Antifungal agent susceptibilities and interpretation of Malassezia pachydermatis and Candida parapsilosis isolated from dogs with and without seborrheic dermatitis skin

Malassezia: Zoonotic Implications, Parallels and Differences in Colonization and Disease in Humans and Animals

Malassezia spp. are commensals of the skin, oral/sinonasal cavity, lower respiratory and gastrointestinal tract. Eighteen species have been recovered from humans, other mammals and birds. They can also be isolated from diverse environments, suggesting an evolutionary trajectory of adaption from an ecological niche in plants and soil to the mucocutaneous ecosystem of warm-blooded vertebrates. In humans, dogs and cats, Malassezia-associated dermatological conditions share some commonalities. Otomycosis is common in companion animals but is rare in humans. Systemic infections, which are increasingly reported in humans, have yet to be recognized in animals. Malassezia species have also been identified as pathogenetic contributors to some chronic human diseases. While Malassezia species are host-adapted, some species are zoophilic and can cause fungemia, with outbreaks in neonatal intensive care wards associated with temporary colonization of healthcare worker’s hands from contact with their pets. Although standardization is lacking, susceptibility testing is usually performed using a modified broth microdilution method. Antifungal susceptibility can vary depending on Malassezia species, body location, infection type, disease duration, presence of co-morbidities and immunosuppression. Antifungal resistance mechanisms include biofilm formation, mutations or overexpression of ERG11, overexpression of efflux pumps and gene rearrangements or overexpression in chromosome 4.

Conventional therapy and new antifungal drugs against Malassezia infections

Malassezia yeasts are commensal microorganisms occurring on the skin of humans and animals causing dermatological disorders or systemic infections in severely immunocompromised hosts. Despite attempts to control such yeast infections with topical and systemic antifungals, recurrence of clinical signs of skin infections as well as treatment failure in preventing or treating Malassezia furfur fungemia have been reported most likely due to wrong management of these infections (e.g., due to early termination of treatment) or due to the occurrence of resistant phenomena. Standardized methods for in vitro antifungal susceptibility tests of these yeasts are still lacking, thus resulting in variable susceptibility profiles to azoles among Malassezia spp. and a lack of clinical breakpoints. The inherent limitations to the current pharmacological treatments for Malassezia infections both in humans and animals, stimulated the interest of the scientific community to discover new, effective antifungal drugs or substances to treat these infections. In this review, data about the in vivo and in vitro antifungal activity of the most commonly employed drugs (i.e., azoles, polyenes, allylamines, and echinocandins) against Malassezia yeasts, with a focus on human bloodstream infections, are summarized and their clinical implications are discussed. In addition, the usefulness of alternative compounds is discussed.

Biology, diagnosis and treatment of Malassezia dermatitis in dogs and cats Clinical Consensus Guidelines of the World Association for Veterinary Dermatology

BACKGROUND

The genus Malassezia is comprised of a group of lipophilic yeasts that have evolved as skin commensals and opportunistic cutaneous pathogens of a variety of mammals and birds.

OBJECTIVES

The objective of this document is to provide the veterinary community and other interested parties with current information on the ecology, pathophysiology, diagnosis, treatment and prevention of skin diseases associated with Malassezia yeasts in dogs and cats.

METHODS AND MATERIAL

The authors served as a Guideline Panel (GP) and reviewed the literature available prior to October 2018. The GP prepared a detailed literature review and made recommendations on selected topics. The World Association of Veterinary Dermatology (WAVD) Clinical Consensus Guideline committee provided guidance and oversight for this process. The document was presented at two international meetings of veterinary dermatology societies and one international mycology workshop; it was made available for comment on the WAVD website for a period of six months. Comments were shared with the GP electronically and responses incorporated into the final document.

CONCLUSIONS AND CLINICAL IMPORTANCE

There has been a remarkable expansion of knowledge on Malassezia yeasts and their role in animal disease, particularly since the early 1990's. Malassezia dermatitis in dogs and cats has evolved from a disease of obscurity and controversy on its existence, to now being a routine diagnosis in general veterinary practice. Clinical signs are well recognised and diagnostic approaches are well developed. A range of topical and systemic therapies is known to be effective, especially when predisposing factors are identified and corrected.

Malassezia spp. Yeasts of Emerging Concern in Fungemia

Malassezia spp. are lipid-dependent yeasts, inhabiting the skin and mucosa of humans and animals. They are involved in a variety of skin disorders in humans and animals and may cause bloodstream infections in severely immunocompromised patients. Despite a tremendous increase in scientific knowledge of these yeasts during the last two decades, the epidemiology of Malassezia spp. related to fungemia remains largely underestimated most likely due to the difficulty in the isolation of these yeasts species due to their lipid-dependence. This review summarizes and discusses the most recent literature on Malassezia spp. infection and fungemia, its occurrence, pathogenicity mechanisms, diagnostic methods, in vitro susceptibility testing and therapeutic approaches.

In Vitro Azole and Amphotericin B Susceptibilities of Malassezia furfur from Bloodstream Infections Using E-Test and CLSI Broth Microdilution Methods

The number of reports of Malassezia furfur bloodstream infections is constantly increasing and there is a need for more simple antifungal susceptibility methods for their management. In this study, a total of 39 M. furfur isolates collected from hospitalized patients with fungemia were screened for antifungal susceptibility to azole and amphotericin B (AmB) using Clinical and Laboratory Standards Institute broth microdilution (CLSI BMD) and E-test in Sabouraud dextrose agar + 1% Tween80 (SDAt) and mDixon agar (DIX). Essential agreement (EA) and discrepancies between the two methods were evaluated after 48 h and 72 h reading times. Itraconazole (ITZ) and posaconazole (POS) displayed the lowest MIC values whereas fluconazole (FLZ) and AmB the highest, regardless of the methods and the reading time. The EA between BMD was >95% for FLZ and voriconazole (VOR) regardless of the media in the E-tests and reading time. The EA between BMD with E-test for AmB was >97% only when E-test in SDAt was used. The EA between BMD and E-test for ITZ and POS varied according to the media in E-test procedures and the reading time and was higher than 66.6% (POS) or 72% (ITZ) only when SABt was used. Substantial discrepancies for ITZ and POS were >5.1% regardless of the media and the reading time. This study suggests that the E-test in SABt represents an alternative method to CLSI BMD to evaluate the susceptibility of M. furfur to FLZ, VOR and AmB and not for ITZ and POS.

Effect of essential oils from Mangifera indica L. cultivars on the antifungal susceptibility of Candida spp. strains isolated from dogs

SUMMARY This work reports the chemical study, and anti-Candida spp. activity of leaf essential oil from Mangifera indica cultivars. The essential oils were obtained by hydro-distillation and analyzed by gas chromatography/mass spectroscopy. The anti-Candida spp. activity was evaluated against strains isolated from dogs by the agar-well diffusion method and the minimum inhibitory concentration (MIC) by the broth microdilution method. Tommy Atkins cultivar presented β–selinene (29.49%), caryophyllene oxide (12.40%) and humulene II epoxide (8.66%) as main constituents, while the main constituents of Rosa, Moscatel and Jasmim varieties were caryophyllene oxide (23.62, 48.42 and 30.77%, respectively) and humulene epoxide II (11.56, 23.45, and16.27%, respectively). The means of inhibition zones were 11 ± 0.71, 13.5 ± 3.54, 10.5 ± 0.71 and 13.5 ± 0.71mm to Tommy Atkins, Rosa, Moscatel and Jasmim varieties, respectively. For Tommy Atkins, the MIC ranged from 0.62 to 1.25 mg/mL; for Rosa, ranged from 0.31 to 1.25 mg/mL; for Jasmim ranged from 0.31 to 0.62 mg/mL; while for the Moscatel variety the MIC value was 1.25 mg/mL for all Candida strains. Essential oils of four M. indica cultivars were active in vitro against Candida spp., demonstrating good antifungal activity and can be a useful source of antifungal compounds for veterinary medicine.

Effects in dogs with behavioural disorders of a commercial nutraceutical diet on stress and neuroendocrine parameters

The well-being of dogs can be affected by changes in human lifestyle, eating habits and increased stressors that lead to behavioural disorders including fear, hyperactivity and anxiety, followed by negative affective moods and poor welfare. This randomised, controlled clinical evaluation involved 69 dogs, 38 males and 31 females, of different breeds, with behavioural disorders related to anxiety and chronic stress. They were fed a control diet or a nutraceutical diet (ND group) for 45 days. Neuroendocrine (serotonin, dopamine, β-endorphins, noradrenaline and cortisol) and stress (derivatives of reactive oxygen metabolites (dROMs) and biological antioxidant potential (BAP)) parameters related to behavioural disorders were evaluated at the beginning and end of the study period. Results showed a significant increase in serotonin, dopamine and β-endorphins plasma concentrations (*P<0.05, *P<0.05 and **P<0.01, respectively) and a significant decrease in noradrenaline and cortisol plasma concentrations in the ND group (*P<0.05). dROMs significantly decreased in the ND group (*P<0.05) while BAP was not affected. This study demonstrated for the first time that a specific diet significantly and positively affected neuroendocrine parameters and dROMs. These results open significant perspectives concerning the use of diet and nutraceuticals in the treatment of behavioural disorders.

The mPEG-PCL Copolymer for Selective Fermentation of Staphylococcus lugdunensis Against Candida parapsilosis in the Human Microbiome

Many human skin diseases, such as seborrheic dermatitis, potentially occur due to the over-growth of fungi. It remains a challenge to develop fungicides with a lower risk of generating resistant fungi and non-specifically killing commensal microbes. Our probiotic approaches using a selective fermentation initiator of skin commensal bacteria, fermentation metabolites or their derivatives provide novel therapeutics to rein in the over-growth of fungi. Staphylococcus lugdunensis (S. lugdunensis) bacteria and Candida parapsilosis (C. parapsilosis) fungi coexist in the scalp microbiome. S. lugdunensis interfered with the growth of C. parapsilosis via fermentation. A methoxy poly(ethylene glycol)-b-poly(ε-caprolactone) (mPEG-PCL) copolymer functioned as a selective fermentation initiator of S. lugdunensis, selectively triggering the S. lugdunensis fermentation to produce acetic and isovaleric acids. The acetic acid and its pro-drug diethyleneglycol diacetate (Ac-DEG-Ac) effectively suppressed the growth of C. parapsilosis in vitro and impeded the fungal expansion in the human dandruff. We demonstrate for the first time that S. lugdunensis is a skin probiotic bacterium that can exploit mPEG-PCL to yield fungicidal short-chain fatty acids (SCFAs). The concept of bacterial fermentation as a part of skin immunity to re-balance the dysbiotic microbiome warrants a novel avenue for studying the probiotic function of the skin microbiome in promoting health.

Agar Diffusion Procedures for Susceptibility Testing of Malassezia pachydermatis: Evaluation of Mueller-Hinton Agar Plus 2 % Glucose and 0.5 µg/ml Methylene Blue as the Test Medium

Aim of this study was to verify whether Mueller-Hinton agar supplemented with 2 % glucose and methylene blue (MH-GM), which is used for disk diffusion susceptibility testing of Candida species by the Clinical and Laboratory Standards Institute, is suitable for testing Malassezia pachydermatis. A variant of the disk diffusion procedure utilizing a 9-mm tablet was used to test 31 isolates against clotrimazole and miconazole using MH-GM as test medium. The MH-GM agar optimally supported the growth of all M. pachydermatis isolates, provided that the yeast inoculum was prepared with a lipid source (Tween 40 and 80). Zone edges were frequently definite and clear, facilitating the measurement of zone size and minimizing subjectivity. The inhibition zones correlated with MIC values obtained in a broth dilution assay. The agar diffusion method with MH-GM as the test medium appears as a suitable procedure for testing the susceptibility of M. pachydermatis to CTZ and MCZ in clinical laboratories. This test format may allow processing a large number of isolates in epidemiological studies. This may in turn facilitate clarifying to what extent the problem "drug resistance" accounts for cases of treatment failure in dogs with Malassezia otitis and dermatitis.

In vitro antifungal susceptibility of Malassezia furfur from bloodstream infections

Fungaemia caused by Malassezia spp. in hospitalized patients requires prompt and appropriate therapy, but standard methods for the definition of the in vitro antifungal susceptibility have not been established yet. In this study, the in vitro susceptibility of Malassezia furfur from bloodstream infections (BSIs) to amphotericin B (AMB), fluconazole (FLC), itraconazole (ITC), posaconazole (POS) and voriconazole (VRC) was assessed using the broth microdilution (BMD) method of the Clinical and Laboratory Standards Institute (CLSI) with different media such as modified Sabouraud dextrose broth (SDB), RPMI and Christensen’s urea broth (CUB). Optimal broth media that allow sufficient growth of M. furfur, and produce reliable and reproducible MICs using the CLSI BMD protocol were assessed. Thirty-six M. furfur isolates collected from BSIs of patients before and during AMB therapy, and receiving FLC prophylaxis, were tested. A good growth of M. furfur was observed in RPMI, CUB and SDB at 32 °C for 48 and 72 h. No statistically significant differences were detected between the MIC values registered after 48 and 72 h incubation. ITC, POS and VRC displayed lower MICs than FLC and AMB. These last two antifungal drugs showed higher and lower MICs, respectively, when the isolates were tested in SDB. SDB is the only medium in which it is possible to detect isolates with high FLC MICs in patients receiving FLC prophylaxis. A large number of isolates showed high AMB MIC values regardless of the media used. In conclusion, SDB might be suitable to determine triazole susceptibility. However, the media, the drug formulation or the breakpoints herein applied might not be useful for assessing the AMB susceptibility of M. furfur from BSIs.