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Yiu B, Robbins N, Cowen LE. Interdisciplinary approaches for the discovery of novel antifungals. Trends Mol Med 2024; 30:723-735. [PMID: 38777733 DOI: 10.1016/j.molmed.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/10/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024]
Abstract
Pathogenic fungi are an increasing public health concern. The emergence of antifungal resistance coupled with the scarce antifungal arsenal highlights the need for novel therapeutics. Fortunately, the past few years have witnessed breakthroughs in antifungal development. Here, we discuss pivotal interdisciplinary approaches for the discovery of novel compounds with efficacy against diverse fungal pathogens. We highlight breakthroughs in improving current antifungal scaffolds, as well as the utility of compound combinations to extend the lifespan of antifungals. Finally, we describe efforts to refine candidate chemical scaffolds by leveraging structure-guided approaches, and the use of functional genomics to expand our knowledge of druggable antifungal targets. Overall, we emphasize the importance of interdisciplinary collaborations in the endeavor to develop innovative antifungal strategies.
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Affiliation(s)
- Bonnie Yiu
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, M5G 1M1, Canada
| | - Nicole Robbins
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, M5G 1M1, Canada
| | - Leah E Cowen
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, M5G 1M1, Canada.
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2
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Sfogliarini C, Pepe G, Cesta CM, Allegretti M, Locati M, Vegeto E. The immune activity of selective estrogen receptor modulators is gene and macrophage subtype-specific yet converges on Il1b downregulation. Biomed Pharmacother 2023; 165:115008. [PMID: 37442065 DOI: 10.1016/j.biopha.2023.115008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/29/2023] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Raloxifene belongs to the family of Selective Estrogen Receptor Modulators (SERMs), which are drugs widely prescribed for Estrogen Receptor alpha (ERα)-related pathologies. Recently, SERMs are being tested in repurposing strategies for ERα-independent clinical indications, including a wide range of microbial infections. Macrophages are central in the fight against pathogen invasion. Despite estrogens have been shown to regulate macrophage phenotype, SERMs activity in these cells is still poorly defined. We investigated the activity of Raloxifene in comparison with another widely used SERM, Tamoxifen, on immune gene expression in macrophages obtained from mouse and human tissues, including mouse peritoneal macrophages, bone marrow-derived macrophages, microglia or human blood-derived macrophages, assaying for the involvement of the ERα, PI3K and NRF2 pathways also under inflammatory conditions. Our data demonstrate that Raloxifene acts by a dual mechanism, which entails ERα antagonism and off-target mediators. Moreover, micromolar concentrations of Raloxifene increase the expression of immune metabolic genes, such as Vegfa and Hmox1, through PI3K and NRF2 activation selectively in peritoneal macrophages. Conversely, Il1b mRNA down-regulation by SERMs is consistently observed in all macrophage subtypes and unrelated to the PI3K/NRF2 system. Importantly, the production of the inflammatory cytokine TNFα induced by the bacterial endotoxin, LPS, is potentiated by SERMs and paralleled by the cell subtype-specific increase in IL1β secretion. This work extends our knowledge on the biological and molecular mechanisms of SERMs immune activity and indicate macrophages as a pharmacological target for the exploitation of the antimicrobial potential of these drugs.
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Affiliation(s)
- Chiara Sfogliarini
- Department of Pharmaceutical Sciences, University of Milan, 20133 Milan, Italy.
| | - Giovanna Pepe
- Department of Pharmaceutical Sciences, University of Milan, 20133 Milan, Italy.
| | | | | | - Massimo Locati
- IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089 Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy.
| | - Elisabetta Vegeto
- Department of Pharmaceutical Sciences, University of Milan, 20133 Milan, Italy.
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Li H, Gao X, Chen Y, Wang M, Xu C, Yu Q, Jin Y, Song J, Zhu Q. Potential risk of tamoxifen: gut microbiota and inflammation in mice with breast cancer. Front Oncol 2023; 13:1121471. [PMID: 37469407 PMCID: PMC10353877 DOI: 10.3389/fonc.2023.1121471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 05/31/2023] [Indexed: 07/21/2023] Open
Abstract
Objective Tamoxifen is an effective anti-tumor medicine, but evidence has been provided on tamoxifen-related inflammation as well as its impact on gut microbiota. In this study, we aimed to investigate tamoxifen-induced gut microbiota and inflammation alteration. Methods We established a BC xenograft mouse model using the MCF-7 cell line. 16S rRNA gene sequencing was used to investigate gut microbiota. qRT-PCR, western blotting, and cytometric bead array were used to investigate inflammation-related biomarkers. Various bioinformatic approaches were used to analyze the data. Results Significant differences in gut microbial composition, characteristic taxa, and microbiome phenotype prediction were observed between control, model, and tamoxifen-treated mice. Furthermore, protein expression of IL-6 and TLR5 was up-regulated in tamoxifen-treated mice, while the mRNA of Tlr5 and Il-6, as well as protein expression of IL-6 and TLR5 in the model group, were down-regulated in the colon. The concentration of IFN-γ, IL-6, and IL12P70 in serum was up-regulated in tamoxifen-treated mice. Moreover, correlation-based clustering analysis demonstrated that inflammation-negatively correlated taxa, including Lachnospiraceae-UCG-006 and Anaerotruncus, were enriched in the model group, while inflammation-positively correlated taxa, including Prevotellaceae_UCG_001 and Akkermansia, were enriched in the tamoxifen-treated group. Finally, colon histologic damage was observed in tamoxifen-treated mice. Conclusion Tamoxifen treatment significantly altered gut microbiota and increased inflammation in the breast cancer xenograft mice model. This may be related to tamoxifen-induced intestinal epithelial barrier damage and TLR5 up-regulation.
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Affiliation(s)
- Hailong Li
- School of Green Intelligent Pharmaceutical Industry, Zhejiang Guangsha Vocational and Technical University of Construction, Dongyang, Zhejiang, China
| | - Xiufei Gao
- Department of Breast Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Yian Chen
- First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Mengqian Wang
- First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Chuchu Xu
- First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qinghong Yu
- First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Ying Jin
- First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jiaqing Song
- First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qi Zhu
- Department of Breast Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
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McMahon CL, Esqueda M, Yu JJ, Wall G, Romo JA, Vila T, Chaturvedi A, Lopez-Ribot JL, Wormley F, Hung CY. Development of an Imaging Flow Cytometry Method for Fungal Cytological Profiling and Its Potential Application in Antifungal Drug Development. J Fungi (Basel) 2023; 9:722. [PMID: 37504711 PMCID: PMC10381375 DOI: 10.3390/jof9070722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023] Open
Abstract
Automated imaging techniques have been in increasing demand for the more advanced analysis and efficient characterization of cellular phenotypes. The success of the image-based profiling method hinges on assays that can rapidly and simultaneously capture a wide range of phenotypic features. We have developed an automated image acquisition method for fungal cytological profiling (FCP) using an imaging flow cytometer that can objectively measure over 250 features of a single fungal cell. Fungal cells were labeled with calcofluor white and FM4-64FX, which bind to the cell wall and lipophilic membrane, respectively. Images of single cells were analyzed using IDEAS® software. We first acquired FCPs of fungal cells treated with fluconazole, amphotericin B, and caspofungin, each with a distinct mode of action, to establish FCP databases of profiles associated with specific antifungal treatment. Once fully established, we investigated the potential application of this technique as a screening methodology to identify compounds with novel antifungal activity against Candida albicans and Cryptococcus neoformans. Altogether, we have developed a rapid, powerful, and novel image-profiling method for the phenotypic characterization of fungal cells, also with potential applications in antifungal drug development.
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Affiliation(s)
- Courtney L McMahon
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Marisol Esqueda
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Jieh-Juen Yu
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Gina Wall
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Jesus A Romo
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Taissa Vila
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Ashok Chaturvedi
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Jose L Lopez-Ribot
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Floyd Wormley
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Chiung-Yu Hung
- Department of Molecular Microbiology and Immunology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
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Giamberardino CD, Schell WA, Tenor JL, Toffaletti DL, Palmucci JR, Marius C, Boua JVK, Soltow Q, Mansbach R, Moseley MA, Thompson JW, Dubois LG, Hope W, Perfect JR, Shaw KJ. Efficacy of APX2039 in a Rabbit Model of Cryptococcal Meningitis. mBio 2022; 13:e0234722. [PMID: 36222509 PMCID: PMC9765414 DOI: 10.1128/mbio.02347-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/14/2022] [Indexed: 11/20/2022] Open
Abstract
Cryptococcal Meningitis (CM) is uniformly fatal if not treated, and treatment options are limited. We previously reported on the activity of APX2096, the prodrug of the novel Gwt1 inhibitor APX2039, in a mouse model of CM. Here, we investigated the efficacy of APX2039 in mouse and rabbit models of CM. In the mouse model, the controls had a mean lung fungal burden of 5.95 log10 CFU/g, whereas those in the fluconazole-, amphotericin B-, and APX2039-treated mice were 3.56, 4.59, and 1.50 log10 CFU/g, respectively. In the brain, the control mean fungal burden was 7.97 log10 CFU/g, while the burdens were 4.64, 7.16, and 1.44 log10 CFU/g for treatment with fluconazole, amphotericin B, and APX2039, respectively. In the rabbit model of CM, the oral administration of APX2039 at 50 mg/kg of body weight twice a day (BID) resulted in a rapid decrease in the cerebrospinal fluid (CSF) fungal burden, and the burden was below the limit of detection by day 10 postinfection. The effective fungicidal activity (EFA) was -0.66 log10 CFU/mL/day, decreasing from an average of 4.75 log10 CFU/mL to 0 CFU/mL, over 8 days of therapy, comparing favorably with good clinical outcomes in humans associated with reductions of the CSF fungal burden of -0.4 log10 CFU/mL/day, and, remarkably, 2-fold the EFA of amphotericin B deoxycholate in this model (-0.33 log10 CFU/mL/day). A total drug exposure of the area under the concentration-time curve from 0 to 24 h (AUC0-24) of 25 to 50 mg · h/L of APX2039 resulted in near-maximal antifungal activity. These data support the further preclinical and clinical evaluation of APX2039 as a new oral fungicidal monotherapy for the treatment of CM. IMPORTANCE Cryptococcal meningitis (CM) is a fungal disease with significant global morbidity and mortality. The gepix Gwt1 inhibitors are a new class of antifungal drugs. Here, we demonstrated the efficacy of APX2039, the second member of the gepix class, in rabbit and mouse models of cryptococcal meningitis. We also analyzed the drug levels in the blood and cerebrospinal fluid in the highly predictive rabbit model and built a mathematical model to describe the behavior of the drug with respect to the elimination of the fungal pathogen. We demonstrated that the oral administration of APX2039 resulted in a rapid decrease in the CSF fungal burden, with an effective fungicidal activity of -0.66 log10 CFU/mL/day, comparing favorably with good clinical outcomes in humans associated with reductions of -0.4 log10 CFU/mL/day. The drug APX2039 had good penetration of the central nervous system and is an excellent candidate for future clinical testing in humans for the treatment of CM.
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Affiliation(s)
- Charles D. Giamberardino
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Wiley A. Schell
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Jennifer L. Tenor
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Dena L. Toffaletti
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Julia R. Palmucci
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Choiselle Marius
- Duke University School of Medicine, Department of Surgery, Durham, North Carolina, USA
| | - Jane-Valeriane K. Boua
- Duke University School of Medicine, Department of Neurosurgery, Durham, North Carolina, USA
| | | | | | - M. Arthur Moseley
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - J. Will Thompson
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - Laura G. Dubois
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - John R. Perfect
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
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De Bels D, Maillart E, Van Bambeke F, Redant S, Honoré PM. Existing and emerging therapies for the treatment of invasive candidiasis and candidemia. Expert Opin Emerg Drugs 2022; 27:405-416. [PMID: 36317695 DOI: 10.1080/14728214.2022.2142207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Invasive candidiasis or candidemia is a severe infection affecting more than 250,000 people worldwide every year. It is present in up to 16% of ICU patients. The prognosis of these infections is unfavorable, with global death estimated around 50,000 per year, which corresponds to up to 40% depending on patient severity and comorbidities. Therapeutic failure is not rare due to the emergence of multiresistant strains and of new species poorly responsive to current therapies like Candida auris. AREAS COVERED We first review the positioning of antifungal drugs used to treat candidiasis, namely polyenes, azoles, echinocandins and pyrimidine analogues. We then discuss the progresses brought by new formulations, new derivatives within these classes, compounds acting on new targets or repurposed drugs in terms of pharmacokinetic profile, spectrum of activity, potency, safety or risk of drug-drug interactions. EXPERT OPINION While new formulations (amphotericin B cochleate) improve oral bioavailability of the corresponding drugs, new azoles or echinocandins offer higher potency including against strains resistant to former generations of drugs. Repurposed drugs show synergism with current therapies in vitro. Results from ongoing and future clinical trials will be decisive to establish the interest for these drugs in our arsenal.
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Affiliation(s)
- David De Bels
- Intensive Care Department, Brugmann University Hospital, Brussels, Belgium
| | - Evelyne Maillart
- Department of Infectious Disease, Brugmann University Hospital, Brussels, Belgium
| | - Françoise Van Bambeke
- Louvain Drug Research Institute, Department of Pharmacology, Université Catholique de Louvain, Brussels, Belgium
| | - Sebastien Redant
- Intensive Care Department, Brugmann University Hospital, Brussels, Belgium
| | - Patrick M Honoré
- Intensive Care Department, Brugmann University Hospital, Brussels, Belgium.,Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium.,Department of ICU, CHU UCL Godinne-Namur, UCL Louvain Medical School
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7
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Robbins N, Cowen LE. Antifungal discovery. Curr Opin Microbiol 2022; 69:102198. [PMID: 36037637 PMCID: PMC10726697 DOI: 10.1016/j.mib.2022.102198] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/29/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
Fungi have a profound impact on human health, leading to billions of infections and millions of deaths worldwide each year. Exacerbating the public health burden is the continued emergence of drug-resistant fungal pathogens coupled with a dearth of treatment options to combat serious infections. Despite this health threat, scientific advances in chemistry, genetics, and biochemistry methodologies have enabled novel antifungal compounds to be discovered. Here, we describe current approaches for the discovery and characterization of novel antifungals, focusing on the identification of novel chemical matter and elucidation of the cellular target of bioactive compounds, followed by a review of the most promising emerging therapies in the antifungal-development pipeline.
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Affiliation(s)
- Nicole Robbins
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Leah E Cowen
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5S 1A8, Canada.
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8
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Sfogliarini C, Pepe G, Dolce A, Della Torre S, Cesta MC, Allegretti M, Locati M, Vegeto E. Tamoxifen Twists Again: On and Off-Targets in Macrophages and Infections. Front Pharmacol 2022; 13:879020. [PMID: 35431927 PMCID: PMC9006819 DOI: 10.3389/fphar.2022.879020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/08/2022] [Indexed: 11/25/2022] Open
Abstract
Beyond the wide use of tamoxifen in breast cancer chemotherapy due to its estrogen receptor antagonist activity, this drug is being assayed in repurposing strategies against a number of microbial infections. We conducted a literature search on the evidence related with tamoxifen activity in macrophages, since these immune cells participate as a first line-defense against pathogen invasion. Consistent data indicate the existence of estrogen receptor-independent targets of tamoxifen in macrophages that include lipid mediators and signaling pathways, such as NRF2 and caspase-1, which allow these cells to undergo phenotypic adaptation and potentiate the inflammatory response, without the induction of cell death. Thus, these lines of evidence suggest that the widespread antimicrobial activity of this drug can be ascribed, at least in part, to the potentiation of the host innate immunity. This widens our understanding of the pharmacological activity of tamoxifen with relevant therapeutic implications for infections and other clinical indications that may benefit from the immunomodulatory effects of this drug.
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Affiliation(s)
- Chiara Sfogliarini
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Giovanna Pepe
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Arianna Dolce
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Sara Della Torre
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | | | | | - Massimo Locati
- IRCCS Humanitas Research Hospital, Rozzano, Italy.,Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Elisabetta Vegeto
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
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Oliveira EAM, Ferreira GF, Lang KL. Drug repositioning of benzimidazole anthelmintics in the treatment of cryptococcosis: a review. Med Chem Res 2021. [DOI: 10.1007/s00044-021-02824-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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Ngan NTT, Thanh Hoang Le N, Vi Vi NN, Van NTT, Mai NTH, Van Anh D, Trieu PH, Lan NPH, Phu NH, Chau NVV, Lalloo DG, Hope W, Beardsley J, White NJ, Geskus R, Thwaites GE, Krysan D, Tai LTH, Kestelyn E, Binh TQ, Hung LQ, Tung NLN, Day JN. An open label randomized controlled trial of tamoxifen combined with amphotericin B and fluconazole for cryptococcal meningitis. eLife 2021; 10:e68929. [PMID: 34581270 PMCID: PMC8547950 DOI: 10.7554/elife.68929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background Cryptococcal meningitis has high mortality. Flucytosine is a key treatment but is expensive and rarely available. The anticancer agent tamoxifen has synergistic anti-cryptococcal activity with amphotericin in vitro. It is off-patent, cheap, and widely available. We performed a trial to determine its therapeutic potential. Methods Open label randomized controlled trial. Participants received standard care - amphotericin combined with fluconazole for the first 2 weeks - or standard care plus tamoxifen 300 mg/day. The primary end point was Early Fungicidal Activity (EFA) - the rate of yeast clearance from cerebrospinal fluid (CSF). Trial registration https://clinicaltrials.gov/ct2/show/NCT03112031. Results Fifty patients were enrolled (median age 34 years, 35 male). Tamoxifen had no effect on EFA (-0.48log10 colony-forming units/mL/CSF control arm versus -0.49 tamoxifen arm, difference -0.005log10CFU/ml/day, 95% CI: -0.16, 0.15, p=0.95). Tamoxifen caused QTc prolongation. Conclusions High-dose tamoxifen does not increase the clearance rate of Cryptococcus from CSF. Novel, affordable therapies are needed. Funding The trial was funded through the Wellcome Trust Asia Programme Vietnam Core Grant 106680 and a Wellcome Trust Intermediate Fellowship to JND grant number WT097147MA.
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Affiliation(s)
- Nguyen Thi Thuy Ngan
- Department of Tropical Medicine, Cho Ray HospitalHo Chi Minh CityViet Nam
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | | | - Nguyen Ngo Vi Vi
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | | | | | - Duong Van Anh
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | - Phan Hai Trieu
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | | | - Nguyen Hoan Phu
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
| | | | - David G Lalloo
- Liverpool School of Tropical MedicineLiverpoolUnited Kingdom
| | - William Hope
- Centre of Excellence in Infectious Disease Research, Institute of Translational Medicine, Liverpool UniversityLiverpoolUnited Kingdom
| | - Justin Beardsley
- The University of Sydney, Marie Bashir Institute, NSWCamperdownAustralia
- Westmead Institute for Medical ResearchWestmeadAustralia
| | - Nicholas J White
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Ronald Geskus
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Damian Krysan
- Department of Paediatrics and Microbiology/Immunology, Carver College of Medicine, University of IowaIowa CityUnited States
| | | | - Evelyne Kestelyn
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Tran Quang Binh
- Department of Tropical Medicine, Cho Ray HospitalHo Chi Minh CityViet Nam
| | - Le Quoc Hung
- Department of Tropical Medicine, Cho Ray HospitalHo Chi Minh CityViet Nam
| | | | - Jeremy N Day
- Oxford University Clinical Research UnitHo Chi Minh CityViet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
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Sutar Y, Fulton SR, Paul S, Altamirano S, Mhatre S, Saeed H, Patel P, Mallick S, Bhat R, Patravale VB, Chauhan H, Nielsen K, Date AA. Docusate-Based Ionic Liquids of Anthelmintic Benzimidazoles Show Improved Pharmaceutical Processability, Lipid Solubility, and in Vitro Activity against Cryptococcus neoformans. ACS Infect Dis 2021; 7:2637-2649. [PMID: 34467755 PMCID: PMC8884109 DOI: 10.1021/acsinfecdis.1c00063] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
As the existing therapeutic modalities for the treatment of cryptococcal meningitis (CM) have suboptimal efficacy, repurposing existing drugs for the treatment of CM is of great interest. The FDA-approved anthelmintic benzimidazoles, albendazole, mebendazole, and flubendazole, have demonstrated potent but variable in vitro activity against Cryptococcus neoformans, the predominant fungal species responsible for CM. We performed molecular docking studies to ascertain the interaction of albendazole, mebendazole, and flubendazole with a C. neoformans β-tubulin structure, which revealed differential binding interactions and explained the different in vitro efficacies reported previously and observed in this investigation. Despite their promising in vitro efficacy, the repurposing of anthelmintic benzimidazoles for oral CM therapy is significantly hampered due to their high crystallinity, poor pharmaceutical processability, low and pH-dependent solubility, and drug precipitation upon entering the intestine, all of which result in low and variable oral bioavailability. Here, we demonstrate that the anthelmintic benzimidazoles can be transformed into partially amorphous low-melting ionic liquids (ILs) with a simple metathesis reaction using amphiphilic sodium docusate as a counterion. In vitro efficacy studies on a laboratory reference and a clinical isolate of C. neoformans showed 2- to 4-fold lower IC90 values for docusate-based ILs compared to the pure anthelmintic benzimidazoles. Furthermore, using a C. neoformans strain with green fluorescent protein (GFP)-tagged β-tubulin and albendazole and its docusate IL as model candidates, we showed that the benzimidazoles and their ILs reduce the viability of C. neoformans by interfering with its microtubule assembly. Unlike pure anthelmintic benzimidazoles, the docusate-based ILs showed excellent solubility in organic solvents and >30-fold higher solubility in bioavailability-enhancing lipid vehicles. Finally, the docusate ILs were successfully incorporated into SoluPlus, a self-assembling biodegradable polymer, which upon dilution with water formed polymeric micelles with a size of <100 nm. Thus, the development of docusate-based ILs represents an effective approach to improve the physicochemical properties and potency of anthelmintic benzimidazoles to facilitate their repurposing and preclinical development for CM therapy.
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Affiliation(s)
- Yogesh Sutar
- Department of Pharmaceutical Sciences, The Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, Hawaii 96720, United States
| | - Sophie R Fulton
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Sagarkumar Paul
- Department of Pharmaceutical Sciences, Creighton University School of Pharmacy and Health Profession, 2200 California Plaza, Omaha, Nebraska 68710, United States
| | - Sophie Altamirano
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Susmit Mhatre
- Department of Pharmaceutical Sciences, Institute of Chemical Technology, N.P Marg, Matunga, Mumbai, Maharashtra 400011, India
| | - Hiwa Saeed
- Department of Pharmaceutical Sciences, The Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, Hawaii 96720, United States
| | - Pratikkumar Patel
- Department of Pharmaceutical Sciences, The Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, Hawaii 96720, United States
| | - Sudipta Mallick
- Department of Pharmaceutical Sciences, The Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, Hawaii 96720, United States
| | - Roopal Bhat
- Department of Pharmaceutical Sciences, The Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, Hawaii 96720, United States
- Department of Pharmaceutics, Shree Chanakya Education Society's Indira College of Pharmacy, Tathawade, Pune, Maharashtra 411033, India
| | - Vandana B Patravale
- Department of Pharmaceutical Sciences, Institute of Chemical Technology, N.P Marg, Matunga, Mumbai, Maharashtra 400011, India
| | - Harsh Chauhan
- Department of Pharmaceutical Sciences, Creighton University School of Pharmacy and Health Profession, 2200 California Plaza, Omaha, Nebraska 68710, United States
| | - Kirsten Nielsen
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Abhijit A Date
- Department of Pharmaceutical Sciences, The Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, Hilo, Hawaii 96720, United States
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii Manoa, Honolulu, Hawaii 96813, United States
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12
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Drug Repurposing in Medical Mycology: Identification of Compounds as Potential Antifungals to Overcome the Emergence of Multidrug-Resistant Fungi. Pharmaceuticals (Basel) 2021; 14:ph14050488. [PMID: 34065420 PMCID: PMC8161392 DOI: 10.3390/ph14050488] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/13/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023] Open
Abstract
Immunodepression, whether due to HIV infection or organ transplantation, has increased human vulnerability to fungal infections. These conditions have created an optimal environment for the emergence of opportunistic infections, which is concomitant to the increase in antifungal resistance. The use of conventional antifungal drugs as azoles and polyenes can lead to clinical failure, particularly in immunocompromised individuals. Difficulties related to treating fungal infections combined with the time required to develop new drugs, require urgent consideration of other therapeutic alternatives. Drug repurposing is one of the most promising and rapid solutions that the scientific and medical community can turn to, with low costs and safety advantages. To treat life-threatening resistant fungal infections, drug repurposing has led to the consideration of well-known and potential molecules as a last-line therapy. The aim of this review is to provide a summary of current antifungal compounds and their main resistance mechanisms, following by an overview of the antifungal activity of non-traditional antimicrobial drugs. We provide their eventual mechanisms of action and the synergistic combinations that improve the activity of current antifungal treatments. Finally, we discuss drug repurposing for the main emerging multidrug resistant (MDR) fungus, including the Candida auris, Aspergillus or Cryptococcus species.
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13
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Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections associated with HIV remain significant contributors to morbidity and mortality, particularly among people living with HIV (PLWH) in resource-limited settings worldwide. In this review, we discuss several recent important scientific discoveries in the prevention, diagnosis, and management around two of the major causes of CNS opportunistic infections-tuberculous meningitis (TBM) and cryptococcal meningitis including immune reconstitution syndrome (IRIS) associated with cryptococcal meningitis. We also discuss the CNS as a possible viral reservoir, highlighting Cerebrospinal fluid viral escape. RECENT FINDINGS CNS infections in HIV-positive people in sub-Saharan Africa contribute to 15-25% of AIDS-related deaths. Morbidity and mortality in those is associated with delays in HIV diagnosis, lack of availability for antimicrobial treatment, and risk of CNS IRIS. The CNS may serve as a reservoir for replication, though it is unclear whether this can impact peripheral immunosuppression. SUMMARY Significant diagnostic and treatment advances for TBM and cryptococcal meningitis have yet to impact overall morbidity and mortality according to recent data. Lack of early diagnosis and treatment initiation, and also maintenance on combined antiretroviral treatment are the main drivers of the ongoing burden of CNS opportunistic infections. The CNS as a viral reservoir has major potential implications for HIV eradication strategies, and also control of CNS opportunistic infections.
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14
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Treatment strategies for cryptococcal infection: challenges, advances and future outlook. Nat Rev Microbiol 2021; 19:454-466. [PMID: 33558691 PMCID: PMC7868659 DOI: 10.1038/s41579-021-00511-0] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 01/31/2023]
Abstract
Cryptococcus spp., in particular Cryptococcus neoformans and Cryptococcus gattii, have an enormous impact on human health worldwide. The global burden of cryptococcal meningitis is almost a quarter of a million cases and 181,000 deaths annually, with mortality rates of 100% if infections remain untreated. Despite these alarming statistics, treatment options for cryptococcosis remain limited, with only three major classes of drugs approved for clinical use. Exacerbating the public health burden is the fact that the only new class of antifungal drugs developed in decades, the echinocandins, displays negligible antifungal activity against Cryptococcus spp., and the efficacy of the remaining therapeutics is hampered by host toxicity and pathogen resistance. Here, we describe the current arsenal of antifungal agents and the treatment strategies employed to manage cryptococcal disease. We further elaborate on the recent advances in our understanding of the intrinsic and adaptive resistance mechanisms that are utilized by Cryptococcus spp. to evade therapeutic treatments. Finally, we review potential therapeutic strategies, including combination therapy, the targeting of virulence traits, impairing stress response pathways and modulating host immunity, to effectively treat infections caused by Cryptococcus spp. Overall, understanding of the mechanisms that regulate anti-cryptococcal drug resistance, coupled with advances in genomics technologies and high-throughput screening methodologies, will catalyse innovation and accelerate antifungal drug discovery.
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15
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NADPH-Cytochrome P450 Reductase Ccr1 Is a Target of Tamoxifen and Participates in Its Antifungal Activity via Regulating Cell Wall Integrity in Fission Yeast. Antimicrob Agents Chemother 2020; 64:AAC.00079-20. [PMID: 32571823 DOI: 10.1128/aac.00079-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/13/2020] [Indexed: 02/07/2023] Open
Abstract
Invasive fungal diseases are a leading cause of mortality among immunocompromised populations. Treatment is notoriously difficult due to the limited number of antifungal drugs as well as the emergence of drug resistance. Tamoxifen (TAM), a selective estrogen receptor modulator frequently used for the treatment of breast cancer, has been found to have antifungal activities and may be a useful addition to the agents used to treat fungal infectious diseases. However, the molecular mechanisms underlying its antifungal actions remain obscure. Here, we screened for mutations that confer sensitivity to azole antifungal drugs by using the fission yeast Schizosaccharomyces pombe as a model and isolated a mutant with a mutation in cls1 (ccr1), an allele of the gene encoding the NADPH-cytochrome P450 reductase Ccr1. We found that strains with a deletion of the ccr1 + gene exhibited hypersensitivities to various drugs, including antifungal drugs (azoles, terbinafine, micafungin), the immunosuppressor FK506, and the anticancer drugs TAM and 5-fluorouracil (5-FU). Unexpectedly, the overexpression of Ccr1 caused yeast cell resistance to TAM but not the other drugs tested here. Additionally, strains with a deletion of Ccr1 displayed pleiotropic phenotypes, including defects in cell wall integrity and vacuole fusion, enhanced calcineurin activity, as well as increased intracellular Ca2+ levels. Overexpression of the constitutively active calcineurin suppressed the drug-sensitive phenotypes of the Δccr1 cells. Notably, TAM treatment of wild-type cells resulted in pleiotropic phenotypes, similar to those of cells lacking Ccr1. Furthermore, TAM inhibited Ccr1 NADPH-cytochrome P450 reductase activities in a dose-dependent manner. Moreover, TAM treatment also inhibited the NADPH-cytochrome P450 reductase activities of Candida albicans and resulted in defective cell wall integrity. Collectively, our findings suggest that Ccr1 is a novel target of TAM and is involved in the antifungal activity of TAM by regulating cell wall integrity in fission yeast.
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16
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Tenforde MW, Jarvis JN. HIV-associated cryptococcal meningitis: ongoing challenges and new opportunities. THE LANCET. INFECTIOUS DISEASES 2020; 19:793-794. [PMID: 31345446 DOI: 10.1016/s1473-3099(19)30295-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Mark W Tenforde
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA 98195, USA; Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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17
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Derivatives of the Antimalarial Drug Mefloquine Are Broad-Spectrum Antifungal Molecules with Activity against Drug-Resistant Clinical Isolates. Antimicrob Agents Chemother 2020; 64:AAC.02331-19. [PMID: 31907188 DOI: 10.1128/aac.02331-19] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/20/2019] [Indexed: 12/21/2022] Open
Abstract
The antifungal pharmacopeia is critically small, particularly in light of the recent emergence of multidrug-resistant pathogens, such as Candida auris Here, we report that derivatives of the antimalarial drug mefloquine have broad-spectrum antifungal activity against pathogenic yeasts and molds. In addition, the mefloquine derivatives have activity against clinical isolates that are resistant to one or more of the three classes of antifungal drugs currently used to treat invasive fungal infections, indicating that they have a novel mechanism of action. Importantly, the in vitro toxicity profiles obtained using human cell lines indicated that the toxicity profiles of the mefloquine derivatives are very similar to those of the parent mefloquine, despite being up to 64-fold more active against fungal cells. In addition to direct antifungal activity, subinhibitory concentrations of the mefloquine derivatives inhibited the expression of virulence traits, including filamentation in Candida albicans and capsule formation/melanization in Cryptococcus neoformans Mode/mechanism-of-action experiments indicated that the mefloquine derivatives interfere with both mitochondrial and vacuolar function as part of a multitarget mechanism of action. The broad-spectrum scope of activity, blood-brain barrier penetration, and large number of previously synthesized analogs available combine to support the further optimization and development of the antifungal activity of this general class of drug-like molecules.
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18
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Wu X, Shen Y. Management of human immunodeficiency virus-associated cryptococcal meningitis: Current status and future directions. Mycoses 2019; 62:874-882. [PMID: 31365770 DOI: 10.1111/myc.12977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 12/30/2022]
Abstract
Cryptococcal meningitis (CM) is one of the most common opportunistic infections of acquired immunodeficiency syndrome (AIDS), as well as an important cause of hospitalisation and death. In recent years, the mortality of CM has remained high in HIV/AIDS population, with up to 30%, including within developed countries. The treatment usually encompasses controls of Cryptococcus, HIV, and increased intracranial pressure. Recent progress on the management of HIV-associated CM mainly centres in optimising induction regimens, looking for appropriate timing of initiating antiretroviral therapy and prevention of symptomatic onset and adverse consequences. This review compared several international guidelines combined with the results from some clinical researches to illustrate the similarities, differences and potential in CM treatment. The present practice is still far from satisfactory, and there remains much to explore due to our limited understanding of the pathogenesis of HIV-associated CM. Thus, screening and monitoring should be strengthened, and better therapies in line with the actual situation of each country should be discovered.
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Affiliation(s)
- Xueyun Wu
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
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