Evaluation of disk diffusion method for determining posaconazole susceptibility of filamentous fungi: comparison with CLSI broth microdilution method

Performances of disk diffusion method for determining triazole susceptibility of Aspergillus species: Systematic review

The therapeutic management of invasive aspergillosis should be guided by antifungal susceptibility testing (AFST). The disk diffusion (DD) method due to its simplicity and low cost could be an appropriate alternative to the reference methods (CLSI, EUCAST) which are not suitable for AFST in routine clinical microbiology laboratories, particularly in resource-constrained settings. This review summarizes the available data on the performance of the DD method in determining triazole susceptibility profile of Aspergillus species. The published articles on the performance of DD method for determining triazole susceptibility of Aspergillus spp. were systematically searched on major medical databases and Google Scholar. We identified 2725 articles of which 13 met the inclusion criteria. The overall average agreement value obtained between DD and CLSI broth microdilution (CLSI-BMD) methods for the itraconazole 10 µg disk (70.75%) was low especially when the medium used was not Mueller-Hinton (MH) agar. In contrast average agreement for the voriconazole 1 µg disk and the posaconazole 5 µg disk were > 94% regardless of media used. The correlation coefficient values between the DD and CLSI-BMD methods on MH agar were acceptable (≥ 0.71) for the itraconazole 10 µg disk and posaconazole 5 µg disk and good (≥ 0.80) for the voriconazole 1 and 10 µg disk. The reproducibility of the DD method regardless to the medium used was ≥ 82%. This systematic review shows that the disk diffusion method could be a real alternative for triazole antifungals susceptibility testing of Aspergillus spp.

Chemical Profile, Antioxidant, Antimicrobial, and Anticancer Activities of the Water-Ethanol Extract of Pulicaria undulata Growing in the Oasis of Central Saudi Arabian Desert

Pulicaria undulata (L.) C. A. Mey has multiple uses as part of the traditional medicament, and several biological activities of the plant have been corroborated in the scientific literature. The current work evaluates the phytochemical constituents and biological properties of the water-ethanol extract of the P. undulata growing in Qassim, the central arid regions of the Kingdom of Saudi Arabia. Qualitative UPLC-ESIQ-TOF analysis identified 27 compounds belonging to the phenolics, flavonoids, triterpenes, coumarins, and of fatty acids chemical classes. The quantitative analysis exhibited 33.3 mg/g GAE (Gallic Acid Equivalents), and 10.8 mg/g QE (Quercetin Equivalents) of the phenolics and flavonoids in the plant’s concentrated (to dryness) water-ethanol extract. The trace elements analysis of the plant’s dry powder established the presence of copper (20.13 µg/kg), and zinc (68.2 µg/kg) in the higher levels of occurrences. In terms of the antioxidant potential of the plant’s extract, the ferric-reducing, and free-radicals scavenging activities were recorded at 47.11 mg/g, and 19.13 mg/g equivalents of the concentrated to dryness water-ethanol extract of the plant. The water-ethanol extract of P. undulata also exhibited antimicrobial activity against the tested Gram-positive bacteria, while no activity was observed against the tested Gram-negative bacteria, or the fungi. The MIC (minimum inhibitory concentration) values were in the range of 49 to 1563 µg/mL, whereas the MBC (minimum bactericidal concentration) values ranged from 49 to 3125 µg/mL, against the tested Gram-positive bacteria. The P. undulata water-ethanol extract also exhibited potent cytotoxic effects with the IC₅₀ value at 519.2 µg/mL against the MCF-7 breast cancer cell-lines, followed by the anticancer activity of erythroleukemic cell-lines, K562 at 1212 µg/mL, and pancreatic cell-lines, PANC-1, at 1535 µg/mL, as compared to the normal fibroblast cells (4048 µg/mL). The Annexin-V assay demonstrated that, as the P. undulata extract’s dose increased from IC₅₀ to twice of the IC₅₀, the percentage of the necrosis was found to be increased in the late apoptosis stage of the cancer cells. These data confirmed the P. undulata extract’s ability to inhibit several human cancer cell lines’ growth in comparison to other local halophytes. The antimicrobial activity of the plant was also confirmed.

Antifungal Activities of cis-trans Citral Isomers against Trichophyton rubrum with ERG6 as a Potential Target

Trichophyton rubrum causes ringworm worldwide. Citral (CIT), extracted from Pectis plants, is a monoterpene and naturally composed of geometric isomers neral (cis-citral) and geranial (trans-citral). CIT has promising antifungal activities and ergosterol biosynthesis inhibition effects against several pathogenic fungi. However, no study has focused on neral and geranial against T. rubrum, which hinders the clinical application of CIT. This study aimed to compare antifungal activities of neral and geranial and preliminarily elucidate their ergosterol biosynthesis inhibition mechanism against T. rubrum. Herein, the disc diffusion assays, cellular leakage measurement, flow cytometry, SEM/TEM observation, sterol quantification, and sterol pattern change analyses were employed. The results showed geranial exhibited larger inhibition zones (p < 0.01 or 0.05), higher cellular leakage rates (p < 0.01), increased conidia with damaged membranes (p < 0.01) within 24 h, more distinct shriveled mycelium in SEM, prominent cellular material leakage, membrane damage, and morphological changes in TEM. Furthermore, geranial possessed more promising ergosterol biosynthesis inhibition effects than neral, and both induced the synthesis of 7-Dehydrodesmosterol and Cholesta-5,7,22,24-tetraen-3β-ol, which represented marker sterols when ERG6 was affected. These results suggest geranial is more potent than neral against T. rubrum, and both inhibit ergosterol biosynthesis by affecting ERG6.

From Ocean to Medicine: Pharmaceutical Applications of Metabolites from Marine Bacteria

Oceans cover seventy percent of the planet's surface and besides being an immense reservoir of biological life, they serve as vital sources for human sustenance, tourism, transport and commerce. Yet, it is estimated by the National Oceanic and Atmospheric Administration (NOAA) that eighty percent of the oceans remain unexplored. The untapped biological resources present in oceans may be fundamental in solving several of the world's public health crises of the 21st century, which span from the rise of antibiotic resistance in bacteria, pathogenic fungi and parasites, to the rise of cancer incidence and viral infection outbreaks. In this review, health risks as well as how marine bacterial derived natural products may be tools to fight them will be discussed. Moreover, an overview will be made of the research pipeline of novel molecules, from identification of bioactive bacterial crude extracts to the isolation and chemical characterization of the molecules within the framework of the One Health approach. This review highlights information that has been published since 2014, showing the current relevance of marine bacteria for the discovery of novel natural products.

Synthesis, Characterization and Bioassay of Novel Substituted 1-(3-(1,3-Thiazol-2-yl)phenyl)-5-oxopyrrolidines

Thiazole derivatives attract the attention of scientists both in the field of organic synthesis and bioactivity research due to their high biological activity. In the present study, thiazole ring was obtained by the interaction of 1-(4-(bromoacetyl)phenyl)-5-oxopyrrolidine-3-carboxylic acid with thiocarbamide or benzenecarbothioamide, as well as tioureido acid. A series of substituted 1-(3-(1,3-thiazol-2-yl)phenyl)-5-oxopyrrolidines with pyrrolidinone, thiazole, pyrrole, 1,2,4-triazole, oxadiazole and benzimidazole heterocyclic fragments were synthesized and their antibacterial properties were evaluated against Gram-positive strains of Staphylococcus aureus, Bacillus cereus, Listeria monocytogenes and Gram-negative Pseudomonas aeruginosa, Escherichia coli and Salmonella enterica enteritidis. The vast majority of compounds exhibited between twofold and 16-fold increased antibacterial effect against the test-cultures when compared with Oxytetracycline.

Antifungal peptides produced by actinomycetes and their biological activities against plant diseases

Antibacterial peptides are a class of naturally occurring peptides produced by eukaryotes and prokaryotes. Some of them exhibit broad-spectrum antifungal activity. Antifungal peptides (AFPs) can be developed as antibiotic to control fungal infections in agriculture due to their different antifungal mechanisms. As actinomycetes are still one of the most important sources of novel antibiotics, in this review, the mechanisms of action of AFPs are explained. Characterization of several AFPs produced by actinomycetes and their biological activities against plant diseases are summarized. Furthermore, the pathway for total synthesis of naturally occurring cyclodepsipeptide, valinomycin, is proposed. Finally, the pathway for biosynthesis of kutzneride 2 is proposed and the structure-activity relationship of kutznerides is discussed.

Methods for in vitro evaluating antimicrobial activity: A review

In recent years, there has been a growing interest in researching and developing new antimicrobial agents from various sources to combat microbial resistance. Therefore, a greater attention has been paid to antimicrobial activity screening and evaluating methods. Several bioassays such as disk-diffusion, well diffusion and broth or agar dilution are well known and commonly used, but others such as flow cytofluorometric and bioluminescent methods are not widely used because they require specified equipment and further evaluation for reproducibility and standardization, even if they can provide rapid results of the antimicrobial agent's effects and a better understanding of their impact on the viability and cell damage inflicted to the tested microorganism. In this review article, an exhaustive list of in vitro antimicrobial susceptibility testing methods and detailed information on their advantages and limitations are reported.

Prevalence of oral Candida colonization in patients with diabetes mellitus

OBJECTIVES OF THE STUDY

We aimed to assess the prevalence of oral Candida colonization in patients with diabetes and its relationship with factors such as Candida species, serum glucose level, and the susceptibility rate of isolated yeasts to antifungals.

PATIENTS

Random samples were obtained from 113 patients with type 2 diabetes, 24 patients with type 1 diabetes, and 105 healthy controls.

MATERIALS AND METHODS

The samples were taken by swabbing the oral mucosa of patients with diabetes mellitus and healthy individuals. Afterwards the samples were inoculated onto CHROMagar-Candida. The growing colonies were counted, and the isolated yeasts were identified by PCR-RFLP and RapID methods. Various isolated species of Candida were also subjected to susceptibility testing of antibiotic drugs. Blood samples were taken to evaluate glycosylated hemoglobin (HbA1c).

RESULTS

Although the Candida carriage rate and density were statistically higher in diabetics than healthy individuals, no direct association was found between having high Candida-burden and glycosylated hemoglobin. The most commonly isolated species in both diabetics and controls was Candida albicans. Of the tested antifungal drugs, the highest rate of resistance was found against itraconazole, followed in frequency by ketoconazole and fluconazole.

CONCLUSIONS

This study identified a significant association between the poor glycemic control and the higher prevalence rates of Candida carriage and density in diabetic patients. In addition, a high prevalence of C. dubliniensis in diabetic patients was found, which might be misdiagnosed with its morphologically related species, C. albicans.

Study of Pathogens of Fungal Keratitis and the Sensitivity of Pathogenic Fungi to Therapeutic Agents with the Disk Diffusion Method

PURPOSE/AIM OF THE STUDY

To identify the causative fungi of fungal keratitis, test their susceptibility to antifungal agents with the disk diffusion method and study the relationship between the organisms, the inhibition zones and the clinical outcomes.

MATERIALS AND METHODS

535 patients with fungal keratitis in one eye were included in this study. Pathogenic fungi were isolated by corneal scraping, identified by fungal cultivation and subjected to drug sensitivity tests conducted with the disk diffusion method. The patients were treated initially with voriconazole, terbinafine and natamycin eye drops for one week. Further treatment continued using the most effective drug according to the drug sensitivity results. The patients were followed up every week until three months after cured. The inhibition zones of fungi cultured with voriconazole, terbinafine and natamycin were compared. The relationship between inhibition zones and organism, organism and treatment results measure, and each treatment results measure and inhibition zones were evaluated.

RESULTS

Of 535 patients, 53.84%, 19.25% and 26.91% were infected with Aspergillus, Fusarium and other fungi, respectively. Keratitis patients infected with Aspergillus keratitis had the worst outcome. The size of the inhibition zones of Aspergillus spp., Fusarium spp. and other fungal genera differed significantly in response to voriconazole, terbinafine and natamycin. The inhibition zone associated with natamycin correlated significantly with the clinical outcome of fungal keratitis (OR = 0.925), but no other such correlations were found for the other drugs tested.

CONCLUSIONS

Aspergillus and Fusarium were the predominant pathogenic genera causing fungal keratitis in our patients. Among the causative fungi, infections due to Aspergillus spp. were associated with the worst outcomes. The inhibition zones of fungal isolates in response to natamycin significantly correlated with the treatment outcomes of keratitis. Specifically, the smaller the natamycin inhibition zone, the lower the probability that the fungal keratitis had been eliminated.

Susceptibility of 100 filamentous fungi: comparison of two diffusion methods, Neo-Sensitabs and E-test, for amphotericin B, caspofungin, itraconazole, voriconazole and posaconazole

We compared the E-test method to that of the Neo-Sensitabs tablet diffusion assay for evaluating the in vitro susceptibility of 100 clinical isolates of filamentous fungi (Aspergillus spp., Fusarium spp., Scedosporium spp., zygomycetes and other molds) to amphotericin B, itraconazole, voriconazole, caspofungin, and posaconazole. We determined the categorical agreement level between E-test minimum inhibitory concentrations (MIC) and tablet end-points, as opposed to the following disagreement parameters: very major error - resistant parameter (R) in E-test and susceptible (S) in tablet; major error - S by E-test and R by tablet; minor error - shifts between S and susceptible dose-dependent (S-DD) or S-DD and R. We also performed linear regression analyses and computed Pearson's correlation coefficients (R values) between the log transforms of MICs and the inhibition zone diameters of the five studied antifungal agents. For itraconazole we obtained 97% categorical agreement and R = -0.727. Categorical agreement for caspofungin and voriconazole was 96% and R =-0.821 and R = -0.789, respectively. For posaconazole the categorical agreement was 94% and R =-0.743. Amphotericin B exhibited a lower degree of agreement (76%, R = -0.672), especially in studies of Aspergillus spp. Our results suggest a potential value of the Neo-Sensitabs assay for in vitro susceptibility testing of molds to itraconazole, voriconazole, caspofungin and posaconazole, while amphotericin B exhibited an overall lower degree of agreement.

Comparison of Neo-Sensitabs tablet diffusion assay with CLSI broth microdilution M38-A and disk diffusion methods for testing susceptibility of filamentous fungi with amphotericin B, caspofungin, itraconazole, posaconazole, and voriconazole

We compared the Neo-Sensitabs tablet assay to both reference M38-A broth microdilution and disk diffusion methods for testing the susceptibility of 183 filamentous isolates to amphotericin B, caspofungin, itraconazole, posaconazole, and voriconazole. Neo-Sensitabs and disk assay inhibition zone diameters, in millimeters, were obtained on nonsupplemented Mueller-Hinton agar at 16 to 48 h. The reproducibility of zone diameters (i.e., the percentage of replicate zone diameters that were within 2 standard deviations of the means), their correlation with either MICs or minimum effective concentrations (for caspofungin only), and the categorical agreement were similar between tablet and disk assays (93 to 100% [R, >0.70] and 79 to 96%, respectively) with four of the five agents. The exceptions were the results for posaconazole tablets (R, 0.686; disk, 0.757; 84% categorical agreement for tablet and 96% for disk). These data suggest the potential value of the Neo-Sensitabs assay for testing 5-microg caspofungin and 1-microg voriconazole posaconazole tablets against all mold isolates, 8-microg itraconazole and 5-microg tablets against all mold isolates except zygomycetes, and 10-microg amphotericin B tablets against zygomycete isolates only.

Current status of antifungal susceptibility testing methods

Antifungal susceptibility testing is a very dynamic field of medical mycology. Standardization of in vitro susceptibility tests by the Clinical and Laboratory Standards Institute (CLSI) and the European Committee for Antimicrobial Susceptibility Testing (EUCAST), and current availability of reference methods constituted the major remarkable steps in the field. Based on the established minimum inhibitory concentration (MIC) breakpoints, it is now possible to determine the susceptibilities of Candida strains to fluconazole, itraconazole, voriconazole, and flucytosine. Moreover, utility of fluconazole antifungal susceptibility tests as an adjunct in optimizing treatment of candidiasis has now been validated. While the MIC breakpoints and clinical significance of susceptibility testing for the remaining fungi and antifungal drugs remain yet unclear, modifications of the available methods as well as other methodologies are being intensively studied to overcome the present drawbacks and limitations. Among the other methods under investigation are Etest, colorimetric microdilution, agar dilution, determination of fungicidal activity, flow cytometry, and ergosterol quantitation. Etest offers the advantage of practical application and favorable agreement rates with the reference methods that are frequently above acceptable limits. However, MIC breakpoints for Etest remain to be evaluated and established. Development of commercially available, standardized colorimetric panels that are based on CLSI method parameters has added more to the antifungal susceptibility testing armamentarium. Flow cytometry, on the other hand, appears to offer rapid susceptibility testing but requires specified equipment and further evaluation for reproducibility and standardization. Ergosterol quantitation is another novel approach, which appears potentially beneficial particularly in discrimination of azole-resistant isolates from heavy trailers. The method is yet investigational and requires to be further studied. Developments in methodology and applications of antifungal susceptibility testing will hopefully provide enhanced utility in clinical guidance of antifungal therapy. However, and particularly in immunosuppressed host, in vitro susceptibility is and will remain only one of several factors that influence clinical outcome.

Comparison between disk diffusion and microdilution methods for determining susceptibility of clinical fungal isolates to caspofungin

We compared the caspofungin (CAS) susceptibility testing results generated by the disk diffusion (DD) assay with the results of the Clinical and Laboratory Standards Institute (CLSI) broth microdilution (BD) reference method for 106 yeast isolates. The isolates represented 11 different fungal species, including Candida albicans (n = 50), C. parapsilosis (n = 10), C. glabrata (n = 10), C. tropicalis (n = 10), C. guillermondii (n = 6), C. rugosa (n = 5), C. krusei (n = 5), C. kefyr (n = 2), C. pelliculosa (n = 2), Saccharomyces cerevisiae (n = 3), and Geotrichum candidum (n = 3). The DD assay was performed in supplemented Mueller-Hinton agar with CAS, which was tested at concentrations of 2, 10, and 25 mug per disk. MICs and inhibition zone diameters were evaluated at 24 and 48 h. In general, the results obtained by the DD assay correlated well with those obtained by the BD method. In particular, a significant correlation between methods was observed when CAS was used at concentration of 2 mug/disk at a reading time of either 24 or 48 h.

Multicenter evaluation of a new disk agar diffusion method for susceptibility testing of filamentous fungi with voriconazole, posaconazole, itraconazole, amphotericin B, and caspofungin

The purpose of this study was to correlate inhibition zone diameters, in millimeters (agar diffusion disk method), with the broth dilution MICs or minimum effective concentrations (MECs) (CLSI M38-A method) of five antifungal agents to identify optimal testing guidelines for disk mold testing. The following disk diffusion testing parameters were evaluated for 555 isolates of the molds Absidia corymbifera, Aspergillus sp. (five species), Alternaria sp., Bipolaris spicifera, Fusarium sp. (three species), Mucor sp. (two species), Paecilomyces lilacinus, Rhizopus sp. (two species), and Scedosporium sp. (two species): (i) two media (supplemented Mueller-Hinton agar [2% dextrose and 0.5 microg/ml methylene blue] and plain Mueller-Hinton [MH] agar), (ii) three incubation times (16 to 24, 48, and 72 h), and (iii) seven disks (amphotericin B and itraconazole 10-microg disks, voriconazole 1- and 10-microg disks, two sources of caspofungin 5-microg disks [BBL and Oxoid], and posaconazole 5-microg disks). MH agar supported better growth of all of the species tested (24 to 48 h). The reproducibility of zone diameters and their correlation with either MICs or MECs (caspofungin) were superior on MH agar (91 to 100% versus 82 to 100%; R, 0.71 to 0.93 versus 0.53 to 0.96 for four of the five agents). Based on these results, the optimal testing conditions for mold disk diffusion testing were (i) plain MH agar; (ii) incubation times of 16 to 24 h (zygomycetes), 24 h (Aspergillus fumigatus, A. flavus, and A. niger), and 48 h (other species); and (iii) the posaconazole 5-microg disk, voriconazole 1-microg disk, itraconazole 10-microg disk (for all except zygomycetes), BBL caspofungin 5-microg disk, and amphotericin B 10-microg (zygomycetes only).

Role of antifungal susceptibility testing in patient management

PURPOSE OF REVIEW

The review focuses on the evolving role of antifungal susceptibility testing in the clinical management of patients with invasive fungal infections. It will clarify how to clinically interpret available susceptibility testing methods.

RECENT FINDINGS

Fluconazole susceptibility testing for yeasts has now shown a relationship between fluconazole resistance and therapeutic failure. Of increasing concern are the reported cases of fluconazole cross-resistance to the newer triazoles. The correlation between amphotericin B and echinocandin susceptibility testing for yeasts, resistance, and outcomes is unknown. Although there are reports of clinical failures with echinocandins, resistance is uncommon and susceptibility testing is unhelpful. There are standardized methods of testing for the triazoles and amphotericin B against molds; however, resistance has not been correlated with outcomes due to host and laboratory factors. Knowing the intrinsic resistance of molds to particular antifungals is of greater importance. Posaconazole is a potent new antifungal agent against many difficult-to-treat molds including fusariosis and zygomycosis.

SUMMARY

Antifungal susceptibility testing of yeasts can assist in treating patients with prior antifungal exposure in determining resistance or cross-resistance. Mold susceptibility testing is of limited clinical benefit, while posconazole is an exciting new agent for treating difficult invasive fungal infections.

Comparison of three commercial assays and a modified disk diffusion assay with two broth microdilution reference assays for testing zygomycetes, Aspergillus spp., Candida spp., and Cryptococcus neoformans with posaconazole and amphotericin B

We compared posaconazole M27-A2 and M38-A MICs to Etest and YeastOne MICs for 92 zygomycetes, 126 Aspergillus isolates, 110 Candida isolates, and Cryptococcus neoformans. Reference MICs were also correlated with inhibition zone diameters in millimeters (modified M44-A disk and Neo-Sensitabs tablet methods). Etest MICs were obtained on solidified (1.5% agar) RPMI 1640 (2% dextrose), and zone diameters were obtained on supplemented (2% glucose and 0.5 microg/ml methylene blue [for all isolates]) and nonsupplemented Mueller-Hinton (MH; molds only) agar. MICs and zone diameters were obtained between 16 and 72 h. The overall agreement (% MIC pairs within a three-dilution range) between reference posaconazole and YeastOne MICs was 98 to 100% at 16 to 24 h for zygomycetes and yeasts and 99% at 24 to 48 h for Aspergillus. The overall agreement was lower between reference posaconazole and Etest MICs (94 to 97%) and by both methods with amphotericin B for all species (95 to 99.3%). For yeasts, the correlation coefficient was similar between reference posaconazole MICs and either disk (R, 0.810) or tablet (R, 0.769) zone diameter at 24 h and was superior on MH agar for molds at 16 to 48 h (R, 0.804 and 0.799 for disk and tablet, respectively). For amphotericin B, the best correlation between reference MICs and zone diameters was observed at 16 to 48 h for molds on MH agar (R, 0.736 to 0.812 and 0.765 to 0.749 for disk and tablet, respectively) and at 48 h for yeasts (R, 0.681 and 0.503 for disk and tablet, respectively). These data suggest the potential value of these alternative broth dilution and agar diffusion methods for testing posaconazole and amphotericin B in the clinical laboratory against the species evaluated.