Addition Of Fluconazole Research Articles

Trichophyton indotineae Erg1Ala448Thr Strain Expressed Constitutively High Levels of Sterol 14-α Demethylase Erg11B mRNA, While Transporter MDR3 and Erg11A mRNA Expression Was Induced After Addition of Short Chain Azoles

Trichophyton indotineae is an emerging pathogen causing recalcitrant skin infections and exhibiting multiple resistances to azoles and allylamines. Squalene epoxidase erg1Ala448Thr mutants often show association with azole resistance. RT-PCR gene expression analysis helps to elucidate the connection between ergosterol biosynthesis regulation and efflux control through the activation of multidrug resistance (MDR) and major facilitator superfamily (MFS1) transporters as well as heat shock proteins (HSP). Several T. indotineae isolates demonstrated a heat-dependent increase of Erg11B transcripts combined with downregulation of Erg1, suggesting a protective role for Erg11B. They also showed persistent upregulation of MFS1. The addition of fluconazole or voriconazole induced the expression of Erg11A, MDR3 and, to a lesser extent, Erg11B and Erg1. The azole-resistant erg1Ala448Thr mutant UKJ 476/21 exhibited exceptionally high transcript levels of sterol 14-αdemethylase Erg11B, combined with the inability of HSP60 and HSP90 to respond to increasing growth temperatures. Itraconazole demonstrated similar effects in a few T. indotineae isolates, but terbinafine did not enhance Erg1 transcription at all. Overexpression of Erg11B may explain the multiple azole resistance phenotype, whereas Erg11B point mutations are not associated with resistance to azoles used for medical treatment.

Comparing the efficacy of fluconazole and cryotherapy Versus cryotherapy alone on treating cutaneous leishmaniasis: a triple-blind randomized clinical trial

ObjectiveCutaneous Leishmaniasis (CL) is one of the highly prevalent endemic diseases in the Middle East. The disease is a complex skin infection imposing a heavy burden on many developing countries. This study aimed to evaluate the impact of adding oral fluconazole to topical cryotherapy on the treatment efficacy and time to achieve complete recovery of CL lesions.MethodThis triple-blind randomized clinical trial included 52 participants with CL. Participants were allocated to receive either weekly cryotherapy with liquid nitrogen and oral fluconazole at a dose of 6 mg/kg daily at a maximum of 400 mg for 6 weeks as the interventional arm or weekly cryotherapy with liquid nitrogen plus the placebo for the same period of 6 weeks as the control arm.ResultsFifty-two eligible participants enrolled the study, with a CL lesion count of 1 to 8 (mean 1.96), and served as the interventional (n = 28) and control (n = 24) arms. The trend of the mean surface area of the lesions was significantly decreasing in both arms (P < 0.001), with no statistically significant difference between arms (P = 0.133) or all assessed time point pairwise comparisons (P > 0.05). There was no significant difference between the treatment arms in terms of the end-point recovery status (P = 0.491) or the frequency of post-treatment secretion (P = 0.437). No adverse effect was observed.ConclusionDespite a slightly higher reduction in the lesion surface in the cryotherapy and fluconazole treatment arm, the addition of fluconazole did not provide statistically significant therapeutic value to cryotherapy in the treatment of CL. However, with adjustment for the initial lesion size, the efficacy of the regimen in the interventional arm was more pronounced, though it was still insignificant.

S3207 Vanishing Tacrolimus Syndrome

Introduction: Cellular rejection is common and therapeutic IS levels are needed to minimize this risk. This case stresses the need to fully explore, and potentially reexplore common causes of subtherapeutic IS levels. Case Description/Methods: A 38-year-old man with history of alcohol related cirrhosis and liver transplant in 2019. followed by 2 episodes of acute rejection, presented with significantly abnormal liver tests. Tacrolimus levels were undetectable and liver biopsy showed moderate rejection. After a course of IV steroid, he was started on prednisone, sirolimus, and increased doses of tacrolimus. Tacrolimus levels remained undetectable despite escalating doses, and addition of fluconazole– used for cytochrome (CYP) inhibition. Liver tests worsened after initial improvements, and repeat biopsy showed changes of chronic rejection. He was treated with a 5-day course of anti-thymocyte globulin, steroids, and maintained on increased immunosuppression (IS). Drug levels for tacrolimus, sirolimus, and mycophenolate were undetectable. He reported medication adherence, and undetectable tacrolimus levels were thought to be due to CYP metabolism. With this concern, he was started on azathioprine and belatacept infusions for IS. He was readmitted with abdominal pain and chronic 10-15 stools daily. Physical exam was notable for abdominal pain, no jaundice or asterixis. Labs showed WBC 5.7, INR 1.03, total bilirubin 11.9, AST 784, ALT 714, Alkaline phosphatase 538, albumin 3.5, negative serology for EBV, CMV, and HSV, and tacrolimus level < 1.0. Lab testing for diarrhea was negative for viral and bacterial causes. With concern for malabsorption, IV tacrolimus was started. EGD and colonoscopy with biopsies were negative for malabsorptive pathology. He was started on pancreatic enzymes for concerns of pancreatic insufficiency, and fecal elastase obtained after was elevated. After 24 hours of IV tacrolimus, serum level was 22.7, and continued to rise even after reduction of dosing suggesting malabsorption as cause of subtherapeutic IS. Discussion: Therapeutic IS levels are vital for transplant success, with an understanding that this needs effective absorption and metabolism. Our patient failed to have therapeutic levels since shortly after his transplant– despite previous negative lab and endoscopic evaluations for malabsorption. We used tactics focused on abnormal metabolism, however, resultant drug levels after IV tacrolimus shows the importance of considering malabsorption as barriers to achieving therapeutic IS.

Diffuse Geometric Erosions on the Skin of a Premature Infant, Fraternal Twin Unaffected

Diffuse Geometric Erosions on the Skin of a Premature Infant, Fraternal Twin Unaffected

Conjugation of Aspergillus flavipes Taxol with Porphyrin Increases the Anticancer Activity of Taxol and Ameliorates Its Cytotoxic Effects.

Taxol is one of the potential anticancer drugs; however, the yield of Taxol and its cytotoxicity are common challenges. Thus, manipulating the Taxol biosynthetic pathway from endophytic fungi, in addition to chemical modification with biocompatible polymers, is the challenge. Four fungal isolates, namely, Aspergillus flavipes, A. terreus, A. flavus, and A. parasiticus, were selected from our previous study as potential Taxol producers, and their potency for Taxol production was evaluated in response to fluconazole and silver nitrate. A higher Taxol yield was reported in the cultures of A. flavipes (185 µg/L) and A. terreus (66 µg/L). With addition of fluconazole, the yield of Taxol was increased 1.8 and 1.2-fold for A. flavipes and A. terreus, respectively, confirming the inhibition of sterol biosynthesis and redirecting the geranyl phosphate pool to terpenoids synthesis. A significant inhibition of ergosterol biosynthesis by A. flavipes with addition of fluconazole was observed, correlating with the increase on Taxol yield. To increase the Taxol solubility and to reduce its cytotoxicity, Taxol was modified via chemical conjugation with porphyrin, and the degree of conjugation was checked from the Thin layer chromatography and UV spectral analysis. The antiproliferative activity of native and modified Taxol conjugates was evaluated; upon porphyrin conjugation, the activity of Taxol towards HepG2 was increased 1.5-fold, while its cytotoxicity to VERO cells was reduced 3-fold.

Short-Course Rather Than Low-Dose Amphotericin B May Exert Potential Influence on Mortality in Cryptococcal Meningitis Patients Treated With Amphotericin B Plus Flucytosine Alone or in Combination With Fluconazole.

BackgroundThe influence of Amphotericin B (AmB) dose and the addition of fluconazole (Flu) on the AmB + 5-flucytosine (5FC) regimen for cryptococcal meningitis (CM) treatment remain debatable.MethodsA retrospective study was conducted to compare 44 CM patients treated with AmB + 5FC and 78 CM patients treated with AmB + 5FC + Flu using the propensity score matching method. The effects of AmB dosage, AmB course and Flu addition on the cerebrospinal fluid (CSF) chemical profile recovery, adverse effects, and 90-day mortality were compared between the groups.ResultsNo differences in adverse effects, the rate of the 14-day CSF chemical profile recovery and 90-day cumulative survival rate (91.2% vs. 87.5%, P = 0.637) were observed between the AmB + 5FC group and the AmB + 5FC + Flu group. However, the incidence rates of hypokalemia (33.9%) and creatinine elevation (7.1%) in patients treated with an AmB dosage of 0.4–0.5 mg/kg/d were less than those (53.0 and 22.7%, respectively) treated with an AmB dosage of 0.6–0.7 mg/kg/d (P = 0.034 and P = 0.018, respectively). The 90-day cumulative survival rate was 70.1% for patients treated with AmB for <14 days and 96.4% for patients treated with AmB for ≥14 days (log-rank P < 0.001). Multivariate Cox proportional hazards models suggested the hazard ratio was 26.8 (95% CI: 3.9–183.2) for patients treated with AmB < 14 days than those treated with AmB ≥ 14 days (P = 0.001).ConclusionTreatment with AmB less than 14 days was associated with a higher 90-day mortality in CM patients. A relative lower dosage but prolonged course of AmB in the +5FC ± Flu regimen led to favorable trends of fewer adverse effects and comparable clinical efficacy.

In vitro interactions of crocin with fluconazole against Candida isolates.

Background and Purpose:The incidence of invasive fungal infections has been increased in recent years. The growing use of azole drugs for prophylactic and therapeutic purposes has resulted in the gradual emergence of azole-resistant species. Accordingly, the introduction of a new strategy to improve the management of Candida infections is an urgent need. Regarding this, the present study was performed to evaluate the antifungal activities of crocin (Cro) alone and in combination with fluconazole.Materials and Methods: This study was conducted on 50 clinical isolates of four different Candida species. The identity of the isolates was confirmed using the internal transcribed spacer identification system. The interactions of Cro with fluconazole were investigated using a microdilution checkerboard method based on the Clinical and Laboratory Standards Institute reference technique with 96-well microtiter plates. Furthermore, the assessment of the interaction of drug combinations was accomplished using the fractional inhibitory concentration index (FICI) based on the Loewe additivity theory. Results:According to the results, Cro alone showed a relatively high MIC50 value (1 g/ml) against Candida species. Our results demonstrated indifferent interactions between Cro and fluconazole with a FICI range of 0.5-4 against Candida strains.Conclusion:The high MIC value for Cro against Candida species indicated its failure to show appropriate antifungal activity against this species. The MIC of this agent was not significantly reduced even by the addition of fluconazole. Therefore, other mechanisms which are not related to the mechanism of azole drugs are involved at high concentration of Cro.

380. Drosophila melanogaster as a Facile Model for Large-Scale Studies of Virulence Mechanisms and Antifungal Drug Efficacy in Candida auris Candidiasis

Background Candida auris is an emerging multi-drug-resistant human pathogen. Experimental data on the pathogenicity of C. auris is scarce, especially regarding its virulence compared with C. albicans. Additionally, studies of drug efficacy against C. auris rely on conventional animal models that are laborious and low throughput; alternative, less cumbersome models are desirable. To that end, we developed a C. auris fly infection model.MethodsWe injected 2-week-old TollI-RXA/Tollr632 female flies with a needle dipped in Candida solutions (108 yeast cells/mL) in the dorsal side of the thorax. Flies were infected with 10 different C. auris strains (source: CDC/FDA) and a C. albicansclinical strain. For drug protection studies, C. auris isolate AR-BANK#0386 [MICs: fluconazole (FLC) > 64, posaconazole (POSA) 0.125–0.25, isavuconazole (ISA) 0.25–1, voriconazole (VRC) 0.5–2 µg/mL)] was used. We assessed survival differences associated with different inocula (107 to 1010 yeast cells/mL) and yeast strains. Moreover, protection conferred by addition of FLC, VRC, ISA, POSA, or FLC combined with 5-FC (flucytosine) and/or nikkomycin Z (NikZ) to fly food was studied. Three independent runs were performed for each experiment.ResultsA) All C. auris strains and C. albicans exhibited comparable in vitro growth rates. B) All strains of C. auris were similarly more virulent than C. albicans (P < 0.0001), with all flies dying by day 7 post-infection. C) FLC, VRC, ISA, FLC+5-FC, FLC+NikZ, or FLC+NikZ+5-FC-fed flies infected with C. auris #0386 had comparably poor survival outcomes compared with untreated C. auris #0386-infected flies. Interestingly, survival rates were improved in POSA-fed infected flies compared with FLC-treated or untreated infected flies (P < 0.0001). As POSA is a cell-associated drug, we are conducting C. auris phagocytosis assays with Drosophila hemocytes that are co-incubated or not with POSA.Conclusion Drosophila is a promising, fast, and inexpensive in-vivo model to study pathogenesis and drug activity in C. auris candidiasis.Disclosures N. Beyda, Astellas: Scientific Advisor, Grant recipient. D. P. Kontoyiannis, Merck: Consultant, Research support and Speaker honorarium. Pfizer: Consultant, Research support. Astellas: Consultant, Research support and Speaker honorarium. Gilead: Speaker’s Bureau, Speaker honorarium. F2G Inc.: Speaker’s Bureau, Speaker honorarium. Cidara Inc.: Speaker’s Bureau, Speaker honorarium. Jazz Pharmaceuticals: Speaker’s Bureau, Speaker honorarium.

53-Year-Old Man With a Swollen Finger

53-Year-Old Man With a Swollen Finger

Amphotericin B colloidal dispersion combined with flucytosine with or without fluconazole for treatment of murine cryptococcal meningitis.

Studies with animals and in vitro studies have demonstrated that flucytosine plus amphotericin B or fluconazole has significantly improved mycologic activity against meningitis caused by Cryptococcus neoformans compared to the activity of amphotericin B or fluconazole used alone. However, few doses have been tested in combination. This study evaluated the antifungal efficacy of amphotericin B colloidal dispersion (ABCD) combined with flucytosine with and without fluconazole in a murine model of cryptococcal meningitis. The following dosages were tested: ABCD at 0 to 12.5 mg/kg of body weight given intravenously 3 days/week, flucytosine at 0 to 110 mg/kg/day, and fluconazole at 0 to 50 mg/kg/day. Meningitis was established in male BALB/c mice by intracerebral injection of C. neoformans. Treatment with flucytosine with or without fluconazole dissolved in the sole source of drinking water was started on day 2; animals were sacrificed at 16 days, and the numbers of fungal colonies in the brain were quantified. A survival rate of 100% was achieved with ABCD plus flucytosine without fluconazole; however, the addition of fluconazole was required to prevent weight loss (P < 0.00001) and to achieve the maximum antifungal effect (P < 0.00001). The only region of dose combinations for which the 99% confidence intervals were less than 100 CFU/g of brain was defined by ABCD at 5.0 to 7.5 mg/kg combined with flucytosine at 20 to 60 mg/kg/day and fluconazole at 30 to 40 mg/kg/day. The triple combination of ABCD plus flucytosine and fluconazole was necessary to achieve the greatest antifungal activity.

In vitro evaluation of combination of fluconazole and flucytosine against Cryptococcus neoformans var. neoformans.

Amphotericin B and fluconazole are current acceptable therapies for cryptococcal meningitis; however, their effect remains suboptimal. The combination of fluconazole and flucytosine has yielded encouraging clinical results in human immunodeficiency virus patients with cryptococcal meningitis. To investigate the biological basis of this finding, we performed in vitro combination testing of fluconazole and flucytosine against 50 clinical strains of Cryptococcus neoformans var. neoformans. Synergy (fractional inhibitory concentration index of < 1.0) was observed in 62% of cases, while antagonism (fractional inhibitory concentration index of > 2.0) was not observed. For cases in which synergy was not achieved (autonomous or additive effects), the beneficial effect of the combination was still seen (i.e., there was still a decrease, although not as dramatic, in the MIC of one or both drugs when used in combination). The in vitro inhibitory action of flucytosine was greatly enhanced by the addition of fluconazole; the flucytosine MICs for Cryptococcus isolates were markedly decreased to concentrations which were severalfold lower than the achievable cerebrospinal fluid flucytosine concentration. On the other hand, the addition of flucytosine did not greatly enhance the in vitro activity of fluconazole if the initial fluconazole MIC for the isolate was > or = 8 micrograms/ml. Controlled clinical studies are warranted to further elucidate the potential utility of fluconazole-flucytosine combination therapy.