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Fungal infections are a pressing concern for human health worldwide, particularly for immunocompromised individuals. Current challenges such as the elevated toxicity of common antifungal drugs and the emerging resistance towards these could be overcome by multidrug therapy. Natural antimicrobial peptides, AMPs, in combination with other antifungal agents are a promising avenue to address the prevailing challenges. However, they possess limited biostability and susceptibility to proteases, which has significantly hampered their development as antifungal therapies. β-peptides are synthetic materials designed to mimic AMPs while allowing high tunability and increased biostability. In this work, we report for the first time the inhibition achieved in Candida albicans when treated with a mixture of a β-peptide model and fluconazole or ketoconazole. This combination treatment enhanced the biological activity of these azoles in planktonic and biofilm Candida, and also in a fluconazole-resistant strain. Furthermore, the in vitro cytotoxicity of the dual treatment was evaluated towards the human hepatoma cell line, HepG2, a widely used model derived from liver tissue, which is primarily affected by azoles. Analyses based on the LA-based method and the mass-action law principle, using a microtiter checkerboard approach, revealed synergism of the combination treatment in the inhibition of planktonic C. albicans. The dual treatment proved to be fungicidal at 48 and 72 h. Interestingly, it was also found that the viability of HepG2 was not significantly affected by the dual treatments. Finally, a remarkable enhancement in the inhibition of the highly azole-resistant biofilms and fluconazole resistant C. albicans strain was obtained.
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The presence of the cryptic species belonging to the Candida glabrata complex has not been studied in Argentina. We analyzed a collection of 117 clinical isolates of C. glabrata complex belonging to a National Culture Collection of Instituto Nacional de Microbiología "Dr. Carlos G. Malbrán" from Argentina (40 isolates from blood samples, 18 from other normally sterile sites, 20 from vagina, 14 from urine, 7 from oral cavity, 3 from catheter, 1 from a stool sample and 14 isolates whose clinical origin was not recorded). The aims of this work were to determine the prevalence of the cryptic species Candida nivariensis and Candida bracarensis and to evaluate the susceptibility profile of isolates against nine antifungal drugs. Identification was carried out by using classical phenotypic tests, CHROMagar™ Candida, PCR and MALDI-TOF. The minimal inhibitory concentrations of amphotericin B, 5-fluorocytosine, fluconazole, itraconazole, voriconazole, ketoconazole, posaconazole, caspofungin and anidulafungin were determined according to the EDef 7.3 (EUCAST) reference document. Of the 117 isolates, 114 were identified as C. glabrata and three as C. nivariensis by using PCR and MALDI-TOF. There were no major differences between C. nivariensis and C. glabrata susceptibility profiles. No resistant strains were found to echinocandins. We have found that the percentage of C. nivariensis in our culture collection was 2.56. This is the first description of C. nivariensis in Argentina, and data obtained could contribute to the knowledge of the epidemiology of this cryptic species.
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Bacterial and fungal infections in pediatric BMT recipients are major causes of morbidity and mortality, although less than those in the adult BMT population. Early in the post-BMT period, when patients are neutropenic, the predominant pathogens are Gram-negative bacteria, mainly E. coli, K. pneumoniae and P. aeruginosa; Gram-positive bacteria, mainly coagulase-negative staphylococcus, S. viridans and E. faecalis; and fungi, mainly Candida spp. and Aspergillus spp. The emerging resistance of a variety of pathogens is of major concern and limits the use of prophylactic antibiotics. Mortality from invasive fungal infections is much greater than that caused by bacterial pathogens. Many centers are currently using prophylactic fluconazole, which may lead to emergence of infections with C. krusei and T. glabrata. Patients with GvHD are at continuous risk from bacterial and fungal pathogens. Late in the post-BMT period, S. pneumoniae may cause septicemia, meningitis, pneumonia and other respiratory infections. This may occur months or years following transplantation, with a significant mortality rate in patients with chronic GvHD. Development of rapid and reliable diagnostic methods for identifying fungal pathogens and of new therapeutic approaches for treating invasive fungal infections are now our greatest future challenges.
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These data indicate that with recent increases in C. glabrata infection, a causative fungus of OC, and in C. glabrata resistance to azoles, caution is needed in the selection of antifungal drugs for the treatment of OC.
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Azole-resistant oropharyngeal and oesophageal candidiasis is a recent phenomenon observed in patients with AIDS usually previously treated with fluconazole. Some variation has been observed in antifungal susceptibility testing among separate colonies of Candida albicans from the same patient. This raises the question of whether there are multiple clones present or simply phenotypic variation in expression of azole resistance. To address this question we took 18 isolates grown from multiple swabs taken before and after experimental azole therapy from a single HIV-positive individual with fluconazole-resistant oral candidiasis and compared morphotype, karyotype, PCR-based DNA typing and azole susceptibility. Ten of the isolates were from a single 2-day period. Amongst these 10 there were seven morphotypes, five karyotypes and four polymerase chain reaction (PCR) types. Three further morphotypes, one karyotype and two PCR types were found amongst the eight isolates obtained during the subsequent 4 months. Limited variation in susceptibility to two azoles--fluconazole and D0870--was also seen. This work emphasizes both the large genotype and phenotypic variability of C. albicans isolates in the mouth of AIDS patients with fluconazole resistance, and the difficulties in interpretation of present typing methods.
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To assess the epidemiological pattern of Candida bloodstream infection (BSI) over an 8-year period (2002-2009) in King Abdulaziz Medical City, western Saudi Arabia.
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Between 2002-2006, the prophylactic use of imipenem, amoxicillin and fluconazole was forbidden and the use of vancomycin and aminoglycosides was limited. Strict microbiological analysis became mandatory in all ITU patients. To achieve this, isolates from the lower airway and genitourinary track from 1330 ITU patients were analyzed using the disc-diffusion method and the E-test method (for MIC values). The VITEK (BioMerieux) automatic analyzing system was used.
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At these doses, amphotericin B plus flucytosine is the most rapidly fungicidal regimen. Quantification of CSF cultures provides a powerful new means to accurately assess the fungicidal activity of new treatment regimens for cryptococcal meningitis.
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Both methods are easy to perform, rapid and cost effective. Our results showed the best agreement between the two methods for testing the susceptibility of Candida isolates to amphotericin B, fluconazole and voriconazole while for the 5-fluorocytosine, the concordance rate was low.
This study demonstrates the importance of species identification and antifungals susceptibility testing for hospitalized patients in ICUs and NICUs wards.
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One hundred and sixty five women with diagnosis of pelvic inflammatory disease were randomized into three equal groups getting ciprofloxacin (500 mg) and tinidazole (600 mg) combination twice daily for 7 days (Group 1), a kit containing fluconazole (150 mg), azithromycin (1 gm) and secnidazole (2 mg) as one time dose (Group 2) and Doxycycline 100mg twice daily and metronidazole 200 mg thrice daily for seven days (Group 3). Severity score was determined on first visit and after 1 week and 4 weeks when patients were called for follow up.
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Recent data suggest that the epidemiology of invasive fungal infections may be changing with the emergence of uncommon molds and the occurrence of invasive aspergillosis in 'nonclassical' immunocompromised hosts. New diagnostic tools and improved antifungal agents are available to facilitate early diagnosis and offer new treatment options.
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Two fungal isolates recovered from the blood of two immunosuppressed patients are described as Phialemonium curvatum. One patient died, while the other, who was infected with Exophiala jeanselmei at the same time, survived after successful treatment with itraconazole. Analysis of internal transcribed spacer sequences demonstrated that the isolates belonged to the same strain and that the source of infection was probably a catheter. The taxonomic position of P. curvatum is discussed, and Phialemonium dimorphosporum is considered a synonym. The in vitro inhibitory activities of six antifungal agents (amphotericin B, itraconazole, ketaconazole, miconazole, flucytosine, and fluconazole) were determined against seven isolates of Phialemonium. Except for flucytosine, all of them were remarkably effective. Phialemonium should be added to the list of potential causes of nosocomial fungemia in cancer patients.
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A series of novel 2,5-bis(guanidino-aryl)-1-methyl-1H-pyrroles 9a-h has been synthesized starting from 1-methyl-1H-pyrrole. The antifungal activities of compounds were evaluated by in vitro agar diffusion and broth dilution assay against Candida spp. and Aspergillus spp. Compound 9c from this series was found to be equipotent or more potent than fluconazole, whereas compound 9d was comparable to fluconazole against most of the tested strains.
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Fungal growth in sputum culture in the neonates with pneumonia was common, Candida was the main genus, and Candida albicans was the most common one. Prematurity and the therapy with carbapenems were the most important independent risk factors associated with fungal growth in culture of sputum specimen from neonates.
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Candida species are the most common cause of fungal infections in hospitalized patients. Recent studies have reported a relative reduction in the rates of infection caused by Candida albicans and a shift toward non-albicans Candida spp. Data on the distribution and susceptibility of Candida spp. from children's hospitals are limited. Clinical isolates of Candida were collected from 4 US children's hospitals in 2003. Broth dilution MICs for amphotericin B, fluconazole, voriconazole, caspofungin, posaconazole, and ravuconazole were performed according to National Committee for Clinical Laboratory Standards-approved methodology. A total of 179 clinical isolates were identified and included. Of 179, 77 (43%) were C. albicans. Candida parapsilosis isolates were the second most frequently identified (57/175, 32%), followed by Candida glabrata, Candida tropicalis, and Candida lusitaniae (approximately 8% each). Caspofungin was the most active agent in vitro against all Candida spp. Fluconazole resistance was seen among C. glabrata, C. tropicalis, and Candida krusei isolates. Newer azoles had improved activity against fluconazole-resistant isolates of Candida. Among isolates of C. parapsilosis, nearly 20% were resistant to amphotericin B. The current study highlights the emergence of C. parapsilosis as a distinct pediatric pathogen with clinical and therapeutic implications. Furthermore, our current susceptibility data include newer antifungal agents that appear to be quite active in vitro and may provide new therapeutic options for the treatment of serious yeast infections in children.
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To test the hypothesis that fluconazole plus standard care is superior to the standard care for diabetic foot wounds infected with deep-seated fungal infections.
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The development of organ failure and mortality in septic shock was significantly reduced by fluconazole given intravenously. The mechanism of action of fluconazole in reducing multiple organ dysfunction in this group of patients may be attributed to the ability of fluconazole to increase recruitment, improve bactericidal activity of neutrophils, and to contain microorganisms locally.
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Interventional case report.
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Dermatophytoses are superficial skin infections due to dermatophytes which are filamentous fungi. Some dermatophytes can be hosted by domestic animals. In Belgium, Microsporum canis, Trichophyton (T.) mentagrophytes variety mentagrophytes, T. verrucosum and T. equinum are zoophilic species capable of infecting humans. Animals, clinical aspects in humans and the investigations needed will be reviewed. Treatment should target animal and patient but also limit the spread of the infection. Topical therapy is sufficient in cases restricted to the skin. When hair is involved, systemic treatment becomes mandatory. The withdrawal of griseofulvin from the Belgian market more than two years ago has made it necessary to introduce the mode of use of the newer antifungals such as fluconazole, Itraconazole and terbinafine.
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We investigated the in vitro activity of caspofungin compared to amphotericin B, fluconazole, and itraconazole against clinical strains of Candida spp. (n =239). Antifungal susceptibility tests were done in accordance with NCCLS M27-A2 microdilution method and the results were read after 24 and 48 h. In general, 24 h MIC readings were similar to those at 48 h for most isolates and all antifungal agents. Caspofungin was active against all species tested. Caspofungin MICs of Candida parapsilosis were slightly higher than those for other Candida spp. Caspofungin MIC (microg/ml) ranges at 24 h for C. albicans, C. glabrata, C tropicalis, C. parapsilosis, C kefyr, C krusei, C. lusitaniae, C. norvegensis, C. guilliermondii and C. lipolytica were 0.06-2, 0.125-2, 0.125-2, 1-4, 0.125-2, 1-2, 0.5-2, 0.5-1, 0.5-2 and 1-2, respectively. Eagle (paradoxical) effect was observed in 31 and 8% of the isolates at highest concentrations of caspofungin and itraconazole, respectively. The activity of caspofungin against fluconazole- and/or itraconazole-resistant isolates was similar to that detected for the susceptible ones. We conclude that caspofungin appears as a promising antifungal agent with enhanced activity against Candida, including the azole-resistant strains.
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To highlight the usefulness of polymerase chain reaction (PCR) for the rapid diagnosis of systemic fungal infections.
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The increase in the incidence of fungal infections and the emergence of resistance call for the development of techniques for measuring in vitro antifungal susceptibility that are useful for predicting clinical outcome in patients suffering from these infections. In the past, the lack of standardized testing techniques led to poor intra- and interlaboratory reproducibility. Recently, the National Committee for Clinical Laboratory Standards (NCCLS) has developed a reference method for antifungal susceptibility testing, document M27A. This document is a necessary and important step towards the standardization of antifungal susceptibility testing, which has important implications in the analysis of clinical and microbiological data. This article provides a comprehensive review of studies correlating in vitro antifungal susceptibility testing and clinical outcome. In general, it is possible to predict the therapeutic outcome, especially in HIV infected patients with oropharyngeal candidiasis treated with fluconazole. However, in other more heterogeneous groups of patients it is more difficult to correlate the in vitro and in vivo data.
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The minimal inhibitory concentration of the three most commonly used antifungal agents--ketoconazole, fluconazole and intraconazole against 28 strains of Malassezia furfur, was studied. The strains were recovered from patients with pityriasis versicolor, pityriasis simplex capitis and dermatitis seborrhoides and were cultured on Dixon's agar. Diagnostic sensitivity test agar was used to determine the minimal inhibitory concentrations of the antifungal agents. The established minimal inhibitory concentration of ketoconazole against Malassezia furfur was 0.02 mg/l, the minimal inhibitory concentration of intraconazole--0.05 mg/l and that of fluconazole--0.09 mg/l. The results of the study are consistent with the data reported by other European authors in their studies. On the basis of the accumulated data it is concluded that the tested antifungal agents are effective in the treatment of infections caused by Malassezia furfur but ketoconazole is superior to intraconazole and fluconazole in the treatment of these infections. This is the first study on the drug susceptibility of Malassezia furfur in Bulgaria.
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The clinical study showed that terbinafine was significantly more effective than fluconazole in the treatment of onychomycosis, achieving statistically higher rates of mycological and clinical cure. We have now shown that terbinafine is also more cost effective. These findings have important implications for both medical and social policy.
The azole antifungal voriconazole and the echinocandin caspofungin have recently become available for the treatment of invasive mycoses. Fluconazole remains the drug of choice for candidemia, except for infections with one of the resistent species such as Candida krusei and some strains of Candida glabrata. In these cases, as well as in patients who cannot tolerate azoles in connection with side effects or drug interactions, caspofungin is an attractive alternative. Voriconazole has become the drug of choice for severe invasive aspergillosis. Itraconazole is a good alternative for milder and chronic forms of aspergillosis. The use of conventional amphotericin B will be limited by the availability of the new drugs. In view of their high costs, the lipid-bound forms of amphotericin B will usually be given only as salvage therapy in case of failure, in patients who are unable to tolerate either conventional amphotericin or one of the newer agents, and for the treatment of zygomycosis.
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The oligosaccharide OligoG, an alginate derived from seaweed, has been shown to have anti-bacterial and anti-biofilm properties and potentiates the activity of selected antibiotics against multi-drug resistant bacteria. The ability of OligoG to perturb fungal growth and potentiate conventional antifungal agents was evaluated using a range of pathogenic fungal strains. Candida (n = 11) and Aspergillus (n = 3) spp. were tested using germ tube assays, LIVE/DEAD staining, scanning electron microscopy (SEM), atomic force microscopy (AFM) and high-throughput minimum inhibition concentration assays (MICs). In general, the strains tested showed a significant dose-dependent reduction in cell growth at ≥6% OligoG as measured by optical density (OD600; P<0.05). OligoG (>0.5%) also showed a significant inhibitory effect on hyphal growth in germ tube assays, although strain-dependent variations in efficacy were observed (P<0.05). SEM and AFM both showed that OligoG (≥2%) markedly disrupted fungal biofilm formation, both alone, and in combination with fluconazole. Cell surface roughness was also significantly increased by the combination treatment (P<0.001). High-throughput robotic MIC screening demonstrated the potentiating effects of OligoG (2, 6, 10%) with nystatin, amphotericin B, fluconazole, miconazole, voriconazole or terbinafine with the test strains. Potentiating effects were observed for the Aspergillus strains with all six antifungal agents, with an up to 16-fold (nystatin) reduction in MIC. Similarly, all the Candida spp. showed potentiation with nystatin (up to 16-fold) and fluconazole (up to 8-fold). These findings demonstrate the antifungal properties of OligoG and suggest a potential role in the management of fungal infections and possible reduction of antifungal toxicity.
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An open, prospective, randomized pilot study was performed to assess the efficacy and safety of oral fluconazole 3 mg/kg once daily compared with oral nystatin 50,000 units/kg/day in four divided doses in preventing candida infections in 50 children undergoing remission induction or consolidation therapy for cancer. In 21 of 25 fluconazole-treated and 20 of 25 nystatin-treated patients the overall outcome of prophylaxis was clearly successful. Mild and transient oropharyngeal candidosis was observed in two and three patients in the fluconazole and nystatin groups respectively. One patient randomized to fluconazole and two patients randomized to nystatin required empirical treatment with amphotericin B and one patient assigned to fluconazole developed tissue-proven candida colitis. Initially non-colonized patients remained yeast-free throughout treatment with no differences between the two study arms. Initially colonized patients stayed colonized throughout treatment although at the end of the study, more patients randomized to nystatin were still harbouring yeasts (P = 0.05). Almost exclusively, Candida albicans (95%) was isolated. A change in species was observed in one patient in each arm of the study. Candida krusei or Candida glabrata were not encountered. Transient elevations of hepatic transaminases were more common in the fluconazole group, although not statistically significant (28% vs 12%, P = 0.15). Reversible grade I gastrointestinal and skin symptoms were observed in four patients randomized to fluconazole (16 vs 0%, P < 0.05). Fluconazole was as safe and effective as nystatin in controlling yeast colonization and in preventing superficial and invasive candida infections and the empirical use of amphotericin B in children and adolescents undergoing intensive chemotherapy for cancer.
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Corneal cultures grew B. capitatus. Systemic fluconazole and systemic and topical amphotericin B treatment were started. Three months after the last operation, no recurrence was observed and the graft remained clear. B. capitatus can rarely cause severe keratitis in patients even in the absence of hematologic disorders.
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This was a prospective study. Mouthwash specimens were cultured on sabouraud dextrose agar twice. Candida species identification was performed and MICs for fluconazole were obtained using NCCLS guidelines. Clinical and mycological responses were assessed on day 14 and 42 in 16 patients who received a 14-day course of fluconazole.