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Cells Nov 2023Candidiasis is a highly pervasive infection posing major health risks, especially for immunocompromised populations. Pathogenic species have evolved intrinsic and... (Review)
Review
Candidiasis is a highly pervasive infection posing major health risks, especially for immunocompromised populations. Pathogenic species have evolved intrinsic and acquired resistance to a variety of antifungal medications. The primary goal of this literature review is to summarize the molecular mechanisms associated with antifungal resistance in species. Resistance can be conferred via gain-of-function mutations in target pathway genes or their transcriptional regulators. Therefore, an overview of the known gene mutations is presented for the following antifungals: azoles (fluconazole, voriconazole, posaconazole and itraconazole), echinocandins (caspofungin, anidulafungin and micafungin), polyenes (amphotericin B and nystatin) and 5-fluorocytosine (5-FC). The following mutation hot spots were identified: (1) ergosterol biosynthesis pathway mutations (ERG11 and UPC2), resulting in azole resistance; (2) overexpression of the efflux pumps, promoting azole resistance (transcription factor genes: and ; transporter genes: CDR1, CDR2, MDR1, PDR16 and SNQ2); (3) cell wall biosynthesis mutations (FKS1, FKS2 and PDR1), conferring resistance to echinocandins; (4) mutations of nucleic acid synthesis/repair genes (FCY1, FCY2 and FUR1), resulting in 5-FC resistance; and (5) biofilm production, promoting general antifungal resistance. This review also provides a summary of standardized inhibitory breakpoints obtained from international guidelines for prominent species. Notably, , and demonstrate fluconazole resistance.
Topics: Antifungal Agents; Candida; Fluconazole; Echinocandins; Azoles
PubMed: 37998390
DOI: 10.3390/cells12222655 -
The Journal of Antimicrobial... Feb 2020Candida albicans is an opportunistic yeast and the major human fungal pathogen in the USA, as well as in many other regions of the world. Infections with C. albicans can... (Review)
Review
Candida albicans is an opportunistic yeast and the major human fungal pathogen in the USA, as well as in many other regions of the world. Infections with C. albicans can range from superficial mucosal and dermatological infections to life-threatening infections of the bloodstream and vital organs. The azole antifungals remain an important mainstay treatment of candidiasis and therefore the investigation and understanding of the evolution, frequency and mechanisms of azole resistance are vital to improving treatment strategies against this organism. Here the organism C. albicans and the genetic changes and molecular bases underlying the currently known resistance mechanisms to the azole antifungal class are reviewed, including up-regulated expression of efflux pumps, changes in the expression and amino acid composition of the azole target Erg11 and alterations to the organism's typical sterol biosynthesis pathways. Additionally, we update what is known about activating mutations in the zinc cluster transcription factor (ZCF) genes regulating many of these resistance mechanisms and review azole import as a potential contributor to azole resistance. Lastly, investigations of azole tolerance in C. albicans and its implicated clinical significance are reviewed.
Topics: Antifungal Agents; Azoles; Candida albicans; Candidiasis; Drug Resistance, Fungal; Fungal Proteins; Humans; Microbial Sensitivity Tests; Transcription Factors
PubMed: 31603213
DOI: 10.1093/jac/dkz400 -
MBio Aug 2023Each year, fungi cause more than 1.5 billion infections worldwide and have a devastating impact on human health, particularly in immunocompromised individuals or...
Each year, fungi cause more than 1.5 billion infections worldwide and have a devastating impact on human health, particularly in immunocompromised individuals or patients in intensive care units. The limited antifungal arsenal and emerging multidrug-resistant species necessitate the development of new therapies. One strategy for combating drug-resistant pathogens is the administration of molecules that restore fungal susceptibility to approved drugs. Accordingly, we carried out a screen to identify small molecules that could restore the susceptibility of pathogenic species to azole antifungals. This screening effort led to the discovery of novel 1,4-benzodiazepines that restore fluconazole susceptibility in resistant isolates of , as evidenced by 100-1,000-fold potentiation of fluconazole activity. This potentiation effect was also observed in azole-tolerant strains of and in other pathogenic species. The 1,4-benzodiazepines selectively potentiated different azoles, but not other approved antifungals. A remarkable feature of the potentiation was that the combination of the compounds with fluconazole was fungicidal, whereas fluconazole alone is fungistatic. Interestingly, the potentiators were not toxic to in the absence of fluconazole, but inhibited virulence-associated filamentation of the fungus. We found that the combination of the potentiators and fluconazole significantly enhanced host survival in a model of systemic fungal infection. Taken together, these observations validate a strategy wherein small molecules can restore the activity of highly used anti-infectives that have lost potency. IMPORTANCE In the last decade, we have been witnessing a higher incidence of fungal infections, due to an expansion of the fungal species capable of causing disease (e.g., ), as well as increased antifungal drug resistance. Among human fungal pathogens, species are a leading cause of invasive infections and are associated with high mortality rates. Infections by these pathogens are commonly treated with azole antifungals, yet the expansion of drug-resistant isolates has reduced their clinical utility. In this work, we describe the discovery and characterization of small molecules that potentiate fluconazole and restore the susceptibility of azole-resistant and azole-tolerant isolates. Interestingly, the potentiating 1,4-benzodiazepines were not toxic to fungal cells but inhibited their virulence-associated filamentous growth. Furthermore, combinations of the potentiators and fluconazole decreased fungal burdens and enhanced host survival in a model of systemic fungal infections. Accordingly, we propose the use of novel antifungal potentiators as a powerful strategy for addressing the growing resistance of fungi to clinically approved drugs.
Topics: Humans; Antifungal Agents; Candida; Fluconazole; Azoles; Pharmaceutical Preparations; Microbial Sensitivity Tests; Candida albicans; Mycoses; Drug Resistance, Fungal; Benzodiazepines
PubMed: 37326546
DOI: 10.1128/mbio.00479-23 -
Microbiology and Immunology Mar 2022Aspergillus fumigatus, a ubiquitous pathogen, causes aspergillosis in humans, especially in immunodeficient patients. Azoles are frontline antifungal drugs for treating... (Review)
Review
Aspergillus fumigatus, a ubiquitous pathogen, causes aspergillosis in humans, especially in immunodeficient patients. Azoles are frontline antifungal drugs for treating aspergillosis. The recent global emergence of azole resistance in A. fumigatus has become a serious problem worldwide. It has arisen through two routes: long-term azole medical therapy, called the patient route, and the use of azole fungicides in its habitats especially for agricultural activities, called the environmental route. Resistant strains developed through the latter route show cross-resistance to medical azoles because of the identical molecular target Cyp51A between azole compounds used for medical treatment and agricultural disease control. In azole-resistant strains arising through the environmental route, A. fumigatus is observed frequently to possess mutations in the cyp51A gene linked to tandem repeats in the promoter region such as TR /L98H and TR /Y121F/T289A. The results of microsatellite genotyping analyses of resistant A. fumigatus strains have suggested a transboundary spread of this microorganism in many countries. Diverse actors are involved in the global highway of transmission. Therefore, the matter must be addressed as a "One Health" issue. This review presents a background of azole resistance in A. fumigatus and introduces newly discovered difficulties generated as this pathogen spreads worldwide.
Topics: Antifungal Agents; Aspergillus fumigatus; Azoles; Drug Resistance, Fungal; Fungal Proteins; Humans; Microbial Sensitivity Tests; Mutation
PubMed: 34870333
DOI: 10.1111/1348-0421.12957 -
Organic & Biomolecular Chemistry Dec 2017This review discusses the chemistry of cyclic azole-homologated peptides (AHPs) from the marine sponges, Theonella swinhoei, other Theonella species, Calyx spp. and... (Review)
Review
This review discusses the chemistry of cyclic azole-homologated peptides (AHPs) from the marine sponges, Theonella swinhoei, other Theonella species, Calyx spp. and Plakina jamaicensis. The origin, distribution of AHPs and molecular structure elucidations of AHPs are described followed by their biosynthesis, bioactivity, and synthetic efforts towards their total synthesis. Reports of partial and total synthesis of AHPs extend beyond peptide coupling reactions and include creative construction of the non-proteinogenic amino acid components, mainly the homologated heteroaromatic and α-keto-β-amino acids. A useful conclusion is drawn regarding AHPs: despite their rarity, exotic structures and the potent protease inhibitory properties of some members, their synthesis is under-developed and beckons solutions for outstanding problems towards their efficient assembly.
Topics: Animals; Azoles; Molecular Conformation; Peptides; Porifera
PubMed: 29210421
DOI: 10.1039/c7ob02628e -
Clinical Microbiology and Infection :... Feb 2022To assess the prevalence and genetic basis of antifungal resistance mechanisms as well as the genotyping of Candida tropicalis from clinical and non-clinical sources in...
Azole and echinocandin resistance mechanisms and genotyping of Candida tropicalis in Japan: cross-boundary dissemination and animal-human transmission of C. tropicalis infection.
OBJECTIVES
To assess the prevalence and genetic basis of antifungal resistance mechanisms as well as the genotyping of Candida tropicalis from clinical and non-clinical sources in Japan.
METHODS
Eighty C. tropicalis isolates, including 32 clinical isolates recovered from 29 patients and 48 non-clinical isolates recovered from 24 different sources (animals and the environment) were evaluated. All isolates were tested phenotypically for resistance to a wide range of antifungals and genotypically for resistance mechanisms to azole and echinocandin. Furthermore, all the isolates were genotyped by multilocus sequence typing (MLST).
RESULTS
Phenotypically, 30.2% (16/53) of the isolates were azole-resistant, with high levels of azole resistance among clinical isolates (51.7%; 15/29) and low levels (4.2%; 1/24) among non-clinical isolates. None of the isolates were reported as echinocandin resistant, with 60.4% (32/53) of the isolates intermediate to caspofungin. Azole resistance was basically attributed to high expression levels of drug efflux transporter genes (CDR2 and CDR3), transcription factors (TAC1 and UPC2) and ergosterol biosynthesis pathway HMG gene. No FKS1 hot spot 1 (HS1) or HS2 missense mutations were detected in any of the isolates. MLST analysis revealed 36 different sequence types (STs), with the first identification of 23 new STs. Phylogenetic analysis confirmed the close relationship between the clinical and non-clinical isolates, with identifications of ST232 and ST933 among patients and marine mammals.
CONCLUSION
Our results confirmed the emergence of azole resistance in C. tropicalis in Japan. Furthermore, phylogenetic analysis confirmed the transboundary dissemination and cross-transmission of C. tropicalis between humans and animals.
Topics: Animals; Antifungal Agents; Azoles; Candida tropicalis; Drug Resistance, Fungal; Echinocandins; Genotype; Humans; Japan; Microbial Sensitivity Tests; Multilocus Sequence Typing; Phylogeny
PubMed: 34687855
DOI: 10.1016/j.cmi.2021.10.004 -
The Journal of Antimicrobial... Sep 2020The voriconazole and echinocandin combination has been found to be synergistic in vitro and in vivo against most Aspergillus fumigatus isolates, both with a WT azole...
BACKGROUND
The voriconazole and echinocandin combination has been found to be synergistic in vitro and in vivo against most Aspergillus fumigatus isolates, both with a WT azole phenotype and an azole-resistant phenotype. The interaction between isavuconazole and echinocandins is less well studied. This is especially true for azole-resistant isolates.
OBJECTIVES
We investigated the in vitro interaction between isavuconazole and anidulafungin for 30 A. fumigatus isolates including 18 azole-resistant isolates with various isavuconazole resistance phenotypes.
METHODS
The isavuconazole/anidulafungin interaction was studied by using an adapted EUCAST-based 2D (12 × 8) chequerboard broth microdilution colorimetric assay using XTT. The interaction was analysed by FIC index (FICi) analysis and Bliss independence (BI) interaction analysis.
RESULTS
Both the FICi analysis and the BI analysis showed synergistic interaction between isavuconazole and anidulafungin for the majority of WT and azole-resistant isolates. As we did not see significant beneficial effects of combination therapy in TR46/Y121F/T289A isolates at clinically achievable drug concentrations, it is unlikely that TR46/Y121F/T289A infections would benefit from isavuconazole and anidulafungin combination therapy.
CONCLUSIONS
In regions with high azole resistance rates this combination may benefit patients with WT disease, azole-resistant invasive aspergillosis and those with mixed azole-susceptible and azole-resistant infection, but may not be beneficial for aspergillosis due to isolates with high isavuconazole resistance, such as TR46/Y121F/T289A isolates.
Topics: Anidulafungin; Antifungal Agents; Aspergillus fumigatus; Azoles; Drug Resistance, Fungal; Fungal Proteins; Humans; Microbial Sensitivity Tests; Nitriles; Pyridines; Triazoles
PubMed: 32516368
DOI: 10.1093/jac/dkaa185 -
The Journal of Antimicrobial... Dec 2023Global emergence of rapidly developing resistance to multiple antifungal drugs and high mortality pose challenges to the treatment of invasive Candida auris infections....
BACKGROUND
Global emergence of rapidly developing resistance to multiple antifungal drugs and high mortality pose challenges to the treatment of invasive Candida auris infections. New therapeutic approaches are needed, such as repurposing drugs including combination with antifungals. Statins have been reported to exert antifungal effects against various Candida species.
OBJECTIVES
Our study investigated potential synergy between the statins (rosuvastatin and fluvastatin) and azoles (voriconazole, posaconazole and isavuconazole) on clinical isolates of C. auris.
METHODS
Twenty-one clinical isolates of C. auris were obtained. Chequerboard assays based on the CLSI broth microdilution method were used to assess synergy based on FIC index (FICI) calculations of MICs of individual drugs and in combinations.
RESULTS
Single drug geometric mean (GM) MICs of fluvastatin and rosuvastatin were ≥128 mg/L in all 21 isolates. GM (range) MICs of posaconazole, voriconazole and isavuconazole were 0.259 (0.016-1 mg/L), 0.469 (0.016-2 mg/L) and 0.085 (0.004-1 mg/L), respectively. Combination of azoles with fluvastatin showed synergy in 70%-90% of C. auris isolates. In particular, voriconazole/fluvastatin resulted in 16-fold reduction in voriconazole MIC and synergy in 14/21 (67%) isolates. Posaconazole/fluvastatin resulted in 8-fold reduction in posaconazole MIC and synergy in 19/21 (90%) isolates.Combining rosuvastatin with the azoles also showed synergy against C. auris in 40%-60% of the isolates and additive effect in 40%-50%. None of the combinations was antagonistic.
CONCLUSIONS
Our results provide a rationale for pursuing in vivo synergy tests as well as clinical studies to explore tolerability, treatment outcomes, optimal dose and exposure targets.
Topics: Antifungal Agents; Voriconazole; Candida auris; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Fluvastatin; Rosuvastatin Calcium; Azoles; Microbial Sensitivity Tests; Drug Resistance, Fungal
PubMed: 37823357
DOI: 10.1093/jac/dkad303 -
Medical Mycology Journal 2022In clinical settings, the number of immune compromised patients have increased as a result of developments in medical technology (e.g., organ transplantation, anticancer... (Review)
Review
In clinical settings, the number of immune compromised patients have increased as a result of developments in medical technology (e.g., organ transplantation, anticancer drugs, steroids, TNF inhibitors, etc.). However, patients with fungal diseases are also increasing globally. In recent years, the distribution and pathogenicity of fungi worldwide have been changing, with reports that new fungi are emerging, and antifungal-resistant fungi are spreading globally. Global warming, globalization, human activities, and other factors have been suggested as contributing to the emergence of new fungi. Some of the antifungals against which resistant fungi have emerged are commonly used not only for human but also for animal health care and crop protection. Consequently, the occurrence of antifungal-resistant fungi has become a clinical issue. Solving these problems entails continuing the "One Health" approach, which in turn requires updating medical mycology information with regard to the emerging pathogenic fungi. In particular, this paper reviews the recent information on Cryptococcus gattii, Candia auris, and azole-resistant Aspergillus fumigatus.
Topics: Animals; Antifungal Agents; Aspergillus fumigatus; Azoles; Drug Resistance, Fungal; Humans; Microbial Sensitivity Tests; Mycology; One Health
PubMed: 35228480
DOI: 10.3314/mmj.22.001 -
Philosophical Transactions of the Royal... Dec 2016Aspergillus fungi are the cause of an array of diseases affecting humans, animals and plants. The triazole antifungal agents itraconazole, voriconazole, isavuconazole... (Review)
Review
Aspergillus fungi are the cause of an array of diseases affecting humans, animals and plants. The triazole antifungal agents itraconazole, voriconazole, isavuconazole and posaconazole are treatment options against diseases caused by Aspergillus However, resistance to azoles has recently emerged as a new therapeutic challenge in six continents. Although de novo azole resistance occurs occasionally in patients during azole therapy, the main burden is the aquisition of resistance through the environment. In this setting, the evolution of resistance is attributed to the widespread use of azole-based fungicides. Although ubiquitously distributed, A. fumigatus is not a phytopathogen. However, agricultural fungicides deployed against plant pathogenic moulds such as Fusarium, Mycospaerella and A. flavus also show activity against A. fumigatus in the environment and exposure of non-target fungi is inevitable. Further, similarity in molecule structure between azole fungicides and antifungal drugs results in cross-resistance of A. fumigatus to medical azoles. Clinical studies have shown that two-thirds of patients with azole-resistant infections had no previous history of azole therapy and high mortality rates between 50% and 100% are reported in azole-resistant invasive aspergillosis. The resistance phenotype is associated with key mutations in the cyp51A gene, including TR/L98H, TR and TR/Y121F/T289A resistance mechanisms. Early detection of resistance is of paramount importance and if demonstrated, either with susceptibility testing or through molecular analysis, azole monotherapy should be avoided. Liposomal amphotericin B or a combination of voriconazole and an echinocandin are recomended for azole-resistant aspergillosis.This article is part of the themed issue 'Tackling emerging fungal threats to animal health, food security and ecosystem resilience'.
Topics: Antifungal Agents; Aspergillosis; Aspergillus fumigatus; Azoles; Drug Resistance, Fungal; Fungicides, Industrial; Phenotype
PubMed: 28080986
DOI: 10.1098/rstb.2015.0460