Rapid flow cytometric susceptibility testing of Candida albicans

A promising antifungal lipopeptide from Bacillus subtilis: its characterization and insight into the mode of action

Emerging resistance of fungal pathogens and challenges faced in drug development have prompted renewed investigations into novel antifungal lipopeptides. The antifungal lipopeptide AF3 reported here is a natural lipopeptide isolated and purified from Bacillus subtilis. The AF3 lipopeptide's secondary structure, functional groups, and the presence of amino acid residues typical of lipopeptides were determined by circular dichroism, Fourier transform infrared spectroscopy, and nuclear magnetic resonance spectroscopy. The lipopeptide's low minimum inhibitory concentrations (MICs) of 4-8 mg/L against several fungal strains demonstrate its strong antifungal activity. Biocompatibility assays showed that ~ 80% of mammalian cells remained viable at a 2 × MIC concentration of AF3. The treated Candida albicans cells examined by scanning electron microscopy, transmission electron microscopy, and atomic force microscopy clearly showed ultrastructural alterations such as the loss of the cell shape and cell membrane integrity. The antifungal effect of AF3 resulted in membrane permeabilization facilitating the uptake of the fluorescent dyes-acridine orange (AO)/propidium iodide (PI) and FUN-1. Using 1,6-diphenyl-1,3,5-hexatriene (DPH) and 4-(2-[6-(dioctylamino)-2-naphthalenyl] ethenyl)-1-(3-sulfopropyl) pyridinium inner salt (di-8-ANEPPS), we observed that the binding of AF3 to the membrane bilayer results in membrane disruption and depolarization. Flow cytometry analyses revealed a direct correlation between lipopeptide activity, membrane permeabilization (~ 75% PI uptake), and reduced cell viability. An increase in 2',7'-dichlorodihydrofluorescein diacetate (DCFH-DA) fluorescence demonstrates endogenous reactive oxygen species production. Lipopeptide treatment appears to induce late-stage apoptosis and alterations to nuclear morphology, suggesting that AF3-induced membrane damage may lead to a cellular stress response. Taken together, this study illustrates antifungal lipopeptide's potential as an antifungal drug candidate. KEY POINTS: • The studied lipopeptide variant AF3 displayed potent antifungal activity against C. albicans • Its biological activity was stable to proteolysis • Analytical studies demonstrated that the lipopeptide is essentially membranotropic and able to cause membrane dysfunction, elevated ROS levels, apoptosis, and DNA damage.

The elucidation of the multimodal action of the investigational anti-Candida lipopeptide (AF4) lead from Bacillus subtilis

Background: Candida species are the main etiological agents for candidiasis, and Candida albicans are the most common infectious species. Candida species' growing resistance to conventional therapies necessitates more research into novel antifungal agents. Antifungal peptides isolated from microorganisms have potential applications as novel therapeutics. AF4 a Bacillus-derived lipopeptide demonstrating broad-spectrum antifungal activity has been investigated for its ability to cause cell death in Candida species via membrane damage and oxidative stress. Methods: Using biophysical techniques, the secondary structure of the AF4 lipopeptide was identified. Scanning electron microscopy and confocal microscopy with fluorescent dyes were performed to visualise the effect of the lipopeptide. The membrane disruption and permeabilization were assessed using the 1,6-diphenyl hexatriene (DPH) fluorescence assay and flow cytometric (FC) assessment of propidium iodide (PI) uptake, respectively. The reactive oxygen species levels were estimated using the FC assessment. The induction of apoptosis and DNA damage were studied using Annexin V-FITC/PI and DAPI. Results: Bacillus-derived antifungal variant AF4 was found to have structural features typical of lipopeptides. Microscopy imaging revealed that AF4 damages the surface of treated cells and results in membrane permeabilization, facilitating the uptake of the fluorescent dyes. A loss of membrane integrity was observed in cells treated with AF4 due to a decrease in DPH fluorescence and a dose-dependent increase in PI uptake. Cell damage was also determined from the log reduction of viable cells treated with AF4. AF4 treatment also caused elevated ROS levels, induced phosphatidylserine externalisation, late-stage apoptosis, and alterations to nuclear morphology revealed by DAPI fluorescence. Conclusion: Collectively, the mode of action studies revealed that AF4 acts primarily on the cell membrane of C. albicans and has the potential to act as an antifungal drug candidate.

Functional Characterization of a Bacillus-Derived Novel Broad-Spectrum Antifungal Lipopeptide Variant against Candida tropicalis and Candida auris and Unravelling Its Mode of Action

Limited treatment options, recalcitrance, and resistance to existing therapeutics encourage the discovery of novel antifungal leads for alternative therapeutics. Antifungal lipopeptides have emerged as potential candidates for developing new and alternative antifungal therapies. In our previous studies, we isolated and identified the lipopeptide variant AF4 and purified it to homogeneity via chromatography from the cell-free supernatant of Bacillus subtilis. AF4 was found to have broad-spectrum antifungal activity against more than 110 fungal isolates. In this study, we found that clinical isolates of Candida tropicalis and Candida auris exposed to AF4 exhibited low MICs of 4 to 8 mg/L. Time-kill assays indicated the in vitro pharmacodynamic potential of AF4. Biocompatibility assays demonstrated ~75% cell viability at 8 mg/L of AF4, indicating the lipopeptide's minimally cytotoxic nature. In lipopeptide-treated C. tropicalis and C. auris cells, scanning electron microscopy revealed damage to the cell surface, while confocal microscopy with acridine orange(AO)/propidium iodide (PI) and FUN-1 indicated permeabilization of the cell membrane, and DNA damage upon DAPI (4',6-diamidino-2-phenylindole) staining. These observations were corroborated using flow cytometry (FC) in which propidium iodide, 2',7'-dichlorodihydrofluorescein diacetate (DCFH-DA), and rhodamine 123 (Rh123) staining of cells treated with AF4 revealed loss of membrane integrity, increased reactive oxygen species (ROS) production, and mitochondrial membrane dysfunction, respectively. Membrane perturbation was also observed in the 1,6-diphenyl-1,3,5-hexatriene (DPH) fluorescence study and the interaction with ergosterol was observed by an ergosterol binding assay. Decreased membrane dipole potential also indicated the probable binding of lipopeptide to the cell membrane. Collectively, these findings describe the mode of action of AF4 against fungal isolates by membrane disruption and ROS generation, demonstrating its antifungal potency. IMPORTANCE C. tropicalis is a major concern for candidiasis in India and C. auris has emerged as a resistant yeast causing difficult-to-treat infections. Currently, amphotericin B (AMB) and 5-flucytosine (5-FC) are the main therapeutics for systemic fungal infections; however, the nephrotoxicity of AMB and resistance to 5-FC is a serious concern. Antifungal lead molecules with low adverse effects are the need of the hour. In this study, we briefly describe the antifungal potential of the AF4 lipopeptide and its mode of action using microscopy, flow cytometry, and fluorescence-based assays. Our investigation reveals the basic mode of action of the investigated lipopeptide. This lipopeptide with broad-spectrum antifungal potency is apparently membrane-active, and there is a smaller chance that organisms exposed to such a compound will develop drug resistance. It could potentially act as a lead molecule for the development of an alternative antifungal agent to combat candidiasis.

Recent Advances in the Application of Essential Oils as Potential Therapeutic Candidates for Candida-Related Infections

Candidiasis (oral, vulvovaginal, or systemic bloodstream infections) are important human fungal infections associated with a high global prevalence in otherwise healthy adults but are also opportunistic infections in immunocompromised patients. With the recent discovery of the multidrug resistant—and often difficult to treat—Candida auris, as well as the rising costs associated with hospitalisations and the treatment of infections caused by Candida species, there is an urgent need to develop effective therapeutics against these pathogenic yeasts. Essential oils have been documented for many years as treatments for different ailments and are widely known and utilised in alternative and complementary therapies, including treating microbial infections. This review highlights knowledge from research on the effects of medicinal plants, and in particular, essential oils, as potential treatments against different Candida species. Studies have been evaluated that describe the experimental approaches used in investigating the anticandidal effects of essential oils (in vivo and in vitro), the established mode of action of the different compounds against different Candida species, the effect of a combination of essential oils with other compounds as potential therapies, and the evidence from clinical trial studies.

The Clinical Microbiology Laboratory and the Opioid Epidemic: Challenges and Opportunities

Increased infections from injection drug use harm patients and are costly to the health care system. The impact on clinical microbiology laboratories is less recognized. Microbiology laboratories face increased test volume and test complexity from the spectrum and burden of pathogens associated with injection drug use, which lead to diagnostic challenges and overtaxed resources. We describe stressed workflows, pathogens that defy protocols, and limits of current technologies. Laboratories may benefit from protocol revisions, additional resources, workflow oversight, and improved communication with clinical providers to optimally meet challenges associated with this public health crisis.

The Antifungal Peptide MCh-AMP1 Derived From Matricaria chamomilla Inhibits Candida albicans Growth via Inducing ROS Generation and Altering Fungal Cell Membrane Permeability

The rise of antifungal drug resistance in Candida species responsible for life threatening candidiasis is considered as an increasing challenge for the public health. MCh-AMP1 has previously been reported as a natural peptide from Matricaria chamomilla L. flowers with broad-spectrum antifungal activity against human pathogenic molds and yeasts. In the current study, the mode of action of synthetic MCh-AMP1 was investigated against Candida albicans, the major etiologic agent of life-threatening nosocomial candidiasis at cellular and molecular levels. Candida albicans ATCC 10231 was cultured in presence of various concentrations of MCh-AMP1 (16-64 μg/mL) and its mode of action was investigated using plasma membrane permeabilization assays, reactive oxygen species (ROS) induction, potassium ion leakage and ultrastructural analyses by electron microscopy. MCh-AMP1 showed fungicidal activity against Candida albicans at the concentrations of 32 and 64 μg/mL. The peptide increased fungal cell membrane permeability as evidenced by elevating of PI uptake and induced potassium leakage from the yeast cells. ROS production was induced by the peptide inside the fungal cells to a maximum of 64.8% at the concentration of 64 μg/mL. Scanning electron microscopy observations showed cell deformation as shrinkage and folding of treated yeast cells. Transmission electron microscopy showed detachment of plasma membrane from the cell wall, cell depletion and massive destruction of intracellular organelles and cell membrane of the fungal cells. Our results demonstrated that MCh-AMP1 caused Candida albicans cell death via increasing cell membrane permeability and inducing ROS production. Therefore, MCh-AMP1 could be considered as a promising therapeutic agent to combat Candida albicans infections.

The small GTPase Rhb1 is involved in the cell response to fluconazole in Candida albicans

Candida albicans is an important fungal pathogen in humans. Rhb1 is a small GTPase of the Ras superfamily and is conserved from yeasts to humans. In C. albicans, Rhb1 regulates the expression of secreted protease 2, low nitrogen-mediated morphogenesis, and biofilm formation. Moreover, our previous studies have indicated that Rhb1 is associated with the target of rapamycin (TOR) signaling pathway. In this study, we further explored the relationship between Rhb1 and drug susceptibility. The RHB1 deletion mutant exhibited reduced fluconazole susceptibility, and this phenotype occurred mainly through the increased gene expression and activity of efflux pumps. In addition, Mrr1 and Tac1 are transcription factors that can activate efflux pump gene expression. However, the RHB1 deletion, RHB1/MRR1 and RHB1/TAC1 double deletion mutants had no significant differences in efflux pump gene expression and fluconazole susceptibility, suggesting that Rhb1-regulated efflux pump genes do not act through Mrr1 and Tac1. We also showed that membrane localization is crucial for Rhb1 activity in response to fluconazole. Finally, Rhb1 was linked not only to the TOR but also to the Mkc1 mitogen-activated protein kinase signaling pathway in response to fluconazole. In sum, this study unveiled a new role of Rhb1 in the regulation of C. albicans drug susceptibility.

Emerging technologies for antibiotic susceptibility testing

Superbugs such as infectious bacteria pose a great threat to humanity due to an increase in bacterial mortality leading to clinical treatment failure, lengthy hospital stay, intravenous therapy and accretion of bacteraemia. These disease-causing bacteria gain resistance to drugs over time which further complicates the treatment. Monitoring of antibiotic resistance is therefore necessary so that bacterial infectious diseases can be diagnosed rapidly. Antimicrobial susceptibility testing (AST) provides valuable information on the efficacy of antibiotic agents and their dosages for treatment against bacterial infections. In clinical laboratories, most widely used AST methods are disk diffusion, gradient diffusion, broth dilution, or commercially available semi-automated systems. Though these methods are cost-effective and accurate, they are time-consuming, labour-intensive, and require skilled manpower. Recently much attention has been on developing rapid AST techniques to avoid misuse of antibiotics and provide effective treatment. In this review, we have discussed emerging engineering AST techniques with special emphasis on phenotypic AST. These techniques include fluorescence imaging along with computational image processing, surface plasmon resonance, Raman spectra, and laser tweezer as well as micro/nanotechnology-based device such as microfluidics, microdroplets, and microchamber. The mechanical and electrical behaviour of single bacterial cell and bacterial suspension for the study of AST is also 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.

Cell wall protection by the Candida albicans class I chitin synthases

Candida albicans has four chitin synthases from three different enzyme classes which deposit chitin in the cell wall, including at the polarized tips of growing buds and hyphae, and sites of septation. The two class I enzymes, Chs2 and Chs8, are responsible for most of the measurable chitin synthase activity in vitro, but their precise biological functions in vivo remain obscure. In this work, detailed phenotypic analyses of a chs2Δchs8Δ mutant have shown that C. albicans class I chitin synthases promote cell integrity during early polarized growth in yeast and hyphal cells. This was supported by live cell imaging of YFP-tagged versions of the class I chitin synthases which revealed that Chs2-YFP was localized at sites of polarized growth. Furthermore, a unique and dynamic pattern of localization of the class I enzymes at septa of yeast and hyphae was revealed. Phosphorylation of Chs2 on the serine at position 222 was shown to regulate the amount of Chs2 that is localized to sites of polarized growth and septation. Independently from this post-translational modification, specific cell wall stresses were also shown to regulate the amount of Chs2 that localizes to specific sites in cells, and this was linked to the ability of the class I enzymes to reinforce cell wall integrity during early polarized growth in the presence of these stresses.

Determination of the minimum inhibitory concentration of Cryptococcus neoformans and Cryptococcus gattii against fluconazole by flow cytometry

Recent studies have used flow cytometry (FCM) as an important alternative method to determine the antifungal susceptibility of yeasts compared to the broth microdilution Clinical and Laboratory Standards Institute (CLSI) reference procedure. We present a comparative study of the broth microdilution method and flow cytometry to assess the in vitro antifungal susceptibility of Cryptococcus neoformans (n = 16) and C. gattii (n = 24) to fluconazole. The minimum inhibitory concentration (MIC) assays by flow cytometry were defined as the lowest drug concentration that showed ∼50% of the count of acridine orange negative cells compared to that of the growth control. Categorical classification showed all C. neoformans isolates were susceptible to fluconazole. Three isolates of C. gattii were susceptible dose-dependent and the remaining 21 isolates were classified as susceptible. MICs comparison of both methodologies demonstrated 100% categorical agreement of the results obtained for C. neoformans and C. gattii. The MICs obtained with the CLSI-approved method and flow cytometry were compared by the Spearman correlation test and a significant Pv = 0.001. The flow cytometric method has the advantage of analyzing a large and constant number of cells in less time, i.e., 9 h incubation for fluconazole using acridine orange versus 72 h for broth microdilution method. In conclusion, the two methods were comparable and flow cytometry method can expedite and improve the results of in vitro susceptibility tests of C. neoformans and C. gattii against fluconazole and also allows comparative studies in vitro/in vivo more rapidly, which along with clinical data, could assist in selecting the most appropriate treatment choice.

In vitro and in vivo activity of a novel antifungal small molecule against Candida infections

Candida is the most common fungal pathogen of humans worldwide and has become a major clinical problem because of the growing number of immunocompromised patients, who are susceptible to infection. Moreover, the number of available antifungals is limited, and antifungal-resistant Candida strains are emerging. New and effective antifungals are therefore urgently needed. Here, we discovered a small molecule with activity against Candida spp. both in vitro and in vivo. We screened a library of 50,240 small molecules for inhibitors of yeast-to-hypha transition, a major virulence attribute of Candida albicans. This screening identified 20 active compounds. Further examination of the in vitro antifungal and anti-biofilm properties of these compounds, using a range of Candida spp., led to the discovery of SM21, a highly potent antifungal molecule (minimum inhibitory concentration (MIC) 0.2 – 1.6 µg/ml). In vitro, SM21 was toxic to fungi but not to various human cell lines or bacterial species and was active against Candida isolates that are resistant to existing antifungal agents. Moreover, SM21 was relatively more effective against biofilms of Candida spp. than the current antifungal agents. In vivo, SM21 prevented the death of mice in a systemic candidiasis model and was also more effective than the common antifungal nystatin at reducing the extent of tongue lesions in a mouse model of oral candidiasis. Propidium iodide uptake assay showed that SM21 affected the integrity of the cell membrane. Taken together, our results indicate that SM21 has the potential to be developed as a novel antifungal agent for clinical use.

Anti-Candida activity of two-peptide bacteriocins, plantaricins (Pln E/F and J/K) and their mode of action

The fungicidal effect of plantaricin peptides PlnE, -F, -J, and -K was studied against pathogenic yeast, Candida albicans. Dose-dependent inhibitory effect was observed by drop in cell viability, further demonstrated by measuring the fluorescence intensity of cells by exposing them to 5, (6)-carboxyfluorescein diacetate (CFDA). Live/dead staining by CFDA and propidium iodide (PI) also suggested the viability loss response. Also, the PI uptake by treated cells suggested the membrane damage. PlnJ was identified as most inhibitory among different plantaricins tested. PlnJ not only induced membrane potential dissipation but also resulted in the release of K(+). In addition, enhanced production of reactive oxygen species (ROS) was also observed by fluorometry using 2',7'-Dichlorodihydrofluorescein diacetate (DCFH-DA). Dual staining with Hoechst stain and PI depicted both early apoptotic and necrotic cells in the treated population. Terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) positive staining further confirmed the ROS-mediated apoptosis. Scanning electron microscopy and transmission electron microscopy also revealed characteristic apoptotic features such as appearance of blebs, indentations, and wrinkling of the cell wall, discontinuity of cell membrane, undefined and damaged nuclei, and shrinkage of protoplasm. Taken together the results suggest that Pln-treatment initiate the apoptosis cell death which may lead to necrosis due to toxicity of the plantaricin peptides.

Anti-Candida activity of spent culture filtrate of Lactobacillus plantarum strain LR/14

OBJECTIVES

This study was undertaken to understand the effect of antimicrobial compounds produced by an environmental isolate of lactic acid bacterium, Lactobacillus plantarum strain LR/14, on growth, viability and biofilm forming ability of the pathogenic yeast, Candida albicans SC5314 and to identify the mode of action of such compounds.

MATERIAL AND METHODS

L. plantarum LR14 was grown at 37°C for 18 h in MRS broth. The spent culture filtrate (SCF) was collected by centrifugation and checked for anti-Candida activity. Live/dead staining followed by fluorescence microscopy was done to study the membrane damage. Increased membrane permeability was confirmed by measuring the release of ions and macromolecules (ATP) using atomic absorption spectrophotometer and luminometer, respectively. Effect on biofilm formation was quantified by MTT reduction assay.

RESULTS

The viability of yeast cells was affected by SCF LR14 treatment in a dose-dependent manner, exerting a fungicidal effect. The active compound was identified as a pH-dependent thermostable proteinaceous metabolite. The fungicidal activity was further confirmed by PI staining, suggesting compromised membrane as the cause of cell death. Leakage of intracellular contents such as, K+ ions and ATP, as a cause of its inhibitory action further confirmed the membrane disruption. Moreover, significant reduction in biofilm formation was also confirmed.

CONCLUSIONS

SCF LR14 showed potent anti-Candida activity, affecting cell viability, membrane permeability, and biofilm formation and leading to cell death, thereby suggested a probable candidate as a natural therapeutic agent.

Next-generation antimicrobial susceptibility testing

Antimicrobial resistance has emerged as one of the most-significant health care problems of the new millennium, and the clinical microbiology laboratory plays a central role in optimizing the therapeutic management of patients with infection. This minireview explores the potential value of innovative methods for antimicrobial susceptibility testing of microorganisms that could provide valuable alternatives to existing methodologies in the very near future.

Application of chip-based flow cytometry for amphotericin B and fluconazole susceptibility testing on Candida strains

Chip-based flow cytometry is a rather new method that offers an easy, fast opportunity for examination of yeasts, such as Candida cells. In our study cell-chip technology was tested with ATCC Candida strains to determine their viability and susceptibility against antifungal agents, amphotericin B and fluconazole. We found this technology to be suitable for the detection of Candida cells, for the differentiation between dead and living cells, and for the determination of amphotericin B and fluconazole susceptibility of different Candida strains (Bouquet et al., Mycoses 55:e90-e96, 2012).

Novel method for evaluating in vitro activity of anidulafungin in combination with amphotericin B or azoles

A combination of drugs possessing different targets has been used as salvage therapy, although without scientific support. In vitro studies validating such combinations are scarce, and the methodology is very laborious and time-consuming. This study proposes a flow cytometric (FC) protocol as an alternative to evaluate the effect of the combination of anidulafungin (AND) with amphotericin B (AMB) and azoles (fluconazole and voriconazole), tested upon 39 and 36 Candida strains, respectively. The concentration assayed in the combination was 0.5× MIC of each drug. The membrane potential marker DiBAC(4)(3) [Bis-(1,3-dibutylbarbituric acid) trimethine oxonol] was used for AND-AMB, and the metabolic marker FUN-1 was used for AND-azoles. Drug interaction was determined by calculating a staining index (SI): the sum of the percentage of depolarized cells (DC) after treatment with drug combinations divided by the DC of the drug alone, and the sum of the mean intensity of fluorescence (MIF) displayed by cells treated with drug combinations divided by the MIF of the drug alone for FUN-1. An SI of <1 means antagonism, an SI between 1 and 4 means no interaction, and an SI of >4 means synergism. The combination of AND and AMB by FC and checkerboard was synergistic for 46 and 43% of isolates and antagonistic for 5 and 8%, respectively. For the combination of AND and azoles, it was synergistic for 36% and antagonistic for 3% by FC and synergistic for 44% and antagonistic for 3% by checkerboard. When the FC method was compared to the gold standard checkerboard method, the agreement was 0.91 (95% confidence interval [95% CI] of 0.88 to 0.94), sensitivity was 0.88 (95% CI of 0.73 to 0.95), and specificity was 0.95 (95% CI of 0.84 to 1). Thus, FC is a rapid and reliable method (<2 h) to assess the effect of antifungal combinations.

Susceptibility tests of oropharyngeal Candida albicans from egyptian patients to fluconazole determined by three methods

Candida albicans frequently cause oropharyngeal candidiasis in immunocompromised patients. As some of these isolates show resistance against azoles, the clinician is wary of initiating therapy with fluconazole (FZ) until a final susceptibility report is generated. We aimed to evaluate the efficacy of rapid flow cytometry (FCM) and disc diffusion (DD) methods in comparison to reference microdilution (MD) of Clinical and Laboratory Standards Institute (CLSI) method for FZ. Thirty seven Candida albicans isolates were tested by the three methods. By both MD and FCM, 26/37 (70.3%) were sensitive with minimal inhibitory concentration (MIC) ≤ 8μg/ml, 5/37 (13.5%) were susceptible dose dependant (S-DD) with MIC 16-32 μg/ml and 6/37 (16.2%) were resistant with MIC ≥64μg/ml. More than 92% of isolates susceptible to FZ by the MD were susceptible by the DD methods with good agreement (81.08%, P = 0.000). However, 4/5 isolates diagnosed as S-DD by MD were resistant by DD. Interestingly, the MIC by FCM at 4 h showed excellent agreement (95.59%, P = 0.000) to that obtained by MD method at 24 h. Overall, FCM antifungal susceptibility testing provided rapid, reproducible results that are valuable alternative to MD. The DD test is recommended as a simple and reliable screening test for the detection of susceptible Candida albicans isolates to FZ.

Antifungal activity of lariciresinol derived from Sambucus williamsii and their membrane-active mechanisms in Candida albicans

Lariciresinol is an enterolignan precursor isolated from the herb Sambucus williamsii, a folk medicinal plant used for its therapeutic properties. In this study, the antifungal properties and mode of action of lariciresinol were investigated. Lariciresinol displays potent antifungal properties against several human pathogenic fungal strains without hemolytic effects on human erythrocytes. To understand the antifungal mechanism of action of lariciresinol, the membrane interactions of lariciresinol were examined. Fluorescence analysis using the membrane probe 3,3'-diethylthio-dicarbocyanine iodide (DiSC(3)-5) and 1,6-diphenyl-1,3,5-hexatriene (DPH), as well as a flow cytometric analysis with propidium iodide (PI), a membrane-impermeable dye, indicated that lariciresinol was associated with lipid bilayers and induced membrane permeabilization. Therefore, the present study suggests that lariciresinol possesses fungicidal activities by disrupting the fungal plasma membrane and therapeutic potential as a novel antifungal agent for the treatment of fungal infectious diseases in humans.

In vitro antifungal activities of amphotericin B in combination with acteoside, a phenylethanoid glycoside from Colebrookea oppositifolia

This study was undertaken to investigate the synergistic interaction between amphotericin B (AmB) and acteoside, isolated from the aerial parts of the shrub Colebrookea oppositifolia (Lamiaceae). Acteoside alone exhibited no intrinsic antifungal activity but showed a potent synergism in combination with AmB against selected pathogenic species, with fractional inhibitory concentration indices in the range of 0.0312-0.1562. The combination of acteoside at 3.12 and 12.5 µg ml(-1) with subinhibitory concentrations of AmB resulted in a potent fungicidal effect and also exhibited a significantly extended post-antifungal effect. Furthermore, the combination also reduced the minimum biofilm reduction concentration values of AmB (2-16-fold) in preformed biofilms of Candida albicans, Cryptococcus neoformans and Aspergillus fumigatus. There was decreased viability of the cells, increased uptake of propidium iodide and enhanced leakage of 260 nm-absorbing material by Candida albicans cells when exposed to AmB in the presence of acteoside. The reason for potentiation is likely to be that the subinhibitory concentrations of AmB facilitated the uptake of acteoside, which resulted in increased killing of the fungal cells. Administration of acteoside in mice at up to 2000 mg (kg body weight)(-1) by the intraperitoneal or oral route produced no overt toxicity. The data presented here support synergism between acteoside and AmB, and it is therefore proposed that a prospective new management strategy for therapeutic application of this combination should be explored.

The effect of Leptospermum petersonii essential oil on Candida albicans and Aspergillus fumigatus

A variety of assays were utilized to determine the effects of Leptospermum petersonii essential oil on both Candida albicans and Aspergillus fumigatus. Hyphal morphology, susceptibility of spheroplasts and uptake of propidium iodide following exposure to the oil suggest that the mode of action of L. petersonii essential oil is through direct disturbance of the fungal cell membrane. Data also confirms that the volatile component of the oil is highly antifungal, independent of direct contact between the liquid oil and the fungal membrane. The degree of inhibition was greater when fungi were directly exposed to oil volatiles compared to pre-inoculation exposure of oil volatiles into the agar. It is likely that the essential oil volatiles are acting both directly and indirectly on the fungi to produce growth inhibition.

In vitro antifungal activity of hydroxychavicol isolated from Piper betle L

Background

Hydroxychavicol, isolated from the chloroform extraction of the aqueous leaf extract of Piper betle L., (Piperaceae) was investigated for its antifungal activity against 124 strains of selected fungi. The leaves of this plant have been long in use tropical countries for the preparation of traditional herbal remedies.

Methods

The minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) of hydroxychavicol were determined by using broth microdilution method following CLSI guidelines. Time kill curve studies, post-antifungal effects and mutation prevention concentrations were determined against Candida species and Aspergillus species "respectively". Hydroxychavicol was also tested for its potential to inhibit and reduce the formation of Candida albicans biofilms. The membrane permeability was measured by the uptake of propidium iodide.

Results

Hydroxychavicol exhibited inhibitory effect on fungal species of clinical significance, with the MICs ranging from 15.62 to 500 μg/ml for yeasts, 125 to 500 μg/ml for Aspergillus species, and 7.81 to 62.5 μg/ml for dermatophytes where as the MFCs were found to be similar or two fold greater than the MICs. There was concentration-dependent killing of Candida albicans and Candida glabrata up to 8 × MIC. Hydroxychavicol also exhibited an extended post antifungal effect of 6.25 to 8.70 h at 4 × MIC for Candida species and suppressed the emergence of mutants of the fungal species tested at 2 × to 8 × MIC concentration. Furthermore, it also inhibited the growth of biofilm generated by C. albicans and reduced the preformed biofilms. There was increased uptake of propidium iodide by C. albicans cells when exposed to hydroxychavicol thus indicating that the membrane disruption could be the probable mode of action of hydroxychavicol.

Conclusions

The antifungal activity exhibited by this compound warrants its use as an antifungal agent particularly for treating topical infections, as well as gargle mouthwash against oral Candida infections.

A novel antifungal analog peptide derived from protaetiamycine

Previously, the 9-mer analog peptides, 9Pbw2 and 9Pbw4, were designed based on a defensin-like peptide, protaetiamycine isolated from Protaetia brevitarsis. In this study, antifungal effects of the analog peptides were investigated. The antifungal susceptibility testing exhibited that 9Pbw4 contained more potent antifungal activities than 9Pbw2. A PI influx assay confirmed the effects of the analog peptides and demonstrated that the peptides exerted their activity by a membrane-active mechanism, in an energy-independent manner. As the noteworthy potency of 9Pbw4, the mechanism(s) of 9Pbw4 were further investigated. The membrane studies, using rhodamine-labeled giant unilamellar vesicle (GUV) and fluorescein isothiocyanate (FITC)-dextran loaded liposome, suggested that the membrane-active mechanism of 9Pbw4 could have originated from the poreforming action and the radii of pores was presumed to be anywhere from 1.8 nm to 3.3 nm. These results were confirmed by 3D-flow cytometric contour-plot analysis. The present study suggests a potential of 9Pbw4 as a novel antifungal peptide.

Direct fluconazole susceptibility testing of positive Candida blood cultures by flow cytometry

The standard methods for yeast susceptibility testing require 24-48 h of incubation. As there has been an increase in incidence of non-albicans Candida species, the clinician is very often wary of initiating therapy with fluconazole until a final susceptibility report is generated, especially when treating very sick patients. A rapid reliable susceptibility testing method would enable the clinician to prescribe fluconazole, thus avoiding more toxic or expensive therapy. To determine the feasibility of direct susceptibility testing of Candida species to fluconazole by a rapid flow cytometric method, 50 Candida strains were seeded into blood culture bottles and were tested for susceptibility to fluconazole directly from the bottles after their being flagged as positive by the blood culture instrument. Minimal inhibitory concentration (MIC) determined by fluorescent flow cytometry (FACS) showed excellent agreement to that determined by macrodilution. Following the seeding experiments, 30 true patient specimens were tested directly from positive blood cultures, and MIC determined by both methods showed excellent agreement. Antifungal susceptibility testing by FACS directly from positive blood culture bottles is a reliable, rapid method for susceptibility testing of Candida to fluconazole. The method allows same-day results, does not require subculture to agar media, and can greatly assist in the selection of appropriate antifungal therapy.

Dormancy of Candida albicans cells in the presence of the polyene antibiotic amphotericin B: simple demonstration by flow cytometry

Flow cytometry light scattering was used to monitor size increase of Candida albicans (isolate ATCC 10231) cells in the presence or absence of the antifungal drug amphotericin B (AmB). This non-invasive and descriptive method allowed for the differentiation of dead and dormant sub-populations of cells. When inoculated into a growth medium without AmB, a progressive increase in light scattering was observed over a period of approximately 4 h, but without proliferation of the yeast. After this period, the light scattering distribution regressed to baseline level, whereas cell proliferation started. In the presence of AmB, all the cells shrank in size within approximately 4 h and proliferation was temporarily halted. However, in the presence of 0.4 microM AmB, a progressive increase of light scattering occurred after 21 h which was similar to that observed within the first 4 h in the absence of the antifungal. After approximately 24 h of incubation at this concentration of AmB, proliferation resumed. These observations indicate that this renewed cell proliferation was due to the reawakening of dormant cells in the presence of AmB (45% in the presence of 0.4 microM AmB) rather than the result of the development of viable cells that had escaped detection. This simple descriptive approach could be extended to other fungal strains or species, to other antifungal drugs and possibly to bacteria.

Antimicrobial effects of liquid anesthetic isoflurane on Candida albicans

Candida albicans is a dimorphic fungus that can grow in yeast morphology or hyphal form depending on the surrounding environment. This ubiquitous fungus is present in skin and mucus membranes as a potential pathogen that under opportunistic conditions causes a series of systemic and superficial infections known as candidiasis, moniliasis or simply candidiasis. There has been a steady increase in the prevalence of candidiasis that is expressed in more virulent forms of infection. Although candidiasis is commonly manifested as mucocutaneous disease, life-threatening systemic invasion by this fungus can occur in every part of the body. The severity of candidal infections is associated with its morphological shift such that the hyphal morphology of the fungus is most invasive. Of importance, aberrant multiplication of Candida yeast is also associated with the pathogenesis of certain mucosal diseases. In this study, we assessed the anti-candidal activity of the volatile anesthetic isoflurane in liquid form in comparison with the anti-fungal agent amphotericin B in an in vitro culture system. Exposure of C. albicans to isoflurane (0.3% volume/volume and above) inhibited multiplication of yeast as well as formation of hyphae. These data suggest development of potential topical application of isoflurane for controlling a series of cutaneous and genital infections associated with this fungus. Elucidiation of the mechanism by which isoflurane effects fungal growth could offer therapeutic potential for certain systemic fungal infections.

Fluconazole susceptibility testing of Candida species by flow cytometry

OBJECTIVE

Currently, antifungal drug susceptibility testing is labor-intensive, limited by delays in obtaining results and high costs. The purpose of this study was to determine the usefulness of flow cytometry (FCM) antifungal drug susceptibility testing as a routine laboratory procedure.

METHODS

A total of 24 clinical isolates of Candida spp. and reference strains were tested for susceptibility to fluconazole by FCM using propidium iodide (PI) as an indicator of viability. The minimum inhibitory concentration (MIC) was defined as the lowest concentration of fluconazole that resulted in an increase of 30% in mean channel fluorescence (MCF), compared to the growth control. FCM results were compared with MIC results as determined by the Clinical and Laboratory Standards Institute (CLSI) method.

RESULTS

An 8h incubation was sufficient for determination of the MICs. The results by FCM at 8h and the NCCLS methods at 24h showed 87.5% agreement to within two drug dilutions. However, the FCM method is labor-intensive in proportion to the larger number of samples. For Candida lusitaniae, MICs by the FCM method showed poor correlation with the CLSI method.

CONCLUSIONS

Further evaluation is necessary to assess the usefulness of FCM as a technique for routine antifungal MIC testing in the clinical laboratory.

Antifungal susceptibility testing by flow cytometry: is it the future?

The current increase in the number and significance of fungal infections, the expanding armamentarium of antifungal agents, and the emergence of the problem of antifungal drug resistance have been intensifying the importance of antifungal susceptibility testing (AST). The Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS) in the United States and the Antifungal Susceptibility Testing Subcommittee of the European Committee on Antimicrobial Susceptibility Testing (AFST-EUCAST) published standard methodologies in order to achieve higher reproducibility and allow direct inter-laboratory comparison of the susceptibility results. Nevertheless, several problems remain unresolved and the methods depend on long incubation periods of a minimum of 24 h (EUCAST) or even 48 h (CLSI). Over the last 15 years, successful applications of flow cytometric techniques to AST of both yeast and moulds have been reported. These techniques are based on the analysis of a great number of fungal cells individually and frequently rely on short incubation times of no more than a few hours. Considering these attributes, flow cytometry (FC) seems to have the potential to achieve clinical usefulness in the near future. The collection of data on the reproducibility of the results and on the correlation with clinical outcomes has barely started, however. Practical validation of the experimental methodologies is not granted before a significant amount of data addressing those questions is available.

Adherence of Candida albicans to silicone induces immediate enhanced tolerance to fluconazole

Wild-type and efflux pump-deficient cells of Candida albicans adhering to silicone were compared with planktonic cells by flow cytometry for their relative resistance to fluconazole (FCZ). Flow cytometry data on cells carrying a fusion of green fluorescent protein to efflux pump promoters confirmed that enhanced tolerance of attached cells to FCZ was due in part to increased expression of CaMDR1 and CDR1 promoters. Within 2 h of their attachment to silicone, the adherent cells demonstrated levels of FCZ tolerance shown by cells from 24-h biofilms. Following their mechanical detachment, this subset of cells retained a four- to eightfold increase in tolerance compared with the tolerance of planktonic cells for at least two generations. Enhanced efflux pump tolerance to FCZ appeared to be induced within the initial 15 min of attachment in a subset of cells that were firmly attached to the substrata.

Flow cytometry antifungal susceptibility testing of Aspergillus fumigatus and comparison of mode of action of voriconazole vis-à-vis amphotericin B and itraconazole

Aspergillus fumigatus isolates were tested with three antifungals by flow cytometry (FC) and fluorescence-activated cell sorting. FC results after 4 h correlated well with MICs obtained by the NCCLS M38-A method; voriconazole exhibited fungicidal activity, albeit to a lesser extent than amphotericin B, but to a greater extent than itraconazole.

Antifungal susceptibility testing of Candida albicans by flow cytometry

Antifungal susceptibilities of 28 Candida albicans isolates and two quality control strains to amphotericin B and fluconazole were determined by flow cytometry and microdilution method. Minimum inhibitory concentrations (MICs) obtained by flow cytometry were compared with the results obtained by The National Committee for Clinical Laboratory Standards Subcommittee (NCCLS) broth microdilution method. The agreement of results (within two dilution) obtained was found as 96 and 93% for amphotericin B and fluconazole, respectively. At least 24 h incubation was required for reading the microdilution assays. Four hours of incubation was required for fluconazole, whereas 2-h incubation was sufficient for amphotericin B to provide MIC by flow cytometry. Results of this study show that flow cytometry provides a rapid and sensitive in vitro method for antifungal susceptibility testing of Candida albicans isolates.

A method for discrimination of subpopulations of Candida albicans biofilm cells that exhibit relative levels of phenotypic resistance to chlorhexidine

Microbes in biofilms are generally found to be resistant to antimicrobial agents. One set of hypotheses attributes biofilm resistance to acquisition of special physiological traits (phenotypic resistance). Methods are presented that allow discrimination of subpopulations of Candida albicans cells that exhibit relative levels of phenotypic resistance to chlorhexidine. The assay for phenotypic resistance is based on microscopic detection of the rate of penetration of propidium iodide (PI) into single cells as their membranes become disrupted by chlorhexidine. Using the assay, it was found that batch cultures became progressively more resistant to the action of chlorhexidine during the transition from exponential growth to early stationary phase. Results are presented demonstrating that the methods can be used to characterize relative levels of phenotypic resistance exhibited by cells at the base of a C. albicans biofilm.

Action of chlorhexidine digluconate against yeast and filamentous forms in an early-stage Candida albicans biofilm

An in situ method for sensitive detection of differences in the action of chlorhexidine against subpopulations of cells in Candida albicans biofilms is described. Detection relies on monitoring the kinetics of propidium iodide (PI) penetration into the cytoplasm of individual cells during dosing with chlorhexidine. Accurate estimation of the time for delivery of the dosing concentration to the substratum was facilitated by using a flow cell system for which transport to the interfacial region was previously characterized. A model was developed to quantify rates of PI penetration based on the shape of the kinetic data curves. Yeast were seeded onto the substratum, and biofilm formation was monitored microscopically for 3 h. During this period a portion of the yeast germinated, producing filamentous forms (both hyphae and pseudohyphae). When the population was subdivided on the basis of cell morphology, rates of PI penetration into filamentous forms appeared to be substantially higher than for yeast forms. Based on the model, rates of penetration were assigned to individual cells. These data indicated that the difference in rates between the two subpopulations was statistically significant (unpaired t test, P < 0.0001). A histogram of rates and analysis of variance indicated that rates were approximately equally distributed among different filamentous forms and between apical and subapical segments of filamentous forms.

Oral candidal infections and antimycotics

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

Cytometric approach for a rapid evaluation of susceptibility of Candida strains to antifungals

OBJECTIVE

To achieve a fast and reliable determination of the susceptibility of Candida strains to amphotericin B (Am B), fluconazole (Flu) and 5-fluorocytosine (5-FC), using cytometric methods as an alternative to the classical dilution method.

METHODS

Twenty-three clinical isolates of Candida with different susceptibility patterns were treated for 1 h with two concentrations each of Am B (2 and 8 mg/L), Flu (8 and 64 mg/L) and 5-FC (4 and 32 mg/L), followed by staining with three different fluorochromes, under conditions previously defined through an optimisation study. These were 1 mg/L propidium iodide (PI)/10(6) cells for 30 min at 30 degrees C (a marker that only penetrates cells with severe lesions of the membrane); 0.5 microM FUN-1/10(6) cells for 30 min at 30 degrees C (a fluorescent probe which after entering the yeast cell is converted, by metabolically active yeasts, from a diffuse cytosolic pool with a yellow-green fluorescence into red cylindrical intravacuolar structures) and 0.25 microM of JC-1/10(6) cells for 15 min at 37 degrees C (a monomer that changes reversibly from green to red the J-aggregates, with the increased membrane potential). About 50 000 yeast cells were analysed by flow cytometry (FCM), at FL3 (red, 620 nm) for PI and FL2 (yellow-green, 575 nm) for FUN-1 and the ratio of FL3 to FL1 was determined (red, 620 nm/green, 525 nm) for JC-1; 200 cells of each suspension were also analysed by epifluorescence microscopy (EPM). Viability studies were performed in parallel to count the number of colony forming units.

RESULTS

Susceptible (S) strains exposed to Am B and stained with JC-1 showed a dose-dependent decrease in the mitochondrial potential, i.e. a decreased ratio between red/green fluorescence by FCM and a decrease in J-aggregates by EPM. Neither FUN-1 nor PI was useful in the study of Am B activity. Susceptibility to Flu and 5-FC could be detected with FUN-1 staining: metabolic changes were detected by an increase in yellow-green intensity of fluorescence by FCM or a decrease of cylindrical intravacuolar structure formation by EPM, although no decrease in total viability was registered. Staining with JC-1 could predict resistance to both drugs, but did not allow distinction between sensitive dose-dependent strains (S-DD) or intermediate (I) resistance to Flu or 5-FC, respectively, from S strains. PI did not stain Candida cells treated with Flu or 5-FC under our experimental conditions.

CONCLUSION

Susceptibility patterns of Candida strains to Am B can be determined by using JC-1, and to Flu and 5-FC by using FUN-1. PI was not a useful probe with which to study the effect of such antifungals under the conditions described here.

Antifungal susceptibility testing: practical aspects and current challenges

Development of standardized antifungal susceptibility testing methods has been the focus of intensive research for the last 15 years. Reference methods for yeasts (NCCLS M27-A) and molds (M38-P) are now available. The development of these methods provides researchers not only with standardized methods for testing but also with an understanding of the variables that affect interlaboratory reproducibility. With this knowledge, we have now moved into the phase of (i) demonstrating the clinical value (or lack thereof) of standardized methods, (ii) developing modifications to these reference methods that address specific problems, and (iii) developing reliable commercial test kits. Clinically relevant testing is now available for selected fungi and drugs: Candida spp. against fluconazole, itraconazole, flucytosine, and (perhaps) amphotericin B; Cryptococcus neoformans against (perhaps) fluconazole and amphotericin B; and Aspergillus spp. against (perhaps) itraconazole. Expanding the range of useful testing procedures is the current focus of research in this area.

In vitro antifungal susceptibility testing

With the rising frequency of fungal infections, as well as increasing reports of resistance to antifungal agents, it is imperative that clinically applicable antifungal susceptibility testing be available. In 1997 the National Committee for Clinical Laboratory Standards published standard guidelines for antifungal susceptibility testing of Candida sp and Cryptococcus neoformans with amphotericin B, flucytosine, fluconazole, itraconazole, and ketoconazole. Although the methods are standard, they are time consuming, can be difficult to interpret, and are approved only for testing limited organisms and drugs. Modifications to the methods and alternative approaches have been proposed to make these tests more convenient and efficient, applicable to a greater number of species, and appropriate for performing in the clinical laboratory.

Antifungal susceptibility testing of fluconazole by flow cytometry correlates with clinical outcome

Susceptibility testing of fungi by flow cytometry (also called fluorescence-activated cell sorting [FACS]) using vital staining with FUN-1 showed a good correlation with the standard M27-A procedure for assessing MICs. In this study we determined MICs for blood culture isolates from patients with candidemia by NCCLS M27-A and FACS methods and correlated the clinical outcome of these patients with in vitro antifungal resistance test results. A total of 24 patients with candidemia for whom one or more blood cultures were positive for a Candida sp. were included. Susceptibility testing was performed by NCCLS M27-A and FACS methods. The correlation of MICs (NCCLS M27-A and FACS) and clinical outcome was calculated. In 83% of the cases, the MICs of fluconazole determined by FACS were within 1 dilution of the MICs determined by the NCCLS M27-A method. For proposed susceptibility breakpoints, there was 100% agreement between the M27-A and FACS methods. In the FACS assay, a fluconazole MIC of <1 microg/ml was associated with cure (P < 0.001) whereas an MIC of > or =1 microg/ml was associated with death (P < 0.001). The M27-A-derived fluconazole MICs did not correlate with outcome (P = 1 and P = 0.133).

Comparison of in vitro activities of amphotericin, clotrimazole, econazole, miconazole, and nystatin against Fusarium oxysporum

The inhibitory activity of amphotericin B, clotrimazole, econazole, miconazole and nystatin was compared against Fusarium oxysporum f.sp. radicis-cucumerinum. The most efficient antifungal agent against the growth of Fusarium oxysporum was econazole, followed by clotrimazole, miconazole, amphotericin and nystatin. The ED50 and ED90 values were 0.053 and 1.002 ppm for econazole, 0.088 and 1.100 ppm for clotrimazole, 0.173 and 3.210 ppm for miconazole, 0.713 and greater than 48 ppm for amphotericin and 3.860 and 16.702 ppm for nystatin. The ED50 values of nystatin and amphotericin against spore germination of Fusarium oxysporum were determined at 3.1427 ppm and 8.3990 ppm respectively, nystatin was 2.76 times more effective than amphotericin, while no effect was observed after the addition of econazole, clotrimazole and miconazole. The tested azoles were more effective than amphotericin and nystatin on growth inhibition of Fusarium oxysporum but amphotericin and nystatin acted significantly better on spore germination of Fusarium.

Flow cytometry antifungal susceptibility testing of pathogenic yeasts other than Candida albicans and comparison with the NCCLS broth microdilution test

Candida species other than Candida albicans frequently cause nosocomial infections in immunocompromised patients. Some of these pathogens have either variable susceptibility patterns or intrinsic resistance against common azoles. The availability of a rapid and reproducible susceptibility-testing method is likely to help in the selection of an appropriate regimen for therapy. A flow cytometry (FC) method was used in the present study for susceptibility testing of Candida glabrata, Candida guilliermondii, Candida krusei, Candida lusitaniae, Candida parapsilosis, Candida tropicalis, and Cryptococcus neoformans based on accumulation of the DNA binding dye propidium iodide (PI). The results were compared with MIC results obtained for amphotericin B and fluconazole using the NCCLS broth microdilution method (M27-A). For FC, the yeast inoculum was prepared spectrophotometrically, the drugs were diluted in either RPMI 1640 or yeast nitrogen base containing 1% dextrose, and yeast samples and drug dilutions were incubated with amphotericin B and fluconazole, respectively, for 4 to 6 h. Sodium deoxycholate and PI were added at the end of incubation, and fluorescence was measured with a FACScan flow cytometer (Becton Dickinson). The lowest drug concentration that showed a 50% increase in mean channel fluorescence compared to that of the growth control was designated the MIC. All tests were repeated once. The MICs obtained by FC for all yeast isolates except C. lusitaniae were in very good agreement (within 1 dilution) of the results of the NCCLS broth microdilution method. Paired t test values were not statistically significant (P = 0.377 for amphotericin B; P = 0.383 for fluconazole). Exceptionally, C. lusitaniae isolates showed higher MICs (2 dilutions or more) than in the corresponding NCCLS broth microdilution method for amphotericin B. Overall, FC antifungal susceptibility testing provided rapid, reproducible results that were statistically comparable to those obtained with the NCCLS method.

Applications of flow cytometry to clinical microbiology

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