Antifungal resistance among Candida species

Efficacy of intravitreal povidone-iodine administration for the treatment of Candida albicans endophthalmitis in rabbits

This study aimed to investigate the efficacy of intravitreal povidone-iodine (PI) administration for the treatment of Candida albicans endophthalmitis. Forty New Zealand white rabbits were divided into four groups (n = 10 per group). After the induction of endophthalmitis using Candida albicans, groups A, B, and C received single intravitreal injections of 0.035 mg voriconazole, 0.3 mg PI, and their combination, respectively. Rabbits that were administered sham injections were in group D as controls. Fundus photography, vitreous culture, electroretinography (ERG), and histologic examinations of the retina were conducted on day 7. The anterior chamber flare (grade 0 to 4), severity of iritis (grade 0 to 4), and vitreous opacity (grade 0 to 3) were scored. Candida albicans was cultured in the vitreous sample. On day 7, the vitreous opacities were found in all groups. Compared to that in group D, groups A, B, and C showed a lower score for flare (p < 0.001) and iritis (p < 0.001) and less fungal growth in the vitreous culture (n = 2, 1, 1, and 10 in groups A, B, C, and D, respectively; p < 0.001). Furthermore, ERG and histologic findings demonstrated less affected a- and b-waves and damaged retinal tissues in groups A, B, and C. However, these findings were not different among groups A, B, and C. PI significantly improved Candida albicans endophthalmitis, and the effect was comparable that of the voriconazole, although some vitreous opacities remained. No synergistic effect of the combination of PI and voriconazole was observed. Intravitreal PI may be useful to treat Candida albicans endophthalmitis.

Dynamics of Mixed- Candida Species Biofilms in Response to Antifungals

Oral infections caused by Candida species, the most commonly isolated human fungal pathogen, are frequently associated with biofilms. Although Candida albicans is the predominant organism found in patients with oral thrush, a biofilm infection, there is an increasing incidence of oral colonization and infections caused by non- albicans Candida species, including C. glabrata, C. dubliniensis, and C. tropicalis, which are frequently more resistant to antifungal treatment. While single-species Candida biofilms have been well studied, considerably less is known about the dynamics of mixed- Candida species biofilms and how these dynamics are altered by antifungal treatment. To address these questions, we developed a quantitative polymerase chain reaction-based approach to determine the precise species composition of mixed- Candida species biofilms formed by clinical isolates and laboratory strains in the presence and absence of clinically relevant concentrations of 3 commonly used antifungals: fluconazole, caspofungin, and amphotericin B. In monospecies biofilms, fluconazole exposure favored growth of C. glabrata and C. tropicalis, while caspofungin generally favored significant growth of all species to a varying degree. Fluconazole was not effective against preformed mixed- Candida species biofilms while amphotericin B was potent. As a general trend, in mixed- Candida species biofilms, C. albicans lost dominance in the presence of antifungals. Interestingly, presence in mixed versus monospecies biofilms reduced susceptibility to amphotericin B for C. tropicalis and C. glabrata. Overall, our data suggest that antifungal treatment favors the growth of specific non- albicans Candida species in mixed- Candida species biofilms.

Tpd3-Pph21 phosphatase plays a direct role in Sep7 dephosphorylation in Candida albicans

Septins are a component of the cytoskeleton and play important roles in diverse cellular processes including cell cycle control, cytokinesis and polarized growth. In fungi, septin organization, dynamics and function are regulated by phosphorylation, and several kinases responsible for the phosphorylation of several septins have been identified. However, little is known about the phosphatases that dephosphorylate septins. Here, we report the characterization of Tpd3, a structural subunit of the PP2A family of phosphatases, in the pathogenic fungus Candida albicans. We found that tpd3Δ/Δ cells are defective in hyphal growth and grow as pseudohyphae under yeast growth conditions with aberrant septin organization. Western blotting detected hyperphosphorylation of the septin Sep7 in cells lacking Tpd3. Tpd3 and Sep7 colocalize at the bud neck and can coimmunoprecipitate. Furthermore, we discovered similar defects in cells lacking Pph21, a catalytic subunit of the PP2A family, and its physical association with Tpd3. Importantly, purified Tpd3-Pph21 complexes can dephosphorylate Sep7 in vitro. Together, our findings strongly support the idea that the Tpd3-Pph21 complex dephosphorylates Sep7 and regulates morphogenesis and cytokinesis. The tpd3Δ/Δ mutant is greatly reduced in virulence in mice, providing a potential antifungal target.

Comparative efficacy of herbal essences with amphotricin B and ketoconazole on Candida albicans in the in vitro condition

Background

The Candida species are the most important factors of fungal infections in humans and animals. It is necessary to prepare antifungal or antimicrobial drugs because of increasing drug resistance. The natural treatment of diseases of bacterial origin using medicinal plants is important. In this study the effect of antimicrobial medicinal herbal essential oils and conventional antifungal drugs were evaluated on Candida albicans in vitro.

Methods

Disc diffusion assay and the microbroth dilution method were used to investigate the anticandidal effects of Foeniculum vulgare Mill, Satureja hortensis L, Cuminum cyminum, and Zataria multiflora Boiss essential oils. The anticandidal effect of these essential oils was compared with that of amphotricin B and ketoconazole in vitro. We then measured the chemical composition of the studied essential oils using gas chromatography–mass spectroscopy.

Results

Z. multiflora Boiss essential oil at the minimum inhibitory concentration (MIC) of 34 μg/mL and minimal lethal concentration [i.e., minimal fungicidal concentration (MFC)] of 64 μg/mL had more powerful anti-Candida activity than the other essential oils. C. cyminum essential oil showed the least effect on the tested fungus. A comparison of the effect of the studied essential oils and antifungal drugs showed that the antifungal effect on the C. albicans fungus was better with the fungicides than with the essential oils.

Conclusion

In the present study, essential oils with different components showed antifungal activity (especially Z. multiflora Boiss essential oil). They can therefore be used as new antifungal substances.

Ppg1, a PP2A-type protein phosphatase, controls filament extension and virulence in Candida albicans

Candida albicans, a major human fungal pathogen, is the primary cause of invasive candidiasis in a wide array of immunocompromised patients. C. albicans virulence requires the ability to undergo a reversible morphological transition from yeast to filaments in response to a variety of host environmental cues. These cues are sensed by the pathogen and activate multiple signal transduction pathways to induce filamentation. Reversible phosphorylation events are critical for regulation of many of these pathways. While a variety of protein kinases are known to function as components of C. albicans filamentous growth signal transduction pathways, considerably little is known about the role of phosphatases. Here we demonstrate that PPG1, encoding a putative type 2A-related protein phosphatase, is important for C. albicans filament extension, invasion, and virulence in a mouse model of systemic candidiasis. PPG1 is also important for downregulation of NRG1, a key transcriptional repressor of C. albicans filamentous growth, and is shown to affect the expression of several filament-specific target genes. An epistasis analysis suggests that PPG1 controls C. albicans filamentation via the cyclic AMP-protein kinase A (cAMP-PKA) signaling pathway. We demonstrate that Ppg1 possesses phosphatase activity and that a ppg1 catalytic mutant shows nearly equivalent filamentation, invasion, and virulence defects compared to those of a ppg1Δ/Δ strain. Overall, our results suggest that phosphatases, such as Ppg1, play critical roles in controlling and fine-tuning C. albicans filament extension and virulence as well as signal transduction pathways, transcriptional regulators, and target genes associated with these processes.

Fluconazole exposure rather than clonal spreading is correlated with the emergence of Candida glabrata with cross-resistance to triazole antifungal agents

The emergence of antifungal resistance in Candida species has raised concern in recent years, especially resistance toward triazole. Several newer triazole antifungal agents have been introduced which have a broader spectrum for fungal infections, such as voriconazole. However, cross-resistance among triazoles is a major concern with regard to their clinical application. Antifungal susceptibility was performed using E-test for 166 clinical isolates (29 blood and 137 nonblood isolates) in 2003 and 2004. We applied pulsed-field gel electrophoresis for genotyping. Ninety isolates of C. albicans, 47 isolates of C. tropicalis, 27 isolates of C. glabrata, and two isolates of C. krusei were included. All isolates were susceptible to amphotericin B. Eleven (40.7%) of the 27 C. glabrata had intermediate resistance to caspofungin. Forty-seven (28.3%) of the 166 isolates were not susceptible to fluconazole, including two C. albicans, 16 C. tropicalis, 27 C. glabrata, and two C. krusei isolates. All except seven of the C. glabrata isolates were susceptible to voriconazole. All the triazole drugs had a positive correlation among their minimum inhibitory concentrations (MICs). Fluconazole MIC was a good predictor for susceptibility to voriconazole, as determined using a receiver operating characteristic curve. Furthermore, a high diversity of pulsotypes for the 27 clinical isolates of C. glabrata was observed. Previous fluconazole exposure within 3 months was associated with reduced triazole susceptibility for C. glabrata. We demonstrated a significant positive correlation of MIC values among the four tested triazole drugs. No amphotericin B and caspofungin resistant isolates were found in this study. The cross-resistance to triazole among C. glabrata isolates was associated with previous fluconazole exposure as opposed to clonal spreading. Selection pressure due to fluconazole use may play a major role in triazole cross-resistance.

Susceptibilities of Candida albicans mouth isolates to antifungal agents, essentials oils and mouth rinses

Forty Candida albicans strains isolated from patient's mouth with fixed orthodontic appliances were analyzed to their susceptibilities to antifungal agents, mouth rinses and essential oils. Susceptibility to fluconazole, econazole, miconazole and ketoconazole, amphotericin B and nystatin was assessed by the disk diffusion (DD) method based on the Clinical and Laboratory Standards Institute M44-A protocol, and by Etest (fluconazole and amphotericin B). The susceptibilities to mouth rinses and essential oils were also determined by the DD technique. All isolates tested were susceptible (S) to amphotericin B, nystatin and fluconazole. The overall concordance between the DD and the Etest was 100% for amphotericin and fluconazole. One isolate was resistant to econazole (2.5%) and the other to ketoconazole (2.5%). Econazole and ketoconazole had the highest percentages of susceptible dose dependent (SDD), 55 and 95%, respectively. Regarding to the susceptibility isolates profile, seven phenotypes were detected, and the 3 more represented (90% of the isolates) of them were SDD to one, two or three azoles. The study of mouth rinses showed a high variability of efficacy against C. albicans. The results showed that the isolates susceptibility to essential oils differed (P < 0.05). The profile activity was: cinnamon > laurel > mint > eucalyptus > rosemary > lemon > myrrh > tangerine. The main finding was that the susceptibility to cinnamon and laurel varied among the three more representative antifungal phenotypes (P < 0.05). The susceptibility of econazole-SDD isolates to cinnamon and lemon was higher than those of the econazole-S yeasts (P < 0.05). In contrast, econazole-SDD isolates were less affected by laurel than econazole-S counterparts (P < 0.05).

Microbial Conversion of Tomato by a Plant Pathogenic Bacterium Pectobacterium atrosepticum: A Plant-Microbial Approach to Control Pathogenic Candida Species

This study was carried out to produce bioconverted products by microbial fermentation of tomato using a plant pathogenic bacterium Pectobacterium atrosepticum and to evaluate their in vitro antimycotic effect against pathogenic Candida species. The bioconverted products (500 μg/disc) provoked promising antimycotic effects against pathogenic isolates of Candida species as shown by the diameters of zones of inhibition (9 ± 0.6 to 14 ± 0.4 mm), along with their respective minimum inhibitory and minimum fungicidal concentration values, which increased from 250 to 1000 and 250 to 2000 μg/mL, respectively. With the viable counts of the tested fungal pathogens, exposure of the bioconverted products revealed a remarkable antimycotic effect. In addition, the morphology of a clinical isolate of C. glabrata KBN06P00368, visualized by scanning electron microscopy, showed a severe detrimental effect produced by the bioconverted products at the minimum inhibitory concentration (250 μg/mL). The bioconverted products significantly inhibited the in vitro growth of all the tested clinical and pathogenic laboratory isolates of Candida species. This study confirmed the potent antimycotic efficacy of the bioconverted products of tomato, hence justifying the therapeutic uses of bioconverted products in pharmaceutical preparations as an alternative approach to support the antifungal activity of conventional antimycotics.

Antifungal Properties of Chenopodium ambrosioides Essential Oil Against Candida Species

The essential oil of the aerial part (leaves, flowers and stem) of Chenopodium ambrosioides was obtained by hydrodistillation and its chemical composition analyzed by GC and GC/MS, which permitted the identification of 14 components, representing 98.8% of the total oil. Major components were α-terpinene (51.3%), p-cymene (23.4%) and p-mentha-1,8-diène (15.3%). The antifungal properties of this essential oil were investigated in vitro by the well diffusion and broth microdilution methods. The in vitro antifungal activity was concentration dependent and minimum inhibitory concentration values varied from 0.25 to 2 mg/mL. The in vivo antifungal activity was evaluated on an induced vaginal candidiasis rat model. The in vivo activity of the oil on mice vaginal candidiasis was not dose-dependent. Indeed, all the three tested doses; 0.1%, 1% and 10% led to the recovery of mice from the induced infection after 12 days of treatment. The effect of the essential oil on C. albicans ATCC 1663 fatty acid profile was studied. This oil has a relatively important dose-dependent effect on the fatty acids profile.

Quinazolinone fungal efflux pump inhibitors. Part 3: (N-methyl)piperazine variants and pharmacokinetic optimization

Further structure-activity relationships of a novel series of fungal efflux pump inhibitors with respect to potentiation of the activity of fluconazole against strains of C. albicans and C. glabrata over-expressing ABC-type efflux pumps are systematically explored. Rat protein binding and pharmacokinetics of selected analogues are reported.

Screening of Tanzanian medicinal plants for anti-Candida activity

Background

Candida albicans has become resistant to the already limited, toxic and expensive anti-Candida agents available in the market. These factors necessitate the search for new anti-fungal agents.

Methods

Sixty-three plant extracts, from 56 Tanzanian plant species obtained through the literature and interviews with traditional healers, were evaluated for anti-Candida activity. Aqueous methanolic extracts were screened for anti-Candida activity by bioautography agar overlay method, using a standard strain of Candida albicans (ATCC 90028).

Results

Twenty- seven (48%) out of the 56 plants were found to be active. Extracts of the root barks of Albizia anthelmintica and Balanites aegyptiaca, and roots of Plectranthus barbatus showed strong activity.

Conclusion

The extracts that showed strong anti-Candida activity are worth of further investigation in order to isolate and identify the active compounds.

Caspofungin: a review of its use in the treatment of fungal infections

Caspofungin (Cancidas) is the first of a new class of antifungal agents, the echinocandins, that inhibit the synthesis of the fungal cell wall component beta-(1,3)-D-glucan. Caspofungin is administered once daily by slow intravenous infusion and is used to treat infections caused by Candida spp. and Aspergillus spp. Caspofungin is a valuable new antifungal agent with a novel mechanism of action. In comparative clinical trials, caspofungin was no less effective than liposomal amphotericin B in the empirical treatment of neutropenic patients with persistent fever, amphotericin B deoxycholate in the treatment of invasive candidiasis or fluconazole in the treatment of oesophageal candidiasis. Caspofungin also displayed broadly similar efficacy to amphotericin B deoxycholate in oesophageal or oropharyngeal candidiasis and was effective as salvage therapy in patients with invasive aspergillosis who were refractory to or intolerant of standard therapy. The tolerability profile of caspofungin was similar to that of fluconazole and superior to that of amphotericin B deoxycholate and liposomal amphotericin B. Therefore, in the appropriate indications, caspofungin is a viable alternative to amphotericin B deoxycholate, liposomal amphotericin B or fluconazole.

Invasive Candida infections in the neonate

Advances in medical therapy have increased premature infant survival. A rise in Candida infections in neonatal intensive care units (NICUs) has followed. Once considered a contaminant, Candida is now recognized as a major cause of mortality and morbidity within these units. We will examine what is known about the epidemiology, risk factors and end-organ involvement of Candida infections with a focus on invasive disease. In addition, diagnostic alternatives to traditional blood culture, experience with antifungal agents for prophylaxis and therapeutic options, including newer antifungal agents, will be presented.

Different anti-Candida activities of two human lactoferrin-derived peptides, Lfpep and kaliocin-1

The synthetic peptides Lfpep and kaliocin-1 include the sequences from positions 18 to 40 and 153 to 183 of human lactoferrin, respectively. Lfpep is a cationic peptide with bactericidal and giardicidal effects, whereas kaliocin-1 is a novel bactericidal peptide that corresponds to a highly homologous sequence present in the transferrin family of proteins. Both peptides presented fungicidal activity against Candida spp., including fluconazole- and amphotericin B-resistant clinical isolates. Lfpep exhibited higher antifungal activity (8- to 30-fold) and salt resistance than kaliocin-1. The killing activity of Lfpep was mediated by its permeabilizing activity on Candida albicans cells, whereas kaliocin-1 was unable to disrupt the cytoplasmic membrane, as indicated by its inability to allow permeation of propidium iodide and the small amount of K+ released. The amino acid sequence of kaliocin-1 includes the "multidimensional antimicrobial signature" conserved in disulfide-containing antimicrobial peptides and a striking similarity to brevinin-1Sa, an antimicrobial peptide from frog skin secretions, exhibiting a "Rana box"-like sequence. These features may be of interest in the design of new antifungals.

Quinazolinone-based fungal efflux pump inhibitors. Part 1: Discovery of an (N-methylpiperazine)-containing derivative with activity in clinically relevant Candida spp

The discovery of a series of quinazolinone-based fungal efflux pump inhibitors by high-throughput screening for potentiation of fluconazole in C. albicans is described. Attempts to improve the aqueous solubility of screening hits led to the discovery of an analog with greatly improved physical properties and activity against clinically-relevant Candida spp.

Well diffusion for antifungal susceptibility testing

INTRODUCTION

The increasing clinical and microbiologic resistance of Candida spp. isolates to several antifungal agents is becoming a serious problem. It is now reasonable to propose the use of antifungal susceptibility testing in Candida spp. isolates from patients who have failed conventional therapy, before the selection of an empirical therapy.

METHODS

One hundred and fifty eight isolates of Candida spp. were evaluated simultaneously by broth microdilution (NCCLS standard) and well diffusion testing (WD), a diffusion method similar to disc diffusion.

RESULTS

According to the Wilcoxon Signed Ranks test performed, there was no significant difference (p>0.05) between both methodologies for all antifungal agents tested (fluconazole, itraconazole, posaconazole, caspofungin and amphotericin B, with C. tropicalis, C. krusei, C. dubliniensis, C. guillermondii, C. parapsilosis, C. albicans and C. glabrata). A significant difference was observed when comparing well diffusion with NCCLS for fluconazole WD 80% (p=0.008) in C. glabrata, as well as WD 80% (p=0.002) and WD 50% (p=0.002) in C. albicans.

CONCLUSIONS

The well diffusion test is simple, easy to reproduce, inexpensive, easy both to read and interpret, and has a good correlation to the reference NCCLS microdilution test and may represent an alternative method for antifungal drug susceptibility testing of Candida spp., mainly in laboratories with few resources.

Inhibition of Clotrimazole-resistant Candida albicans by plants used in Iranian folkloric medicine

In vitro anticandidal activity of methanol extracts of 42 plant species of 29 families used in Iranian folkloric medicine were evaluated at 20 mg/ml concentration against Clotrimazole-resistant Candida albicans. Nineteen plant species in 16 families showed anticandidal activities. The lowest MIC of 0.62 mg/ml belonged to Terminalia chebula and Thymus vulgaris.

Successful treatment of Candida krusei infection with caspofungin acetate: a new antifungal agent

OBJECTIVE

Systemic fungal infections have high mortality, and therapy is often toxic. Caspofungin acetate, a new antifungal agent with minimal toxicity, may provide a better alternative to typical therapy for Candida krusei.

DESIGN

Case report.

SETTING

Multidisciplinary intensive care unit (ICU) of a community teaching hospital.

PATIENT

A 22-yr-old male with acute lymphoblastic leukemia and Candida krusei fungemia failed therapy with fluconazole and amphotericin B.

INTERVENTIONS

Caspofungin acetate given intravenously as a 70-mg loading dose, followed up by 50 mg daily along with standard ICU care.

RESULTS

Survival without toxicity from therapy.

CONCLUSION

Efficacy of caspofungin acetate in a patient with life-threatening Candida Krusei infection.

Conservative management of polymicrobial peritonitis complicating peritoneal dialysis--a series of 140 consecutive cases

PURPOSE

Because polymicrobial peritonitis is believed to be caused by bowel perforation in peritoneal dialysis patients, surgical exploration is often recommended. However, there is recent evidence that antibiotic therapy may be a safe alternative.

METHODS

We studied 140 consecutive episodes of dialysis-related polymicrobial peritonitis from January 1995 to June 2001. All episodes were treated primarily with intraperitoneal antibiotics. When there was no response, the Tenckhoff catheter was removed, usually after about 10 days of treatment. Laparotomy was performed only when there was clinical suspicion of surgical pathology.

RESULTS

Ninety patient-episodes (64%) responded to antibiotics alone by day 10; 56 patients (40%) had complete cure with no relapse in 4 months. Nine patients (6%) died within 2 days. Laparotomy was performed in 8 patients who did not respond by day 10, but only 3 had underlying surgical disease (strangulated hernia, ischemic colitis, and colonic cancer). In a multivariate logistic regression analysis, age and the presence of fungus, anaerobes, or Pseudomonas species in the dialysis fluid were independent predictors of poor primary response; and presence of fungus was the only independent predictor of failure to cure in 4 months.

CONCLUSION

Most patients with dialysis-related polymicrobial peritonitis responded to antibiotic therapy, and surgical exploration was needed only in a few patients. A careful examination of isolated organisms may help in identifying patients who need Tenckhoff catheter removal or surgical intervention.

Systemic Candida infections in patients with leukemia: an overview of drug therapy

Systemic fungal infections are becoming increasingly common in patients with hematologic malignancies receiving antineoplastic therapy. The presence of acute myeloid or acute lymphoid leukemia, plus the use of chemotherapy to totally ablate malignant bone marrow cells, puts patients in a protracted neutropenic state. During this profound and prolonged neutropenic phase, patients receive antibiotic therapy for suspected or identified bacterial infections. However, when fever or other signs of infection continue despite antibiotic therapy, patients frequently need to be treated for suspected or identified systemic fungal infections. These infections may occur in patients receiving either standard antileukemia therapy or research protocol therapy involving new drugs, new drug combinations, higher doses, or newer schedules of established drugs. After antifungal therapy is initiated, it may be continued postdischarge in outpatient or homecare settings. Therefore, becoming knowledgeable about antifungal therapy is important for all oncology nurses regardless of practice setting.