Antifungal Treatment Strategies Research Articles

Epidemiology and antifungal susceptibility of fungal infections from 2018 to 2021 in Shandong, eastern China: A report from the SPARSS program

PurposeWe analyzed the pathogenic fungal epidemiology and antifungal susceptibility from 2018 to 2021 in Shandong Province, China, to provide the basis for empiric antifungal therapy. MethodsFungal isolates were collected from 54 hospitals in Shandong province from 2018 to 2021 through the Shandong Province Pediatric bacterial & fungal Antimicrobial Resistance Surveillance System (SPARSS), WHONET v5.6 and SPSS software v20.0 were used for statistical analysis. ResultsA total of 15,348 strains of fungi were collected, with Candida accounting for 78.25 %, followed by Aspergillus at 15.45 %, and other species at 6.27 %. Candida albicans was the predominant Candida species, but more than half of the Candida isolates were non-albicans species, with C. tropicalis being the most dominant (22.74 %), followed by C. glabrata (17.50 %) and C. parapsilosis (11.02 %). The composition of fungi varied significantly among different age groups. Children had a higher proportion of C. albicans (47.30 %) compared to non-children (32.06 %). The non-wild-type phenotype rate of Candida for Amphotericin B was less than 3 %, while Cryptococcus neoformans was 16.67 %. In addition, less than 6 % of C. albicans and C. parapsilosis were resistant to fluconazole and voriconazole, and 96.30 % of C. glabrata were SDD to fluconazole. We also found that 80.56 % of C. glabrata and 83.70 % of C. krusei were voriconazole WT/susceptibility phenotype. However, the susceptibility rates of C. tropicalis to fluconazole/voriconazole decreased from 70.40 %/46.40 % in 2018 to 62.30 %/35.20 % in 2021. The comprehensive susceptibility rate to fluconazole of C. albicans, C. tropicalis, C. parapsilosis and C. glabrata isolated from the blood has decreased from 69.36 % to 56.62 %. ConclusionsThe study reveals that the composition and antifungal susceptibility of pathogenic fungi in Shandong Province differ from other regions. Moreover, the resistance to azoles is more severe, especially in C. tropicalis. These findings indicate the need for region-specific antifungal treatment strategies to combat fungal infections effectively.

Drug Utilization Evaluation of Systemic Antifungals in a Tertiary Care Hospital

Introduction: The incidence of Invasive Fungal Infection has increased, and it constitutes a serious threat to human health and life, especially in immunocompromised and critically ill patients. We aimed to evaluate the appropriateness of antifungal agents along with their risk factors and sensitivity pattern. Methods: It is a retrospective, cross-sectional study, which includes details of patients prescribed with systemic antifungal agents during a period of five years (01-06-2016 to 31-05-2021). Collected details were compared with Infectious Diseases Society of America (IDSA) guidelines and mycological results to determine the overall appropriateness. Results: A total of 102 patients prescribed with systemic antifungals were selected for the study. The majority of the drugs were prescribed as Definitive (59.19%) and T Fluconazole (39.4%) was the most common drug given. The most common indication for antifungal prescriptions was found to be Respiratory tract infection. Appropriateness of antifungal use was assessed on indication, dosage, contraindication, and drug-drug interaction. Overall assessment of antifungal agents and treatment strategy demonstrated that antifungal treatment was appropriate in 41.6% cases, debatable in 36% cases and inappropriate in 22.4% of cases. The most common culture specimen collected was urine and Candida tropicalis (42.86%) was the frequently separated organism from it. Sepsis (21.4%) was the most common risk factor associated with invasive fungal infection. Conclusion: By implementing an effective antifungal stewardship program, we could improve the rational use of systemic antifungals and thereby prevent the future resistance and improve clinical outcome.

Hard nut to crack: Solving the disulfide linkage pattern of the Neosartorya (Aspergillus) fischeri antifungal protein 2.

As a consequence of the fast resistance spreading, a limited number of drugs are available to treat fungal infections. Therefore, there is an urgent need to develop new antifungal treatment strategies. The features of a disulfide bond-stabilized antifungal protein, NFAP2 secreted by the mold Neosartorya (Aspergillus) fischeri render it to be a promising template for future protein-based antifungal drug design, which requires knowledge about the native disulfide linkage pattern as it is one of the prerequisites for biological activity. However; in the lack of tryptic and chymotryptic proteolytic sites in the ACNCPNNCK sequence, the determination of the disulfide linkage pattern of NFAP2 is not easy with traditional mass spectrometry-based methods. According to in silico predictions working with a preliminary nuclear magnetic resonance (NMR) solution structure, two disulfide isomers of NFAP2 (abbacc and abbcac) were possible. Both were chemically synthesized; and comparative reversed-phase high-performance liquid chromatography, electronic circular dichroism and NMR spectroscopy analyses, and antifungal susceptibility and efficacy tests indicated that the abbcac is the native pattern. This knowledge allowed rational modification of NAFP2 to improve the antifungal efficacy and spectrum through the modulation of the evolutionarily conserved γ-core region, which is responsible for the activity of several antimicrobial peptides. Disruption of the steric structure of NFAP2 upon γ-core modification led to the conclusions that this motif may affect the formation of the biologically active three-dimensional structure, and that the γ-core modulation is not an efficient tool to improve the antifungal efficacy or to change the antifungal spectrum of NFAP2. This article is protected by copyright. All rights reserved.

Interactions between antifungals and everolimus against Cryptococcus neoformans.

Cryptococcus is the causal agent of cryptococcosis, a disease with high mortality mainly related to HIV immunosuppression and usually manifests with pneumonia and/or meningoencephalitis. There are very few therapeutic options; thus, innovative approaches are required. Herein, We examined the interaction of everolimus (EVL) with amphotericin B (AmB) and azoles [fluconazole (FLU), posaconazole (POS), voriconazole (VOR), itraconazole (ITR)] against Cryptococcus. Eighteen Cryptococcus neoforman clinical isolates were analyzed. Following the guidelines of the Clinical and Laboratory Standards Institute (CLSI) M27-A4, we conducted a broth microdilution experiment to determine the minimum inhibitory concentrations (MICs) of azoles, EVL, and AmB for assessing antifungal susceptibility. A fractional inhibitory concentration index (FICI) of less than and equal to 0.5 indicated synergy, with a range of 0.5 to 4.0 indicated indifference and a value more than 4.0 indicated antagonism. These experiments revealed that EVL had antifungal activity against C. neoforman. Moreover, EVL, POS, AmB, FLU, ITR, and VOR exhibited MIC values ranging from 0.5-2 μg/mL, 0.03125-2 μg/mL, 0.25-4 μg/mL, 0.5-32μg/mL, 0.0625-4μg/mL and 0.03125-2μg/mL, respectively. The combination of EVL with AmB and azoles (POS, FLU, ITR, and VOR) exhibited synergistic antifungal effects against 16 (88.9%), 9 (50%), 11 (61.1%), 10 (55.6%) or 6 (33.3%) of analyzed Cryptococcus strains. In the presence of EVL, the MIC values of AmB and azoles were significantly lowered. No antagonism was observed. Subsequently, in vivo analyses conducted using the G. mellonella model further confirmed that combination EVL+ POS, EVL+ FLU, and EVL+ITR treatment were associated with significantly improved larval survival following Cryptococcus spp. infection. These findings provide the first published evidence suggesting that a combination of EVL and AmB or azoles exhibit a synergistic effect and may be an effective antifungal disease treatment strategy for infections caused by Cryptococcus spp.

Fungal cell barriers and organelles are disrupted by polyhexamethylene biguanide (PHMB)

The similarities between fungal and mammalian cells pose inherent challenges for the development of treatments for fungal infections, due to drug crossover recognition of host drug targets by antifungal agents. Thus, there are a limited number of drug classes available for treatment. Treatment is further limited by the acquisition and dissemination of antifungal resistance which contributes to the urgent need of new therapies. Polyhexamethylene biguanide (PHMB) is a cationic antimicrobial polymer with bactericidal, parasiticidal and fungicidal activities. The antifungal mechanism of action appears to involve preferential mechanical disruption of microbial cell structures, offering an alternative to conventional antifungals. However, the antifungal mechanisms have been little studied. The aim of this study was to characterise PHMB’s activities on selected yeast (Saccharomyces cerevisiae, Candida albicans) and filamentous fungal species (Fusarium oxysporum, Penicillium glabrum). Fungal membrane disruption, cell entry and intracellular localisation activities of PHMB were evaluated using viability probe entry and polymer localisation studies. We observed that PHMB initially permeabilises fungal cell membranes and then accumulates within the cytosol. Once in the cytosol, it disrupts the nuclear membrane, leading to DNA binding and fragmentation. The electrostatic interaction of PHMB with membranes suggests other intracellular organelles could be potential targets of its action. Overall, the results indicate multiple antifungal mechanisms, which may help to explain its broad-spectrum efficacy. A better understanding of PHMB’s mechanism(s) of action may aid the development of improved antifungal treatment strategies.

The therapeutic role and mechanism of 4-Methoxycinnamic acid in fungal keratitis

Fungal keratitis is an infectious vision-threatening disease that has a poor prognosis, and the clinical therapeutic drugs have multiple limitations, such as epithelial toxicity and low bioavailability. Therefore, new antifungal treatment strategies must be developed.4-Methoxycinnamic acid (MCA) is a widely occurring natural phenolic acid that has been proven to have multiple effects, such as antibacterial, antifungal, anti-inflammatory, neuroprotective, and inhibiting cancer. In this research, we explored the effects and underlying mechanisms of MCA on A. fumigatus keratitis and the antifungal effects of the combination of MCA and natamycin (NATA) on A. fumigatus. We found that MCA exerts antifungal effects by inhibiting the synthesis of the fungal cell wall, changing the permeability of fungal cell membranes. Moreover, the MCA-NATA combination exhibited synergy for A. fumigatus.In addition, MCA exerted an anti-inflammatory effect by downregulating the inflammatory factors (IL-1β, TNF-α, IL-6, and iNOS) in C57BL/6 mice and RAW264.7 cells. The anti-inflammatory mechanism of MCA was associated with the Mincle signal pathway.In summary, MCA acts as a potential therapeutic drug for fungal keratitis and a potential antifungal sensitizer for natamycin. MCA inhibits fungal cell wall synthesis, destroys the permeability of fungal cell membranes, and mediates the anti-inflammatory, immune response of the host.

Nitric oxide-releasing poly(ionic liquid)-based microneedle for subcutaneous fungal infection treatment.

Poor permeation of therapeutic agents and similar eukaryotic cell metabolic and physiological properties of fungi and human cells are two major challenges that lead to the failure of current therapy for fungi-induced skin and soft tissue infections. Herein, a nitric oxide (NO)-releasing poly(ionic liquid)-based microneedle (PILMN-NO) with the capacity of deep persistent NO toward subcutaneous fungal bed is presented as a synergistic antifungal treatment strategy to treat subcutaneous fungal infection. Upon the insertion of PILMN-NO into skin, the contact fungicidal activities induced by electrostatic and hydrophobic effects of poly(ionic liquid) and the released NO sterilization resulting from the peroxidation and nitrification effect of NO achieved enhanced antifungal efficacy against fungi (Candida albicans) both in vitro and in vivo. Simultaneously, PILMN-NO showed biofilm ablation ability and efficiently eliminated mature biofilms. In vivo fungal-induced subcutaneous abscess studies revealed that PILMN-NO could effectively sterilize fungi while suppressing the inflammatory reaction, facilitating collagen deposition and angiogenesis, and promoting wound healing. This work provides a new strategy to overcome the difficulties in deep skin fungal infection treatment and has potential for further exploitation of NO-releasing microbicidal therapy.

Antifungal and Immunomodulatory Ingredients from Traditional Chinese Medicine.

Fungal infections have become a growing public health challenge due to the clinical transmission of pathogenic fungi. The currently available antifungal drugs leave very limited choices for clinical physicians to deal with such situation, not to mention the long-standing problems of emerging drug resistance, side effects and heavy economic burdens imposed to patients. Therefore, new antifungal drugs are urgently needed. Screening drugs from natural products and using synthetic biology strategies are very promising for antifungal drug development. Chinese medicine is a vast library of natural products of biologically active molecules. According to traditional Chinese medicine (TCM) theory, preparations used to treat fungal diseases usually have antifungal and immunomodulatory functions. This suggests that if antifungal drugs are used in combination with immunomodulatory drugs, better results may be achieved. Studies have shown that the active components of TCM have strong antifungal or immunomodulatory effects and have broad application prospects. In this paper, the latest research progress of antifungal and immunomodulatory components of TCM is reviewed and discussed, hoping to provide inspiration for the design of novel antifungal compounds and to open up new horizons for antifungal treatment strategies.

Utilization of Antifungal Prophylaxis and Treatment for Newly Diagnosed AML Patients Treated with Venetoclax Based Regimens in Routine Clinical Practice - a Prospective Analysis from the Revive Study

Background: Venetoclax (VEN)-based low intensity combinations are approved for the treatment of patients (pts) with acute myeloid leukemia (AML) ineligible for intensive chemotherapy. These combinations can be associated with prolonged cytopenias in particular neutropenia. Invasive fungal infections (IFIs) remain a major cause of morbidity and mortality in pts with AML but their incidence and impact on pts treated with VEN-based low intensity approach are uncertain. In the current study we assess real-world patterns of IFI's and antifungal treatments among newly-diagnosed (ND) AML patients treated with VEN-based low intensity therapies. Methods: The REVIVE study is a prospective, real-life, observational study that assesses patterns of pt. selection, efficacy and toxicity. ND pts with AML were enrolled at the time of VEN-based therapy initiation from 12 medical centers in Israel. Demographic, clinical and pt.-related baseline characteristics were documented. Antifungal medication selection for prophylaxis or therapy use and the incidence of IFIs were documented. The impact of prophylactic antifungal use on the incidence of IFIs and on leukemia related outcomes were assessed. Results: Between August 12, 2019, and April 15, 2022(data cut) ,189 AML pts were enrolled to receive VEN based therapy. Overall, the incidence of possible IFIs was relatively low and was observed in 17 patients (9% of patients). 23 pts (12.1%) were reported to have received prophylactic antifungal treatment, whereas 166 pts (87.8%) did not receive. Baseline characteristics of these two groups are shown in Table 1. Of note, pts. receiving antifungal prophylaxis were more likely to be treated as outpatients. A trend towards treatment in a tertiary center and unfavorable ELN risk was observed in pts. receiving antifungal prophylaxis vs. pts not receiving prophylaxis. All other characteristics seemed equally balanced between both groups. Antifungal prophylaxis included fluconazole (18 pts), voriconazole (6 pts) and posaconzole (1 pt). Of note, 2 patients received two different prophylactic treatments. The incidence of IFIs was not reduced in pts receiving antifungal prophylaxis. Of the 23 patients who received antifungal prophylaxis, 4 were considered to have an IFI (17.4%) compared with 13 in the non-prophylactic group (7.8%). Antifungal treatment in pts with an IFI included fluconazole (10pts) voriconazole (5 pts) posaconazole (1 pt) amphotericin B (1 pt) and anidulafungin (1pt). Of note, 3 patients received two different antifungal treatments. No difference in 30-day mortality was observed between the two groups:1 pt in the prophylaxis group died compared with 8 pts in the no-prophylaxis group (4.3% vs 4.8% respectively, p=0.92). Prophylactic antifungal treatment did not affect the rate of adverse events (AEs) leading to treatment discontinuation: 4 pts in the prophylaxis group and 31 pts in the no prophylaxis group discontinued VEN based treatment due to adverse events (17.4% vs 18.7%, p=0.88). The efficacy of VEN based treatment for AML was similar between pts who received or did not receive antifungal prophylaxis. Composite complete remission (CRc) rates were 60.9% in the antifungal prophylaxis group vs 54.2% in pts with no antifungal prophylaxis (p=0.54). A Kaplan-Meier analysis for overall survival (OS) showed no difference between the prophylaxis and no prophylaxis groups (p=0.505). 1year OS rates were: 50.6% (CI 28-73.3) and 39.4% (CI 30.5-48.3) for prophylaxis and no prophylaxis groups respectively. Median follow up in the prophylaxis group was 237 days (CI 56-878) compared with 173 days (CI 19-850) in the no-prophylaxis group. Conclusion: In this prospective 'real world' observational study, a low rate of IFIs were noted despite low utilization rates of antifungal prophylaxis, mostly with non-mold active azoles. Moreover, administration of antifungal prophylaxis was not associated with a reduced incidence of IFIs. Reassuringly, use of antifungal azoles as prophylactic treatment, which requires VEN dose adjustments, did not affect CRc and OS rates. Similarly, azole based prophylaxis did not affect for the rate of treatment discontinuation due to AEs or early mortality. This study does not support the routine use of antifungal prophylaxis and suggests that such treatment is safe if deemed necessary. Additional insights on antifungal treatment patterns and strategies are pending. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The Antimicrobial Peptide AMP-17 Derived from Musca domestica Inhibits Biofilm Formation and Eradicates Mature Biofilm in Candida albicans.

The biofilm formation of C. albicans represents a major virulence factor during candidiasis. Biofilm-mediated drug resistance has necessitated the search for a new antifungal treatment strategy. In our previous study, a novel antimicrobial peptide named AMP-17 derived from Musca domestica was confirmed to have significant antifungal activity and suppress hyphal growth greatly in C. albicans. In the current work, we aimed to investigate the antibiofilm property of AMP-17 in C. albicans and explore the underlying mechanism. An antifungal susceptibility assay showed that AMP-17 exerted a strong inhibitory efficacy on both biofilm formation and preformed biofilms in C. albicans. Furthermore, AMP-17 was found to block the yeast-to-hypha transition and inhibit the adhesion of biofilm cells with a reduction in cellular surface hydrophobicity. A morphological analysis revealed that AMP-17 indeed suppressed typical biofilm formation and damaged the structures of the preformed biofilm. The RNA-seq showed that the MAPK pathway, biosynthesis of antibiotics, and essential components of the cell were mainly enriched in the biofilm-forming stage, while the citrate cycle (TCA cycle), phenylamine metabolism, and propanoate metabolism were enriched after the biofilm matured. Moreover, the co-expressed DEGs in the two pairwise comparisons highlighted the terms of transmembrane transporter activity, regulation of filamentation, and biofilm formation as important roles in the antibiofilm effect of AMP-17. Additionally, qRT-PCR confirmed that the level of the genes involved in cell adhesion, filamentous growth, MAPK, biofilm matrix, and cell dispersal was correspondingly altered after AMP-17 treatment. Overall, our findings reveal the underlying antibiofilm mechanisms of AMPs in C. albicans, providing an interesting perspective for the development of effective antifungal agents with antibiofilm efficacy in Candida spp.

Protocolo diagnóstico y terapéutico de las micosis pulmonares

Fungal infections are less common than bacterial or viral infections and are associated with a high rate of morbidity and mortality. This text will discuss infections by Aspergillus in their different clinical symptoms, histoplasmosis, and coccidioidomycosis. The diagnosis is determined by compatible symptoms, characteristic risk factors, radiological findings, and microbiological isolation. There are a wide variety of prophylaxis and antifungal treatment strategies. Antifungal treatment in aspergillosis and other types of pulmonary mycoses are based on the use of liposomal amphotericin B, echinocandins, and azoles, all based on the isolation of the described species and resistances. This type of treatment has different profiles of effectiveness, safety, pharmacological interactions, and important side effects to take into account.

Pharmacokinetic/Pharmacodynamic Target Attainment of Different Antifungal Agents in De-escalation Treatment in Critically Ill Patients: a Step toward Dose Optimization Using Monte Carlo Simulation.

Differences in pharmacokinetics/pharmacodynamics (PK/PD) target attainment are rarely considered when antifungals are switched in critically ill patients. This study intends to explore whether the antifungal de-escalation treatment strategy and the new intermittent dosing strategy of echinocandins in critically ill patients are able to achieve the corresponding PK/PD targets. The published population PK models of antifungals in critically ill patients and a public data set from the MIMIC-III database (n = 662) were employed to evaluate PK/PD target attainment of different dosing regimens of antifungals. Cumulative fraction of response (CFR) was calculated for each dosing regimen. Most guideline-recommended dosing regimens of fluconazole and voriconazole could achieve target exposure as de-escalation treatment in critically ill patients. For initial echinocandin treatment, achievement of the target exposure decreased as body weight increased, and the intermittent dosing strategy had a slightly higher CFR value in most simulations compared to conventional dosing strategy. For Candida albicans and Candida glabrata infection, caspofungin at the lowest dose achieved a CFR of >90%, while micafungin or anidulafungin required almost the highest doses simulated in this study to achieve the same effect. None of the echinocandins other than 150 mg every 24 h (q24h) or 200 mg q48h of caspofungin achieved the target CFR for Candida parapsilosis infection. These findings support the guideline-recommended dose of triazoles for antifungal de-escalation treatment and confirm the insufficient dosage of echinocandins in critically ill patients, indicating that a dosing regimen based on body weight or intermittent dosing of echinocandins may be required.

Genetic validation of Aspergillus fumigatus phosphoglucomutase as a viable therapeutic target in invasive aspergillosis

Aspergillus fumigatus is the causative agent of invasive aspergillosis, an infection with mortality rates of up to 50%. The glucan-rich cell wall of A. fumigatus is a protective structure that is absent from human cells and is a potential target for antifungal treatments. Glucan is synthesized from the donor uridine diphosphate glucose, with the conversion of glucose-6-phosphate to glucose-1-phosphate by the enzyme phosphoglucomutase (PGM) representing a key step in its biosynthesis. Here, we explore the possibility of selectively targeting A. fumigatus PGM (AfPGM) as an antifungal treatment strategy. Using a promoter replacement strategy, we constructed a conditional pgm mutant and revealed that pgm is required for A. fumigatus growth and cell wall integrity. In addition, using a fragment screen, we identified the thiol-reactive compound isothiazolone fragment of PGM as targeting a cysteine residue not conserved in the human ortholog. Furthermore, through scaffold exploration, we synthesized a para-aryl derivative (ISFP10) and demonstrated that it inhibits AfPGM with an IC50 of 2 μM and exhibits 50-fold selectivity over the human enzyme. Taken together, our data provide genetic validation of PGM as a therapeutic target and suggest new avenues for inhibiting AfPGM using covalent inhibitors that could serve as tools for chemical validation.

Nanostructured Lipid Carriers Loaded with Lippia sidoides Essential Oil as a Strategy to Combat the Multidrug-Resistant Candida auris

The emerging pathogen Candida auris is an emerging fungal pathogen that was associated with nosocomial infectious outbreaks. Its worldwide incidence and the emerging multidrug-resistant strains highlight the urgency for novel and effective antifungal treatment strategies. Lippia sidoides essential oil (LSEO) proved antifungal activity, including anti-Candida. However, it may undergo irreversible changes when in contact with external agents without adequate protection. Herein, we encapsulated LSEO in nanostructured lipid carriers (NLC) through the hot emulsification method followed by sonication. NLC matrix was based on oleic acid and Compritol® 888, or a combination of carnauba wax and beeswax, stabilized by sodium dodecyl sulfate. Eight formulations were produced and characterized by the determination of the particle size (213.1 to 445.5 nm), polydispersity index (around 0.3), and ζ-potential (−93.1 to −63.8 mV). The antifungal activity of nanoparticles and LSEO against C. auris and the in vivo toxicity in Galleria mellonella model were also evaluated. Both NLC and LSEO exhibited potent activity against the yeast, with Minimum Inhibitory Concentration between 281 and 563 µg/mL, and did not evidence toxicity in the in vivo model. Therefore, this study confirms the viability of NLCs loaded with LSEO in combating drug-resistant pathogens as a potential new therapeutic strategy for managing of candidemia.

Antifungal Treatment Strategy in Hematological Patients

Antifungal Treatment Strategy in Hematological Patients

Implementation of a clinical decision rule for selecting empiric treatment for invasive aspergillosis in a setting with high triazole resistance.

World-wide, emerging triazole resistance increasingly complicates treatment of invasive aspergillosis (IA). In settings with substantial (>10%) prevalence of triazole resistance, empiric combination therapy with both a triazole and liposomal amphotericin B (LAmB) can be considered because of the low yields of susceptibility testing. To avoid toxicity while optimizing outcome, a strategy with monotherapy would be preferable. A newly designed treatment algorithm based on literature and expert consensus provided guidance for empiric monotherapy with either voriconazole or LAmB. Over a four and a half year period, all adult patients in our hospital treated for IA were included and patient data were collected. An independent committee reviewed the attributability of death to IA for each patient. Primary outcomes were 30- and 100-day crude mortality and attributable mortality. In total, 110 patients were treated according to the treatment algorithm. Fifty-six patients (51%) were initially treated with voriconazole and 54 patients (49%) with LAmB. Combined attributable and contributable mortality was 13% within 30 days and 20% within 100 days. Treatment switch to LAmB was made in 24/56 (43%) of patients who were initially treated with voriconazole. Combined contributable and attributable 100-day mortality in this subgroup was 21% and was not increased when compared with patients initially treated with LAmB (P = 0.38). By applying a comprehensive clinical decision algorithm, an antifungal-sparing regime was successfully introduced. Further research is warranted to explore antifungal treatment strategies that account for triazole-resistance.Lay summaryDue to resistance of Aspergillus against triazoles, combination therapy with liposomal amphotericin B (LAmB) is applied more often as primary therapy against invasive aspergillosis. This study presents the results of a decision tool which differentiated between triazole or LAmB monotherapy.

Novel Antifungal Activity of Q-Griffithsin, a Broad-Spectrum Antiviral Lectin.

ABSTRACTThere is a rising global incidence of Candida strains with high levels of resistance to fluconazole and other antifungal drugs, hence the need for novel antifungal treatment strategies. Here, we describe the first evidence of antifungal activity of Q-Griffithsin (Q-GRFT), a recombinant oxidation-resistant variant of Griffithsin, a marine red algal lectin with broad-spectrum antiviral activity. We demonstrated that Q-GRFT binds to α-mannan in the Candida albicans cell wall. We also observed that Q-GRFT binding disrupted cell wall integrity and induced reactive oxidative species (ROS) formation, resulting in cell death. Furthermore, we showed that Q-GRFT inhibited the growth of other Candida species C. glabrata, C. parapsilosis, and C. krusei and had modest activity against some strains of multi- and pandrug-resistant C. auris. We found that Q-GRFT induced differential expression of numerous genes involved in response to cell stress, including those responsible for neutralizing ROS production and cell cycle regulation. In conclusion, this novel antifungal activity suggests that Q-GRFT is potentially an ideal drug candidate and represents an alternative strategy for the prevention and treatment of candidiasis.IMPORTANCE Fungal infections contribute to morbidity and mortality annually, and the number of organisms that are nonresponsive to the current available drug regimens are on the rise. There is a need to develop new agents to counter these infections and to add to the limited arsenal available to treat fungal infections. Our study has identified Q-GRFT, a broad-spectrum antiviral protein that harbors growth-inhibitory activity against several Candida strains, as a potential candidate for the prevention and treatment of fungal infections.

Invasive Mucormycosis in Patients with Hematological Diseases Identified in the Global Fungiscope Registry

Background:Invasive fungal diseases (IFD) are a frequent complication in hematological patients. Hematological malignancies and their treatment are main risk factors for IFD. Less frequent IFD, such as invasive mucormycoses (IM), are increasing worldwide and are associated with mortality up to 100%. Efficient diagnostic and treatment approaches for IM are not known or validated yet. Thus, it is urgent to better understand clinical presentation and management of IM in hematological patients to eventually improve patient outcome.Methods:Clinical data on IM were collected in FungiScope, an international web-based registry. Cases with cultural, histological or molecular evidence of IM are enrolled. Data collected include demographics, underlying conditions and their treatment, clinical signs and symptoms, sites of infection, diagnostic tests, antifungal treatment and outcome. Clinical isolates are collected for centralized identification, molecular analyses and exchange between collaborators.Results:To date, 194 cases of IM with an underlying hematologic disease (HD) were captured in the FungiScope database. AML, ALL, Non-Hodgkin's Lymphoma and CLL were the most frequent malignancies (50.5%, 16%, 5.6%, and 5.6%, respectively). Treatment of HD was chemotherapy in 76%, for 72% of these it was the primary course. Prolonged neutropenia (>10 days) was reported in 70% of cases (information available for 111 cases). The majority of patients received antifungal agents (94.3%; median 55 days, range 0 to 750 days) and 37% underwent surgical debridement. Antifungals known to be active against Mucorales (amphotericin B, isavuconazole, itraconazole, posaconazole) were administered in 82.5% of cases, in 16% of those amphotericin B was used as a single agent once the pathogen had been identified. Overall mortality was 62.4% and death due to IM was reported for 74% of cases. Mortality in patients receiving antifungals active against Mucorales was 56%. Median follow-up time was 45 days (range 0-2110 days). Favourable response (complete or partial response or stable disease) was present in 44% of all cases. Due to premature death, twelve patients did not receive antifungal therapy.Conclusion:The FungiScope registry is a feasible approach to collect data on a relevant amount of rare cases of rare IFD. IM remains a life threatening disease in hematological patients. Despite aggressive antifungal treatment strategies, outcome remains poor. More effective treatment strategies are urgently needed to improve patient outcome. DisclosuresKarthaus:Riemser: Honoraria, Other: Travel grant; HELSINN: Honoraria, Other: Travel grant. Vehreschild:Pfizer, MSD/ Merck, Gilead Sciences, Organobalance and Astellas Pharma: Speakers Bureau; 3M, Astellas Pharma, DaVolterra and Gilead Sciences: Research Funding; Berlin Chemie, MSD/Merck and Astellas Pharma: Consultancy. Meißner:Accelerate Diagnostics: Honoraria. Wisplinghoff:Beckmann, BioMerieux, Bruker Daltonics, Cepheid, Hologic, i-Sense, r-biopharm, Siemens, Specific Technologies: Research Funding; Beckmann, BioMerieux, Bruker Daltonics, Cepheid, Hologic, i-Sense, r-biopharm, Siemens, Specific Technologies: Consultancy; Beckmann, BioMerieux, Bruker Daltonics, Cepheid, Hologic, i-Sense, r-biopharm, Siemens, Specific Technologies: Honoraria. Vehreschild:Pfizer, Merck, Gilead, Basilea and Astellas: Speakers Bureau; Astellas, Gilead, Infectopharm, Merck/MSD, Basilea and Pfizer: Research Funding; Astellas, Gilead, Basilea and Merck/MSD: Consultancy. Cornely:Anacor, Amplyx, Actelion, Astellas, Basilea, Cidara, Da Volterra, F2G, Gilead, Janssen Pharmaceuticals, Matinas, Menarini Ricerche, Merck/MSD, Paratek Pharmaceuticals, Scynexis, Seres, Summit, Vical, Vifor: Consultancy; Actelion, Aramis Pharma, Astellas, AstraZeneca, Basilea, Bayer, Cidara, Duke University (NIH UM1AI104681), F2G, Gilead, GSK, Leeds University, MedPace, Melinta Therapeutics, Merck/MSD, Miltenyi, Pfizer, Rempex, Roche, Sanofi Pasteur, Scynexis, Seres Thera: Research Funding; Astellas, Basilea, Gilead and Merck/ MSD: Honoraria. Seidel:Basilea and Astellas: Other: Travel grant.

The role of fungi in fungal keratitis

Fungal keratitis (FK) accounts for approximately half of the microbial keratitis encountered in low middle income countries (LMICs) and predominantly affect the working rural-poor. FK causes significant morbidity with the majority of patients left with moderate or worse visual impairment and approximately 25% requiring expensive and often unsuccessful surgical interventions. The severity of FK and the resultant corneal damage or resolution can be attributed to i) the virulence and bioburden of the fungal pathogen, ii) the host defense mechanism and immune response and iii) sub-optimal diagnostics and anti-fungal treatment strategies. This review provides a comprehensive overview of the multifaceted components that drive FK progression and resolution, highlighting where knowledge gaps exist and areas that warrant further research.

Triazole Evolution of Candida parapsilosis Results in Cross-Resistance to Other Antifungal Drugs, Influences Stress Responses, and Alters Virulence in an Antifungal Drug-Dependent Manner.

The number of invasive infections caused by Candida species is increasing worldwide. The incidence of candidiasis cases caused by non-albicans Candida species, such as Candida parapsilosis, is also increasing, and non-albicans Candida species are currently responsible for more invasive infections than C. albicans Additionally, while the development of azole resistance during invasive disease with C. albicans remains uncommon, azole-resistant C. parapsilosis strains are frequently isolated in the hospital setting. In this study, we applied direct selection to generate azole-adapted and azole-evolved C. parapsilosis strains in order to examine the effect of azole resistance development on fungal viability and pathogenesis progression. Depending on the drug applied, the different evolved strains developed distinct cross-resistance patterns: the fluconazole-evolved (FLUEVO) and voriconazole-evolved (VOREVO) strains gained resistance to fluconazole and voriconazole only, while posaconazole evolution resulted in cross-resistance to all azoles and the posaconazole-evolved (POSEVO) strains showed higher echinocandin MIC values than the FLUEVO and VOREVO strains. Whole-genome sequencing results identified the development of different resistance mechanisms in the evolved strains: the FLUEVO and VOREVO strains harbored amino acid substitutions in Mrr1p (A808T and N394Y, respectively), and the POSEVO strain harbored an amino acid change in Erg3p (D14Y). By revealing increased efflux pump activity in both the FLUEVO and the VOREVO strains, along with the altered sterol composition of the POSEVO strain, we now highlight the impact of the above-mentioned amino acid changes in C. parapsilosis azole resistance development. We further revealed that the virulence of this species was only slightly or partially affected by fluconazole and voriconazole adaptation, while it significantly decreased after posaconazole adaptation. Our results suggest that triazole adaptation can result in azole cross-resistance and that this process may also result in virulence alterations in C. parapsilosis, depending on the applied drug.IMPORTANCECandida parapsilosis causes life-threatening fungal infections. In the last 2 decades, the increasing number of azole-resistant C. parapsilosis clinical isolates has been attributable to the overuse and misuse of fluconazole, the first-line antifungal agent most commonly used in several countries. To date, the range of applicable antifungal drugs is limited. As a consequence, it is essential to understand the possible mechanisms of antifungal resistance development and their effect on virulence in order to optimize antifungal treatment strategies in the clinical setting. Our results revealed that the prolonged exposure to azoles resulted not only in azole resistance but also in cross-resistance development. Our data further indicate that resistance development may occur through different mechanisms that can also alter the virulence of C. parapsilosis These results highlight the consequences of prolonged drug usage and suggest the need for developing alternative antifungal treatment strategies in clinical practice.