerobic bacteria, yeasts, Pneumocystis carinii and Cryptosporidium parvum, by using microbroth dilution methods. The peptides exhibited different antibacterial activities and rapid time-dependent killing. The gram-negative organisms were more susceptible to buforin II and cecropin P1, whereas buforin II and ranalexin were the most active compounds against the gram-positive strains. Similarly, ranalexin showed the highest activity against Candida spp., whereas magainin II exerted the highest anticryptococcal activity. Finally, the peptides showed high anti-Pneumocystis activity, whereas no compound had strong inhibitory effect on C. parvum.
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Affiliation(s)
- A Giacometti
- Institute of Infectious Diseases and Public Health, University of Ancona, Italy.
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