Use of turbidimetric growth curves for early determination of antifungal drug resistance of filamentous fungi

Eicosane: An antifungal compound derived from Streptomyces sp. KF15 exhibits inhibitory potential against major phytopathogenic fungi of crops

In the present scenario, food security is of major concern due to exponentially increasing population and depleted crop production. The fungal diseases have contributed majorly to the scarcity of staple food products and economic loss worldwide. This problem could be tackled by preventing the crop loss during both pre and post-harvest seasons. During the current investigation, the bioactive compound eicosane was extracted from Streptomyces sp. KF15, subjected to purification and identified based on mass spectrometry and NMR analysis. The evaluation of in-vitro antifungal activity was done by poisoned food method, SEM analysis and growth pattern analysis. The bioactive compound eicosane with molecular weight of 282.5475 g/mol was purified by column chromatography and the straight chain hydrocarbon structure of CH3CH2(18)CH3 was elucidated by NMR analysis. In poisoned food assay, eicosane effectively inhibited the radial growth of all tested fungal pathogens; F. oxysporum was found to be the most sensitive with 24.2%, 33.3%, 42.4%, and 63.6% inhibition at 25-100 μg/ml concentrations. The SEM micrograph established clear differences in the morphology of eicosane treated fungi with damaged hyphae, flaccid mycelium and collapsed spores as compared to the tubular, turgid and entire fungi in control sample. Finally, the growth curve assay depicted the right side shift in the pattern of eicosane treated fungi indicating the delay in adapting to the conditions of growth and multiplication. The findings of this study encourage further research and development towards the novel antifungal drugs that can act against major phytopathogens.

Real-time monitoring of mycelial growth in liquid culture using hyphal dispersion mutant of Aspergillus fumigatus

Hyphal pellet formation by Aspergillus species in liquid cultures is one of the main obstacles to high-throughput anti-Aspergillus reagent screening. We previously constructed a hyphal dispersion mutant of Aspergillus fumigatus by disrupting the genes encoding the primary cell wall α-1,3-glucan synthase Ags1 and putative galactosaminogalactan synthase Gtb3 (Δags1Δgtb3). Mycelial growth of the mutant in liquid cultures monitored by optical density was reproducible, and the dose-response of hyphal growth to antifungal agents has been quantified by optical density. However, Δags1Δgtb3 still forms hyphal pellets in some rich growth media. Here, we constructed a disruptant lacking all three α-1,3-glucan synthases and galactosaminogalactan synthase (Δags1Δags2Δags3Δgtb3), and confirmed that its hyphae were dispersed in all the media tested. We established an automatic method to monitor hyphal growth of the mutant in a 24-well plate shaken with a real-time plate reader. Dose-dependent growth suppression and unique growth responses to antifungal agents (voriconazole, amphotericin B, and micafungin) were clearly observed. A 96-well plate was also found to be useful for the evaluation of mycelial growth by optical density. Our method is potentially applicable to high-throughput screening for anti-Aspergillus agents.

Different wavelengths of laser: are they significant for treatment of denture stomatitis?: an in-vitro study

BACKGROUND

Denture stomatitis (DS) is an inflammatory disorder that affects the mucosal surface underneath the dentures and frequently causes oral mucosal irritation, discomfort, and altered taste perception, which prevents people from consuming enough nutrients. One of the main causes of DS is an overgrowth of the fungus Candida albicans (C. albicans). A possible alternative treatment for Candida infections is thought to be laser therapy. The aim of this study was to evaluate how different wavelengths of laser would affect growth and pathogenic properties of Candida albicans.

METHODS

A concentration of 106 viable cells/ml of Candida albicans were used in the preparation process. Four groups were created from the specimens. Culturing of the control group was completed with no intervention. The other 3 groups received laser radiation for 60 seconds at a power of 1W. The 2nd and 3rd groups were irradiated with diode laser at a wavelength of 940 nm and 980 nm respectively. The 4th group was irradiated with Nd-YAG laser at a wavelength of 1064 nm. Turbidimetric growth was defined as variations in the optical density of fungal growth. These measures were made at three different times: baseline, 48 hours, and 72 hours.

RESULTS

In both groups of diode laser, the growth of Candida albicans showed no remarkable differences at baseline, after 48 and 72 hours using a power of 1 W and duration of 60 seconds. The Nd-YAG group showed significant increase in optical density after 48 hrs then significant decrease after 72 hrs. The optical density values in the control group showed no notable difference between the control and diode study groups at different time periods. However, the Nd:YAG group showed a statistically significant difference compared to the control and the 2 diode laser groups.

CONCLUSIONS

Different laser parameters have a different effect on growth and pathogenic properties of Candida albicans. Diode laser therapy with wavelengths 940 and 980 nm used in continuous mode with power of 1 W for duration of 60 seconds can result in proliferation of Candida albicans instead of destroying them. Nd:YAG laser, used in pulsed mode, with power of 1 W for a duration of 60 seconds can be used to destroy Candida albicans and therefore, can be used as an effective treatment for denture stomatitis.

In-vitro investigation on the biological activities of squalene derived from the soil fungus Talaromyces pinophilus

The consistent increase in multidrug resistance among pathogens and increased cancer incidence are serious public health concerns and threaten humans by killing countless lives. In the present study, Talaromyces pinophilus CJ15 was characterized and evaluated for its antibacterial, candidicidal and cytotoxic activities. The selected isolate Talaromyces pinophilus CJ15 with 18S rRNA gene sequence of 1021 base pairs exhibited antifungal activity on plant pathogens via dual culture. The GC-MS profiling of crude extract illustrated the existence of many bioactive macromolecules which include squalene belonging to the terpenoids family. The biological macromolecules in the bioactive fraction of CJ15 exhibited increasing antibacterial activity with an increase in concentration such that the highest activity was recorded against Shigella flexneri with 15, 18, 20, and 24 mm inhibition zones at 25, 50, 75 and 100 μl concentrations, respectively. The squalene, having a molecular weight of 410.718 g/mol, displayed candidicidal activity with a right-side shifted log phase in the growth curve of all the treated Candida species, indicating delayed exponential growth. In cytotoxic activity, the extracted squalene exhibited an IC50 concentration of 26.22 μg/ml against JURKAT cells and induced apoptosis-induced cell death. This study's outcomes encourage the researchers to explore further the development of new and improved bioactive macromolecules that could help to prevent infections and human blood cancer.

Cave Soil Streptomyces sp. strain YC69 Antagonistic to Chilli Fungal Pathogens Exhibits In Vitro Anticancer Activity Against Human Cervical Cancer Cells

Cancer is one of the fatal diseases and has high mortality worldwide, and the major drawback with the cure is the side effects from the chemotherapeutic agents. The increased multidrug resistance among microbial pathogens is a serious threat to plant and animal health. There is an urgent need for an alternative that can battle against pathogens and can be used for cancer treatment. Presently, actinomycetes were isolated from cave soil, and the crude extract obtained from the potent isolate was analyzed with gas chromatography-mass spectrometry (GC-MS) and high-performance thin layer chromatography (HPTLC) to identify bioactive metabolites. The crude extract was examined for in vitro antimicrobial activity on human pathogens and antifungal activity on plant pathogens. The isolate Streptomyces sp. strain YC69 exhibited antagonistic activity and antimicrobial activity in a dose-dependent manner, with the highest inhibition in Staphylococcus aureus. GC-MS revealed many bioactive compounds, and HPTLC depicted metabolite fingerprints. The antifungal activity exhibited a delayed lag phase in growth curve assay and distorted and collapsed cells of Fusarium oxysporum in scanning electron microscopy (SEM) images. In the MTT assay, the IC50 of 41.98 µg/ml against HeLa cells was obtained with clear evidence for deformed cells and blebbing of the cell membrane. The results from the current study suggest that the crude extract from Streptomyces sp. strain YC69 contains antimicrobial metabolites that can inhibit pathogenic microbes in plants and humans. The MTT assay results conclude that further studies on purification may lead to the use of Streptomyces sp. strain YC69 as a source for anti-oncogenic compounds.

A swamp forest Streptomyces sp. strain KF15 with broad spectrum antifungal activity against chilli pathogens exhibits anticancer activity on HeLa cells

During the investigation, soil actinomycetes were isolated from Kathlekanu swamp forest and the crude ethyl acetate extract from the potent isolate KF15 was analysed with GC-MS and HPTLC to identify bioactive metabolites. The crude extract was examined for in-vitro antifungal activity on pathogens of chilli; MTT cytotoxicity assay was performed against HeLa cell line to determine the anticancer potential. The isolate Streptomyces sp. strain KF15 exhibited antagonistic activity against fungal pathogens by inhibiting growth and altering growth pattern with increased antimicrobial activity in dose-dependent manner. GC-MS revealed many bioactive compounds and HPTLC depicted metabolite fingerprint. The IC₅₀ of 99.85 µg/ml indicated the high potential of KF15 extract to prevent proliferation of HeLa cells. Therefore, the findings of this study indicate that the crude extract from Streptomyces sp. strain KF15 contains antifungal and anticancer metabolites; further study on purification could help in controlling many fungal diseases as well as cervical cancer in humans.

The facilitating effect of blue light on the antifungal agent susceptibilities of passaged conidia from the ocular-derived Fusarium solani species complex

The eye is a light-receiving organ and has anatomical advantages to accept phototherapy. Fungi colonizing on the eyes, which cause ocular mycoses, are affected by daily blue light and could easily accept additional light irritation. Ocular mycoses are recalcitrant and blindness-causing eye diseases, and antifungal agent treatments are insufficient. Our team previously found that blue light could inhibit Fusarium solani hyphal growth but promote conidiation. Here, we investigated the antifungal susceptibilities and biological characteristics of the passaged conidia. Twelve Fusarium solani strains (11 ocular-derived strains and 1 standard laboratory strain) were inoculated under blue light (0.5 mW/cm2) and darkness conditions, respectively, to obtain the passaged conidia of blue light group (n = 12) and darkness group (n = 12). Two groups were tested to determine the growth abilities and in vitro antifungal susceptibilities to five antifungal drugs (voriconazole (VRC), amphotericin B (AMB), terbinafine (TRB), caspofungin (CAS), and 5-flucytosine (5FC)), which were examined by microscopy for morphological observation and spectrophotometry for turbidity analysis. The results showed that blue light group passaged conidia were more sensitive to antifungal drugs (AMB, VRC, TRB, and CAS) compared to darkness group. The MIC50 of VRC significantly decreased after blue light treatment (P < 0.05). The fungal inhibition rate significantly increased for VRC, AMB, and TRB in the low concentration range (P < 0.05 or P < 0.01). Blue light did not affect germination or hyphal extension of passaged conidia. These results suggested that blue light could facilitate fungal inhibition effect of AMB, VRC, TRB, and CAS and may improve the therapeutic efficiency in VRC and AMB clinical applications. Blue light phototherapy may provide a new adjuvant approach for the treatment of ocular mycosis.

Double-stranded RNA targeting fungal ergosterol biosynthesis pathway controls Botrytis cinerea and postharvest grey mould

Pathogenic fungi cause major postharvest losses. During storage and ripening, fruit becomes highly susceptible to fungi that cause postharvest disease. Fungicides are effective treatments to limit disease. However, due to increased public concern for their possible side effects, there is a need to develop new strategies to control postharvest fungal pathogens. Botrytis cinerea, a common postharvest pathogen, was shown to uptake small double-stranded RNA (dsRNA) molecules from the host plant. Such dsRNA can regulate gene expression through the RNA interference system. This work aimed to develop a synthetic dsRNA simultaneously targeting three essential transcripts active in the fungal ergosterol biosynthesis pathway (dsRNA-ERG). Our results show initial uptake of dsRNA in the emergence zone of the germination tube that spreads throughout the fungus and results in down-regulation of all three targeted transcripts. Application of dsRNA-ERG decreased B. cinerea germination and growth in in vitro conditions and various fruits, leading to reduce grey-mould decay. The inhibition of growth or decay was reversed by the addition of ergosterol. While dual treatment with dsRNA-ERG and ergosterol-inhibitor fungicide reduced by 100-fold the required amount of fungicide to achieve the same protection rate. The application of dsRNA-ERG induced systemic protection as shown by decreased decay development at inoculation points distant from the treatment point in tomato and pepper fruits. Overall, this study suggests that dsRNA-ERG can effectively control B. cinerea growth and grey-mould development suggesting its efficacy as a future method for postharvest control of fungal pathogens.

Spectrophotometric reading of EUCAST antifungal susceptibility testing of Aspergillus fumigatus

OBJECTIVES

Given the increasing number of antifungal drugs and the emergence of resistant Aspergillus isolates, objective, automated and high-throughput antifungal susceptibility testing is important. The EUCAST E.Def 9.3 reference method for MIC determination of Aspergillus species relies on visual reading. Spectrophotometric reading was not adopted because of concern that non-uniform filamentous growth might lead to unreliable and non-reproducible results. We therefore evaluated spectrophotometric reading for the determination of MICs of antifungal azoles against Aspergillus fumigatus.

METHODS

Eighty-eight clinical isolates of A. fumigatus were tested against four medical azoles (posaconazole, voriconazole, itraconazole, isavuconazole) and one agricultural azole (tebuconazole) with EUCAST E.Def 9.3. The visually determined MICs (complete inhibition of growth) were compared with spectrophotometrically determined MICs and essential (±1 twofold dilution) and categorical (susceptible/intermediate/resistant or wild-type/non-wild-type) agreement was calculated. Spectrophotometric data were analysed with regression analysis using the E_max model, and the effective concentration corresponding to 5% (EC₅) was estimated.

RESULTS

Using the 5% cut-off, high essential (92%-97%) and categorical (93%-99%) agreement (<6% errors) was found between spectrophotometric and visual MICs. The EC₅ also correlated with the visually determined MICs with an essential agreement of 83%-96% and a categorical agreement of 90%-100% (<5% errors).

CONCLUSIONS

Spectrophotometric determination of MICs of antifungal drugs may increase objectivity, and allow automation and high-throughput of EUCAST E.Def 9.3 antifungal susceptibility testing of Aspergillus species.

Aspergillus fumigatus DBM 4057 biofilm formation is inhibited by chitosan, in contrast to baicalein and rhamnolipid

The biofilms of filamentous-forming fungi are a novel and still insufficiently understood research topic. We have studied Aspergillus fumigatus, an ubiquitous opportunistic pathogenic fungus, as a representative model for a study of biofilm formation by filamentous fungi and for assessing the potential anti-biofilm activity of natural substances. The activity of antibiotic amphotericin B and selected natural substances: baicalein, chitosan and rhamnolipid was studied. The minimum suspension inhibitory concentrations (MIC) were determined and the biofilm susceptibility was investigated by determining the metabolic activity of sessile cells (XTT assay) and total biofilm biomass (crystal violet staining). Significant time-dependent differences in substances' anti-biofilm activity were observed. Images of A. fumigatus biofilm were obtained by Cellavista automatic light microscope and spinning disc confocal microscopy. Baicalein and rhamnolipid were not found as suitable substances for inhibition of the A. fumigatus biofilm formation, as neither of the substances inhibited the sessile cells metabolic activity or the total biofilm biomass even at tenfold MIC after 48 h. In contrast, chitosan at 10 × MIC (25 µg mL^-1), suppressed the biofilm metabolic activity by 90 % and the total biofilm biomass by 80 % even after 72 h of cultivation. Amphotericin B inhibited only 14 % of total biofilm biomass (crystal violet staining) and 35 % of metabolic activity (XTT assay) of adherent cells under the same conditions. Our results therefore suggest chitosan as potential alternative for treating A. fumigatus biofilm-associated infections.

Exploration of anti-Malassezia potential of Nyctanthes arbor-tristis L. and their application to combat the infection caused by Mala s1 a novel allergen

Background

Malassezia commensal yeasts along with multitude of antigens have been found to be associated with various skin disorders including Pityriasis versicolor (PV). Amongst them Mala s1, a 37 kDa protein has been proved to be a major allergen reacting with a large panel of sera. However, there exists no therapeutic alternative to combat such problems in form of plant based natural compounds. The purpose of this study is in the first place, to determine the anti-Malassezia activity of Nyctanthes arbor-tristis L. (NAT) ethanolic leaf extract through turbidimetric growth curves, disruption of plasma membrane and secondly, it aims to present in silico validation of its active constituents over Mala s1a novel allergen.

Methods

The antifungal susceptibility 50 % ethanolic extract of NAT was determined by broth microdilution method according to CLSI guidelines. Further MICs and IC₅₀ were determined spectrophotometrically using the software SoftMax® Pro-5 (Molecular Devices, USA). Active constituents mediated disruption of plasma membrane was studied through flowcytometry by permeabilization of fluorescent dye Propidium Iodide (PI). Antioxidant activity of the extract was determined using the DPPH stable radical. Molecular validation of fungal DNA from the extract was observed using PCR amplification. In silico analysis of its active constituents over Mala s1 was performed using HEX software and visualized through Pymol.

Results

The anti-Malassezia potential of NAT leaf extracts reflected moderate MIC 1.05 μg/μl against M. globosa, while least effective against M. restricta with MIC 1.47 μg/μl. A linear correlation coefficient R² = 0.866 was obtained in case of M. globosa while minimum was observed in M. restricta with R² = 0.732. The flow cytometric data reveal ~ 75 % cell death when treated with active constituents β-Sitosterol and Calceolarioside A. The docking confirmations and the interaction energies between Mala s1 and the active constituents (β-Sitosterol and Calceolarioside A) from extracts showed an effective binding which suggests Mala s1 as efficient allergen for site specific targeting.

Conclusions

This study revealed that Nyctanthes arbor-tristis L. (NAT) extracts possess high anti-Malassezia potential which is driven mainly by disruption of plasma membrane. Also in silico validation and molecular modeling studies establishes Mala s1 as a novel allergen that could be a potential target in disease treatment. Our results would also provide a foundation for the development of new therapeutic approach using NAT extract as lead compound with high antioxidant property as an added trait for skin care.

Spectrum and the In Vitro Antifungal Susceptibility Pattern of Yeast Isolates in Ethiopian HIV Patients with Oropharyngeal Candidiasis

Background. In Ethiopia, little is known regarding the distribution and the in vitro antifungal susceptibility profile of yeasts. Objective. This study was undertaken to determine the spectrum and the in vitro antifungal susceptibility pattern of yeasts isolated from HIV infected patients with OPC. Method. Oral pharyngeal swabs taken from oral lesions of study subjects were inoculated onto Sabouraud Dextrose Agar. Yeasts were identified by employing conventional test procedures and the susceptibility of yeasts to antifungal agents was evaluated by disk diffusion assay method. Result. One hundred and fifty-five yeast isolates were recovered of which 91 isolates were from patients that were not under HAART and 64 were from patients that were under HAART. C. albicans was the most frequently isolated species followed by C. glabrata, C. tropicalis, C. krusei, C. kefyr, Cryptococcus laurentii, and Rhodotorula species. Irrespective of yeasts isolated and identified, 5.8%, 5.8%, 12.3%, 8.4%, 0.6%, and 1.3% of the isolates were resistant to amphotericin B, clotrimazole, fluconazole, ketoconazole, miconazole, and nystatin, respectively. Conclusion. Yeast colonization rate of 69.2% and 31% resistance to six antifungal agents was documented. These highlight the need for nationwide study on the epidemiology of OPC and resistance to antifungal drugs.

Effects of low-level laser irradiation on the pathogenicity of Candida albicans: in vitro and in vivo study

OBJECTIVE

The purpose of this study was to evaluate the effects of low-level laser irradiation (LLLI) on the in vitro growth characteristics and in vivo pathogenicity of Candida albicans in a murine model in the absence of a photosensitizer.

BACKGROUND DATA

C. albicans is an opportunistic commensal organism that causes a wide variety of diseases in human beings, ranging from superficial infections to life-threatening invasive candidiasis. The incidence of C. albicans infection is increasing, because of the greater frequency of acquired immunodeficiency conditions. A high recurrence rate has been reported for vulvovaginal and oral candidiasis, despite the best available treatments. Therefore, the search for new treatment modalities seems quite rational.

METHODS

Candida culture plates were exposed to common clinical energies of LLLI: 3, 5, 10, and 20 J at 685 nm (BTL Laser 5000, Medicinos Projektai, Czech Republic, Prague, max power output 50 mW) and 3, 5, 10, 30, and 50 J at 830 nm (BTL Laser 5000, Medicinos Projektai, Czech Republic, Prague, max power output 400 mW).

RESULTS

Following LLLI with energies >10 J at both 685 and 830 nm wavelengths, statistically significant effects were observed in vitro on the turbidimetric growth kinetics of C. albicans and in vivo on the survival rate of infected mice (p value ≤ 0.05). Therefore, this energy could be considered a threshold for clinical investigation.

CONCLUSIONS

Translating our data into the clinical setting, it can be proposed that a direct laser-based approach without using a photosensitizing dye can significantly reduce the pathogenicity of Candida albicans. It can also be concluded that laser light at specific wavelengths could be a possible promising novel treatment for superficial and mucocutaneous C. albicans infections.

The future of fungal susceptibility testing

ABSTRACT 

The antifungal treatment failures and the emergence of resistant fungal strains have stimulated the need for reproducible and clinically relevant antifungal susceptibility testing (AFST). While the standard reference methods are not intended for routine use, commercial methods are widely used for performing AFST. However, to accelerate AFST and to improve the detection of antifungal resistance, which is the most challenging goal of AFST, novel assays have been developed. Following brief drug exposures of fungal cells, the new antifungal susceptibility end points seem to provide a reliable means of identifying fungal isolates, which harbor mutations that have been associated with antifungal resistance. This article summarizes the recent progress in AFST that is destined to enhance its clinical utility in the near future.

Bacterial nanoscale cultures for phenotypic multiplexed antibiotic susceptibility testing

An optimal antimicrobial drug regimen is the key to successful clinical outcomes of bacterial infections. To direct the choice of antibiotic, access to fast and precise antibiotic susceptibility profiling of the infecting bacteria is critical. We have developed a high-throughput nanowell antibiotic susceptibility testing (AST) device for direct, multiplexed analysis. By processing in real time the optical recordings of nanoscale cultures of reference and clinical uropathogenic Escherichia coli strains with a mathematical algorithm, the time point when growth shifts from lag phase to early logarithmic phase (Tlag) was identified for each of the several hundreds of cultures tested. Based on Tlag, the MIC could be defined within 4 h. Heatmap presentation of data from this high-throughput analysis allowed multiple resistance patterns to be differentiated at a glance. With a possibility to enhance multiplexing capacity, this device serves as a high-throughput diagnostic tool that rapidly aids clinicians in prescribing the optimal antibiotic therapy.

Composite survival index to compare virulence changes in azole-resistant Aspergillus fumigatus clinical isolates

Understanding resistance to antifungal agents in Aspergillus fumigatus is of increasing importance for the treatment of invasive infections in immunocompromised patients. Although a number of molecular resistance mechanisms are described in detail, the potential accompanying virulence changes and impact on clinical outcome have had little attention. We developed a new measure of survival, the composite survival index (CSI) to use as a measure of the virulence properties of A. fumigatus. Using a novel mathematical model we found a strong correlation between the in vitro growth characteristics and virulence in vivo expressed as CSI. Our model elucidates how three critical parameters (the lag phase (τ), decay constant (λ), and growth rate (ν)) interact with each other resulting in a CSI that correlated with virulence. Hence, strains with a long lag phase and high decay constant were less virulent in a murine model of invasive aspergillosis, whereas high virulence for isolates with a high CSI was associated in vitro with rapid growth and short lag phases. Resistant isolates with cyp51A mutations, which account for the majority of azole resistant aspergillosis cases, did not show a lower virulence compared to azole-susceptible isolates. In contrast, the CSI index revealed that a non-cyp51A-mediated resistance mechanism was associated with a dramatic decrease in CSI. Because of its predictive value, the mathematical model developed may serve to explore strain characteristics in vitro to predict virulence in vivo and significantly reduce the number of experimental animals required in such studies. The proposed measure of survival, the CSI can be used more in a general form in survival studies to explore optimal treatment options.

In vitro pharmacokinetic/pharmacodynamic modeling of voriconazole activity against Aspergillus species in a new in vitro dynamic model

The pharmacodynamics (PD) of voriconazole activity against Aspergillus spp. were studied using a new in vitro dynamic model simulating voriconazole human pharmacokinetics (PK), and the PK-PD data were bridged with human drug exposure to assess the percent target (near-maximum activity) attainment of different voriconazole dosages. Three Aspergillus clinical isolates (1 A. fumigatus, 1 A. flavus, and 1 A. terreus isolate) with CLSI MICs of 0.5 mg/liter were tested in an in vitro model simulating voriconazole PK in human plasma with C(max) values of 7, 3.5, and 1.75 mg/liter and a t(1/2) of 6 h. The area under the galactomannan index-time curve (AUC(GI)) was used as the PD parameter. In vitro PK-PD data were bridged with population human PK of voriconazole exposure, and the percent target attainment was calculated. The in vitro PK-PD relationship of fAUC(0-24)-AUC(GI) followed a sigmoid pattern (global R(2) = 0.97), with near-maximum activities (10% fungal growth) observed at an fAUC(0-24) (95% confidence interval [CI]) of 18.9 (14.4 to 23.1) mg · h/liter against A. fumigatus, 26.6 (21.1 to 32.9) mg · h/liter against A. flavus, and 36.2 (27.8 to 45.7) mg · h/liter against A. terreus (F test; P < 0.0001). Target attainment for 3, 4, and 5 mg/kg-of-body-weight voriconazole dosages was 24% (11 to 45%), 80% (32 to 97%), and 93% (86 to 97%) for A. fumigatus, 12% (5 to 26%), 63% (17 to 93%), and 86% (73 to 94%) for A. flavus, and 4% (2 to 11%), 36% (6 to 83%), and 68% (47 to 83%) for A. terreus. Based on the in vitro exposure-effect relationships, a standard dosage of voriconazole may be adequate for most patients with A. fumigatus but not A. flavus and A. terreus infections, for which a higher drug exposure may be required. This could be achieved using a higher voriconazole dosage, thus highlighting the usefulness of therapeutic drug monitoring in patients receiving a standard dosage.

Epidemiology of invasive fungal infections in the mediterranean area

Although Candida species remain the relevant cause of IFI, other fungi (especially moulds) have become increasingly prevalent. In particular, Aspergillus species are the leading cause of mould infections but also Glomeromycota (formerly Zygomycetes) and Fusarium species are increasing in frequency, and are associated with high mortality rates. Many of these emerging infections occur as breakthrough infections in patients treated with new antifungal drugs. The causative pathogens, incidence rate and severity are dependent on the underlying condition, as well as on the geographic location of the patient population. France and Italy show the highest incident rates of Fusarium infections in Europe, following the US, where numbers are still increasing. Scedosporium prolificans, which primarily is found in soil in Spain and Australia, is most frequently isolated from blood cultures in a Spanish hospital. Geotrichum capitatum represents another species predominantly found in Europe with especially high rates in Mediterranean countries. The increasing resistance to antifungal drugs especially of these new emerging pathogens is a severe problem for managing these IFIs.

Development of azole resistance in Aspergillus fumigatus during azole therapy associated with change in virulence

Four sequential Aspergillus fumigatus isolates from a patient with chronic granulomatous disease (CGD) eventually failing azole-echinocandin combination therapy were investigated. The first two isolates (1 and 2) were susceptible to antifungal azoles, but increased itraconazole, voriconazole and posaconazole MICs were found for the last two isolates (3 and 4). Microsatellite typing showed that the 4 isolates were isogenic, suggesting that resistance had been acquired during azole treatment of the patient. An immunocompromised mouse model confirmed that the in vitro resistance corresponded with treatment failure. Mice challenged with the resistant isolate 4 failed to respond to posaconazole therapy, while those infected by susceptible isolate 2 responded. Posaconazole-anidulafungin combination therapy was effective in mice challenged with isolate 4. No mutations were found in the Cyp51A gene of the four isolates. However, expression experiments of the Cyp51A showed that the expression was increased in the resistant isolates, compared to the azole-susceptible isolates. The microscopic morphology of the four isolates was similar, but a clear alteration in radial growth and a significantly reduced growth rate of the resistant isolates on solid and in broth medium was observed compared to isolates 1 and 2 and to unrelated wild-type controls. In the mouse model the virulence of isolates 3 and 4 was reduced compared to the susceptible ones and to wild-type controls. For the first time, the acquisition of azole resistance despite azole-echinocandin combination therapy is described in a CGD patient and the resistance demonstrated to be directly associated with significant change of virulence.

Barrier Function, Epidermal Differentiation, and Human β-Defensin 2 Expression in Tinea Corporis

Tinea corporis is a superficial mycotic infection resulting in substantial epidermal changes. We determined skin barrier function, epidermal differentiation, and human-beta-defensin 2 (hBD-2) protein expression in 10 patients with tinea corporis caused by Trichophyton rubrum (T. rubrum). We found disturbed skin barrier function as shown by a significant increase in transepidermal water loss (TEWL) and specific ultrastructural changes including disturbed formation of extracellular lipid bilayers, lamellar body extrusion, and deposit of clotted material at the stratum granulosum/stratum corneum interface. Epidermal proliferation in tinea increased several fold and accordingly, proliferation and inflammation-associated keratins K6, K16, and K17 were expressed. Expression of basal keratins K5 and K14 increased, whereas differentiation-associated K10 was reduced. Reduction of the cornified envelope proteins involucrin, loricrin, and the S100 protein filaggrin was also seen. Reduced filaggrin expression correlated with reduced skin hydration; protein breakdown products of filaggrin have been shown to be important for water binding. Surprisingly, we found pronounced epidermal protein expression of hBD-2, which may be related to disturbed epidermal differentiation and inflammation. hBD-2 showed a weak, although significant, antifungal activity against T. rubrum in the turbidimetric assay and the immunohistological staining was somewhat less pronounced in areas directly underneath fungal hyphae in the stratum corneum. Together, we describe profound changes in skin barrier structure and function, epidermal proliferation, and differentiation including pronounced protein expression of hBD-2 in tinea corporis.

Rapid susceptibility testing of medically important zygomycetes by XTT assay

The XTT colorimetric assay quantifies fungal growth by measuring fungal metabolism and has been used successfully for susceptibility testing of Aspergillus species after 24 and 48 h of incubation. In the present study using 14 clinical isolates of Zygomycetes (Rhizopus oryzae [5 isolates], Cunninghamella spp. [3 isolates], Mucor spp. [3 isolates], and Absidia corymbifera [3 isolates]), significant metabolic activity was demonstrated before visual or spectrophotometric detection of fungal growth by performing the XTT assay as early as 6 h after inoculation. Testing of susceptibility to amphotericin B, posaconazole, and voriconazole was subsequently performed using the XTT method (100 microg/ml XTT, 25 microM menadione) at 6, 8, or 12 h after inoculation and the CLSI (formerly NCCLS) M38-A method with visual and spectrophotometric MIC determinations at 24 h after inoculation. Concentration-effect curves obtained with the use of the E(max) model (a sigmoid curve with variable slope) were comparable between the early XTT and spectrophotometric readings at 24 h. Complete inhibition of early metabolic activity with the azoles was delayed in comparison to that with amphotericin B. Using appropriate cutoff levels, agreement was demonstrated between the early XTT and 24-h spectrophotometric or visual readings. In particular, for MIC-0 (the lowest drug concentration showing absence of visual growth) of amphotericin B, overall agreement levels were 90 to 93% for the 6-h XTT assay and 100% for the 8- and 12-h time points. For MIC-0 of posaconazole, agreement levels were 86% for the 6-h XTT and 93 to 100% for the 8- and 12-h time points. The overall agreement levels for MIC-0 and MIC-2 (the lowest drug concentration showing prominent reduction of growth compared with the control well) of voriconazole (compared with 24-h spectrophotometric readings) were 93 to 98% for the 8- and 12-h XTT assays. These results support the use of the XTT method for rapid MIC determination for Zygomycetes.

Update on antifungal drug resistance mechanisms of Aspergillus fumigatus

Although the arsenal of agents with anti-Aspergillus activity has expanded over the last decade, mortality due to invasive aspergillosis (IA) remains unacceptably high. Aspergillus fumigatus still accounts for the majority of cases of IA; however less susceptible to antifungals non-fumigatus aspergilli began to emerge. Antifungal drug resistance of Aspergillus might partially account for treatment failures. Recent advances in our understanding of mechanisms of antifungal drug action in Aspergillus, along with the standardization of in vitro susceptibility testing methods, has brought resistance testing to the forefront of clinical mycology. In addition, molecular biology has started to shed light on the mechanisms of resistance of A. fumigatus to azoles and the echinocandins, while genome-based assays show promise for high-throughput screening for genotypic antifungal resistance. Several problems remain, however, in the study of this complex area. Large multicenter clinical studies--point prevalence or longitudinal--to capture the incidence and prevalence of antifungal resistance in A. fumigatus isolates are lacking. Correlation of in vitro susceptibility with clinical outcome and susceptibility breakpoints has not been established. In addition, the issue of cross-resistance between the newer triazoles is of concern. Furthermore, in vitro resistance testing for polyenes and echinocandins is difficult, and their mechanisms of resistance are largely unknown. This review examines challenges in the diagnosis, epidemiology, and mechanisms of antifungal drug resistance in A. fumigatus.

Relationship between metabolism and biomass of medically important zygomycetes

Little is known about the relationships between metabolic activity and fungal biomass or time of incubation for medically important fungal pathogens. Understanding these relationships may be especially relevant for rapidly growing organisms, such as zygomycetes. A range of inocula of five clinical isolates of zygomycetes (one each of Rhizopus oryzae,Rhizopus microsporus, Cunninghamella bertholletiae, Mucor circinelloides and Absidia corymbifera) were incubated for 6, 8, 12, 24 and 48 h, after which hyphal mass was assessed spectrophotometrically and metabolic activity was measured using various concentrations of XTT and menadione. Both linear regression and the Boltzmann sigmoid model were used and compared for description of relationships between metabolic activity, biomass and time of incubation. Modeling was further applied to eleven additional zygomycete isolates. The relationships of biomass or metabolic activity as a function of time of incubation were well described with the Boltzmann sigmoid model. The latter was superior to linear regression in describing the relationship between metabolic activity and fungal biomass. For all isolates of zygomycetes, increases in metabolic activity preceded increases in biomass. Inter-species differences in growth patterns were observed, with Rhizopus microsporus and Mucor spp. reaching the plateau of growth earlier compared to other species. These findings on the temporal relationship and inter-species differences of hyphal growth and metabolic activity for zygomycetes may be useful in the design and interpretation of in vitro studies of these emerging pathogens.

Correlation betweenin vitrogrowth rate andin vivovirulence inAspergillus fumigatus

We describe a kinetic microbroth method of measuring the growth rate of Aspergillus fumigatus spectrophotometrically. Using this method, growth rates were determined for nine A. fumigatus isolates for which an LD90 value in immunosuppressed CD-1 mice had previously been obtained. Comparison of the growth rates and LD90 values of these isolates suggests that a correlation exists between the two parameters.

Determination of antifungal drug susceptibilities of Aspergillus species by a fluorescence-based microplate assay

OBJECTIVES

We have investigated the use of a viability dye, chloromethylfluorescein di-acetate (CMFDA), for antifungal susceptibility testing in a fluorescence microplate (FM) assay format.

METHODS

For this FM assay, conidia were incubated in increasing concentrations of antifungal drug for 16 h and stained with CMFDA. Fluorescence, measured as mean fluorescence units (MFU) in a fluorescence microplate reader, was graphed relative to that of a drug-free control, and the MIC was defined as the lowest concentration of the drug that resulted in complete reduction (100%) in MFU for amphotericin B, or 90% reduction in MFU for itraconazole and voriconazole. Susceptibilities of 10 clinical isolates of Aspergillus fumigatus, Aspergillus terreus and Aspergillus niger to amphotericin B, itraconazole and voriconazole were tested in a blinded fashion using the FM and the NCCLS methods.

RESULTS AND CONCLUSIONS

Reproducibility of the FM assay was excellent, and results correlated with those of the NCCLS microdilution method. The FM assay appears to be a rapid, objective method for testing fungal susceptibilities to itraconazole, voriconazole and amphotericin B.